This study seeks to define baseline variation and clinical correlates of body composition in a large international cohort of patients undergoing esophagectomy for cancer. Patients who underwent esophagectomy in 14 high-volume centers between 2007 to 2019 were eligible for inclusion. Skeletal muscle, visceral and subcutaneous adipose tissues within computer tomography images (L3 axial image), acquired routinely at diagnosis, were analyzed in accordance with a standardized protocol. In total, 1716 patients were recruited from three global regions: North America (22%), Europe (55%), and Asia (23%). Patients were predominantly male (79.5%) and adenocarcinoma was the most common histological subtype (66.6%). Characteristics significantly associated with levels of muscle and adiposity were global region, sex, age, and histological subtype (P < 0.001). Compared to adenocarcinoma, squamous cell carcinoma was associated with significantly lower levels of muscle and adiposity, a finding that was independent of global region, sex, and age using a multivariable linear regression model (P < 0.001). Reduced skeletal muscle and an excess of total adiposity at diagnosis was associated with increased 90-day mortality and reduced long-term survival. A prediction model including skeletal muscle, total adiposity at diagnosis and other tumor and patient specific variables was constructed to allow convenient survival prediction. This study adopts a standardized method to define international variation in parameters of body composition in esophageal cancer patients. Findings provide clinically relevant information regarding operative mortality and overall survival and can inform future guidelines for the use of body composition assessment in routine clinical practice.

Indications for the repair of hiatal and paraesophageal hernias (HH/PEH) have evolved considerably over the past two decades, largely driven by the growing adoption of minimally invasive surgical (MIS) techniques. This shift highlights the need to assess surgical trends and clinical outcomes associated with open (OPEN), laparoscopic (LAP), and robotic (ROBOT) approaches, particularly in cases involving large hernias, with more than 50% exhibiting intrathoracic gastric content. Understanding these trends is crucial as MIS continues to gain prominence in the management of complex cases, including large hernias. The aim of this study is to evaluate key outcomes during the transition from OPEN and LAP to ROBOT-assisted HH/PEH repair at a high-volume surgical center. This retrospective review examined 1,834 patients who underwent consecutive hiatal and paraesophageal hernia (HH/PEH) repairs-open (OPEN, n = 958), laparoscopic (LAP, n = 390), or robotic (ROBOT, n = 486)-between 2000 and 2023 at a large medical center. All patients were prospectively enrolled in an IRB-approved database. The study assessed trends in surgical technique, hernia size, and length of stay (LOS) over time. Additionally, patient demographics, the three most common preoperative symptoms, hernia type and size, surgical course, and clinical outcomes-including LOS, radiographic recurrence (evaluated by esophagrams at 3 and 12 months), reoperation rates, and postoperative symptom improvement-were also evaluated. Robotic surgery was introduced in 2018, with a steady annual increase in its use. The total number of operations performed also saw a significant rise over the study period. Mean hernia size decreased during the study, and the majority of patients (99.1%) presented with symptoms. Robotic surgery (ROBOT) demonstrated significantly superior symptom resolution compared to open surgery (OPEN) (p < 0.01), with this advantage sustained in patients with large hernias (p < 0.01). Additionally, length of stay (LOS) decreased over time. While the overall radiographic recurrence rate (8.6%) and reoperation rate (2.4%) were comparable across surgical techniques, ROBOT showed a higher radiographic recurrence rate for large hernias (18%, p < 0.01) without increase in reoperations. The volume of surgeries for HH/PEH repair has increased over time, driven by expanding surgical indications and advancements in minimally invasive and robotic techniques. Surgical intervention leads to significant improvements in HH/PEH symptoms, with more pronounced benefits seen in larger hernia cases. Minimally invasive surgery (MIS), particularly robotic surgery, demonstrates notable improvements in length of stay (LOS) and at least equivalent clinical outcomes when compared to traditional approaches. While the rates of anatomic recurrence and reoperation remain relatively low, ongoing evaluation-especially of robotic surgery-is essential to further minimize these occurrences.

Background: Application of enhanced recovery after surgery (ERAS) pathways in robotic lobectomy have been associated with decreased length of stay (LOS). We evaluated differences in patient characteristics and achievements of ERAS benchmarks by discharge groups at a tertiary referral center. Materials and Methods: We performed a retrospective analysis of a prospectively maintained ERAS database of patients undergoing robotic lobectomy for pulmonary malignancy. Patients were trifurcated into LOS groups, postoperative day 1, 2-3, and 4+. Preoperative and perioperative variables, ERAS achievement, complications, and readmissions were analyzed. Results: Between October 2018 and August 2022, 145 consecutive patients were reviewed. Eighty-two (56.6%) were discharged on POD 1, 50 (34.5%) on POD 2-3, and 13 (9.0%) on POD 4+. Patients achieving POD 1 discharge were associated with better preoperative pulmonary function (FEV1 p = 0.023 and DLCO p = 0.007) and shorter operative times (p < 0.001). Most air leaks (n = 30, 54.5%) were resolved by discharge; however, 25 (17.2%) were discharged with a chest tube. The POD 1 discharge group ambulated earlier (p = 0.005) and experienced no inpatient complications. Multivariate analysis reveals that operative time, time to first ambulation, and postoperative day 1 air leak were negatively associated with POD 1 discharge. Those who experienced a minor inpatient complication ambulated 5.8 h later than those who did not. Conclusion: Utilization of ERAS principles can facilitate POD 1 discharge in the majority of patients undergoing robotic assisted lobectomy without an increase in complications or readmissions. Early ambulation and chest tube removal are modifiable elements of ERAS associated with POD 1 discharge.

Obesity is associated with several chronic conditions including diabetes, cardiovascular disease, and metabolic dysfunction-associated steatotic liver disease and malignancy. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, is an effective treatment modality for obesity and can improve associated comorbidities. Over the last 20 years, there has been an increase in the rate of bariatric surgeries associated with the growing obesity epidemic. Sleeve gastrectomy is the most widely performed bariatric surgery currently, and while it serves as a durable option for some patients, it is important to note that several complications, including sleeve leak, stenosis, chronic fistula, gastrointestinal hemorrhage, and gastroesophageal reflux disease, may occur. Endoscopic methods to manage post-sleeve gastrectomy complications are often considered due to the risks associated with a reoperation, and endoscopy plays a significant role in the diagnosis and management of post-sleeve gastrectomy complications. We perform a detailed review of the current endoscopic management of post-sleeve gastrectomy complications.

Abstract Background Intraoperative volume management in patients undergoing esophagectomy is nuanced. Data is conflicting in regards to the benefits of volume restrictive versus liberal approaches. Within a hybrid robotic assisted minimally invasive esophagectomy (hRAMIE) population undergoing oncologic resection there is a paucity of data regarding intraoperative volume status as it affects postoperative outcomes and no data regarding the impact on enhanced recovery after surgery (ERAS) outcomes. Methods Demographics, anthropometrics, cancer characteristics, and perioperative outcome data were gathered between January 2020 and December 2023 at a single, tertiary referral center in patients undergoing oncologic hRAMIE. Intraoperative volume status was defined, as in other reports, by identifying the median operative volume rate per hour and normalizing via the Du Bois body surface area; above or below 225 mL/hour/m2. ERAS outcomes were reported. Complications were stratified in accordance with the Esophagectomy Complications Consensus Group guidelines. Continuous variables were compared via Mann-Whitney U-Test; categorical via Fisher's Exact. Alpha set to 0.05. Results 96 patients (46 volume restrictive, 45 volume liberal) were identified. There were no differences in age, sex, body mass index, ASA class, Charlson Comorbidity Index, cancer histology, location, rate of neoadjuvant chemotherapy, or chemoradiotherapy. ERAS outcomes analysis reveals no statistical difference in ICU length of stay, mobilization times, return of bowel function, or length of stay (Table 1). Complications were reported in 45.8% of patients and did not differ between groups (p=0.8934). Pulmonary complications were most frequent (total 21.9%; restrictive 17.4%, liberal 28.9%, p=0.1422) followed by anastomotic leak (total 12.5%; restrictive 17.4%, liberal 8.9%, p=0.3681). Conclusion The current study demonstrates no impact of volume restriction on perioperative outcomes, ERAS benchmarks, or length of stay in patients undergoing hRAMIE for esophageal cancer. Data suggests that minimally invasive approaches may be associated with less total body and pleural inflammatory mediator generation, perhaps limiting susceptibility to variation in volume status. Highly powered, multicenter retrospective minimally invasive esophagectomy and volume status investigation is warranted prior to proceeding with controlled trial.

Abstract Background Growing evidence has supported a role for body composition in predicting survival in patients undergoing esophagectomy. A contemporary meta-analysis of published data (n=44 studies) conducted for this study confirmed an association between reduced muscle mass at diagnosis and worse overall survival (HR 1.72, 95%CI 1.49-1.97). Variation in methods of assessing and defining parameters of body composition remain however an important barrier to the wider adoption in routine clinical practice. This is particularly pertinent in esophageal cancer due to known sex, biological and geographical difference in tumor subtypes. This study seeks to define baseline variation in body composition parameters and to report their association with 90-day and overall survival in a large international cohort of patients undergoing esophagectomy for cancer. Methods Patients who underwent esophagectomy in fourteen high-volume centers between January 2007 to December 2019 were eligible for inclusion. Survival data were included up until June 2022. Skeletal muscle, visceral and subcutaneous adipose tissues within CT images, acquired at the time of diagnosis, were analyzed in accordance with a standardized protocol. Results 1716 patients were recruited to this study from three global regions: North America (n=386;22.5%), Europe (n=940;54.8%) and Asia (n=390;22.7%). Patients were predominantly male (79.5%) and adenocarcinoma was the most common histological subtype (66.6%). Wide variation of skeletal muscle (17.1-83.5cm2), visceral adiposity (0.2-170.1cm2) and subcutaneous adiposity (0.2-216.8cm2) was observed at presentation. Characteristics significantly associated with levels of muscle and adiposity were global region, sex, age, and histological subtype (P<0.001) (Figure 1). Compared to adenocarcinoma, squamous cell carcinoma was associated with significantly lower levels of muscle and adiposity, a finding that was independent of global region, sex, and age using a multivariable linear regression model (p<.0001). Median follow-up was 71.3 (95%CI 69.1-73.5) months with a median overall survival of 60.9 (95%CI 53.0-68.9) months. Reduced skeletal muscle and an excess of total adiposity at the time of diagnosis was associated with worse 90-day mortality and long-term survival. An interactive online survival prediction tool was developed to provide personalized survival estimates based on relevant predictors including skeletal muscle, total adiposity at diagnosis and other tumor and patient specific variables. Conclusions This is the first and largest study to adopt standardized methods to define international variation in parameters of body composition in esophageal cancer patients. Findings corroborate the potential role of body composition as a method of prognostication in esophageal cancer and presents a on-line tool for convenient integration into clinical practice.

Abstract Introduction Gastroesophageal reflux disease (GERD) is one of the main concerns after bariatric surgery with an occurrence of about 30% after Sleeve Gastrectomy. While Gastric Bypass surgery (GBP) often relieves symptoms, upto 8% still suffer from significant GERD. Effective treatment options for patients with large hiatal hernia and severe obesity as well as those with refractory GERD after GBP are scarce. The aim of this study was to evaluate the feasibility of the Hill reflux procedure as an adjunct to gastric bypass. Method The study is a phase 2a-trial aimed to include 8 consecutive patients with refractory GERD after gastric bypass surgery or large hiatal hernia, GERD and severe obesity. Preoperative and 1 year follow-up evaluation includes upper-GI endoscopy, 24h-pH measure, manometry, radiology and subjective symtoms estimated with GerdQ. All operations are performed laparoscopically by one surgeon according to the Hill-technique (fig1). Each procedure is filmed and postoperatively evaluated by a team of international experts. Result Preliminary report involves data for the first three cases, including one patient with severe GERD with intrathoracic pouch herniation after GBP and two patients with primary gastric bypass and large hiatal hernia. There were no conversions or intraoperative complications, but one Grade-2 postoperative complication. During 1-4 months follow-up GerdQ has been normalized in all three cases. Discussion Early, data suggest feasibility of the procedure in a group of patients with today few effective treatment options.

Background: Oesophago-gastric cancer surgery negatively affects quality of life with a high postoperative symptom burden. Several conditions that may be diagnosed and treated after surgery are recognised. However, consensus regarding their definition and management is lacking. This study aimed to develop consensus regarding the definition, investigation and management of the common symptoms and conditions, and triggers to consider disease recurrence, as a foundation for improving management and quality of life in these patients. Method: Modified two-round Delphi consensus study of a multidisciplinary expert panel. Results: Eighty-six of 127 (67.7%) and 77 of 93 (82.8%) responses were received in rounds 1 and 2. Consensus was achieved in defining 26 symptoms. For 10 conditions (anastomotic stricture, acid reflux, non-acid reflux, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption), definitions, diagnostic criteria, first- and second-line investigation and first-line treatments were agreed. Consensus was not reached for third-line investigation of some conditions, or for second-, third- or fourth-line treatments for others. Twelve of 14 (85.7%) symptoms were agreed as triggers to consider cancer recurrence, during the early (<1 year) and late (>1 year) postoperative periods. Conclusion: Expert consensus regarding symptoms, conditions and triggers to consider investigation for recurrence after oesophago-gastric cancer surgery was achieved. This may allow standardization and timely diagnosis and treatment of postoperative conditions, reducing variation in care and optimizing patients' quality of life.

Previous assessments suggest that surgical results of paraesophageal hernia (PEH) repair were negatively impacted by increasing levels of obesity. A better understanding of the association of obesity on outcomes of PEH repair will support surgeons making evidence-based decisions on the surgical candidacy of individual patients. This single institution retrospective cohort study included 884 consecutive patients with giant PEH undergoing surgical repair between 1 January 2000 and 30 June 2020. Preoperative body mass index (BMI) was documented at the time of surgery. Main outcomes included perioperative blood loss, length of hospital stay, major complications, early hernia recurrence, and mortality. The mean (standard deviation [SD]) age at surgery was 68.4 (11.1), and 645 (73.0%) were women. Among the 884 patients, 875 had a documented immediate preoperative BMI and were included in the analysis. Mean (SD) BMI was 29.24 (4.91) kg/m2. Increasing BMI was not associated with increased perioperative blood loss (coefficient, 0.01; 95% confidence interval [CI], -0.01 to 0.02), prolonged length of stay (coefficient, -0.01; 95% CI, -0.02 to 0.01), increased incidence of recurrent hernia (odds ratio [OR], 1.03; 95% CI, 0.95-1.10), or increased major complications (OR, 0.93; 95% CI, 0.82-1.05). The 90-day mortality rate was 0.3%. Furthermore, when compared with the normal weight group, overweight and all levels of obesity were not related to unfavorable outcomes. No association was found between BMI and perioperative outcomes or short-term recurrence in patients undergoing PEH repair. Although preoperative weight loss is advisable, a higher BMI should not preclude or delay surgical management of giant PEH.

Objective:To evaluate prognostic differences between minimally invasive esophagectomy (MIE) and open esophagectomy (OE) in patients with surgery after a prolonged interval (>12 wk) following chemoradiotherapy (CRT). Background:Previously, we established that a prolonged interval after CRT before esophagectomy was associated with poorer long-term survival. Methods:This was an international multicenter cohort study involving 17 tertiary centers, including patients who received CRT followed by surgery between 2010 and 2020. Patients undergoing MIE were defined as thoracoscopic and laparoscopic approaches. Results:A total of 428 patients (145 MIE and 283 OE) had surgery between 12 weeks and 2 years after CRT. Significant differences were observed in American Society of Anesthesiologists grade, radiation dose, clinical T stage, and histologic subtype. There were no significant differences between the groups in age, sex, body mass index, pathologic T or N stage, resection margin status, tumor location, surgical technique, or 90-day mortality. Survival analysis showed MIE was associated with improved survival in univariate (P=0.014), multivariate analysis after adjustment for smoking, T and N stage, and histology (HR=1.69; 95% CI: 1.14-2.5) and propensity-matched analysis (P=0.02). Further subgroup analyses by radiation dose and interval after CRT showed survival advantage for MIE in 40 to 50 Gy dose groups (HR=1.9; 95% CI: 1.2-3.0) and in patients having surgery within 6 months of CRT (HR=1.6; 95% CI: 1.1-2.2). Conclusions:MIE was associated with improved overall survival compared with OE in patients with a prolonged interval from CRT to surgery. The mechanism for this observed improvement in survival remains unknown, with potential hypotheses including a reduction in complications and improved functional recovery after MIE.

Abstract Background Indications for repair of hiatal and paraesophageal hernia (HH/PEH) repair evolved significantly over the past two decades, impacted by the increasing application of minimally invasive surgical (MIS) approaches. This transition underscores the importance of evaluating the operative trends and clinical outcomes associated with open (open), laparoscopic (lap), and robotic surgeries especially in cases of giant hernias (over 50% intrathoracic stomach). Understanding these dynamics is crucial, especially as MIS becomes increasingly prevalent in managing complex cases, including giant hernias. The aim of this study is to assess critical outcomes achieved during the evolution from open to lap to robotic HH/PEH repair in a high volume center. Methods This is a retrospective review of 1834 patients undergoing open (958), lap (390), and robot (486), consecutive HH/PEH repairs prospectively entered into an IRB approved database from 2000 to 2023 at a high-volume center. Patient demographics, operative techniques, and top three most common presenting symptoms were studied overtime. Impact of operative technique, hernia type and size, operative outcomes including length of stay (LOS), radiographic recurrence (esophagram at 3 and 12 months), revisional surgery, on post-operative symptom resolution was evaluated. Results Annual volume increased overtime, with 418 repairs (78% robotic) in the last two years. Average hernia size decreased over the study period. The majority of patients (99.1%) presented with symptoms (Fig 1) and robotic repair had significantly better symptomatic resolution than open surgery (p<0.05). This advantage persists with symptoms in giant hernias (p<.001) LOS decreased over the study period (Fig 1). Overall radiographic recurrence (8.6%) and reoperative rate (2.4%) did not differ among operative techniques, however robotic repair had higher radiographic recurrence rate in case of giant hernia (18%, p<.001). Conclusion The operative volume of HH/PEH repair has increased overtime associated with the increased application along with advancements in MIS and robotic operative techniques. Surgical interventions markedly ameliorate HH/PEH symptoms, with greater improvement observed in large hernia cases. Significant improvement in LOS and at least equivalent clinical results favors MIS, particularly robotic surgery. Although the incidence of anatomic recurrent hernia and reoperation is relatively low continued assessment of especially robotic operations to decrease this incidence further is warranted.

The outcomes for sliding and paraesophageal hiatal hernias (PHH) are jointly reported. By combining outcomes of sliding hernia and PHH repair, surgeons are conflating the outcomes of surgical management for GERD with the outcomes of PHH repair. PHH is a distinct clinical entity from sliding hernia, requiring a more complex operation with higher risk of complications and, ultimately, comparatively diminished outcomes. The practice of combining PHH and sliding hernia surgical data confounds the true outcomes of ARS and contributes to misconceptions that reduce referral rates. Current and future research assessments must be based on accurate discrimination between the 2 anatomic presentations. Surgeons have a responsibility to ensure this distinction is clearly drawn when disseminating their ARS outcomes.

Summary Surgery for cancer of the esophagus or gastro-esophageal junction can be performed with a variety of minimally invasive and open approaches. The left thoracoabdominal esophagectomy (LTE) is an open technique that gives an opportunity to operate in the chest and abdomen with excellent exposure of the gastro-esophageal junction through a single incision, and there is currently no equivalent minimally invasive technique available. The aim of this multi-institutional review was to study a large contemporary international study cohort of patients treated with LTE. An international multicenter cohort study was performed including all patients treated with LTE at six high-volume centers for gastro-esophageal cancer surgery between 2012 and 2022. Patient data were prospectively collected in each participating centers’ institutional database. Information about patient, tumor, and treatment details were collected. The study cohort included a total of 793 patients treated with LTE during the study period. The most frequently observed complications were pneumonia in 185/727 (25.5%) patients and atrial fibrillation in 91/727 (12.5%). Anastomotic leak occurred in 35/727 (4.8%) patients; no patient suffered from conduit necrosis. Thirty-day mortality occurred in 15/785 (1.9%) patients and 90-day mortality in 39/785 (5.0%) patients. Factors with statistically significant association with survival were American Society for Anesthesiologists-score, tumor location, tumor stage, and tumor free resection margins. Neoadjuvant therapy was not associated with increased survival compared to surgery alone but neoadjuvant chemoradiotherapy compared to neoadjuvant chemotherapy showed statistically significant improved survival with hazard ratio 0.60 (95% confidence intervals:0.44–0.80, P = 0.001) in a multivariable adjusted model. This study demonstrates that LTE can be applied in selected patients with results that are comparable to other large studies of open and minimally invasive surgery for esophageal or gastro-esophageal cancer at high-volume centers.

Background With increasing incidence of esophageal cancer, a growing number of patients are at risk of developing delayed gastric conduit emptying (DGCE) in the early postoperative phase after esophagectomy. This condition is of great postoperative concern due to its association with adverse outcomes. Purpose To give a narrative review of the literature concerning radiological diagnosis of DGCE after esophagectomy and a proposal for an improved, functional protocol with objective measurements. Material and Methods The protocol was designed at Virginia Mason Medical Center in Seattle and is based on the Timed Barium Esophagogram (TBE) concept, which has been adapted to assess the passage of contrast from the gastric conduit into the duodenum. Results The literature review showed a general lack of standardization and scientific evidence behind the use of radiology to assess DGCE. We found that our proposed standardized upper gastrointestinal (UGI) contrast study considers both the time aspect in DGCE and provides morphologic information of the gastric conduit. This radiological protocol was tested on 112 patients in a trial performed at two high-volume centers for esophageal surgery and included an UGI contrast study 2-3 days postoperatively. The study demonstrated that this UGI contrast study can be included in the standardized clinical pathway after esophagectomy. Conclusion This new, proposed UGI contrast study has the potential to diagnose early postoperative DGCE in a standardized manner and to improve overall patient outcomes after esophagectomy.

Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.

Abstract Background Oesophago-gastric cancer surgery negatively affects quality of life with a high post-operative symptom burden. Several conditions that may be diagnosed and treated after surgery are recognised. However, consensus regarding their definition and management is lacking. We aimed to develop consensus regarding the definition, investigation and management of the common symptoms and conditions, and triggers to consider disease recurrence, as a foundation for improving management and quality of life in these patients. Design Modified 2-round Delphi consensus study of a multidisciplinary expert panel. Results 86/127(67.7%) and 77/100(77.0%) responses were received in rounds 1 and 2. Consensus was achieved in defining 26 symptoms. For 10 conditions (anastomotic stricture, acid reflux, non-acid reflux, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption), definitions, diagnostic criteria, first and second-line investigation and first-line treatments were agreed. Consensus was not reached for third line investigation of some conditions, nor for second, third or fourth-line treatments for others. 12 of 14(85.7%) symptoms were agreed as triggers to consider cancer recurrence, during the early (< 1 year) and late (> 1 year) post-operative periods. Conclusion Expert consensus regarding symptoms, conditions and triggers to consider investigation for recurrence after oesophago-gastric cancer surgery was achieved. This will allow standardisation and timely diagnosis and treatment of post-operative conditions, reducing variation in care. It will facilitate comparative, prospective research to establish the incidence and response to treatment of these conditions, helping develop robust evidence to optimise patients’ quality of life.

Abstract Background Oesophago-gastric (OG) cancer surgery is life-changing with a significant impact on quality of life (QOL). OG cancer surgery reconfigures the upper gastrointestinal (GI) tract altering its physiological function. Certain disorders such as anastomotic stricture are well recognised whereas others, such as small intestinal bacterial overgrowth, are increasingly being diagnosed. As multimodality treatment improves survival, more poly-symptomatic patients are living with these disorders as a consequence of surgery. We aimed to establish consensus on the definitions of relevant symptoms and disorders, as well as appropriate investigation and treatment. Standardisation will form a foundation for optimising QOL in this growing patient group. Methods This on-line modified Delphi study focused on patients after oesophagectomy, gastrectomy or subtotal gastrectomy for cancer (OG cancer surgery). The survey covered symptoms, common conditions, and symptoms triggering investigation for recurrence. The survey was designed using non-systematic reviews and expert opinion. Items were rated from 1 (completely disagree) to 9 (absolutely agree). Multi-disciplinary experts were identified through word of mouth and expressions of interest at previous conferences. Two rounds were completed, with some revisions after first round review. Median ratings were determined. Consensus agreement was judged as 70% or more respondents in agreement (7-9) and less than 15% disagreement (1-3). Results 86 and 77 complete surveys were received in rounds 1 and 2. Respondents were multidisciplinary, including OG surgeons, oncologists, gastroenterologists, radiologists, dietitians and nurse specialists. 7 upper GI, 13 non-specific and 6 lower GI symptom definitions were agreed. Clinical definitions, diagnostic criteria, first line investigations and treatments were agreed for 10 conditions: anastomotic stricture, acid reflux, non-acid reflux oesophagitis, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption. Agreement was also reached across many second-line investigations and treatments, and 12 of 14 (86%) symptom triggers to investigate for recurrence. Conclusions The RESTORE multidisciplinary consensus study has established a foundation for assessing and treating 10 conditions negatively affecting QOL after OG cancer surgery. Standardised symptom definitions will guide diagnostic assessments. Agreed condition definitions and diagnostic criteria will allow robust measurement of their incidence, and evaluation of treatment effects. Future work will aim to develop algorithms for managing these conditions. This work will raise standards of diagnosis and treatment of conditions that affect patients after OG cancer surgery, allowing collection of robust data to evaluate improvements in symptoms and QOL.

BackgroundCurrently, little is known regarding the optimal technique for the abdominal phase of RAMIE. The aim of this study was to investigate the outcome of robot-assisted minimally invasive esophagectomy (RAMIE) in both the abdominal and thoracic phase (full RAMIE) compared to laparoscopy during the abdominal phase (hybrid laparoscopic RAMIE).MethodsThis retrospective propensity-score matched analysis of the International Upper Gastrointestinal International Robotic Association (UGIRA) database included 807 RAMIE procedures with intrathoracic anastomosis between 2017 and 2021 from 23 centers.ResultsAfter propensity-score matching, 296 hybrid laparoscopic RAMIE patients were compared to 296 full RAMIE patients. Both groups were equal regarding intraoperative blood loss (median 200 ml versus 197 ml, p = 0.6967), operational time (mean 430.3 min versus 417.7 min, p = 0.1032), conversion rate during abdominal phase (2.4% versus 1.7%, p = 0.560), radical resection (R0) rate (95.6% versus 96.3%, p = 0.8526) and total lymph node yield (mean 30.4 versus 29.5, p = 0.3834). The hybrid laparoscopic RAMIE group showed higher rates of anastomotic leakage (28.0% versus 16.6%, p = 0.001) and Clavien Dindo grade 3a or higher (45.3% versus 26.0%, p < 0.001). The length of stay on intensive care unit (median 3 days versus 2 days, p = 0.0005) and in-hospital (median 15 days versus 12 days, p < 0.0001) were longer for the hybrid laparoscopic RAMIE group.ConclusionsHybrid laparoscopic RAMIE and full RAMIE were oncologically equivalent with a potential decrease of postoperative complications and shorter (intensive care) stay after full RAMIE.