To compare perioperative, oncological, and survival outcomes of total gastrectomy (TG) versus subtotal gastrectomy (SG) in patients with locally advanced distal diffuse gastric adenocarcinoma treated with perioperative 5-fluorouracil, leucovorin, oxaliplatin and docetaxel (FLOT) chemotherapy. Diffuse distal gastric cancer is characterized by infiltrative growth patterns and early nodal metastasis. Whilst radical resection remains the cornerstone of curative treatment, the optimal extent of surgery with TG or SG, remains debated. This international multicenter cohort study analyzed data from patients with histologically confirmed diffuse gastric adenocarcinoma, located > 5 cm from the gastroesophageal junction. Endpoints included surgical margin status, nodal yield, perioperative morbidity, recurrence patterns, time-to-recurrence (TTR), and overall survival (OS). Outcomes were compared using multivariate analyses. In total, 188 (39.0

This study assessed the educational value of a novel, low-cost virtual reality headset system designed for stereoscopic 3D viewing of robotic upper gastrointestinal surgery, targeting medical students and junior doctors. Ten participants observed robotic surgical procedures using a prototype 3D video streaming system in combination with a phone-based VR headset. Following the experience, participants completed a structured questionnaire evaluating immersion, ease of use, comfort, spatial understanding, and overall educational value. Responses were collected using Likert scales and open-text feedback. Ninety per cent of participants (9/10) rated the VR experience as highly immersive (score ≥4/5), with the same proportion reporting an improved understanding of robotic surgical procedures. All participants preferred the VR system over traditional 2D displays, particularly for conveying spatial awareness and depth perception. Key educational benefits included a clearer appreciation of the surgeon’s perspective and enhanced visualisation of anatomical depth. While 70 per cent found the headset comfortable to use, some noted limitations such as reduced image resolution and occasional latency. Despite these minor drawbacks, all participants supported the continued use of VR in surgical training, with 60 per cent strongly endorsing its integration. Suggested improvements focused on increasing image quality and enhancing headset ergonomics to further enrich the learning experience. A low-cost VR headset system offers a highly immersive and educationally effective tool for observing robotic upper GI surgery. Its affordability and minimal setup requirements support its potential for broader adoption in surgical education.

This study aimed to evaluate post-operative opioid analgesic consumption and the necessity of opioid analgesic prescriptions on discharge in patients undergoing Ivor Lewis Gastro-oesophagectomy (ILGO) at a high-volume centre with the best UK length of stay. A retrospective review was conducted on ILGO patients from January to June 2023. Inclusion criteria were adherence to the ERAS programme, and discharge within 10 days; patients with complications or unplanned ICU admissions were excluded. Opioid analgesia use from postoperative day 5 to discharge was compared with opioid analgesia prescriptions issued on discharge. After the review, a prescribing tool for analgesia on discharge was implemented, and its impact evaluated. Of 34 patients, 24 met the inclusion criteria (mean age 68; 18 men, 6 women). Exclusions were due to delayed gastric emptying (6), unplanned ICU admission (1), and pneumonia (3). From day 5 to discharge, 63% (15/24) used no opioids, yet 87% (13/15) of these were still prescribed opioid analgesia on discharge. All 9 patients requiring opioids beyond day 5 had open chest surgery. Ten months after implementing the analgesia on discharge tool, 33% (5/15) were discharged with opioids. 20% (3/15) contacted their GP for stronger analgesia. Most ILGO patients do not require opioids in later recovery, revealing significant overprescribing. The study led to revised prescribing guidelines, reducing opioid discharge prescriptions, pharmacy workload, and potential dependency risk. As a pilot with limited sample size, further research with larger datasets is needed to better define post-discharge analgesia requirements.

Gastro-esophageal junction (GOJ) adenocarcinoma is increasingly common and despite significant changes in management over the past decade, overall survival remains poor. Determining factors that influence survival is important for optimizing curative surgery. The prognostic significance of subcarinal lymph node involvement is unclear. The purpose of this study was to assess the prognostic significance of subcarinal lymph node involvement in patients undergoing curative resection of GOJ adenocarcinoma. Consecutive patients undergoing curative 2-stage Ivor-Lewis esophagectomy between February 2010 and January 2022 were analyzed retrospectively from a prospectively maintained database for Siewert type I and II GOJ adenocarcinoma confirmed on histopathology. Outcomes were compared based on subcarinal node involvement confirmed on histopathology. A total of 698 patients with Siewert type I (n = 314) and II (n = 384) adenocarcinoma were analyzed [median age 68 (31-85), 604 males (87%) neo-adjuvant use 491 (74.4%)]. Eighteen patients (2.6%) had subcarinal lymph node involvement. These patients had more advanced overall stage of disease and positive node involvement than those without and a significantly lower median survival of 6 months (<1-25) compared to 53 months (41-65) (p < 0.001). On multivariate analysis, pathological T stage, para-gastric and subcarinal lymph node involvement were found to be the independent and significant factors influencing survival. Subcarinal lymph node involvement is an indicator of advanced disease and high positive node burden. It is an independent prognostic factor in patients undergoing curative surgery for Siewert type I and II GOJ adenocarcinoma.

Abstract Background Adenocarcinoma of the gastro-esophageal junction (GEJ) is increasingly common in Western societies. GEJ tumours are typically categorized using the Siewert classification, which divides the tumours in to 3 types based on location relative to the GEJ. Studies have shown that there is improved survival with a proximal surgical resection such as esophagectomy for type 1 tumours while type 3 tumours have improved survival when managed as other gastric cancers with a total or extended total gastrectomy. This requires accurate clinical classification. This study aims to evaluate the accuracy of commonly used staging modalities in the clinical classification of GEJ tumours. Methods A review of 807 consecutive patients undergoing curative resection for GEJ cancer was performed. Patient data was obtained from a prospectively maintained database between February 2010 and April 2023. Siewert type was established clinically as part of the staging process. The standard staging modalities used for every patient included computerized tomography (CT) and endoscopy, with most patients also undergoing positron emission tomography (PET). Endoscopic ultra-sonography (EUS) and staging laparoscopy was also used selectively. Accuracy was determined by comparing clinical classification to pathological classification following surgery. Results 807 patients were included [319 type 1, 401 type 2, 87 type 3]. Clinical classification was the same as pathological classification in 59.5% of cases [69.6% for type 1, 48.6% for type 2, 71.3% for type 3 (p<0.001). The use of different staging modalities for each sub-type is presented in table 1. For patients that underwent EUS, Siewert type was accurate in 59.4% of cases overall. The failure rate for EUS was 2.9%. For patients undergoing staging laparoscopy Siewert type was accurate in 69.3% and for patients that underwent PET, EUS and staging lap the accuracy was 74.4%. Conclusion Accurately determining Siewert type clinically is challenging. This is particularly relevant for type 2 tumours which had the least accurate comparison of clinical to pathological type. The use of additional modalities including EUS, and staging laparoscopy improves accuracy but may not be feasible in all patients.

BACKGROUND:As waiting lists for elective surgery grow, there seems to be a disconnect between the public's expectations on the amount of time surgeons spend operating compared with reality. On average, a surgeon in the NHS spends one day a week performing elective surgery. We aimed to investigate the public's perception on the amount of time surgeons spend performing elective surgery and what they would desire.METHODS:Members of the public in the UK were approached randomly either on-line or in-person to complete an anonymised 6-question survey. The questionnaire included demographic details, surgical history, occupational experience in the healthcare sector, the number of days a week they believe and wish for surgeons to be performing elective surgery.RESULTS:252 members of the public responded to the survey (150 females, 102 males). 38.5% have experience working in the healthcare sector and 58.5% have had surgery in the past. 83.7% believe surgeons spend at least 3 days a week performing elective surgery [3-4 days (43.2%), 5-7 days (40.5%)]. 45.7% of respondents want their surgeon to operate between 5 and 7 days per week.CONCLUSION:The public appears to overestimate the amount of time that surgeons spend performing elective surgery and have unrealistic expectations of how much they want their surgeons to operate.

Abstract Background Curative cancer surgery relies on understanding the lymphatic spread of the tumour to guide lymphadenectomy. The lymphatic involvement in patients with esophageal squamous cell carcinoma (SCC) has been evaluated extensively in large cohort studies from the East where SCC predominates, but the pattern of lymph node spread in gastro-esophageal junction (GEJ) adenocarcinoma is less clear. The primary aim of this study was to compare differences in the pattern of lymph node involvement according to the Siewert classification. Methods Consecutive patients who underwent curative resection for GEJ adenocarcinoma between February 2010 and April 2023 were analysed from a prospectively maintained database. Patient demographic data, neo-adjuvant treatment, operation type and histopathological report data were collected and analysed according to the pathological Siewert classification of GEJ cancer. Results 807 patients who underwent curative surgery for GEJ adenocarcinoma were analysed. The median lymph node yield was 26 (5-81). Comparing positive para-esophageal node yields, Type I and II tumours were similar but both significantly higher than Type III. For positive para-gastric nodes, Type 2 and 3 tumours were similar but both significantly higher than type 1. The significance of these comparisons is presented in table 1. There were no differences comparing other specific nodal groups. Evaluating the effect of node involvement on overall survival positive node status and positive hepatic artery nodes were found to be independent factors adversely affecting survival. Conclusion Siewert type I tumours have greater proximal lymph node involvement compared to type III tumours with higher proportions of positive para-esophageal nodes. Type III tumours on the other hand have higher proportions of para-gastric nodes. Type II tumours have similar para-esophageal node involvement to type 1 tumours and similar para-gastric involvement to type III tumours. Involvement of more specific nodal groups does not seem to vary between the sub types.

Background: Delayed gastric emptying (DGE) affects up to 37% of patients after esophagectomy. An international expert consensus (IEC) agreed on a diagnostic criterion in 2020. The degree of adoption of this definition worldwide and how it compares to well established definitions locally with subtle, yet significant differences is unknown. The aim of this observational study was to compare the IEC definition of DGE to the definition at the University Hospital Plymouth (UHP) esophago-gastric surgery unit. Methods: Consecutive patients who underwent esophagectomy for cancer at UHP between April 2019 and August 2020 were analysed. The IEC definition was applied retrospectively and the rates of DGE were compared between the two criteria. Results: One hundred patients [74 male (74%), median age 60 (range, 45-84 years)] were analysed. The rates of early DGE according to the UHP and IEC definitions were 27% and 20% respectively (P=0.24). Twenty-nine patients (29%) underwent pyloric dilatation (17 patients within 14 days post operatively). The sensitivity and specificity of the UHP vs. IEC definition of early DGE in identifying those who required pyloric dilation were 86.2% and 97.2% vs. 37.9% and 87.3% respectively. Out of the 12 patients who underwent late dilatations (>14 days post op), the UHP and IEC early DGE definition predicted 75% (n=8) and 17% (n=2) respectively (P=0.52). Conclusions: The sensitivity and specificity of the IEC criteria at identifying patients with early DGE is lower than the UHP criteria which also appeared to predict patients with late DGE.

Abstract Background Gastro-Esophageal Junction (GEJ) adenocarcinoma is becoming increasingly common in the west. Given the anatomical location of the junction there are several surgical approaches that can be used to treat these tumours, this is often guided by the sub-type of tumour, categorised using the Siewert classification. While overall survival for GEJ cancer tends to be poor compared with other solid organ cancers, changes in diagnosis and treatment have led to improvements in recent years. This study represents one of the largest retrospective reviews of its type to focus on the short- and long-term outcomes of patients undergoing curative resection for GEJ cancer. Methods Information was collected on 807 consecutive patients undergoing curative resection for gastro-esophageal junction adenocarcinoma between February 2010 and April 2023. The primary outcome was overall 5- and 10-year survival. Secondary outcomes included: disease free survival, survival based on surgical resection, 30- and 90-day mortality, post operative complications, oncology and pathology outcomes. For each outcome overall results and analysis comparing Siewert types was performed. Results 807 patients were included [319 type I cancers (39.5%), 401 type II (50%) and 87 type III (10.8%)]. Type I and II were predominantly managed with Esophagectomy (Type I = 100%, Type II = 97.5%). For Type III tumours 49% had esophagectomy and 51% had either a total or extended total gastrectomy. Siewert groups had comparable short-term outcomes, presented in table 1. Overall survival was 46% at 5 years and 37% at 10 years with no significant difference between Siewert types (p=0.24). Disease free survival was 55% at 5 years and 50% at 10 years with no significant difference between Siewert type (p=0.34). Conclusion The 3 Siewert classification subtypes of gastro-esophageal junction adenocarcinoma have similar short-term outcomes, overall and disease-free survival.

BackgroundThere is no consensus on the ideal surgical management of patients with Siewert type II gastroesophageal junctional (GEJ) cancers. Due to its anatomical location, total gastrectomy and oesophagectomy are widely used methods of resection. The aim of this study was to determine the optimal surgical treatment of these patients.MethodA systematic search of PubMed, Medline and Cochrane libraries was conducted for literature published between 2000 and 2022. Studies directly comparing oesophagectomy to gastrectomy for Siewert type II tumours were included. Outcome measures included rates of anastomotic leak, 30-day mortality, R0 resection and 5-year survival. Statistical analysis was performed using Review Manager 5.4.ResultsEleven studies involving 18,585 patients undergoing either oesophagectomy (n = 8618) or total gastrectomy (n = 9967) for Siewert type II GEJ cancer were included. There were no significant differences between the rates of anastomotic leak (OR 0.91, CI 0.59-1.40, p = 0.66) and R0 resection (OR 1.51, CI 0.93-2.42, p = 0.09). Patients undergoing total gastrectomy had a lower 30-day mortality (OR 0.66, CI 0.45-0.95, p = 0.03) and a greater 5-year overall survival (OR 1.49, CI 1.34-1.67, p < 0.001) compared to patients undergoing oesophagectomy. These differences were not statistically significant after excluding two large studies, which accounted for the majority of the total population in the analysis.ConclusionThese results suggest that total gastrectomy results in lower 30-day mortality and improved overall survival in patients with Siewert type II GEJ cancer. However, interpretation of these results may be biased by the effect of two large studies.

Abstract Background Up to 80% of surgeons report musculoskeletal problems which significantly affect their personal and professional lives. The cost of back pain alone in the NHS costs £400 million per year (for all staff), and surveyed surgeons report 40% have sustained an injury at work. Laparoscopic cholecystectomy is one of the most frequently performed surgical procedures but the musculoskeletal impact of this procedure on surgeons is unknown, though anecdotally it is likely to be high. Methods We observed the positions held by surgeons undertaking laparoscopic cholecystectomy and measured them against the Rapid Entire Body Assessment (REBA) score, which is widely used to assess the risk of an activity causing musculoskeletal injury. The higher the score, the less ergonomic the posture and the higher the risk of long term harm. Photographs were taken of the operating surgeon with consent (excluding views of the patient) and then measured against the score to assess the risk. Operations were graded to give an average risk score which represents the need for a change of process to safeguard staff. Results Eight laparoscopic cholecystectomies, undertaken by 6 different surgeons were analysed. Scores for trunk posture were generally low but score for upper limb position were higher. The mean and median REBA scores were both 4 and the maximum score during one operation was 6. Conclusions The scores measured in this small study were very consistent and suggest that the practice of laparoscopic cholecystectomy as currently practised has a medium risk of causing operator harm; practice change is recommended to safeguard staff. Further research is needed with larger sample sizes as well as different arms for techniques such as position changes or robotic surgery, while observing outcomes for patients and time taken.

Abstract Background Oesophago-gastric cancer resections are complex operations. Many centres routinely manage patients in higher acuity settings such as surgical HDU, ITU or fast track beds. The UK has 2.4 critical care beds per 1000, compared to an average of 5 per 1000 across OECD-EU nations. The COVID-19 pandemic has also had a significant impact on availability of these beds. Patients in our unit are routinely admitted to a standard level one surgical bed with continuous non-invasive cardiac monitoring and nursing care ratio of 1 to 5. This has been in practice for over 10 years with good outcomes. Methods Consecutive major oesophago-gastric resections between April 2020 and March 2023 in a single tertiary unit were included. Patients were split into two groups: Patients who were admitted directly to the surgical ward or had a planned admission to ITU based on pre-operative assessment and routine Integrated Cardiopulmonary Exercise Testing (CPEX) outcomes were considered to have completed a standard pathway. The primary outcome was unplanned ITU admission rate. Secondary outcomes included: total length of stay (TLOS), 30- and 90-day mortality. Results 238 patients (187 M: 51 F) were identified with a median age of 69 (33 – 84 years). The resections performed were Ivor Lewis oesophago-gastrectomy (ILGO) (n=196, 81%), total/extended total (n=30), subtotal (n=10) or distal gastrectomy (n=3). 34 patients were admitted to ITU, of which 23 were unplanned (9.2%) and all had undergone an ILGO. The median TLOS and mortality data are outlined in Table 1, with <1% 30 and 90-day mortality for patients on the standard pathway. The median ITU length of stay was 5 days (1 – 48 days) with reasons for admission listed in Table 2. Conclusions Major oesophago-gastric cancer resections can be managed safely in the early post-operative period, outside of higher acuity care settings with good outcomes.

Abstract Background The aim of this video is to present our technique for performing a robotic semi-mechanical oesophago-gastric anastomosis. Methods The four-minute video was edited from a recording of a 2-stage robotic Ivor Lewis procedure for gastro-oesophageal junction cancer. The thoracic stage shown was performed using the Da-Vinci Xi system. The video focuses on demonstrating our standard semi-mechanical robotic anastomosis. We highlight the techniques involved in ensuring satisfactory join length and placement. Relevant regional anatomy and landmarks are highlighted. Results Post procedure the patient was transferred to a level one ward bed. They had an uneventful recovery following our standard enhanced recovery post-oesophagectomy protocol. The patient was discharged on day 7. Conclusions This video provides a clear guide to performing our technique for a robotic Oesophago-Gastric anastomosis. It is a useful resource for new robotic and trainee surgeons.

Abstract Background Tumours of the gastro-oesophageal junction are amenable to different surgical resections. There is an increasing body of evidence to suggest Siewert type III tumours should be managed as gastric cancers and hence may be more appropriately resected via total gastrectomy. The aim of this study was to compare the outcomes of total gastrectomy and oesophagectomy in patients diagnosed with Siewert type III gastro-oesophageal junction (GOJ) adenocarcinoma. Methods Consecutive patients who underwent curative surgery [total gastrectomy (n=42) or oesophagectomy (n=35)] between 1 January 2010 – 03 April 2023 for Siewert type III GOJ adenocarcinoma were analysed prospectively [median age 68 years, (range 43-83 years), 76.6% male, neo-adjuvant treatment 74.0%]. The primary outcome measure was overall 5 and 10-year survival. Secondary outcomes included: 30- and 90-day mortality, lymph node harvest, positive node harvest, margin involvement, anastomotic leak and length of stay. Results Demographic details between both groups of patients were similar. Patients undergoing total gastrectomy had a significantly shorter length of hospital stay compared with patients undergoing oesophagectomy (median 8 vs. 10 days, p<0.006). Distal margin involvement was significantly higher in patients undergoing oesophagectomy (0% vs. 12.1 %, p=0.027). Overall, 5 and 10-year survival was significantly higher in patients undergoing total gastrectomy (62% and 52% vs. 36% and 22% respectively, p=0.013). There were no significant differences in lymph node harvest (median 29.5 vs. 33.0 nodes), anastomotic leak rates (2.4% vs. 11.4%), 30- (2.4% vs 0%) and 90-day (2.4% vs 2.9%) mortality. Conclusions Patients undergoing total gastrectomy have improved short and long-term outcomes compared with patients undergoing oesophagectomy for Siewert type III GOJ adenocarcinoma.

Abstract Background Delayed gastric emptying (DGE) affects up to 37% of patients after esophagectomy and is treated with dilatation of the pylorus with either a 20mm or 30mm balloon. Although pyloric balloon dilatation (PBD) with the 20mm balloon is safe, it may not be as effective as the 30mm balloon. The aim of this study was to assess the safety and efficacy of PBD with a 30mm balloon in the acute setting. Methods Details of consecutive patients who underwent esophagectomy for cancer and diagnosed with DGE and underwent PBD between April 2014 to July 2021 were analysed retrospectively from a prospectively maintained database. The main outcome measures were rates of re-dilatation and morbidity. Results Out of 584 patients who underwent esophagectomy, 106 patients [71 Male (67.7%), median age (range) 68 (38-81 years)] were diagnosed with DGE (18.2%). Seventeen patients (16%) were treated conservatively. Six patients (5.7%) underwent intra-operative pyloroplasty. A total of 83 patients (78%) underwent PBD. Seventy-one patients (67%) underwent PBD with a 30mm balloon) on the index admission at a median of 9 days (range 2 – 27 days) post-operatively. Two patients (2.8%) developed leaks post dilatation. Patients were discharged home after a median (range) of 4 (1-91) days after PBD. Total length of stay was a median (range) of 13 days (7-119). Conclusions Pyloric balloon dilatation with a 30mm balloon is a safe and effective treatment option for delayed gastric emptying after esophagectomy in the index admission.