Prehabilitation prior to gastric cancer resection aims to optimise pre-operative physical and nutritional status to improve perioperative resilience. However, the current evidence-base is fragmented. This review synthesized randomized controlled trial (RCT) evidence evaluating effectiveness of prehabilitation interventions prior to gastric cancer resection and characterized reported outcomes. A systematic review was conducted following PRISMA guidelines (PROSPERO registration -CRD420251233981). MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL were searched up to August 2025. Eligible studies were RCTs investigating unimodal or multimodal prehabilitation interventions (minimum duration 7 days) prior to gastric cancer resection. Two reviewers independently performed study selection, data extraction, and risk-of-bias assessment. Heterogeneity precluded meta-analysis and results were synthesized narratively. Fourteen RCTs were included: four multimodal, and ten unimodal interventions (nutritional (n = 9), spirometry (n = 1)), duration range (7-days to 15-weeks). Fifty-three unique outcomes were reported across five domains: clinician/observer-reported outcomes, performance outcomes, patient-reported outcomes, biomarkers, and non-health outcomes. Multimodal prehabilitation programs suggest potential benefits; fewer postoperative complications, and improved functional capacity. Short-duration unimodal nutritional interventions demonstrated mixed effects, although immune-nutrition and targeted supplementation reduced infectious complications in malnourished patients. Findings were limited by risk-of-bias (some concerns (n = 7), high (n = 7)). Prehabilitation in gastric cancer surgery demonstrated a potential benefit, particularly when delivered as multimodal interventions. However, the evidence base is limited by substantial heterogeneity, variable methodological quality, and inconsistent outcome reporting. Development of a disease-specific core outcome set is urgently required, in addition to adequately powered, risk-stratified trials to advance evidence synthesis and implementation of gastric cancer prehabilitation.

Abstract Topic Benign Disease: Iatrogenic Esophageal Disease, Perforation and Postsurgical Complications Background Esophageal transmural defects are associated with high morbidity and mortality. Sponge-based endoscopic vacuum therapy (EVT) is effective but costly and requires frequent exchanges under general anesthesia. We describe a modified, cost-effective EVT approach using a fenestrated, spongeless radio-opaque silicone drain for both prevention and treatment of esophageal leaks. Methods A retrospective case series was conducted across three tertiary upper gastrointestinal centers in Singapore (2024–2026). Eighteen consecutive patients received an 18Fr fenestrated drain treatment, connected to continuous wall suction (-150 to -200 mmHg), with a daily 30-minute rest period. Therapeutic group (n=8) included post-esophagectomy anastomotic leaks (n=4), Boerhaave’s syndrome (n=2), squamous cell carcinoma perforation (n=1) and post-leiomyoma excision leak (n=1). The fenestrated drain was placed endoscopically, either intraluminally or within the leak cavity. Prophylactic group (n=10) were deemed high-risk pre-operatively (age >65, ASA>2, ECOG>1, BMI>29, HbA1c>8.0%, smoking, or end-stage renal failure) and received intraoperative intraluminal drain placement spanning the anastomosis following esophagectomy. A water-soluble contrast study was performed on postoperative days 5–7 prior to drain removal. Primary outcomes were complete leak healing (therapeutic) and leak prevention (prophylactic). Secondary outcomes included drainage duration, exchange interval(s) of the drain, anesthesia requirements during drain exchanges and time to oral feeding. Results Technical success of drain placement was 100%. In the therapeutic group (mean age 66 ±13.3 years), all eight patients achieved leak closure. Median treatment duration was 27.5 days (range 7–52). Six patients (75%) healed with the fenestrated drain alone (median: 20.5 days [range: 7–50]); two (25%) transitioned to sponge-based EVT due to surgeon preference despite adequate initial sepsis control. Median time to oral feeding was 23 days (range: 8–52). In the prophylactic group (mean age 57.8 ±8.8 years), nine of ten patients (90%) achieved uneventful anastomotic healing. Median time to oral feeding was 8 days (range: 6–18). One patient with an aorto-esophageal fistula developed conduit necrosis requiring re-operation. Eleven patients required no drain exchanges. Among those needing adjustments, the median exchange interval was 10 days (range: 4–30); 82.4% were performed under local anesthesia or sedation. One superficial gastric conduit ulceration occurred. No drain-related mortality occurred. Conclusion EVT using a fenestrated surgical drain appears safe and cost-effective when compared to conventional sponge-based EVT. Its reduced anesthesia requirements and infrequent exchange intervals address key limitations of existing techniques. While these findings support its utility for both therapeutic and prophylactic purposes, larger prospective studies are needed to confirm its effectiveness.

BACKGROUND:Enhanced recovery after surgery (ERAS) protocols aim to optimize perioperative care, accelerate recovery, and reduce length of hospital stay (LOS). This study aimed to evaluate the implementation and evolution of an ERAS protocol for esophageal resection in a western high-volume tertiary center. METHODS:This retrospective cohort study analyzed all consecutive patients who underwent esophagectomy for esophageal cancer at the University Medical Center Utrecht between May 2015 and December 2023, divided into 4 cohorts based on protocol changes. Robot-assisted minimally invasive esophagectomy with cervical esophagogastrostomy and epidural pain management was the standard of care. An ERAS protocol, focused on preoperative optimization of nutritional and physical fitness, intrathoracic anastomosis, and multidisciplinary postoperative support, was implemented in October 2016. The first cohort served as the pre-ERAS baseline, with subsequent cohorts indicating a change in protocol. Data were extracted from a prospectively maintained database. The primary outcome was median LOS. Secondary outcomes included perioperative dietary, surgical, clinical, and physiotherapeutic measures. RESULTS:A total of 526 patients were included. Median LOS decreased from 16 days (IQR, 11-25) in the pre-ERAS cohort to 13 (IQR, 9-21), 11 (IQR, 8-15), and 11 days (IQR, 8-18) in successive cohorts (P <.001; hazard ratio [HR], 0.68; 95% CI, 0.52-0.90; P =.007). This reduction remained significant after adjusting for covariates (HR, 0.58; 95% CI, 0.44-0.77; P <.001). Median LOS of patients with a textbook outcome decreased from 11 days (IQR, 11-14) in the pre-ERAS cohort to 10 (IQR, 8-13), 10 (IQR, 8-12), and 8 days (IQR, 7-11) in subsequent cohorts (P <.001). Several secondary ERAS outcomes improved over the years (dietitian involvement, surgical approach, extubation in the operating room, drain/line management). A reduction in postoperative complications was observed (from 81% to 74%; P =.033), whereas mortality and readmission rates remained stable. CONCLUSION:After ERAS implementation for esophagectomy, median LOS decreased from 16 to 11 days over 7 years, with stable readmission rates. These results support ERAS as a valuable tool to optimize perioperative care, leading to a significant reduction in length of postoperative hospital stay.

Epidural analgesia has been the gold standard for pain management in minimally invasive esophagectomy (MIE), with paravertebral analgesia as a safe alternative. This cost-effectiveness analysis, conducted alongside a randomized controlled trial, evaluates the cost-effectiveness of paravertebral analgesia compared to epidural analgesia. This multicenter randomized controlled trial across four Dutch hospitals, including 192 patients, compared epidural and paravertebral analgesia in patients undergoing MIE. Cost-effectiveness was evaluated from a healthcare perspective, including in-hospital costs only, with time horizons from initial hospital stay and 90 days postoperatively. Procedural costs were calculated with a bottom-up approach, and analgesia costs with data from the electronic case report form (eCRF). Other hospital costs were calculated using insurance claim data from hospital registries. Effectiveness was displayed as Quality of Recovery (QoR-40) scores. Bootstrapping was used to estimate uncertainty. Mean initial surgery costs were €10,469 for the epidural and €10,051 for the paravertebral group, primarily due to a shorter mean operating room time (mean difference 19 min; 95

Objective:Tracheoesophageal fistula (TEF) is a severe complication often associated with advanced thoracic malignancies or chemoradiotherapy. This study introduces an innovative approach combining endoscopic submucosal dissection (ESD) and esophageal bypass surgery. This retrospective study aimed to evaluate the prognosis of patients with TEF in complete clinical remission after definitive chemoradiotherapy who underwent repair with such approach. Methods:This is a retrospective analysis of 12 patients with TEF secondary to thoracic malignancies treated between June 2021 and June 2022. Patients underwent ESD for de-epithelialization of the esophageal lumen, followed by esophageal bypass surgery. Key outcomes included survival rates, fistula closure rates, postoperative clinical outcomes, and functional status improvement assessed by Karnofsky Performance Status scores. Results:All patients had complete clinical remission of their primary malignancies before treatment. TEF closure was achieved in 10 patients (83.3%) within 28 to 72 days post-ESD. Median duration from ESD to bypass surgery was 39 days. Kaplan-Meier analysis revealed a 1-year survival rate of 65% and a 2-year survival rate of 60%. Postoperative morbidity included 1 anastomotic leak and 1 case of esophageal mucoceles, both successfully managed. Functional outcomes significantly improved, with 91.6% of patients achieving a Karnofsky Performance Status score >80 at 6 months. Conclusions:The combination of ESD and esophageal bypass surgery represents a promising approach for TEF management, demonstrating high rates of fistula closure, enhanced functional outcomes, and overall survival. Future studies should aim to validate these findings in larger cohorts and explore the long-term sustainability of these outcomes.

BACKGROUND:While the development in multimodal therapies has helped improve treatment outcomes for patients with locally advanced gastric adenocarcinoma (LAGC), there still exist disparities in opinion with an optimal treatment plan. This consensus hopes to provide clinicians with structured guidelines to aid in the decision-making for treatment options for LAGC. METHODS:The consensus statement was initiated by establishing a taskforce in collaboration with the Asia Pacific Gastroesophageal Cancer Congress (APGCC) and a multidisciplinary expert panel was selected. Clinical questions on LAGC where perceived variance in practice or opinion may exist were formulated. Studies involving patients with Stage 2 or 3 gastric or Siewert 3 junctional cancers with treatment arms of perioperative chemotherapy, neoadjuvant chemotherapy, adjuvant chemotherapy, immunotherapy and surgery were included. A total of two rounds of voting were performed. Consensus was determined to be reached when a single answer or a combination of either "strongly agree/agree" or "strongly disagree/disagree" responses exceeded 75%. RESULTS:A total of thirteen clinical questions were developed. They were identified through five main categories: Distal LAGC, Proximal LAGC, Deficient mismatch repair tumors, Chemotherapy and Immunotherapy, and Elderly/Unfit patients. After two rounds of voting by our multidisciplinary expert panel, eleven out of a total thirteen clinical questions had reached consensus. No consensus was reached for two clinical questions. CONCLUSION:The APGCC consensus statement aims to guide clinicians in the treatment options for LAGC and Siewert 3 junctional cancer and has clarified some of the roles of perioperative chemotherapy and immunotherapy.

OBJECTIVE:To compare the quality of recovery in patients receiving epidural or paravertebral analgesia for minimally invasive esophagectomy (MIE). BACKGROUND:Paravertebral analgesia may be a promising alternative to epidural analgesia, avoiding potential side effects and improving postoperative recovery. METHODS:This randomized controlled superiority trial was conducted across 4 Dutch centers with esophageal cancer patients scheduled for transthoracic MIE with intrathoracic anastomosis, randomizing patients to receive either epidural or paravertebral analgesia. The primary outcome was Quality of Recovery (QoR-40) on the third postoperative day (POD). Secondary outcomes included quality of life, postoperative pain, opioid consumption, inotropic/vasopressor medication use, hospital stay, complications, readmission, and mortality. RESULTS:From December 2019 to February 2023, 192 patients were included: 94 received epidural and 98 paravertebral analgesia. QoR-40 score on POD3 was not different between groups (mean difference: 3.7, 95% CI: -2.3 to 9.7; P =0.268). Epidural patients had significantly higher QoR-40 scores on POD1 and 2 (mean difference: 7.7, 95% CI: 2.3-13.1; P =0.018 and mean difference: 7.3, 95% CI: 1.9-12.7; P =0.020) and lower pain scores (median 1 vs 2; P <0.001 and median 1 vs 2; P =0.033). More epidural patients required vasopressor medication on POD1 (38.3% vs 13.3%; P <0.001). Urinary catheters were removed earlier in the paravertebral group (median POD3 vs 4; P <0.001). No significant differences were found in postoperative complications or hospital/intensive care unit stay. CONCLUSIONS:This randomized controlled trial did not demonstrate the superiority of paravertebral over epidural analgesia regarding the quality of recovery on POD3 after MIE. Both techniques are effective and can be offered in clinical practice.

Introduction The OligoMetastatic Esophagogastric Cancer (OMEC) project aims to provide clinical practice guidelines for the definition, diagnosis, and treatment of esophagogastric oligometastatic disease (OMD). Methods Guidelines were developed according to AGREE II and GRADE principles. Guidelines were based on a systematic review (OMEC-1), clinical case discussions (OMEC-2), and a Delphi consensus study (OMEC-3) by 49 European expert centers for esophagogastric cancer. OMEC identified patients for whom the term OMD is considered or could be considered. Disease-free interval (DFI) was defined as the time between primary tumor treatment and detection of OMD. Results Moderate to high quality of evidence was found (i.e. 1 randomized and 4 non-randomized phase II trials) resulting in moderate recommendations. OMD is considered in esophagogastric cancer patients with 1 organ with ≤3 metastases or 1 involved extra-regional lymph node station. In addition, OMD continues to be considered in patients with OMD without progression in number of metastases after systemic therapy. 18F-FDG PET/CT imaging is recommended for baseline staging and for restaging after systemic therapy when local treatment is considered. For patients with synchronous OMD or metachronous OMD and a DFI ≤2 years, recommended treatment consists of systemic therapy followed by restaging to assess suitability for local treatment. For patients with metachronous OMD and DFI >2 years, upfront local treatment is additionally recommended. Discussion These multidisciplinary European clinical practice guidelines for the uniform definition, diagnosis and treatment of esophagogastric OMD can be used to standardize inclusion criteria in future clinical trials and to reduce variation in treatment.

Importance Minimally invasive esophagectomy (MIE) is a complex procedure with substantial learning curves. In other complex minimally invasive procedures, suboptimal surgical performance has convincingly been associated with less favorable patient outcomes as assessed by peer review of the surgical procedure. Objective To develop and validate a procedure-specific competency assessment tool (CAT) for MIE. Design, Setting, and Participants In this international quality improvement study, a procedure-specific MIE-CAT was developed and validated. The MIE-CAT contains 8 procedural phases, and 4 quality components per phase are scored with a Likert scale ranging from 1 to 4. For evaluation of the MIE-CAT, intraoperative MIE videos performed by a single surgical team in the Esophageal Center East Netherlands were peer reviewed by 18 independent international MIE experts (with more than 120 MIEs performed). Each video was assessed by 2 or 3 blinded experts to evaluate feasibility, content validity, reliability, and construct validity. MIE-CAT version 2 was composed with refined content aimed at improving interrater reliability. A total of 32 full-length MIE videos from patients who underwent MIE between 2011 and 2020 were analyzed. Data were analyzed from January 2021 to January 2023. Exposure Performance assessment of transthoracic MIE with an intrathoracic anastomosis. Main Outcomes and Measures Feasibility, content validity, interrater and intrarater reliability, and construct validity, including correlations with both experience of the surgical team and clinical parameters, of the developed MIE-CAT. Results Experts found the MIE-CAT easy to understand and easy to use to grade surgical performance. The MIE-CAT demonstrated good intrarater reliability (range of intraclass correlation coefficients [ICCs], 0.807 [95% CI, 0.656 to 0.892] for quality component score to 0.898 [95% CI, 0.846 to 0.932] for phase score). Interrater reliability was moderate (range of ICCs, 0.536 [95% CI, −0.220 to 0.994] for total MIE-CAT score to 0.705 [95% CI, 0.473 to 0.846] for quality component score), and most discrepancies originated in the lymphadenectomy phases. Hypothesis testing for construct validity showed more than 75% of hypotheses correct: MIE-CAT performance scores correlated with experience of the surgical team ( r = 0.288 to 0.622), blood loss ( r = −0.034 to −0.545), operative time ( r = −0.309 to −0.611), intraoperative complications ( r = −0.052 to −0.319), and severe postoperative complications ( r = −0.207 to −0.395). MIE-CAT version 2 increased usability. Interrater reliability improved but remained moderate (range of ICCs, 0.666 to 0.743), and most discrepancies between raters remained in the lymphadenectomy phases. Conclusions and Relevance The MIE-CAT was developed and its feasibility, content validity, reliability, and construct validity were demonstrated. By providing insight into surgical performance of MIE, the MIE-CAT might be used for clinical, training, and research purposes.

Recurrent oesophageal perforation treated with endoluminal vacuum suction drain without a spongeEsophageal perforations (Boerhaave's syndrome) are uncommon and potentially life-threatening conditions, while recurrent esophageal perforations are extremely rare.Esophageal perforations are generally managed surgically with Kehr's T-tube and drains or primary surgical repair.We present a patient with recurrent esophageal perforation due to Barrett's esophageal ulcer.He was successfully managed with an endoluminal vacuum suction drain without a sponge.

BACKGROUND:Local treatment improves the outcomes for oligometastatic disease (OMD, i.e. an intermediate state between locoregional and widespread disseminated disease). However, consensus about the definition, diagnosis and treatment of oligometastatic oesophagogastric cancer is lacking. The aim of this study was to develop a multidisciplinary European consensus statement on the definition, diagnosis and treatment of oligometastatic oesophagogastric cancer. METHODS:In total, 65 specialists in the multidisciplinary treatment for oesophagogastric cancer from 49 expert centres across 16 European countries were requested to participate in this Delphi study. The consensus finding process consisted of a starting meeting, 2 online Delphi questionnaire rounds and an online consensus meeting. Input for Delphi questionnaires consisted of (1) a systematic review on definitions of oligometastatic oesophagogastric cancer and (2) a discussion of real-life clinical cases by multidisciplinary teams. Experts were asked to score each statement on a 5-point Likert scale. The agreement was scored to be either absent/poor (<50%), fair (50%-75%) or consensus (≥75%). RESULTS:A total of 48 experts participated in the starting meeting, both Delphi rounds, and the consensus meeting (overall response rate: 71%). OMD was considered in patients with metastatic oesophagogastric cancer limited to 1 organ with ≤3 metastases or 1 extra-regional lymph node station (consensus). In addition, OMD was considered in patients without progression at restaging after systemic therapy (consensus). For patients with synchronous or metachronous OMD with a disease-free interval ≤2 years, systemic therapy followed by restaging to consider local treatment was considered as treatment (consensus). For metachronous OMD with a disease-free interval >2 years, either upfront local treatment or systemic treatment followed by restaging was considered as treatment (fair agreement). CONCLUSION:The OMEC project has resulted in a multidisciplinary European consensus statement for the definition, diagnosis and treatment of oligometastatic oesophagogastric adenocarcinoma and squamous cell cancer. This can be used to standardise inclusion criteria for future clinical trials.

BACKGROUND:Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer.METHODS:Data were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction.RESULTS:Amongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%.CONCLUSIONS:This study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant.

Objective: This study aimed to compare the postoperative and pathological outcomes between carboplatin, paclitaxel, radiotherapy (CROSS) and 5-FU, leucovorine, oxaliplatin and docetaxel (FLOT) in esophageal adenocarcinoma (EAC) patients from an international, multicenter cohort. Summary of Background Data: Ongoing debate exists around optimum approach to locally advanced EAC, with proponents for perioperative chemotherapy, such as FLOT, or multimodal therapy, in particular the CROSS regimen. Methods: Patients undergoing CROSS (n = 350) and FLOT (n = 368), followed by curative esophagectomy for EAC were identified from the Oesophagogastric Anastomosis Audit. Results: The 90-day mortality was higher after CROSS than FLOT (5% vs 1%, P = 0.005), even on adjusted analyses [odds ratio (OR): 3.97, confidence interval (CI)(95%): 1.34-13.67]. Postoperative mortality in CROSS were related to higher pulmonary (74% vs 60%) and cardiac complications (42% vs 20%) compared to FLOT. CROSS was associated with higher pathologic complete response (pCR) rates (18% vs 10%, P = 0.004) and margin-negative resections (93% vs 76%, P < 0.001) compared with FLOT. On adjusted analyses, CROSS was associated with higher pCR rates (OR: 2.05, CI95%: 1.26-3.34) and margin-negative resections (OR: 4.55, CI95%: 2.70-7.69) compared to FLOT. Conclusions: This study provides real-world data CROSS was associated with higher 90-day mortality than FLOT, related to cardio-pulmonary complications with CROSS. These warrant a further review into causes and mechanisms in selected patients, and at minimum suggest the need for strict radiation therapy quality assurance. Research into impact of higher pCR rates and R0 resections with CROSS compared to FLOT on long-term survival is needed.

OBJECTIVE:To identify the most prevalent symptoms and those with greatest impact upon health-related quality of life (HRQOL) among esophageal cancer survivors. BACKGROUND:Long-term symptom burden after esophagectomy, and associations with HRQOL, are poorly understood. PATIENTS AND METHODS:Between 2010 and 2016, patients from 20 European Centers who underwent esophageal cancer surgery, and were disease-free at least 1 year postoperatively were asked to complete LASER, EORTC-QLQ-C30, and QLQ-OG25 questionnaires. Specific symptom questionnaire items that were associated with poor HRQOL as identified by EORTC QLQ-C30 and QLQ-OG25 were identified by multivariable regression analysis and combined to form a tool. RESULTS:A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had symptoms associated with their esophagectomy. Ongoing weight loss was reported by 10.4% of patients, and only 13.8% returned to work with the same activities.Three LASER symptoms were correlated with poor HRQOL on multivariable analysis; pain on scars on chest (odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81 ± 0.02 and 0.82 ± 0.09 respectively. CONCLUSION:Two-thirds of patients experience significant symptoms more than 1 year after surgery. The 3 key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased support.

BACKGROUND:There is currently a lack of evidence-based guidelines regarding surveillance for recurrence after esophageal and gastric (OG) cancer surgical resection, and which symptoms should prompt endoscopic or radiological investigations for recurrence. The aim of this study was to develop a core symptom set using a modified Delphi consensus process that should guide clinicians to carry out investigations to look for suspected recurrent OG cancer in previously asymptomatic patients. METHODS:A web-based survey of 42 questions was sent to surgeons performing OG cancer resections at high volume centers. The first section evaluated the structure of follow-up and the second, determinants of follow-up. Two rounds of a modified Delphi consensus process and a further consensus workshop were used to determine symptoms warranting further investigations. Symptoms with a 75% consensus agreement as suggestive of recurrent cancer were included in the core symptom set. RESULTS:27 surgeons completed the questionnaires. A total of 70.3% of centers reported standardized surveillance protocols, whereas 3.7% of surgeons did not undertake any surveillance in asymptomatic patients after OG cancer resection. In asymptomatic patients, 40.1% and 25.9% of centers performed routine imaging and endoscopy, respectively. The core set that reached consensus, consisted of eight symptoms that warranted further investigations included; dysphagia to solid food, dysphagia to liquids, vomiting, abdominal pain, chest pain, regurgitation of foods, unexpected weight loss and progressive hoarseness of voice. CONCLUSION:There is global variation in monitoring patients after OG cancer resection. Eight symptoms were identified by the consensus process as important in prompting radiological or endoscopic investigation for suspected recurrent malignancy. Further randomized controlled trials are necessary to link surveillance strategies to survival outcomes and evaluate prognostic value.

Abstract Studies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma, with equal oncological results as open surgery. The number of MIEs in Europe are increasing. Postoperative complications have been recently reviewed by a multicenter study that benchmarked MIE outcomes. There are no studies, to date, regarding major intraoperative complications during MIE and their effect on patient survival. Data was gathered retrospectively from 10 European centers with a minimum MIE experience of 3 years and more than 20 procedures annually. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal- and GE junction cancers operated between 2003–2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, major anesthesiologic complications including intubation injuries, arrhythmias, pulmonary embolism and myocardial infarction. We also included minor intraoperative events that led to additional repair or resection of vascular structures or airways. Amongst 2862 MIE cases we identified 99 patients with 103 intraoperative complications. Of the 34 different complications the most common were vascular lesions during laparoscopy (n = 40). There were 20 splenic artery and -capsular injuries, 11 requiring splenectomy. Four losses of conduit due to gastroepiploic artery injury and five colon injuries were reported. Six tracheobronchial lesions needed repair, and 12 patients had significant lung parenchyma injuries. During thoracoscopy nine of the 13 cases with bleeding were converted and an additional 5 patients required postoperatively emergency re-intervention for thoracic bleeding. There were 2 on-table deaths. 10 of the 99 patients died in-hospital. This study offers a good overview of the wide range of possible intraoperative complications. Knowing the pitfalls can help trainees, and experienced surgeons, avoid common complications. Unfortunately, this study does not offer us incidence, which would require a prospective trial. On-table deaths are exceedingly rare. There is a possible underreporting of complications, an issue not avoided by implementing specific surveying criteria. Surgical registries need to capture intraoperative complications better in the future.

The Ivor Lewis MIE has been growing in popularity globally ever since it was made popular among the Western population by J. D. Luketich at the University of Pittsburgh Medical Center (UPMC). Most patients in the West present with distal esophageal or esophago-gastric junction cancers, which favour the Ivor Lewis MIE, and an intrathoracic anastomosis as the operation of choice. However, the debate continues over which type of esophago-gastric anastomosis should be performed. The end-to-side stapled intrathoracic esophago-gastric anastomosis with a 28 or 29 mm circular stapler, and covering the anastomosis with an omental flap, is a well-established standardised technique at the UPMC and Norwich. In experienced hands, this technique is easy to execute once the anvil is inserted into the esophagus and the two purse-string sutures are tied. It has a low leak rate (<5%) when executed correctly. In the rare occurrence of a leak, the exact site of the leak can be visualised with a computerised tomography scan, since the titanium staples are easily identified radiologically. As a result, the defect at the circular anastomosis is easily located endoscopically. In addition, the leak is often small. Altogether, these factors favour the use of an EndoVac to treat the leak from a circular stapler. Hence, the authors advocate doing the circular stapled end-to-side esophago-gastric anastomosis, which is covered with an omental patch under a pleural tent.

Objective: To describe the pooled learning curves of Ivor Lewis totally minimally invasive esophagectomy (TMIE) in hospitals stratified by predefined hospital- and surgeon-related factors. Background: Ivor Lewis (TMIE is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning. Methods: A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity, and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and 2-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, TMIE experience, clinic visits, courses and fellowships followed, and proctor supervision. Results: This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume >50 compared to centers with an annual volume <50. Analysis with an annual volume cut-off of 30 cases showed similar but less pronounced results. No outcomes suggesting more efficient learning were found for longer experience as consultant, visiting an expert clinic, completing a minimally invasive esophagectomy fellowship or implementation under proctor supervision. Conclusions: More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

Background: Consensus about the definition and treatment of oligometastatic oesophagogastric cancer is lacking. Objective: To assess the definition and treatment of oligometastatic oesophagogastric cancer across multidisciplinary tumour boards (MDTs) in Europe. Material and methods: European expert centers (n Z 49) were requested to discuss 15 real-life cases in their MDT with at least a medical, surgical, and radiation oncologist present. The cases varied in terms of location and number of metastases, histology, timing of detection (i.e. synchronous versus metachronous), primary tumour treatment status, and response to systemic therapy. The primary outcome was the agreement in the definition of oligometastatic disease at diagnosis and after systemic therapy. The secondary outcome was the agreement in treatment strategies. Treatment strategies for oligometastatic disease were categorised into up -front local treatment (i.e. metastasectomy or stereotactic radiotherapy), systemic therapy followed by restaging to consider local treatment or systemic therapy alone. The agreement across MDTs was scored to be either absent/poor (< 50%), fair (50%-75%), or consensus (>= 75%). Results: A total of 47 MDTs across 16 countries fully discussed the cases (96%). Oligometastatic disease was considered in patients with 1-2 metastases in either the liver, lung, retroperitoneal lymph nodes, adrenal gland, soft tissue or bone (consensus). At follow-up, oligometastatic disease was considered after a median of 18 weeks of systemic therapy when no progression or progression in size only of the oligometastatic lesion(s) was seen (consensus). If at restaging after a median of 18 weeks of systemic therapy the number of lesions progressed, this was not considered as oligometastatic disease (fair agreement). There was no consensus on treatment strategies for oligometastatic disease. Conclusion: A broad consensus on definitions of oligometastatic oesophagogastric cancer was found among MDTs of oesophagogastric cancer expert centres in Europe. However, high practice variability in treatment strategies exists. (C) 2022 The Authors. Published by Elsevier Ltd.

Background: No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer. Method: This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III-V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%). Results: Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC. Conclusion: Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer. (C) 2020 Elsevier Ltd, BASO similar to The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.