# 01. Design and validation of a unique endoscopy simulator using a commercial video game {#article-title-2} Procedural simulation has been shown to enhance early endoscopy training. In this proof of concept study, we aimed to show that a first-person shooter (FPS) video game with a novel in-house

Introduction Timely progress through diagnostic pathways is a leading quality measure for NHS cancer services. A hypothesis of sooner diagnosis being achievable with direct access to hospital tests from primary care is a core part of CRUK ACE program (1), and in the context of UGI cancer pathway, there is known wide variation of direct access (DA) OGD (2). This pilot evaluates the efficacy and utility of DA OGD or clinic (DA OPD) for GP concerns a patient may have OG cancer. Comparison was made with the standard 2WW pathway, where allocation to OGD v OPD first is performed by OG consultant. Method Pilot and UGI standard 2WW referrals 01/01-01/08/16 were identified from Cancer Centre records. Results 192 patients were in the pilot pathway, 430 via the standard 2WW. GPs were more likely to allocate patients to DA OGD (52%) compared to 32% having DTT OGD allocated by the hospital. Despite under-utilisation of protected slots for DA OGD, time to DA OGD compared to DTT did not differ (11.0d, 95% CI 10.5,11.2 v 12.4d, 95% CI 11.0,13.9). The same was seen for DA OPD. The total time on pathway was not improved in the pilot group at 16.8d (95% CI 4.9,28.6) compared to 17.9d (95% CI 16.9, 18.9). The subgroup of patients allocated in the pilot to DA OGD did have a quicker exit from the pathway, at 12.4d (95% CI 6.5,18.3) compared to 14.8 (95%CI 12.9,16.6) on the DTT OGD group. The pilot overall detected 8 cancers (4.2%); the standard 2WW path detected 55 (12.8%). OG cancers were in 4 of the DA OGD (4%) and 14 of the DTT OGD (10.2%). A further 10 non-OG cancers were detected in the DTT group after clinicians requested further investigations to determine the cause of their symptoms. Those patients allocated to OPD first by either GP or hospital were as likely to have cancer as those having OGD, with 4.3% of those in the pilot having a cancer detected this way, but none OG cancer, and 10.3% found to have cancers in the standard 2WW group following investigation directed after clinic visit. Of these 65% were cancers other than OG cancers and would not be detected on OGD alone. Conclusion OGD as a sole investigation for symptoms has its utility in excluding or detecting OG cancer. A high proportion of cancers detected via 2WW criteria on OG pathway are outside of OG tract and require other tests to diagnose them. In this pilot no additional utility of opening direct access OGD for GP concerned a patient may have an OG cancer was not demonstrated unless exclusion of OG cancer is viewed as the major purpose of the pathway. Our data demonstrates that such a view would be detrimental and lead to missed opportunity to detect other cancers that cause symptoms overlapping with those often ascribed to OG tumours. References . www.cancerresearchuk.org . PLoS ONE11(7):e0159725. Disclosure of Interest None Declared

Introduction Per-oral endoscopic myotomy (POEM) is a novel technique which involves performing a myotomy endoscopically after creating a submucosal tunnel. Despite being widely adopted in the USA, Europe and Asia, its introduction into the UK has been limited. We describe one of the first series of POEM procedures in the UK, assessing its feasibility, safety and efficacy. Method POEM was performed as inpatient under general anaesthesia with endotracheal intubation using the Olympus video endoscopy system. Two experienced endoscopists performed the procedures after undergoing hands on training in live animal models. The procedure involved mucosal entry, submucosal tunnelling, myotomy and clip closure of mucosal defect. The Endolumenal Functional Lumen Imaging Probe (EndoFLIP) was used to assess the gastroesophageal junction (GOJ) distensibility at balloon volumes of 30 and 40 ml at the start and end of procedures. Contrast swallow was performed 24–48 hours prior to discharge. Eckardt scores were prospectively recorded at the time initial clinic visit and at follow up visits, 4–8 weeks post procedure. Results Twenty six patients underwent POEM at our institution. Median age was 51 years (interquartile range (IQR) 42–60) and 69% were males. 17 patients (65%) had type II achalasia; 5 (19%) were type I; 2 (8%) type III; and 2 (8%) unclassified. Procedure failed in 2 patients who were excluded from the analysis. Median length of hospital stay was 3 days (IQR 2–3) days. Median (IQR) GOJ pressures reduced from 18.2 (15.3–27.9) and 33.0 (28.2–40.5) to 14.2 (12.4–18) and 23.1 (18–26.3) mmHg at 30 ml (p=0.10) and 40 ml (p=0.002) volumes, respectively. Median (IQR) Eckardt score was 8 (6-9) pre-procedure and 1 (1-2) post procedure (p<0.001). Perioperative complications included pneumoperitoneum (n=1) and mucosal laceration (n=3) all treated successfully. No post-operative complications occurred during a median (IQR) follow up of 6 months (1-10). Conclusion Evidence from this early series of POEM procedures in the UK confirms its feasibility, safety and efficacy in the treatment of achalasia by experienced endoscopists with adequate training. The use of EndoFLIP assists in assessing response to myotomy immediately post procedure. Disclosure of Interest None Declared

Introduction The volume of 2WW referrals continues to increase with little evidence of increased rates of cancer diagnoses or earlier stages of cancers [1]. The Cancer Plan which introduced 2WW pathways and cancer treatment targets was intended to improve outcome for patients with sooner diagnoses and earlier stages of cancer found [2]. We have observed the mortality risk and stage of oesophago-gastric (OG) cancer according to diagnostic referral route to see if 2WW pathways improve outcome for patients. Method OG cancers diagnosed at Nottingham University NHS Trust between 1 st Janaury 2015 – 31 st December 2015 were identified from systematic searches of histopathological records, endoscopy database, radiological reports and registration at the Nottinghamshire OG Cancer MDT. Univariate logistic regression analysis was performed to determine the association between OG cancer mortality, stage of cancer with mode of referral. Kaplan Meier survival curves were used to describe mortality rate by stage of OG cancer and mode of referral. Results 159 people were diagnosed with OG cancer with mean age 73.1 [SD 26.8] years. 52% (n=84) of OG cancers were diagnosed following 2WW referral with 24% (n=38) diagnosed following emergency presentation and unplanned hospitalisation. Patients diagnosed as an emergency had 4-fold increased risk of death at 1 year in comparison to those patients diagnosed along 2WW pathways (odds ratio 4.1 [95%CI 1.7, 9.7]). There was no difference in mortality risk in those referred along 2WW pathways to routine referral routes (p>0.05). Patients diagnosed as an emergency with OG cancer had 3-fold increased risk of stage 4 disease in comparison to those diagnosed along 2WW pathways (odds ratio 3.1; 95% CI 1.4, 6.8). There was no difference in the proportion of stage 4 OG cancer in those referred along 2WW pathways to routine referral routes (difference in proportion 7.0%; 95% CI −19.3, 28.2). Following review of performance status, co-morbidity and other patient factors, only 47% of patients from all routes of diagnosis were eligible for curative treatments. Conclusion In keeping with recent literature on other tumour sites, emergency diagnosis of OG cancers is associated with higher stage at presentation [3]. We are unable to demonstrate that diagnosis through 2WW pathways confers a lower stage at diagnosis or improved survival. References . https://www.england.nhs.uk/statistics/category/statistics/annual-cwt/ . https://www.england.nhs.uk/wp-content/uploads/2016/05/cancer-strategy.pdf . Br J Cancer2016;115(7):866–75. Disclosure of Interest None Declared

Aims: Surgical resection is often the only curative treatment for oesophageal cancer. The aim of this retrospective cohort study was to analyse outcomes following oesophageal resection in patients aged 75 years and older and the impact of an Enhanced Recovery after Surgery (ERAS) program in this cohort.Methods: Patients aged over 75 years undergoing oesophagectomy between 2003 and 2013 were identified from a single centre using an electronic database. Data on pre-operative comorbidity, tumour stage and length of hospital stay (LOS) were collected. Complications were classified according to the Clavien-Dindo system. Thirty day, 1- and 5-year mortality rates were calculated.Results: 147 patients were identified with a median age of 78.5 (IQR 76.7-80.9). 33% (n = 44) had a grade 3 complication or higher. Median LOS in hospital was 16 days (IQR 13.0-22.0). Thirty-day mortality was 3.4%, 1-year and 5-year survival was 65% and 21% respectively. 45% of patients were enrolled into an Enhanced Recovery After Surgery program and they demonstrated a significantly reduced length of stay from 18 to 14 days (p = 0.005) and 30-day mortality from 6.2% to 0% (p = 0.04) compared to the time period before the program.Conclusion: Long-term survival is achievable in patients aged over 75 years. (C) 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction Anaemia is common in oesophagogastric cancer. Major operations performed for these cancers are associated with significant blood loss and need for transfusions. Concerns exist about the side effects of blood transfusion, cost and availability of donated blood. Our study aims to identify incidence of anaemia, change in haemoglobin, rates of blood transfusion and mortality associated with the diagnosis and treatment of oesophagogastric cancer. Method We conducted a retrospective analysis of all patients diagnosed with oesophagogastric cancer in 2012–2013 at a single high-volume referral centre. Data was collected on site, histology, staging, haemoglobin, blood transfusions, survival and treatment. WHO definitions were used to define anaemia. Results 550 patients were included in the study. Median haemoglobin at time of diagnosis was 127 g/L (37–188 g/L). 227 patients (45%) were anaemic at diagnosis. Higher haemoglobin at diagnosis improved survival (irrespective of a diagnosis of anaemia) with high normal haemoglobin (>150 g/L) showing significantly better survival than low normal haemoglobin (130–150 g/L), p < 0.001. Mild anaemia (110–130 g/L) had significantly poorer survival again but superior to moderate and severe anaemia (p < 0.05 Breslow-Wilcoxon). Anaemia prior to surgery was also associated with poorer survival (p < 0.05). In the 233 patients treated with surgery, 86 (38.9%) were anaemic at diagnosis. However, this increases to 144 patients (66.9%) prior to surgery and 203 (93.9%) post-operatively. If anaemic prior to curative surgery patients were 29.5% more likely to receive a blood transfusions. Logistic regression analysis revealed male sex, anaemia at diagnosis and neoadjuvant chemotherapy correlated with pre-operative anaemia (p < 0.05). Staging was not a predictor of anaemia. Neo-adjuvant chemotherapy increased the number of patients who were anaemic prior to surgery by 26.5% and the average drop in haemoglobin to 15 g/L compared to 5 g/L for those who went straight to surgery. Conclusion Anaemia is common in oesophagogastric cancer and becomes worse during treatment. Neoadjuvant treatment increases the rates and severity of anaemia. Lower haemoglobin at diagnosis and anaemia prior to surgery are both associated with poorer survival and more blood transfusions. A more proactive strategy to the management of anaemia is required if we are to attempt to avoid the excess mortality and blood transfusions seen here in oesophagogastric cancer. Disclosure of interest None Declared.

INTRODUCTION Fast track methodology or enhanced recovery schemes have gained increasing popularity in perioperative care. While evidence is strong for colorectal surgery, its importance in gastric and oesophageal surgery has yet to be established. This article reviews the evidence of enhanced recovery schemes on outcome for this type of surgery.METHODS A systematic literature search was conducted up to March 2014. Studies were retrieved and analysed using predetermined criteria.RESULTS From 34 articles reviewed, 18 eligible studies were identified: 7 on gastric and 11 on oesophageal resection. Three randomised controlled trials, five case-controlled studies and ten case series were identified. The reported protocols included changes to each stage of the patient journey from pre to postoperative care. The specific focus following oesophageal resections was on early mobilisation, a reduction in intensive care unit stay, early drain removal and early (or no) contrast swallow studies. Following gastric resections, the emphasis was on reducing epidural anaesthesia along with re-establishing oral intake in the first three postoperative days and early removal of nasogastric tubes. In the papers reviewed, mortality rates following fast track surgery were 0.8% (9/1,075) for oesophageal resection and 0% (0/329) for gastric resection. The reported morbidity rate was 16.5% (54/329) following gastric resection and 38.6% (396/1,075) following oesophageal resection. Length of stay was reduced in both groups compared with conventional recovery groups in comparative studies.CONCLUSIONS The evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay.

Introduction: Radiotherapy is increasingly used for both curative and palliative treatment of oesophageal malignancy. Accurate treatment depends on determining tumour location and length. This study assessed the value of PET-CT versus other staging modalities in determining tumour length.Materials and methods: Oesophageal cancer patients who underwent staging with PET/CT and endoscopic ultrasound (EUS) in addition to their diagnostic upper GI endoscopy and subsequent surgical resection were assessed. PET/CT length was obtained retrospectively by using Hermes Hybrid Viewer (TM) with a 1-5 Standardised Uptake Value grey scale. An SUV of 5 was used as the cut off for determining length. Direct measurement by EUS and OGD were determined.Results: 53 patients underwent PET-CT, EUS, OGD and surgical resection for oesophageal cancer. Overall the correlation between PET-CT and histopathological length was strongest (Pearson r = 0.5977, 95% CI 0.390-0.747) versus EUS (Pearson R = 0.5365, 95% CI 0.311-0.705) and OGD (Pearson r = 0.1574, 95% CI -0.118 to 0.410). After excluding tumours with a significant chemotherapy response, PET-CT length correlated significantly with histopathological length (R = 0.5651, p = 0.0005). In comparison, the correlation between histological length and EUS (R = 0.4637, p = 0.0057) measurement was less significant and this did not correlate with OGD (R = 0.1084, p = 0.5417).Conclusion: Tumour length estimated by PET-CT correlated most strongly with histopathological length of oesophageal malignancy and is the most accurate determinant of tumour length of all the staging modalities. This suggests a potential role for PET-CT in the planning of radiotherapy and resection, particularly when considering the practical limitations of EUS. (C) 2014 Elsevier Ireland Ltd. All rights reserved.