Esophageal cancer incidence is rising globally, with at least 500,000 new cases diagnosed annually. Management options for non-metastatic disease include primary resection, neoadjuvant or perioperative therapies, or definitive non-surgical treatment, with the choice being guided by tumor staging, histology, patient fitness, and available resources. However, even with the use of advanced diagnostic modalities, preoperative clinical staging is challenging with respect to accuracy of both tumor and nodal assessment. Early-stage esophageal cancer may be managed with local therapies, such as endoscopic mucosal resection or submucosal dissection, while for more advanced tumors managed with curative intent neoadjuvant oncologic therapy is commonly recommended. However, between these two groups lies an infrequent but important subgroup of patients, clinically staged cT2N0M0 esophageal cancer. Guidelines such as the NIH's National Cancer Institute recommends either surgery alone or neoadjuvant therapy followed by surgery for AJCC Stage I cancers, and add the option of definitive chemoradiation for Stage II disease. With cT2N0 disease straddling both AJCC classifications, management guidance is lacking. This guideline will provide an evidence-based recommendation from the International Society For Disease Of The Esophagus on the management of cT2N0 esophageal cancer, of all types. The recommendations are intended to support surgeons, oncologists, and patients in decisions about the best practice preoperative oncologic management of cT2N0M0 esophageal cancer.A Working Group within the International Society for Diseases of the Esophagus (ISDE) Guidelines Committee performed a systematic review of the literature. Results of the systematic review were presented to a panel of experts and these results informed the panel discussion about the guideline. This panel used Grading of Recommendations Assessment, Development, and Evaluation approach to deliberate and formulate recommendations.The panel agreed on a conditional recommendation for the use of neoadjuvant therapy followed by surgery over primary surgical resection (PSR) for adult patients with cT2N0M0 esophageal cancer.Preoperative clinical staging of esophageal cancer is uncertain, with deficiencies in all diagnostic modalities. However, when all modern staging techniques are utilized, the ISDE recommends neoadjuvant therapy followed by surgical resection as the favored treatment of cT2N0 esophageal cancer. Certain patient groups may still be offered PSR, particularly those unable to tolerate neoadjuvant therapies, or those patients with very low risk of lymph node metastasis as suggested by histological features, small tumor size, and other features.

BACKGROUND:Esophageal perforation is a rare condition with high mortality. Spontaneous perforations may be associated with worse outcomes because of the degree of mediastinal contamination when compared with "clean" iatrogenic perforations, with different timings for intervention. This study aims to assess the differences in treatment and outcomes between these 2 groups. METHODS:Data were collected retrospectively from a tertiary center from 2009 to 2021 using the electronic patient record (n = 73, 42 spontaneous, 31 iatrogenic). Complications were quantified using the Comprehensive Complication Index. Univariate analysis was used to determine statistical significance. RESULTS:Spontaneous perforations had a significantly greater 30-day mortality compared with iatrogenic perforations (21.4% vs 3.2% P = .025), although not at 90 days and 1 year (21.4% vs 16.1% P = .570 and 21.4% vs 19.4% P = .828). Iatrogenic perforations were more commonly managed nonoperatively (73.8% iatrogenic vs 22.6% spontaneous perforations P < .001). All of the iatrogenic deaths that occurred between 30 days to 1 year had been managed nonoperatively. Median length of intensive care stay was greater in spontaneous perforations (15 days vs 6 days P = .047), with no significant difference in median overall length of stay (48 days spontaneous perforations vs 38 days iatrogenic P = .885). Median Comprehensive Complication Index score was greater in those with spontaneous perforations (53.9 vs 29.6 P = .002) CONCLUSION: Although Comprehensive Complication Index and 30-day mortality were greater in spontaneous perforations, there was no difference in 90-day and 1-year mortality, suggesting that long-term survival is not dictated by etiology of the perforation. Most iatrogenic perforations were managed nonoperatively, which raises the question whether iatrogenic perforation should be managed more aggressively.

A recent National Oeosphagogastric Nutrition Audit in the UK concluded there was a lack of confidence to provide nutritional support at the ‘front end’ of the pathway, a large variation of resource allocation and raised concerns over funding and staffing resource. This multidisciplinary collaborative study aimed to use best available evidence to produce guideline statements and recommendations on optimisation of nutrition in patients undergoing OG resections. A modified Delphi process, previously developed by the Peri-Operative Quality Initiative, was employed to develop consensus statements regarding the optimisation of nutrition in patients undergoing elective OG resections for cancer. The POQI board provided approval and independent supervision of the POQI process and meetings. Following a multicentre survey, thirty-nine consensus statements were agreed upon over the course of three online POQI conferences. A total of 30 participants took part in the POQI consensus process. The consensus statements covered four subgroups: 1. Nutrition Assessment, 2. Pre-Operative Nutrition Optimisation, 3. Post-Operative Nutrition Optimisation and 4. Nutrition Optimisation in Long Term Survivors. The level of evidence to support each statement was considered and recorded. Areas where evidence was limited, but felt to be critical for further optimisation, were identified as recommendations for research. Consensus guidelines to optimise nutrition in patients undergoing OG cancer resections have been developed and refined. These guidelines will facilitate the multidisciplinary team in their goal to improve outcomes for patients undergoing OG resections.

BACKGROUND:Endoscopic submucosal dissection (ESD) is increasingly used to treat gastric dysplasia and early neoplasia in the West. Unlike Eastern countries, data for Caucasian patients in the United Kingdom is limited due to its limited implementation in a few tertiary centres. AIM:To evaluate the outcomes of ESD on gastric dysplasia and neoplasia in Caucasian patients. METHODS:Our ten-year retrospective study at a single tertiary centre included data spanning from May 2012 to July 2023. The efficacy of ESD on gastric dysplasia and early neoplasia was measured using parameters set out by the National Institute for Health and Care Excellence, which include en-bloc and curative resection (CR) rates, local recurrence and survival rates. RESULTS:ESD was attempted on 111 lesions in 93 patients. 95.0% of completed procedures achieved endoscopic clearance. 74.3% were en-bloc resections and the rest were hybrid ESD with piecemeal resections. In all, 34.7% achieved histological CR. Overall, disease recurrence was 10.9% at latest follow-up (63 months, median follow-up). Importantly 100% of lesions in the CR group showed no disease recurrence at subsequent and latest follow-up. In the Indeterminate and Non-CR group, 18.8% of lesions showed disease recurrence at subsequent endoscopic follow-ups. ESD changed the histological staging of 44.5% of lesions. Immediate complications were observed in 9.9% of all ESD procedures. The median survival time was 69 months post-ESD. The mean age at death is 82.2 years old. CONCLUSION:The study affirms the long-term efficacy and safety of ESD for gastric dysplasia and early neoplasia in Caucasian patients.

BACKGROUND:For patients with locally advanced esophagogastric cancer, the standard of care in the UK is neoadjuvant chemotherapy (NAC) followed by surgery. Prehabilitation exercise training can improve physiological function and fitness. If such improvements translate to increased immune infiltration of tumors, exercise could be prescribed as an immune adjuvant during NAC and potentially improve clinical outcomes. As such, we aimed to determine whether prehabilitation increased tumor infiltrating lymphocytes (TILs). METHODS:We assessed 22 patients with locally advanced esophageal cancer on a randomized control trial comparing 16 weeks of low-to-moderate intensity twice weekly supervised and thrice weekly home-based exercise (Prehab: n = 11) to no prehabilitation (Control: n = 11). Our primary outcome was to compare tumor-immune responses between Controls and Prehab. We compared formalin-fixed paraffin-embedded tumors by high-resolution multispectral immunohistochemistry (mIHC) and NanoString spatial transcriptomics. Secondarily, we determined relationships between changes in fitness to the exercise training and tumor-immune measures. Specifically, we assessed percentage changes in peak cardiorespiratory fitness as assessed by peak oxygen uptake (V̇O2peak) before NAC (Baseline) and after 8 weeks of NAC (Post-NAC), and changes between Baseline and following 8 weeks of NAC recovery before surgery (Pre-surgery) and correlated changes in fitness with tumor-immune responses. Finally, as an exploratory aim, we assessed clinical outcomes between groups, including survival, therapy tolerance, and tumor regrading. RESULTS:We observed that Prehab had significantly more CD8+ lymphocytes in their tumors (mean difference (diff.) = 1.79, 95% confidence interval (95%CI): 0.76‒2.82, p < 0.001) and their stroma (mean diff. = 1.59, 95%CI: 0.66‒2.52, p < 0.001) than the Controls. When normalized to total numbers of TILs, Prehab had higher levels of CD56+ natural killer (NK) cells (median diff. = 0.87, 95%CI: 0.25‒2.18), p = 0.0274), consisting primarily of CD56dim NK cells (median diff. = 0.48, 95%CI: 0.03‒2.53), p = 0.0464). Evaluation of the presence and localization of tumor-associated tertiary lymphoid structures (TLS) in the esophageal tumors revealed that most TLS were in the peritumoral regions. Prehab had a higher TLS cell density (cells/mm2; median diff. = 18,959, 95%CI: 13,518‒22,635), p < 0.001) and more clearly defined germinal centers indicative of mature TLS visually. We observed that Prehab maintained their V̇O2peak during NAC while the Controls' V̇O2peak reduced by 9.0% ± 10.2% (mean ± SD) (Post-NAC: p = 0.018). Pre-surgery, Prehab V̇O2peak was a clinically meaningful 3.27 ± 1.31 mL/kg/min higher than Controls (p = 0.022). Between Baseline and Post-NAC, where the Prehab maintained V̇O2peak better than Controls, there were significant positive associations with percentage changes in V̇O2peak and the frequencies of CD8+ TILs (r = 0.531, p = 0.016), programmed death-ligand 1+ (PDL1+) cells (r = 0.566, p = 0.009), and granzyme B+ (GrzB+) TILs (r = 0.582, p = 0.007). Similar relationships were observed for changes in V̇O2peak from Baseline to Pre-Surgery only in the Prehab group. We observed no differences between groups regarding clinical outcomes such as survival, therapy tolerance, or tumor regrading. CONCLUSION:We show that exercise training during NAC, which promotes higher levels of cardiorespiratory fitness than no exercise, is associated with increased frequencies of TILs and maturity of TLS. These data suggest that exercise during NAC enhances the immune system. Future studies are warranted to understand the clinical consequences of this.

BACKGROUND:Prehabilitation is increasingly being used in patients undergoing multimodality treatment for oesophagogastric cancer (OGC). Most studies to date have been small, single-centre trials. This collaborative study sought to assess the overall impact of prehabilitation on patient outcomes following OGC surgery. METHODS:Data came from four prospective prehabilitation trials conducted in the UK or Ireland in patients undergoing multimodality treatment for OGC. The studies included three randomised and one non-randomised clinical trial, each comparing a prehabilitation intervention group to controls. The prehabilitation interventions included aerobic training delivered by exercise physiologists alongside dietetic input throughout the treatment pathway. The primary outcome was survival (all-cause and disease-specific mortality). Secondary outcomes were differences in complications, cardio-respiratory fitness (changes in VO2 peak and anaerobic threshold (AT)), chemotherapy completion rates, hospital length of stay, changes in body mass index, tumour regression and complication rates of anastomotic leak and pneumonia. Cox and logistic regression analysis provided hazard ratios (HR) and odds ratios (OR), respectively, with 95% confidence intervals (CI), adjusted for confounders. RESULTS:Among 165 patients included, 88 patients were in the prehabilitation group and 77 patients were in the control group. All-cause and disease-specific mortality were not improved by prehabilitation (HR 0.67 95% CI 0.21-2.12 and HR 0.82 95% CI 0.42-1.57, respectively). The prehabilitation group experienced fewer major complications (20% vs. 36%, p = 0.034; adjusted OR of 0.54; 95%CI 0.26-1.13). There was a mitigated decline in VO2 peak following neo-adjuvant therapy (delta prehabilitation -1.07 mL/kg/min vs. control -2.74 mL/kg/min; p = 0.035) and chemotherapy completion rates were significantly higher following prehabilitation (90% vs. 73%; p = 0.016). Hospital length of stay (10 vs. 12 days, p = 0.402) and neoadjuvant chemotherapy response (Mandard 1-3 41% vs. 35%; p = 0.494) favoured prehabilitation, albeit not statistically significantly. CONCLUSION:Despite some limitations in terms of heterogeneity of study methodology, this study suggests a number of meaningful clinical benefits from prehabilitation before surgery for OGC patients. Current initiatives to agree on national standards for delivering prehabilitation and the results of ongoing trials will help to further refine this important intervention and expand the evidence base to support the widespread adoption and implementation of prehabilitation programs.

Objective: Positive peritoneal cytology is traditionally viewed as representative of metastatic disease and a poor prognostic factor. The objective of this multi-center study was to define the prognostic role of peritoneal cytology in curative gastrectomy, evaluate international variation in cytology sampling, and assess the impact on positive peritoneal cytology yields. Methods: This was a multi-center international retrospective cohort study of 16 tertiary gastric cancer centers. Adult patients who underwent peritoneal lavage cytology at staging laparoscopy and subsequent gastrectomy between 2009 and 2023 were included. The primary outcome measure was overall survival at five years. Multivariable Cox regression provided hazard ratios (HRs) with 95 % CIs, adjusted for relevant confounding factors. Results: 837 patients with no radiological or macroscopic M1 disease were included, with a mean age of 66 (IQR 58-73) and 71 % were male. Non-distal gastric cancer was most common (47 %), with 59 % and 43 % of tumors staged pT3/4 and pN2/3, respectively. 66 patients (7.9 %) had positive cytology. Positive cytology was not associated with overall survival in multivariable analysis, controlled for stage and neoadjuvant treatment (HR=1.0; 95 %CI 0.51-2.0). Higher T and N stages were associated with positive cytology (p < 0.001). The proportion of patients with positive cytology was variable, depending on how many quadrants were sampled. Conclusion: Positive peritoneal cytology with otherwise M0 disease was not associated with decreased survival after curative intent gastrectomy in this study, meaning prospective study is needed. The technique of performing peritoneal washings influenced cytology yield and thus must be standardized in a much-needed prospective evaluation of peritoneal cytology. Synopsis: The POPEC multicenter international retrospective cohort study included 837 patients receiving curative gastrectomy. This study showed the technique of performing peritoneal washings influenced cytology yield, however positive peritoneal cytology was not associated with decreased survival. Therefore, positive peritoneal cytology should not be considered an absolute contradiction to curatively intended gastrectomy.

BACKGROUND:Prehabilitation is safe, feasible and may improve a range of outcomes in patients with oesophago-gastric cancer (OGC). Recent studies have suggested the potential of prehabilitation to improve body composition, sarcopenia and physical fitness, reduce surgical complications and improve quality of life. Despite this, prehabilitation services are not offered throughout all OGC centres in the UK. Where prehabilitation is offered, delivery and definitions vary significantly, as do funding sources and access. METHODS:A professional association endorsed series of consensus meetings were conducted using a modified Delphi process developed by the Peri-Operative Quality Initiative (POQI) to identify and refine consensus statements relating to the development and delivery of prehabilitation services for OGC patients. Participants from a variety of disciplines were identified based on a track record of published studies in the field of prehabilitation and/or practice experience encompassing prehabilitation of OGC patients. Approval from the POQI board was obtained and independent supervision provided by POQI. RESULTS:A total of 20 statements were developed and agreed by 26 participants over a preliminary meeting and 2 semi-structured formal POQI meetings. Ten research themes were identified. In the case of one statement, consensus was not reached and the statement was recorded and developed into a research theme. A strong recommendation was made for the majority of the consensus statements (17 of 20). DISCUSSION:Consensus statements encompassing the interventions and outcomes of prehabilitation services in oesophago-gastric cancer surgery have been developed to inform the implementation of programmes.

Abstract Sarcopenia is an important prognosticator during treatment for Oesophagogastric (OG) cancer. Despite this, sarcopenia is not routinely measured in clinical practice due to resource availability. Ultrasound is emerging as a potential tool to quantify muscle mass and quality and might predict treatment-related complications. Skeletal muscle ultrasound has not been investigated in patients undergoing cancer treatment. Patients receiving treatment for OG cancer (chemotherapy plus surgery) were prospectively recruited. Ultrasound was performed at 4 time points during treatment. Primary outcome was a measurable change in skeletal muscle. Secondary outcome measures included correlation with gold-standard measures of muscle mass (CT skeletal muscle index (SMI)), and the association between sarcopenia on ultrasound and treatment-related complications. Fifty patients were recruited. Significant deterioration in quadriceps muscle thickness, cross sectional area, rectus femoris echointensity, and ultrasound sarcopenia index (USI) was observed during chemotherapy. USI showed moderate correlation with CT SMI (r = -.511, p=0.001) with ultrasound classifying more patients as sarcopenic (37% vs 18%, p=0.001), plus detecting a greater magnitude of muscle loss during chemotherapy (-20.2 ±18% vs -6.5 ±7.4%, p=<0.001). USI correlated better with physical function (1-minute sit to stand) compared to CT SMI (r .589, p=<0.001 versus r .149, p=0.169). Ultrasound-defined sarcopenia at baseline was associated with a higher incidence of dose limiting chemotoxicity and severe chemotoxicity but did not post-operative complications. Further validation studies are required, but bedside muscle ultrasound could provide an effective bedside assessment of muscle health and identifies a higher proportion of patients at risk of chemotoxicity prior to major surgery.

Oesophageal adenocarcinoma (OAC) is amongst the most lethal cancers worldwide, with poor treatment response leading to low survival rates. Recent improvements have been achieved by including the tumour microenvironment (TME) and patients' immune profiles in treatment decisions. We already know that patients with immune-enriched/inflamed TME have better survival outcomes. However, OAC TME is largely immunosuppressed and appears to be treatment-resistant. Immunotherapeutic strategies are already part of the therapeutic plans in OAC; a greater understanding of the immune microenvironment underlying oesophageal adenocarcinoma is needed if we are to exploit the inherent cancer-fighting capabilities of each patient's immune system. Therefore, implementing the crosstalks between the tumour and its microenvironment (TME) might be the key to improving overall survival. In this review, we discuss accumulated evidence regarding TME and immune checkpoint inhibitors in OAC, as well as recent and ongoing therapeutic attempts to improve patient treatment and outcomes at an individual level.

Abstract Background Oesophagogastric cancer (OGC) 5-year survival is poor (15%). Only 34% of patients are considered for potentially curative treatment, which is associated with a 41% chance of survival. In other cancer, deprivation is associated with poor outcomes. This study aims to determine the association between deprivation, tumour and treatment intent (TI), and 5-year all-cause mortality (M) in OGC. Method This retrospective cohort study analysed patients newly diagnosed with OGC (adenocarcinoma or squamous cell carcinoma) across Greater Manchester between January 2018 and January 2023. TI was defined as the treatment pathway, at completion of staging investigations, either curative (pathway to resection or definitive chemoradiotherapy) or palliative (best supportive care, palliative chemotherapy or radiotherapy). Statistical analysis encompassed methods such as binary logistic regression, Cox proportional hazards models and Kaplan-Meier survival curves with adjustments made for age, gender, and clinical stage. IMD scores were grouped from deciles into quintiles leaving 5 groups, with IMD1 representing the most deprived. Results 3027 patients were included (2102, 69.4% males). Patients in IMD1 were diagnosed 4 years younger than in IMD5 (most affluent) (median age 70 (IQR=17) vs 74 (IQR=16), p<0.001). There was a higher proportion of deprived patients (32.9% IMD1 vs 15.3% IMD5, p<0.001). The proportion of stage 4b disease in IMD1 compared with IMD5 was not different (406 (40.7%) vs 174 (37.5%), p=0.081). The median survival was lower in IMD1 compared with IMD5 (0.81 vs 0.90 years, p=0.074). Following adjustment for confounders IMD1 was associated with a poorer overall survival when compared with IMD5 (HR 1.16, CI[1.02-1.32],p=0.020). Conclusion This study highlights a significant health inequality in the outcomes of OGC. Poorer outcomes in the most deprived group were independent of tumour stage, gender and age. Urgent measures to address socioeconomic health inequalities need to be instigated.

Abstract Introduction Pre-clinical studies suggest that exercise during cancer treatment may enhance tumour regression and promote an anti-tumorigenic immune microenvironment. Considering the evolution of immunotherapy in oesophagogastric cancer, further understanding of the host-tumour immune response to exercise therapy is of significant interest. Methods Using multiplex immunofluorescence, resection specimens of 30 patients with oesophageal adenocarcinoma were labelled for CD3, CD4, CD8, PD-1, PD-L1, FOXP3, CD68, and PanCK to characterise tumour and peri-tumoral immune infiltrate. All patients received the same neoadjuvant chemotherapy prior to oesophagectomy. 14 patients who engaged with a structured prehabilitation exercise program (mixed aerobic and resistance training twice-weekly) were case-matched with 16 control patients who did not. Results The prehabilitation group had a significant increase (per mm2 ) in cytotoxic T-cells (99.4 vs 13.8, p=0.003). There was also a significant increase in immune suppressive macrophages, exhausted T-helper and cytotoxic T-cells. The only significant change in the peritumoural sections was an increase in exhausted CD8 cytotoxic-T cells in the prehabilitation group (3.3 vs 1.4, p=0.043). There was no difference in the number of Treg or T-helper cells within, or around the tumour sections. Conclusions This study is the ‘first-in-man’ to show that exercise prehabilitation during chemotherapy impacts on the tumour immune microenvironment in patients with oesophageal adenocarcinoma. Exercise results in an increased abundance of both anti-tumorigenic and immunosuppressive cell types. These finding warrant further investigation, especially in the context of modern immunotherapy treatments, to understand the clinical impact that exercise oncology has on tumour regression.

Abstract Prehabilitation is being widely adopted to optimise physical health prior to surgery. However, there remains a lack of consensus regarding exercise type and intensity with current guidance extrapolated from generic, non-cancer populations. The WHO and American College of Sports Medicine (ACSM) recommend 600-1200 Metabolic Equivalent minutes (MET-mins) per week of physical activity (PA) but the effectiveness of this recommendation in cancer populations is unknown. Patients undergoing treatment for Oesophagogastric cancer were prospectively recruited. International Physical Activity Questionnaire (IPAQ) quantified PA at baseline and throughout treatment. Two cohorts were defined (lowPA and highPA) based on ACSM cut-off of 1200 MET-mins/week. Outcome measures were physical function (1 minute sit-to-stand, 1mSTS), CT muscle mass, chemotoxicity, and failure to complete planned treatment. 38 patients completed all study assessments (highPA n=20, lowPA n=18) with no difference in baseline characteristics or disease stage between groups. LowPA group showed declines in 1mSTS performance following chemotherapy, whereas the highPA group improved (mean difference -4 versus +10, p=0.001). Whilst both saw a decline in skeletal muscle mass, the lowPA group lost significantly more (mean difference -5.1 versus -1.8, p=0.007). There were trends towards a lower incidence of severe chemotoxicity (30% vs 61%, p=0.054) and failure to complete planned treatment (15% versus 28%, p=.33) in the highPA group. Whilst further research is required to define the most effective prehabilitation strategy, this study is the first to suggest a new benchmark to preserve muscle mass and function is higher than current guidelines and should be considered when developing prehabilitation recommendations.

Abstract Background Locally advanced non-metastatic gastric cancer is primarily managed with surgical resection and peri-operative oncological therapies. Positive peritoneal cytology is often considered to be indicative of disseminated malignancy. We have previously shown that conversion from positive (Cy+) to negative (Cy0) cytology with systemic therapy, and absence of macroscopic disease, improves survival. With the advent of novel chemo- and radiotherapy regimes as well as immunotherapy, we recognise a lack of current understanding of the role of peritoneal cytology as a prognostic factor. Our study aims to determine the role of positive peritoneal cytology as a prognostic factor in gastric cancer. Methods This is an international multi-centre retrospective cohort study including high-volume, gastric cancer tertiary referral centres. Adult patients without macroscopic metastatic disease who underwent peritoneal cytology, and subsequently multi-modality treatment including surgical resection between 2011 and 2021 were included. The primary outcome measure is overall survival at 1, 3 and 5 years. Secondary outcome measures include recurrence-free survival at 1, 3 and 5 years; 30-day and 90-day major postoperative morbidity; and subset survival analyses were performed in patients who converted to Cy0 in restaging laparoscopy after neoadjuvant therapy. Statistical analysis was performed using R software. Results This is an interim analysis of the data of 280 patients with a mean age of 64.9 (0.72). 231 patients received pre-operative chemotherapy. 51.0% underwent open gastrectomy (41.2% laparoscopic and 4.64% robotic). 55% of patients underwent a total gastrectomy. 25.9% patients had positive cytology on laparoscopy, while 9.71% had indeterminate cytology. There was significant variation in the sites of peritoneal washings (Figure 1). So far, only 1 patient has shown conversion from positive to negative cytology after oncological therapy. At 1 year, the mortality rate was 41.5% (figure 2), while the recurrence rate was 41.4%. Conclusions In this interim report, we demonstrate significant heterogeneity in the way peritoneal cytology is performed, and the peri-operative management of this cohort. The POPEC study closes to patient recruitment at the end of August 2023, and thus at AUGIS we plan to report on the final findings of this study with an anticipated sample size of over 1000 patients.

Abstract Background This abstract presents the findings of a study investigating health inequality in oesophago-gastric (OG) cancer throughout Greater Manchester (GM). The study aimed to assess the impact of socio-economic deprivation on cancer incidence, clinical stage at diagnosis and treatment intent. Methods The study reviewed MDT minutes from 2022 for patients newly diagnosed with oesophageal or gastric cancer. Treatment intent at diagnosis, patient age, and deprivation scores based on national data were examined. Patients were categorised into quintile (Groups 1 to 5) based on their Index of Multiple Deprivation (IMD) score from their postcode. Results 674 patients were included from a population of 3.5 million. Stages 1-2 accounted for only 21% of cases and stage 4 accounted for 57% of cases. 31.6% of all cases occurred in the MD (p=.565). Among all cancers, 9% more patients who had palliative disease resided in the MD (12% vs 21%, p=.565). There were 7.2% more stage 4 cancer in the MD (10.2% vs 17.4%, p=.865). Men were proportionally more represented in stage 4 disease compared to stage 1 (65.5% vs. 72.7%, p=.155). Patients in the MD had earlier onset of disease (median 70 years vs. 75 years, p=.051). Conclusions This retrospective study highlights important trends that warrant further research. It identifies health inequalities in OG cancer, particularly in terms of age at diagnosis, incidence rates in deprived areas, and gender disparities. The study underscores the urgency for targeted interventions, public awareness campaigns, and resource allocation to address these disparities, alleviate the burden of advanced-stage OG cancer, and improve access to early diagnosis and effective treatment in an equitable manner. The findings contribute to the growing body of evidence on health inequality in cancer, however further research is required.

OBJECTIVE:To identify prognostic factors associated with 90-day mortality in patients with oesophageal perforation (OP), and characterize the specific timeline from presentation to intervention, and its relation to mortality. BACKGROUND:OP is a rare gastro-intestinal surgical emergency with a high mortality rate. However, there is no updated evidence on its outcomes in the context of centralized esophago-gastric services; updated consensus guidelines; and novel non-surgical treatment strategies. METHODS:A multi-center, prospective cohort study involving eight high-volume esophago-gastric centers (January 2016 to December 2020) was undertaken. The primary outcome measure was 90-day mortality. Secondary measures included length of hospital and ICU stay, and complications requiring re-intervention or re-admission. Mortality model training was performed using random forest, support-vector machines, and logistic regression with and without elastic net regularisation. Chronological analysis was performed by examining each patient's journey timepoint with reference to symptom onset. RESULTS:The mortality rate for 369 patients included was 18.9%. Patients treated conservatively, endoscopically, surgically, or combined approaches had mortality rates of 24.1%, 23.7%, 8.7%, and 18.2%, respectively. The predictive variables for mortality were Charlson comorbidity index, haemoglobin count, leucocyte count, creatinine levels, cause of perforation, presence of cancer, hospital transfer, CT findings, whether a contrast swallow was performed, and intervention type. Stepwise interval model showed that time to diagnosis was the most significant contributor to mortality. CONCLUSIONS:Non-surgical strategies have better outcomes and may be preferred in selected cohorts to manage perforations. Outcomes can be significantly improved through better risk-stratification based on afore-mentioned modifiable risk factors.