Abstract Introduction The combination of 5-flurouracil, oxaliplatin, leucovorin and docetaxel (FLOT) is an effective chemotherapy regime in locally advanced, resectable gastro-oesophageal adenocarcinoma. Since the FLOT4-AIO randomised controlled trial demonstrated superiority over ECF/ECX it has been standard of care at many centres and European Society of Medical Oncology’s recommended perioperative regimen. After over five years of offering this treatment to patients we assessed how this evidence had translated into practice; identifying factors that predict dose reduction or incomplete therapy and overall survival. Method Patients who had the combination of neoadjuvant FLOT chemotherapy and oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction between February 2018 and September 2023 were identified from a prospectively collected database. Data on completion of chemotherapy, perioperative outcomes and long-term survival were collected. Pathological regression was assessed using Mandard tumour regression grade (TRG). The peri-operative, pathological, and long-term outcomes of patients who completed four cycles of neoadjuvant FLOT was compared with those who had reduced dose or early cessation. Statistical analysis used IBM SPSS, with Mann-Whitney U and Chi squared for variable analysis and univariate cox regression for survival. Results Eighty patients were included with a median age of 66 (47-79), 84% were male. Full dose completion was achieved by 57 (71%) patients, 20 (25%) had dose reduction and 7(8%) did not complete four cycles. Age, anaerobic threshold and VO2 max were not significantly different between those completing or not completing neoadjuvant chemotherapy (p=0.460, p=0.624, p=0.104 respectively); or requiring dose reductions (p=0.317, p=0.587, p=0.82). Median TRG across all three groups was 3. Median follow up was 55.4 months and mean overall survival was 53.4 months. No difference in survival was observed between those who completed or did not complete neoadjuvant FLOT (p=0.45). Conclusion Completion of neoadjuvant chemotherapy was lower in this cohort of patients than FLOT4-AIO. Rates of pathological complete response were similar. This translated into similar mean overall survival. Median survival was unable to be calculated as survival exceeds 50% at the time of our study. The use of FLOT has translated well into the routine neoadjuvant clinical setting with acceptable short- and long-term outcomes.

Abstract Background Perforated peptic ulcer remains a common cause of morbidity and mortality worldwide. Surgical treatment includes a trend towards minimally invasive surgery. To safely implement this, it is important to understand the key steps that have been assessed in clinical trials. The aim of this review is to assess the reporting of intervention steps in laparoscopic and open ulcer repair. Methods A systematic search was performed of the MEDLINE, EMBASE, & clinical trial databases (PROSPERO (CRD42023404537)). Randomised trials on laparoscopic vs open repair of peptic ulcer were included. Data extracted included study metadata, as well as technical aspects of interventions, use of co-interventions. Study design was assessed using the PRECIS-2 tool, to explore whether trials were predominantly pragmatic or explanatory, and also using the Cochrane Risk of Bias tool. Results 408 studies were screened for eligibility, and nine full-texts were included. This included six studies from China, two from India, and one from the Netherlands. Incision, ulcer closure details, and lavage, were the best reported aspects of laparoscopic repair (n=7). Method of access, incision, and ulcer closure were well described in 8 studies. Co-interventions such as antibiotic use, analgesia, and H pylori eradication were poorly described. Interventions were delivered by high volume laparoscopic surgeons. Studies were considered at high risk of bias. PRECIS-2 assessment found studies were neither fully pragmatic nor explanatory. Conclusions Laparoscopic repair of perforated peptic ulcer is a poorly defined intervention. Standardisation of key steps and co-interventions is required to facilitate a well designed randomised trial.

Postoperative ileus is a common and distressing complication after intestinal surgery. It presents clinically as impairment of intestinal motility, characterized by abdominal pain, vomiting, and delayed recovery of defaecatory function. For patients, this increases the risk of serious complications, such as pneumonia, venous thromboembolic events, and malnutrition. For healthcare systems, it leads to a substantial economic burden associated with increased medical, nursing, dietitian, and laboratory costs. Accordingly, postoperative ileus is now recognized as a research priority by expert and public stakeholder groups. Numerous clinical interventions have been evaluated in efforts to prevent postoperative ileus, but few have led to meaningful patient benefit. A key challenge for researchers is the absence of a standardized and agreed framework to describe the effectiveness of new interventions in clinical studies. Common outcomes include the time taken until first passage of flatus/stool, time until tolerance of oral diet, and the return of bowel sounds. It remains unclear, however, whether these are sufficiently relevant to patients and healthcare professionals when evaluating new treatments and implementing them in clinical practice. A solution to this problem is the development of an agreed core outcome set developed through patient–clinician consensus. Core outcome sets provide a minimum set of outcomes that should be reported in all studies of a defined clinical condition and are supported by the Core OutcomeMeasures in Effective Trials (COMET) Initiative. The present report describes the international development and final content of an agreed core outcome set for postoperative ileus relevant to patients undergoing intestinal surgery.

ABSTRACT In thinking about the developing online harms regime (in the UK and elsewhere) it is forgivable to think only of how laws placing responsibility on social media platforms to prevent hate speech may benefit society. Yet these laws could have insidious implications for free speech. By drawing on Germany’s Network Enforcement Act I investigate whether the increased prospect of liability, and the fines that may result from breaching the duty of care in the UK’s Online Safety Act - once it is in force - could result in platforms censoring more speech, but not necessarily hate speech, and using the imposed ‘responsibility’ as an excuse to censor speech that does not conform to their objectives. Thus, in drafting a Bill to protect the public from hate speech we may unintentionally open Pandora’s Box by giving platforms a statutory justification to take more ‘control of the message’.

Abstract Background Pancreatic ductal adenocarcinoma (PDAC) is the twelfth commonest cancer worldwide, and predicted to be the second most common cause of cancer death by 2030. Outcomes are poor, just 20% of patients present with resectable disease of which up to 85% recur post-surgery. Loco-regional treatment of limited metastatic recurrence, termed metachronous oligometastases (a transitional state between localised and widespread systemic disease) may confer a survival benefit. In 2020 the European Organisation for Research and Treatment of Cancer recommended definitions for characterisation and classification of oligometastatic disease using consensus methods. However, there remains no universally agreed definition of this disease state, which may contribute to heterogeneous outcome reporting and limit comparison between studies. The aim of this systematic review is to i) summarise the published loco-regional treatments of metachronous oligometastatic PDAC and ii) identify reported definitions of the oligometastatic state. Methods All articles reporting management and outcomes for patients with metachronous oligometastatic PDAC cancer were eligible for inclusion. Searches for ‘pancreatic cancer’ and ‘oligometastatic disease’ were undertaken via Medline, Embase, PubMed, Web of Science, the Cochrane Central Register of Controlled Trials and Google Scholar. Bibliographies of relevant studies were used to identify additional studies. Screening was performed independently by at least two authors. Articles produced in languages other than English, abstracts and conference proceedings, case reports, reports of fewer than five patients, and articles published before 2000 were excluded. The full-text versions of articles were accessed for further assessment. Data extraction was undertaken independently by at least two authors using a standardised proforma including general demographics, treatment of primary, recorded definitions of oligometastatic disease, methods of treatment for liver oligometastatic disease, local recurrence, other sites of recurrence, and survival outcomes. Results 6602 articles were identified for title screening, 284 for full-text review and 35 articles were included, of which 29 were case series and six were non-randomised comparative studies. Of these, 29 (83%) were retrospective. Five (14%) were multicentre, and participant numbers ranged from 10 to 332. Descriptions of oligometastatic disease were variable, with no study using the same definition. No studies reported an oligometastatic subtype as described by the European Organisation for Research and Treatment of Cancer consensus recommendation. Liver oligometastases were reported in 15 studies and demonstrated variable treatments including radiofrequency (4), stereotactic body radiotherapy (SBRT) (2), and selective internal radiation therapy (SIRT) (2). Nine studies reported surgical management of liver metastasis. The Median overall survival (OS) for these treatments was 29.5, 28.9, 27.5, and 39.5 months respectively. Management of local recurrence was reported in 22 studies and included SBRT (9), trans-arterial chemoembolisation (4) radiofrequency (1), and surgical resection (8). Median OS were 28.1, 29.9, 79.3 and 49.3 respectively. Three studies reported on the treatment of peritoneal oligometastases, including SIRT (1) and surgical resection (2) with Median OS as 12.3 and 61 months respectively. Conclusions The majority of studies were single-centre, non-randomised retrospective, without comparators and with low patient numbers. Treatments offered for local and distant recurrence were heterogeneous. There was no consensus for the definition of oligometastatic disease, which resulted in a lack of consistent patient selection. There is an urgent need for future studies to use a consistent definition to allow for a more homogenous patient selection and allow meaningful comparison of treatment delivery and outcomes.

This chapter explains the monograph's purpose and what it hopes to achieve. It presents four fundamental questions addressed by the book: (i) at which point do individuals publishing information become 'media', and should therefore be treated as journalists? (ii) because citizen journalists are not necessarily socialised into the norms of professional journalism, should they be subject to the same law and regulation as 'institutional professional' journalists, or should they be treated differently? (iii) if we accept the existence of certain 'duties and responsibilities' for institutional journalists, should the same or similar 'burdens' apply to citizen journalists? (iv) (a) if they should be treated differently, to what extent should the law and regulation differ for them compared to their institutional counterparts? (b) if they should be subject to the same law and regulation as institutional journalists, should the nature and needs of citizen journalism be considered when implementing law and regulation?

This chapter introduces the conceptual 'key' to address the problem identified in Chapter 4: how should media and non-media entities be distinguished for the purposes of media freedom. This key is a functional rather than institutional definition of media, deriving from the media-as-a-constitutional-component concept. The chapter begins by making the claim that libertarianism is the de facto normative paradigm, which forms the foundation for my contention, based on analysis of the argument from truth and the marketplace of ideas, that libertarianism should be rejected as a normative framework for online speech and the media-as-a-constitutional-component concept. This leads on to my advancement of the proposition that social responsibility theory should be embraced as the dominant normative paradigm. In making this argument I discuss the relationship between the media-as-a-constitutional-component concept and other participatory theories of free speech. Finally, the chapter asks how the new normative framework, in offering an alternative means of interpreting free speech that recognises twenty-first century methods of communication, could better deal with some of the legal challenges that arise from the media operating within the current libertarian paradigm.

The parameters imposed by the media-as-a-constitutional-component concept on media freedom are set out in this chapter. It discusses the standards and norms attached to media conduct and discourse by the concept, which answers, in the affirmative, one of the four questions that are posed in Chapter 1: if we accept the existence of certain ‘duties and responsibilities’ for institutional journalists, should the same or similar ‘burdens’ apply to citizen journalists? Specifically, it explores the notion of public interest, media conduct and the media’s requirement to act in good faith. In respect of public interest, it claims that the concept, and the social responsibility theory and argument from democratic self-governance rationales underpinning it, align it clearly with the jurisprudence of the ECtHR: a position that is diametrically opposed to a divergent line of English and Welsh case law supporting a ‘role model’ principle. Consequently, it advances three factors to be considered to provide guidance on what is in the public interest in line with the norms and values inherent within the concept.

Abstract Aims Following ERCP, NICE guidance suggests that surgically fit patients undergo cholecystectomy to prevent recurrence of choledocholithiasis and its complications. However, for many patients who are deemed unfit or who choose not to have surgery, ERCP is their definitive management. This study examines the clinical outcomes and costs of expectant management (EM) or cholecystectomy following ERCP. Methods All patients that underwent ERCP, sphincterotomy and common bile duct (CBD) clearance at St James’s University Hospital between January 2015 and December 2018 were identified from a prospectively maintained ERCP database. The clinical outcomes for patients that had undergone an ERCP, sphincterotomy and CBD clearance for gallstones were identified from their electronic patient record. A cost analysis for the complete patient pathway was performed. Results 820 patients underwent ERCP and CBD clearance for gallstones with a median 3.9 year follow up. 222 patients had undergone a cholecystectomy prior to ERCP and were excluded from analysis. 203 patients underwent planned cholecystectomy with 15% (31 patients) requiring complex surgery and 12% (24 patients) needing readmission. 395 patients received expectant management (EM). 9 (2.3%) patients returned with CBD stone symptoms, 6 (1.5%) went on to laparoscopic cholecystectomy (LC). The readmission rate in the EM group was 9%. The average cost per patient in the expectant management group was £7,487 and in the cholecystectomy group was £10,584. Conclusion The results from this study suggest that the need for cholecystectomy following ERCP is uncertain, with similar rates of biliary re-admissions in both groups.

Abstract Background Choledocholithiasis is common, with patients usually treated with ERCP and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focussed on recurrent CBD stones, negating the risks of cholecystectomy. Methods Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James’s University Hospital January 2015 - December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated. Results 844 patients received ERCP and CBD clearance with 3.9 years follow up. 209 patients underwent cholecystectomy with 15% requiring complex surgery. 373 patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive. Conclusions The majority of patients do not require readmission following ERCP for CBD stones and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but difficult biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Abstract Esophagectomy is associated with considerable morbidity and mortality and a significant reduction in quality of life. Early identification of patients at high-risk of early recurrence and death would allow a more informed discussion about the benefits of surgery. Previous studies have shown that histological tumour length may be an independent predictor of survival. In this study we have determined whether tumour length at diagnosis can predict survival after esophagectomy. Methods From a single-centre prospective clinical database (2012 to 2018), we obtained data on tumour characteristics and 18F-FDG PET-CT (PET-CT) measurement of tumour length. The primary endpoint was overall survival (OS).We performed multivariate modelling using semi-parametric Cox models, and additionally explored flexible parametric modelling using fractional polynomials to explore non-linear relationships. Relationships between tumour length and known prognosticators were assessed using standard statistical techniques. Results We included 300 patients with esophageal adenocarcinoma and pre-operative PET-CT imaging. Tumour length was measurable on PET-CT in 91% of patients (274) (median 4.7 cm, range 1.3–12). 77% of patients received neo-adjuvant therapy. One and five-year overall survival rates were 79% and 44%, respectively. There was no relationship between survival and tumour length. One year survival for patients with tumours greater than 8 cm was 67% compared with 82% for tumours less than 8 cm although this was not statistically significant (p = 0.86). Tumour length was associated with tumour stage but not resection margin positivity or number of positive lymph nodes. Conclusion Tumour length as measured by PET-CT at diagnosis does not predict survival in patients undergoing esophagectomy for esophageal adenocarcinoma. This data supports the notion that tumour length by itself should not be used as a means of stratifying treatment.

This chapter considers how citizen journalism contributes to the public sphere. Providing useful analysis of this cannot be achieved in a vacuum; it needs to be framed within the broader context of the internet and social media, as they provide the mechanisms through which citizen journalism occurs. After setting out the early hopes for the transformative effect that the internet and social media would have on the democratisation of the public sphere, it looks at how they have altered the media ecology by changing the way in which we consume news. It asks whether social media platforms are now operating as both technology and media companies. The chapter deals with the impact that our transition to online news consumption has had on press viability, what this means for the public sphere, and how social media has distorted the public sphere. Finally, it considers the positive impact of the internet and social media on the public sphere, in that they have facilitated citizen journalism. However, it argues that there are limitations to this, some of which can be remedied by the adoption of the media-as-a-constitutional-component concept.

This chapter argues that the voluntary self-regulatory regime in the UK is not satisfactory for the institutional press, let alone citizen journalists. It claims that the media-as-a-constitutional-component concept provides a conceptual framework for a modified regulatory regime which could provide robust regulation of citizen journalists and the institutional press. Thus, the chapter explains why the UK’s current regulatory regime is deficient, why it largely excludes citizen journalists, and why mandatory regulation does not provide a viable alternative to this in respect of citizen journalism. The regulatory scheme that it advances draws on regulation in other jurisdictions. Finally, it explains the nature and scope of the reimaged regulatory scheme. The purpose of this final section is not to set out the scheme’s precise terms (for instance, I have not drafted a standards code). Rather, it provides a framework, or blueprint, for the principles upon which the scheme is based, and the parameters of its nature and scope.

This chapter lays the foundations for the following chapters. It distinguishes media freedom from freedom of expression, establishing that the former provides enhanced protection, for actors operating as part of the media. In doing this, it compares the jurisprudence of the European Court of Human Rights with US scholarship and jurisprudence from the US Supreme Court. The chapter analyses the concept of media freedom; firstly, explaining its role and why the right is conceptually important to media actors; secondly, setting out what the right means for the protection it affords media speech and the media institutionally. It provides the rationale for why there is a need to distinguish media from non-media entities, arguing that the growth of citizen journalism means that the ability to reach mass audiences is no longer reserved to the traditional media. This blurring of the lines has created doctrinal uncertainty as to how the courts should determine the beneficiaries of media freedom. Thus, it identifies the shortfalls of the traditional methods for distinguishing between media and non-media actors (including the press-as-technology model), and therefore who/what is subject to media freedom.

The use of defamation law to protect corporate reputation is controversial. Australia, Canada and England and Wales have been at the centre of this debate, as although their defamation laws share many common characteristics, they adopt distinct approaches to allowing companies to sue in defamation. Consequently, in all three jurisdictions defamation law remains a cause of action that is relied upon by companies to protect their reputations. The primary concern of this paper is the efficacy of these approaches, 1 particularly in light of the reforms made to Australia's defamation laws, adopted in 2020, that further restrict the right of corporations to sue in defamation. Ultimately, it argues that the Australian and English and Welsh approaches disproportionately disadvantage companies, particularly small ones, whereas the Canadian approach overprotects corporate reputation. It concludes by offering an alternative way forward that, although not perfect, provides a better balance between the interests.

Surgical site infection (SSI) is a common complication following emergency laparotomy, occurring in around 25% of patients in UK practice. The adoption of single‐use negative‐pressure dressings (SUNPDs) has been proposed as a prophylactic method of reducing the rate of SSI. The primary aim of the randomized controlled trial (RCT) described herein is to determine if a SUNPD reduces SSI at 30 days after an emergency laparotomy.

In Australia, pursuant to Section 9 of the Defamation Act 2005, companies trading for profit with ten or more employees are prohibited from bringing an action in defamation. In June 2018, the New South Wales government published a Statutory Review of the Act. Although it is of the view that the balance struck by Section 9 continues to be appropriate, it recognised the importance of corporate reputation, and has recommended a further discrete review of the provision. One of the persuading factors for making this recommendation is that Australia's approach does not correspond with the treatment of corporate reputation in other similar jurisdictions, including the UK. This is ironic, as prior to the enactment of the Defamation Act 2013, the UK very nearly followed Australia by prohibiting companies from bringing a claim in defamation. Rather than following the Australian example, the day before the 2013 Act received Royal Assent, Parliament introduced a qualification for the Section 1(1) serious harm requirement for bodies trading for profit; to meet the serious harm threshold, under Section 1(2), they need to demonstrate actual or likely serious financial loss. Thus, this paper critically analyses the efficacy of the Section 9 prohibition, and the Section 1(2) serious financial loss requirement. Ultimately, it argues that neither are fit for purpose, and that a cultural shift is needed to better protect companies of all sizes.

Within this special journal edition, the pathophysiology of achalasia, high-resolution manometry, available treatment modalities, and how to tailor treatment to an individual patient have been discussed in detail. This article does not seek to summarize these areas. Instead, historic and contemporary achalasia guidelines are reviewed with particular reference to how these have evolved over time to reflect the introduction and impact of key technological advances, namely laparoscopic surgery, high-resolution manometry and per-oral endoscopic myotomy (POEM).

AbstractThis article approaches corporate reputation from an English law perspective. It argues that corporate reputation is at least as important as individual reputation, as it is not only vital for the health and prosperity of businesses themselves (whether large or small), but also for the communities within which they operate. Following analysis of conflicting jurisprudence from the European Court of Human Rights, which has led to a lack of clarity within English law, this paper contends that business reputation should be subsumed within the concept of property. Such an approach would then enable businesses to avail themselves of a positive right to the protection of reputation, as property, under Article 1 Protocol 1 of the European Convention of Human Rights.