METHODS:This prospective, multi-centre RCT was conducted in accordance with the CONSORT guidelines for prospective, parallel group randomised studies. Adult patients undergoing elective laparoscopic surgery at two teaching hospitals in Dublin, Ireland were recruited and assigned to one of three closure methods (sutures (SU), staples (ST) or tissue glue (TG)) with primary outcome being cosmesis and secondary outcomes being closure speed, wound complications, cost effectiveness and sustainability outcomes being assessed by a blinded outcomes assessor. RESULTS:A total of 147 patients were recruited and randomised with a total of 138 being examined in the final analysis (SU = 48, ST = 63, TG = 27). Patient demographics were similar across all groups for gender, mean age, body mass index and American Society of Anaesthesiologists grade (all p > 0.050). For cosmesis, SU had the lowest overall mean observer (p < 0.001) and patient (p = 0.005) scar scores. Furthermore, when evaluating the breakdown for Observer Scar Score (OSS), SU had the lowest vascularity (p = 0.001), pigmentation (p = 0.006), thickness (p < 0.001), relief (p = 0.003) and pliability (p < 0.001). For patient scar score (PSS), SU had the lowest irregularity (p = 0.035). SU was the most cost-effective (p < 0.001) and had the lowest total produced non-recyclable waste (p < 0.001). ST had the shortest closure time (p < 0.001). Overall, there was a no difference in wound complication rates (SU = 6.3 %, ST = 6.4 %, TG = 18.5 %; p = 0.130). CONCLUSION:In conclusion, SU was the most effective method for laparoscopic port site closure with regards to cosmesis, cost-efficiency and surgical sustainability. ST was the marginally quicker method of closure and demonstrated equipoise in terms of complication rate. We advocate for SU as the current 'gold standard' with reduced non-recyclable waste generated and a valuable training opportunity for junior trainees. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT03843866.

Abstract Aim To perform a systematic review and network meta-analysis (NMA) of randomised clinical trials (RCTs) evaluating the optimal analgesia strategy post-oesophagectomy. Method A Network Meta-Analysis was performed according to PRISMA-NMA guidelines. Statistical analysis was performed using Shiny and R. Results 14 RCTs which included 565 patients and assessed 9 analgesia techniques were included. Relative to systemic opioids (SO), thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): −13.73, 95% Confidence Interval (CI): −27.01−0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: −36.2, 95% CI: −61.44−10.96) (n = 569, 15 RCTs) and dynamic (MD: −42.90, 95% CI: −68.42−17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: −13.05, 95% CI: −22.74−3.36) and dynamic (MD: −18.08, 95% CI: −31.70−4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: −33.20, 95% CI: −60.57−5.83) and 48 hours (MD: −42.66, 95% CI: −59.45−25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: −5.00, 95% CI: −6.82−3.18) and time to extubation (MD: −4.40, 95% CI: −5.91−2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91−18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87−26.87). Conclusions TEA provides optimal pain control and improved post operative respiratory function in patients post-oesophagectomy, reducing ICU stays, one of the benchmarks of improved post operative recovery.

Summary Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): −13.73, 95% Confidence Interval (CI): −27.01–0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: −36.2, 95% CI: −61.44–10.96) (n = 569, 15 RCTs) and dynamic (MD: −42.90, 95% CI: −68.42–17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: −13.05, 95% CI: −22.74–3.36) and dynamic (MD: −18.08, 95% CI: −31.70–4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: −33.20, 95% CI: −60.57–5.83) and 48 hours (MD: −42.66, 95% CI: −59.45–25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: −5.00, 95% CI: −6.82–3.18) and time to extubation (MD: −4.40, 95% CI: −5.91–2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91–18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87–26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy.

IntroductionThis timely study assesses the immunosuppressive effects of surgery on cytotoxic Th1-like immunity and investigates if immune checkpoint blockade (ICB) can boost Th1-like immunity in the perioperative window in upper gastrointestinal cancer (UGI) patients.MethodsPBMCs were isolated from 11 UGI patients undergoing tumour resection on post-operative days (POD) 0, 1, 7 and 42 and expanded ex vivo using anti-CD3/28 and IL-2 for 5 days in the absence/presence of nivolumab or ipilimumab. T cells were subsequently immunophenotyped via flow cytometry to determine the frequency of T helper (Th)1-like, Th1/17-like, Th17-like and regulatory T cell (Tregs) subsets and their immune checkpoint expression profile. Lymphocyte secretions were also assessed via multiplex ELISA (IFN-γ, granzyme B, IL-17 and IL-10). The 48h cytotoxic ability of vehicle-, nivolumab- and ipilimumab-expanded PBMCs isolated on POD 0, 1, 7 and 42 against radiosensitive and radioresistant oesophageal adenocarcinoma tumour cells (OE33 P and OE33 R) was also examined using a cell counting kit-8 (CCK-8) assay to determine if surgery affected the killing ability of lymphocytes and whether the use of ICB could enhance cytotoxicity.ResultsTh1-like immunity was suppressed in expanded PBMCs in the immediate post-operative setting. The frequency of expanded circulating Th1-like cells was significantly decreased post-operatively accompanied by a decrease in IFN-γ production and a concomitant increase in the frequency of expanded regulatory T cells with an increase in circulating levels of IL-10. Interestingly, PD-L1 and CTLA-4 immune checkpoint proteins were also upregulated on expanded Th1-like cells post-operatively. Additionally, the cytotoxic ability of expanded lymphocytes against oesophageal adenocarcinoma tumour cells was abrogated post-surgery. Of note, the addition of nivolumab or ipilimumab attenuated the surgery-mediated suppression of lymphocyte cytotoxicity, demonstrated by a significant increase in tumour cell killing and an increase in the frequency of Th1-like cells and Th1 cytokine production.ConclusionThese findings support the hypothesis of a surgery-mediated suppression in Th1-like cytotoxic immunity and highlights a rationale for the use of ICB within the perioperative setting to abrogate tumour-promoting effects of surgery and ameliorate the risk of recurrence.

Oesophageal adenocarcinoma (OAC) is a poor prognosis cancer with limited response rates to current treatment modalities and has a strong link to obesity. To better elucidate the role of visceral adiposity in this disease state, a full metabolic profile combined with analysis of secreted pro-inflammatory cytokines, metabolites, and lipid profiles were assessed in human ex vivo adipose tissue explants from obese and non-obese OAC patients. These data were then related to extensive clinical data including obesity status, metabolic dysfunction, previous treatment exposure, and tumour regression grades. Real-time energy metabolism profiles were assessed using the seahorse technology. Adipose explant conditioned media was screened using multiplex ELISA to assess secreted levels of 54 pro-inflammatory mediators. Targeted secreted metabolite and lipid profiles were analysed using Ultra-High-Performance Liquid Chromatography coupled with Mass Spectrometry. Adipose tissue explants and matched clinical data were collected from OAC patients (n = 32). Compared to visceral fat from non-obese patients (n = 16), visceral fat explants from obese OAC patients (n = 16) had significantly elevated oxidative phosphorylation metabolism profiles and an increase in Eotaxin-3, IL-17A, IL-17D, IL-3, MCP-1, and MDC and altered secretions of glutamine associated metabolites. Adipose explants from patients with metabolic dysfunction correlated with increased oxidative phosphorylation metabolism, and increases in IL-5, IL-7, SAA, VEGF-C, triacylglycerides, and metabolites compared with metabolically healthy patients. Adipose explants generated from patients who had previously received neo-adjuvant chemotherapy (n = 14) showed elevated secretions of pro-inflammatory mediators, IL-12p40, IL-1α, IL-22, and TNF-β and a decreased expression of triacylglycerides. Furthermore, decreased secreted levels of triacylglycerides were also observed in the adipose secretome of patients who received the chemotherapy-only regimen FLOT compared with patients who received no neo-adjuvant treatment or chemo-radiotherapy regimen CROSS. For those patients who showed the poorest response to currently available treatments, their adipose tissue was associated with higher glycolytic metabolism compared to patients who had good treatment responses. This study demonstrates that the adipose secretome in OAC patients is enriched with mediators that could prime the tumour microenvironment to aid tumour progression and attenuate responses to conventional cancer treatments, an effect which appears to be augmented by obesity and metabolic dysfunction and exposure to different treatment regimes.

Abstract Aim The closure of surgical wounds following laparoscopic surgery is not currently standardised. The aim of this study was to compare the three main methods of closure – Stitches, Staples, and Tissue Glue to evaluate which of these produce optimum cosmetic outcomes, results in least wound complications and which is most cost-effective. This would enable the adoption of a standard protocol for closure of laparoscopic wound sites. Method This was a prospective, randomised controlled trial. Patients undergoing elective, laparoscopic surgeries were consented and randomised into one of the three treatment arms (Stitches–Subcuticular 4–0Monocryl;Skin Staples or Tissue Glue). Pre-defined, specific guidelines for each of the closure methods were followed. Data recorded at the time of surgery included: Number/Size of Port Sites, time taken and Quantity of closure material used. At an interval follow-up appointment, the wounds were evaluated using the ‘Patient and Observer Scar Assessment Scale’ (POSAS), wound complications recorded, and photographs taken to facilitate further evaluation by a third-party clinician. Results A total of 147 patients were recruited with 138 completing full follow-up. In the ‘Sutures’ arm the average Observer Scar Score(OSS) was 10.3;Patient Scar Score(PSS) was 12.6;Rate of wound closure(RWC) 4.3mm/min;Wound complication rate(WCR) 0.08%;Cost €4.22/patient. The ‘Staples’ arm demonstrated an average OSS-13.1;PSS-16.4;RWC-15.7mm/min;WCR-0.06%;Cost €21.97/patient(excluding labour for ROS). In the ‘Tissue Glue’ arm there was an average OSS-15.7;PSS-18.4;RWC-5.1mm/min;WCR-.19%; Cost €21.10/patient. Conclusions Laparoscopic port site closure with 4–0 Monocryl was most superior with regards to cosmetic outcome and cost-effectiveness. Staples was the fastest method of closure and lowest complication rate.

Background Immune checkpoint inhibitors (ICIs) are being investigated for their role as an adjunct in the multimodal treatment of esophageal adenocarcinoma (EAC). The most effective time to incorporate ICIs remains unknown. Our study profiles systemic anti-tumor immunity perioperatively to help inform the optimal timing of ICIs into current standards of care for EAC patients. Methods Systemic immunity in 11 EAC patients was phenotyped immediately prior to esophagectomy (POD-0) and post-operatively (POD)-1, 3, 7 and week 6. Longitudinal serological profiling was conducted by ELISA. The frequency of circulating lymphocytes, activation status, immune checkpoint expression and damage-associated molecular patterns was assessed by flow cytometry. Results The frequency of naïve T-cells significantly increased in circulation post-esophagectomy from POD-0 to POD-7 (p<0.01) with a significant decrease in effector memory T-cells by POD7 followed by a subsequent increase by week 6 (p<0.05). A significant increase in activated circulating CD27 + T-cells was observed from POD-0 to POD-7 (p<0.05). The percentage of PD-1 + and CTLA-4 + T-cells peaked on POD-1 and was significantly decreased by week 6 (p<0.01). There was a significant increase in soluble PD-1, PD-L2, TIGIT and LAG-3 from POD-3 to week 6 (p<0.01). Increased checkpoint expression correlated with those who developed metastatic disease early in their postoperative course. Th1 cytokines and co-stimulatory factors decreased significantly in the immediate post-operative setting, with a reduction in IFN-γ, IL-12p40, IL-1RA, CD28, CD40L and TNF-α. A simultaneous increase was observed in Th2 cytokines in the immediate post-operative setting, with a significant increase in IL-4, IL-10, IL-16 and MCP-1 before returning to preoperative levels at week 6. Conclusion Our study highlights the prevailing Th2-like immunophenotype post-surgery. Therefore, shifting the balance in favour of a Th1-like phenotype would offer a potent therapeutic approach to promote cancer regression and prevent recurrence in the adjuvant setting and could potentially propagate anti-tumour immune responses perioperatively if administered in the immediate neoadjuvant setting. Consequently, this body of work paves the way for further studies and appropriate trial design is needed to further interrogate and validate the use of ICI in the multimodal treatment of locally advanced disease in the neoadjuvant and adjuvant setting.

Traditionally, esophageal oncological resections have been performed via open approaches with well-documented levels of morbidity and mortality complicating the postoperative course. In contemporary terms, minimally invasive approaches have garnered sustained support in all areas of surgery, and there has been an exponential adaptation of this technology in upper GI surgery with the advent of laparoscopic and robotic techniques. The current literature, while growing, is inconsistent in reporting on the benefits of minimally invasive esophagectomies (MIEs) and this makes it difficult to ascertain best practice. The objective of this review was to critically appraise the current evidence addressing the safety, efficacy, and cost-effectiveness of MIEs versus open esophagectomies. A systematic review of the literature was performed by searching nine electronic databases to identify any systematic reviews published on this topic and recommended Joanna Briggs Institute approach to critical appraisal, study selection, data extraction and data synthesis was used to report the findings. A total of 13 systematic reviews of moderate to good quality encompassing 143 primary trials and 36,763 patients were included in the final synthesis. Eleven reviews examined safety parameters and found a generalized benefit of MIE. Efficacy was evaluated by eight systematic reviews and found each method to be equivalent. There were limited data to judiciously appraise cost-effectiveness as this was only evaluated in one review involving a single trial. There is improved safety and equivalent efficacy associated with MIE when compared with open esophagectomy. Cost-effectiveness of MIE cannot be sufficiently supported at this point in time. Further studies, especially those focused on cost-effectiveness are needed to strengthen the existing evidence to inform policy makers on feasibility of increased assimilation of this technology into clinical practice.

Immune checkpoint inhibitors (ICIs) are being investigated for their role as an adjunct in the multimodal treatment of oesophageal adenocarcinoma (OAC). The most appropriate time to incorporate ICIs remains unknown. Our study profiles systemic anti-tumour immunity perioperatively to help inform the optimal timing of ICIs into current standards of care for OAC patients.Systemic immunity in 11 OAC patients was phenotyped prior to oesophagectomy and on post-operative days (POD) 0, 1, 3, 7 and week 6 using flow cytometry. Longitudinal serological profiling was conducted by 54-plex-ELISA. The frequency of circulating lymphocytes, T cells, T helper cells and cytotoxic T lymphocytes was profiled longitudinally. The activation status of T cells was also assessed using CD69, CD27, CD62L and CD45RA as well as the proportion of T cell subsets in circulation, which included: naïve, central memory, effector memory and terminally differentiated effector memory T cells. This study also profiled the longitudinal alteration of immune checkpoint expression on circulating T cells, which included: PD-1, CTLA-4, TIGIT, TIM-3, LAG-3, PD-L1 and PD-L2. Damage-associated molecular patterns (calreticulin, HMGB1 and MIC-A/B) were also assessed.The frequency of naïve T cells increased in circulation post-oesophagectomy from POD-0 to POD-7 (p<0.01) but returned to baseline at week 6. Effector memory T cells had decreased by POD7 but increased substantially by week 6 (p<0.05). A steady increase in activated circulating CD27+ T cells was observed from POD-0 to POD-7 (p<0.05). The percentage of PD-1+ and CTLA-4+ T cells peaked on POD-1 and was substantially decreased by week 6 (p<0.01). Th1 cytokines were decreased in the immediate post-operative setting with a reduction in IFN-Y, IL-12p40, CD28, CD40L and TNF Alpha. In addition to this IP-10 aka cxcl-10 which is an important chemokine ligand in recruiting anti-tumour TH1 cells and polarising the immune response to a Th1 phenotype is significantly reduced perioperatively. There is a simultaneous increase in Th2 cytokines in the immediate post-operative setting with a significant increase in IL4, IL10, IL16, IL1RA and MCP1 before returning to preoperative levels at week 6.Our study highlights the prevailing immunophenotype and responses to surgery with a switch in balance towards a Th2 and potentially M2 phenotype and consequently, an immunosuppressive milieu. Therefore, orchestrating M2 reprogramming toward an M1 phenotype and similarly shifting the balance in favour of a Th1 phenotype would offer a potent therapeutic approach for augmenting tumourigenesis and promoting cancer regression. Consequently, this study paves the way for further studies and appropriate trial design are needed to interrogate the use of ICB as a trimodal approach with chemoradiotherapy and chemotherapy alone for locally advanced disease in the neoadjuvant and adjuvant setting to determine the optimal timing and subset of patients for their use in the era of precision targeted therapies.N.E. Donlon: None. M. Davern: None. A. Sheppard: None. F. O’Connell: None. S. Ramjit: None. C. Hayes: None. M. Mc Clean: None. H. Temperley: None. C. Butler: None. N. Ravi: None. C. Donohoe: None. J. O’ Sullivan: None. M.R. Dunne: None. J.V. Reynolds: None. J. Lysaght: None.

Abstract Background Robotic-assisted minimally invasive surgery (MIS) for rectal cancer is a relatively new technique. Studies to date suggest that short term outcomes including TME quality, margin status, lymph node retrieval and 30-day morbidity and mortality are equivalent in robotic-assisted and laparoscopic MIS for rectal cancer. By contrast, there is a paucity of data on the medium and long-term oncologic safety of robotic-assisted comparative to laparoscopic surgery for rectal cancer. Methods A retrospective review was conducted of all robotic-assisted (n = 31) and laparoscopic (n = 23) rectal cancer cases performed at our institution between January 2016 to December 2018. Inclusion criteria were patients scheduled electively for a laparoscopic or robotic-assisted resection of rectal cancer (anterior resection or abdomino-perineal resection). Patients with distant metastases at presentation, those who proceeded to surgery as an emergency and those with a non-colorectal primary were excluded from analysis. Results A total of 54 (n = 54) cases met the inclusion criteria and were included in the final analysis. The median follow-up was 34 months. Of the 54, 21 patients received neoadjuvant chemoradiotherapy prior to definitive surgery. No significant difference was detected in local recurrence rates (p = 0.5), overall survival (p = 0.7) or disease-free survival (p = 0.8) between the robotic-assisted and laparoscopic cohorts. Conclusion In this series, robotic-assisted rectal cancer resections were associated with equivalent medium term oncological outcomes as laparoscopic procedures. However, given the small numbers in this cohort, outcomes from larger scale datasets will be required to confirm these results.

Abstract Background While the use of robotic-assisted surgery is now mainstream for procedures such as robotic prostatectomy, its role in general surgery is less well established. Access to training in robotics for general surgery trainees in the Republic of Ireland is variable. Further, there is no data on attitudes of Irish trainees towards the role of robotics. We aimed to establish attitudes of Irish general surgery trainees towards the perceived utility of robotic surgery as well as access and satisfaction with training. Methods A survey was disseminated to trainees in the Republic of Ireland enrolled in a General Surgery training scheme via email and social media. Data collected included stage of training, intended subspecialty, interest in developing robotic skills, previous exposure to robotic surgery, satisfaction with current access to robotic training and opinion on formally incorporating training in robotics into the general surgery curriculum. Results The response rate was 44.8%. Of these, 83% reported interest in training in robotics and 69% anticipated using the technology regularly in consultant practice. Previous exposure to robotic-assisted surgery was significantly predictive of interest in developing the skillset (p = 0.014). Over 71% of trainees reported that they were not satisfied with access to robotic training. Of those satisfied with access, 40% felt there was a role for incorporating robotic training into the curriculum, compared to 68% of those dissatisfied. Conclusion Irish general surgery trainees perceive robotic-assisted surgery to be highly relevant to their future practice. There is an unmet need to provide additional training in the skillset.

Abstract Introduction The COVID-19 pandemic has interfered with many aspects of cancer management, including delayed diagnoses, stalled screening programmes, limiting treatment and clinical trials. Colorectal cancer is the second commonest cause of cancer death in Ireland. The objective of the current study is to assess the impact of this pandemic on colorectal cancer diagnoses and surgery, at a national level. Methods Data on endoscopy, emergency and elective colorectal operations nationally in Ireland over a three year period (2018-2020) were obtained from the National Quality Assurance Improvement System. Data relating to cancer surgery only were included and patient demographics, type of surgery (open/laparoscopic), length of stay (LOS), mortality, admission to critical care and re-admission rates were collected and analysed. Results 31.33% less cancers have been diagnosed between March and November 2020 inclusive when compared to the same period over the past two years with 22% less rectal cancers identified. There has been a 34% reduction in colorectal cancer surgeries over the same period with a reduction of 42% at the initial wave during the period March-May and of concern, this trend has continued. Laparoscopic right hemicolectomies have reduced by 41%, anterior resections have reduced by 51% with no change in the number of temporary ileostomies over the three year period. Conclusion The impact of COVID-19 on colorectal cancer surgery nationally has been profound. The reduction in diagnoses and cancer surgery is concerning and may result in increased late or incurable stage disease as a consequence of late presentation and diagnosis.

Background: Immune checkpoint inhibitors (ICIs) are being investigated for their role as an adjunct in the multimodal treatment of oesophageal cancer. The most appropriate time to incorporate ICIs remains unknown. Our study profiles systemic anti-tumour immunity perioperatively to help inform the optimal timing of ICIs into current standards of care for oesophageal adenocarcinoma (OAC) patients.Methods: Systemic immunity was immunophenotyped pre- and post-oesophagectomy on days 0, 1, 3, 7 and week 6 by flow cytometry (n=14). The frequency of circulating lymphocytes, T cells, cytotoxic and helper T lymphocytes was profiled longitudinally including the proportion of T cell subsets in circulation. This study also profiled immune checkpoint expression on circulating T cells including: PD-1, CTLA-4, TIGIT, TIM-3, LAG-3, PD-L1 and PD-L2. Markers of immunogenicity (calreticulin, HMGB1 and MIC-A/B) were also assessed.Results: The frequency of naïve T cells increased in circulation from POD-0 to POD-7 (P<0.01) but returned to baseline at week 6. Effector memory T cells decreased by POD7 (P<0.01) returning to normal by week 6. Increases in activated circulating CD27+ T cells was observed from POD-0 to POD-7 (P<0.01), interestingly remaining high in a proportion of patients that experienced complications. The percentage of immune checkpoint positive T cells peaked on POD-1 and was substantially decreased by week 6 (P<0.01).Conclusions: We observed increased T cell activation and immune checkpoints immediately post-surgery with returns to baseline by week 6. These results suggest that ICIs such as anti-PD-1 may be beneficial immediately post-surgery to maintain T cell activation and prevent exhaustion of this increased population of activated T cells observed immediately post-surgery.

Background: Traditionally, oesophageal oncological resections have been performed via open approaches with well-documented levels of morbidity and mortality complicating the post-operative course. Recently, minimally invasive approaches have garnered sustained support in all areas of surgery, and there has been an exponential adaptation of this technology in upper GI surgery with the advent of laparoscopic techniques and, the more recently, robotic surgery. The current literature while growing, is inconsistent in reporting on the benefits of minimally invasive oesophagectomies (MIE) and this makes it difficult to decide on appropriate healthcare provision to maintain best practice.Methods: A systematic review (SR) of the literature was performed by searching 9 electronic databases to identify any SRs published on this topic. The recommended Joanna Briggs Institution (JBI) approach to critical appraisal, study selection, data extraction and data synthesis for umbrella reviews (URs) was used and the findings reported according to these guidelines.Results: A total of 13 SRs encompassing 143 primary trials of differing study designs and 36,763 patients were included in the final synthesis. All SRs were critically appraised and found to be of moderate to good quality. Eleven reviews examined safety parameters and found a generalized benefit or at least an equivalency of MIE in this regard. Efficacy was evaluated by 8 SRs and found both methods to be equivalent. There was limited data to judiciously appraise cost-effectiveness as this was only evaluated in one review involving a single trial.Conclusions: Safety and efficacy of MIE is equivalent when compared to open oesophagectomies (OE) with a possible improvement in safety. Cost-effectiveness of MIE cannot be sufficiently supported at this point in time. Early experiences are promising but further studies are warranted to better identify the comparative utility of MIE in oesophageal resection.

Background: The unprecedented burden of the COVID pandemic has brought with it many challenges including economic, social, infrastructural, and crucially significant disruptions in healthcare provision. Consequently, certain aspects of elective care have been deprioritised to enable health systems to respond resulting in growing waiting lists, delayed and in some cases suboptimal care. The purpose of the current study is to evaluate the impact of COVID on elective scheduled care nationally.Methods: Data was sourced from the National Quality Assurance Improvement System via Health Atlas Ireland for the months March–August inclusive over a three-year period (2018–2020). Procedures were divided into elective and emergency and data was identified for the major specialities.Results: During the months of March, April and May 2020, there was a reduction in elective surgical activity of 47%, 83% and 75% respectively compared to the same period over the preceding 2 years. This was the case for all 11 major specialities in the study cohort, with 91% reduced activity reported in Vascular and 92% in ENT during April. In the three subsequent months after easing of lockdown restrictions and curtailment of elective procedures national elective scheduled care was still 33% below the same period in 2018 and 2019. Similarly, endoscopy figures reduced by 90% over the three months of COVID leading to suboptimal and delayed diagnostics.Conclusions: The impact of COVID has been profound in elective surgical care and consequently, training and waiting lists have suffered immensely. This may, however, provide new avenues to replace the current model of care and alternatives to the National Treatment Purchase Fund.