Importance:Percutaneous cholecystostomy drains (PCDs) are frequently used in patients with acute cholecystitis (AC) who are poor surgical candidates. However, standardized guidance on the indications, follow-up, and management of PCDs is lacking in the literature. Objective:To gather expert consensus recommendations and develop guidelines on the management of PCDs in patients with AC. Evidence Review:This Delphi consensus study was conducted between August 2024 and April 2025. Statements were generated following a structured literature review and evaluated through a 3-round Delphi process. Consultant surgeons and interventional radiologists practicing in Ireland and the UK were invited to participate through national surgical societies and professional networks. The primary outcome was the level of agreement among experts on statements addressing indications, follow-up imaging, duration of drainage, and timing of definitive surgery following percutaneous cholecystostomy. Consensus was predefined as agreement of 80% or greater among panelists. Findings:The panel included 45 experts (39 surgeons [86.7%] and 6 interventional radiologists [13.3%]). After 3 Delphi rounds, consensus was reached on 20 statements regarding PCD management. The panel agreed that laparoscopic cholecystectomy should be the first-line management for AC. Use of PCDs was considered an appropriate alternative strategy to cholecystectomy for patients with severe AC who were poor candidates for surgery. Transhepatic drains were preferred to transperitoneal drains, and panelists agreed drains should remain in situ for at least 4 to 6 weeks postinsertion. The panel agreed that cholangiography should be performed prior to PCD removal. A completion cholecystectomy was considered feasible with low perioperative complications in most cases. The optimal time for interval laparoscopic cholecystectomy was agreed to be 6 to 8 weeks after drain insertion. Endoscopic drainage was considered a novel technique that could be used where available. There was no consensus on the management of AC during pregnancy or the feasibility of clamping tests. Conclusions and Relevance:In this Delphi consensus study, expert agreement was achieved on key aspects of the management and follow-up of PCDs. These recommendations may help standardize clinical practice and inform decision-making in the management of AC.

The anticipated surgical and postoperative outcomes following robotic-assisted single anastomosis duodeno-ileal bypass with sleeve gastrectomy (R-SADI-S) are not well described in the surgical literature. To perform a systematic review to evaluate clinical and surgical outcomes in patients who have undergone R-SADI-S. A systematic review was performed in accordance with the PRISMA guidelines. Basic descriptive statistics were performed using SPSS v26.0. Overall, 4 studies including data from 160 patients were included. The mean age at the time of surgery was 38.1 years and 55.6

BACKGROUND:The optimal oesophagogastric anastomosis technique for oesophageal cancer surgery remains unclear. The aim of this study was to perform a network meta-analysis (NMA) of randomised clinical trials (RCTs) to compare oesophagogastric anastomosis techniques for oesophageal cancer surgery. METHODS:A systematic review and NMA were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines-NMA extension. Statistical analyses were performed using R and Shiny. RESULTS:Overall, 16 RCTs were included (14 provided data eligible for NMA). These included 2520 patients and 4 different anastomosis techniques: 1055 (41.9 %) patients underwent circular stapled (CS), 1232 (48.9 %) underwent handsewn (HS), 100 (3.9 %) underwent triangulated stapled (TS) and 133 (5.3 %) underwent linear stapled (LS). Fourteen studies reported on open surgery, while one reported on both open and minimally invasive techniques. At NMA, no significant difference was observed regarding anastomotic leak rates among all techniques, while HS significantly reduced anastomotic leaks following cervical technique (odds ratio (OR): 0.32, 95 % confidence interval (CI): 0.13-0.78). Moreover, HS (OR: 0.58, 95 % CI: 0.38-0.90) and LS (OR: 0.21, 95%CI: 0.06-0.71) significantly reduced anastomotic stricture rates, while LS significantly reduced anastomotic strictures following intrathoracic anastomotic technique (OR: 0.17, 95%CI: 0.06-0.90). CONCLUSION:HS reduced anastomotic leaks following cervical anastomoses, while HS and LS reduced overall anastomotic strictures (with LS significantly reducing strictures following intrathoracic anastomoses). Importantly, institutional and surgeon expertise should be considered prior to adopting these results into contemporary practice for open oesphagectomy, with a call for the harmonisation of trials to align with contemporary, minimally invasive approaches.

The optimal hypoabsorptive surgical approach for management of severe obesity remains unclear. To perform a network meta-analysis (NMA) of randomized clinical trials (RCTs) comparing Roux-en-y gastric bypass (RYGB), SADI-S (single anastomosis duodeno-ileal bypass with sleeve gastrectomy), one anastomosis gastric bypass (OAGB) and duodenal switch (DS). A systematic review was performed as per PRISMA-NMA guidelines. Statistical analyses were performed using R and shiny. 12 RCTs (with 5 sequential analyses) were included, involving 986 patients [471 RYGB (47.8

Oesophagectomy remains a highly morbid operation, in spite of advances in neoadjuvant approaches, perioperative care, and minimally invasive surgery. Textbook outcome (TBO) is a composite metric assessing surgical quality and perioperative outcomes. Our group has previously demonstrated a survival advantage with a TBO. Additionally, operating by a minimally invasive approach combined with TBO further improves survival. Robotic assisted minimally invasive oesophagectomy (RAMIO) is oncologically safe and may improve perioperative outcomes. This study aims to determine rates of TBO in RAMIO, and compare this with a pre-existing cohort. Patients undergoing oesophagectomy from 2011-2024 were included. Only patients undergoing RAMIO were included post-February 2020. Standard clinicopathologic variables were recorded. TBOs were calculated as previously described1. Statistical analyses were performed with jamovi 2.3.28. 362 patients underwent oesophagectomy. 93 had a RAMIO, 139 underwent open oesophagectomy (OO) and 130 underwent laparoscopic oesophagectomy (LO). 53% of RAMIO patients achieved a TBO, compared with 19% of OO and 45% LO (p=0.001, 0.34). For the RAMIO group the most common reason for not achieving a TBO was a post-operative complication (39%), followed by a prolonged length of stay (19%), similar to the non-RAMIO group (32% and 28% respectively). In the RAMIO group there were no associations between age, ASA status, patient sex and neoadjuvant regimen and the likelihood of achieving a TBO. The introduction of RAMIO incrementally improve TBO rates, particularly compared with OO. As the use of RAMIO expands, there may be a corresponding incremental impact on long-term oncologic outcomes.

Background Little is known regarding long-term outcomes of survivors beyond 5 years after esophagectomy. This study assesses oncological outcomes of long-term survivors of esophageal cancer. Methods Data is derived from a multi-center randomized controlled trial comparing neoadjuvant chemoradiotherapy (NCRT) and surgery to surgery alone for clinically stage I and II esophageal cancers (FFCD9901). Only patients undergoing esophagectomy were included in this study. Clinicopathological variables of 5-year survivors were analyzed. Multivariate logistic regression analysis identified factors predictive of death prior to 5 years. Patterns of disease recurrence and second primary tumor development were established. Results From June 2000 until June 2009, 195 patients from 30 French centers were randomly assigned to NCRT followed by surgery or surgery alone. Of 170 patients who underwent esophagectomy, 70 patients were alive at 5 years - an overall 5-year survival of 41.2 %. In logistic regression multivariate analysis, WHO performance status of ≥1 (p = 0.045), advanced pT category (p = 0.030) and post-operative complications (p = 0.047) predicted death prior to 5 years. Twenty patients died after the 5-year time point, 9 of these due to progression of their esophageal cancer. Nineteen patients developed a second primary malignancy, of whom 14 developed either a head and neck or lung cancers. Conclusions Being alive 5 years after esophagectomy does not equate to cure. In clinically staged early disease, a distinct group of patients develop disease recurrence later than 5 years from treatment. Development of a second primary cancer in this population poses a clinical threat. Surveillance protocols should be adapted accordingly.

Transversus abdominus plane (TAP) blocks have become increasingly popular, due to a perceived reduction in post-operative pain following laparoscopic surgery. Their value following sleeve gastrectomy remains unclear. To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) evaluating the efficacy of TAP block in patients undergoing laparoscopic sleeve gastrectomy. Integration of data from bariatric surgery units across the world. A systematic review was performed as per PRISMA guidelines. Meta-analysis was performed using Review Manager v5.4. Eleven RCTs including 776 patients were included with 338 randomized to TAP block (50.0

Oesophageal cancer incidence is rising, with a concurrent increase in oesophagectomy as neoadjuvant and perioperative therapies improve. Oesophagectomy remains the cornerstone of curative treatment. The adoption of robotic-assisted surgery (RAS) in oesophagectomy has been slow, with concerns regarding the learning curve and safety. This series describes the safe introduction of RAS for oesophagectomy in Ireland. A review of prospectively maintained data from a single surgeon was performed, encompassing the period from February 2016 to December 2024. Standard clinicopathological variables were extracted. The RAS program (using DaVinci X/Xi) for oesophagectomy began in March 2020. Operations were classified as open, hybrid, minimally invasive, RAS-hybrid, or totally RAS. Length of stay (LOS), margin status, nodal yield, perioperative complications, and mortality were compared, as well as ERAS outcomes, where applicable. A total of 198 patients underwent oesophagectomy; 93 underwent RAS (52 total RAS, 41 hybrid). Demographics were comparable between RAS and non-RAS groups. There was an improvement in nodal yield for the total-RAS patients compared to non-RAS patients (mean 27.8, SD 8.7 vs 23.2, SD 9.1; p = 0.1). There was no difference in margin status (p = 0.55), overall complications (p = 0.23), LOS (p = 0.31), or 90-day mortality (p = 0.85) between RAS and non-RAS groups. The anastomotic leak rate was 3

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.

Paraconduit hernia occurs uncommonly after oesophagectomy, with the displacement of abdominal contents through the post operative hiatus into the thorax. Clinical presentations vary from asymptomatic to life-threatening visceral ischaemia and can present many years post-operatively. As such, they present a dilemma to oesophageal surgeons in respect of diagnosis and appropriate management. A minimally invasive approach has been repeatedly cited as a risk factor for hernia formation. A prospectively maintained database of oeospahgectomies performed at our centre was interrogated from 2019–2023. Demographics, operative approach andclinico-pathological data were extracted. Statistical analyses were conducted using MinitabTM v18. From 2019–2023 190 oesophagectomies were completed of which 76%(145) were oesoaphgeal and 24% (45) were oesophago-gastric junctional tumours. The mean age was 66 years ( +/- 9.8 years) and male patients represented 78% of cases. The distribution of surgical approach was Minimally invasive oesophagectomy (MIO)65/190, Robotically assisted minimally invasive oesophagectomy (RAMIO)63/190, Open 2/190 and Hybrid 60/190. The overall rate of paraconduit hernia was 11.6% (22/190). 5/22 occurred within 3 months of oesophagectomy and 10/22 presented symptomatically. The most common organ to herniate was the transverse colon in 19 cases, followed by small bowel in 6. The rate of herniation among the different approaches was hybrid 4/60, RAMIO 12/63 and MIO 6/65 p-0.076. The rates of paraconduit hernia at our institution are comparable to international standards. The transition towards a more minimally invasive approach to oesophagectomy and the adoption of robotic platforms to achieve it has not significantly impacted the rate of hernia development.

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.

There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6 years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features.

Background: Obesity is a complex disease with global implications for public health and economic costs. Bariatric surgery is recognized as an effective and cost-efficient treatment for severe obesity. Some individuals may turn to medical tourism if they cannot access bariatric surgery domestically. However, this presents challenges for clinicians when patients return with postoperative complications.

Neoadjuvant cancer treatment (NCT) reduces both physical fitness and physical activity (PA) levels, which can increase the risk of adverse outcomes in cancer patients. This study aims to determine the effect of exercise prehabilitation on PA and sedentary behavior (SB) in patients undergoing NCT and surgery for esophagogastric malignancies. This study is a randomized pragmatic controlled multi-center trial conducted across three Irish hospitals. Participants were aged >= 18 years scheduled for esophagectomy or gastrectomy and were planned for NCT and surgery. Participants were randomized to an exercise prehabilitation group (EX) that commenced following cancer diagnosis, continued to the point of surgery, and resumed following recovery from surgery for 6 weeks or to usual care (UC) who received routine treatment. The primary outcome measures were PA and SB. Between March 2019 and December 2020, 71 participants were recruited: EX (n = 36) or UC (n = 35). No significant differences were found between the EX group and UC group on levels of PA or SBs across all measured timepoints. Significant decreases in moderate-vigorous physical activity levels (MVPAs) were found between baseline and post-surgery (P = 0.028), pre-surgery and post-surgery (P = 0.001) and pre-surgery and 6-week follow-up (P = 0.022) for all participants. Step count also significantly decreased between pre-surgery and post-surgery (P < 0.001). Baseline aerobic fitness was positively associated to PA levels and negatively associated with SB. Esophagogastric cancer patients have lower than recommended levels of PA at the time of diagnosis and this decreased further following completion of NCT. An optional home- or group-based exercise intervention was not effective in improving PA levels or behaviors across the cancer treatment journey.

INTRODUCTION:There is uncertainty regarding the optimal mesh fixation techniques for laparoscopic ventral and incisional hernia repair. AIM:To perform a systematic review and network meta-analysis of randomised control trials (RCTs) to investigate the advantages and disadvantages associated with absorbable tacks, non-absorbable tacks, non-absorbable sutures, non-absorbable staples, absorbable synthetic glue, absorbable sutures and non-absorbable tacks, and non-absorbable sutures and non-absorbable tacks. METHODS:A systematic review was performed as per PRISMA-NMA guidelines. Odds ratios (ORs) and mean differences (MDs) were extracted to compare the efficacy of the surgical approaches. RESULTS:Nine RCTs were included with 707 patients. Short-term pain was significantly reduced in non-absorbable staples (MD; -1.56, confidence interval (CI); -2.93 to -0.19) and non-absorbable sutures (MD; -1.00, CI; -1.60 to -0.40) relative to absorbable tacks. Recurrence, length of stay, operative time, conversion to open surgery, seroma and haematoma formation were unaffected by mesh fixation technique. CONCLUSION:Short-term post-operative pain maybe reduced by the use of non-absorbable sutures and non-absorbable staples. There is clinical equipoise between each modality in relation to recurrence, length of stay, and operative time.

Introduction:Although the benefits of post-operative rehabilitation in cancer surgery are well established, the role of prehabilitation is less defined. Oesophagogastric cancers present a unique opportunity to study the impact of prehabilitation during the neoadjuvant window, whether with chemotherapy or chemoradiotherapy (NCT) in patients who are frequently nutritionally depleted. This trial examines the impact of a community-based exercise programme on patient fitness during and after the neoadjuvant window.Methods:A pragmatic, randomized controlled multicentre trial was undertaken in three centres. Inclusion criteria were patients aged at least 18 years planned for NCT and esophagectomy or gastrectomy. Participants were randomized 1:1 to an exercise prehabilitation group (EX) or to usual care (UC). The primary endpoint was cardiorespiratory fitness between baseline and pre-surgery time point using the 6-minute walk test (MVT). Secondary endpoints included a hand dynamometer, 10-s sit-to-stand, activity behaviour, body mass index, semi-structured interviews, questionnaires assessing the quality of life, surgical fear, general self-efficacy and mastery.Results:Between March 2019 and December 2020, 71 participants were recruited: EX (n=36) or UC (n=35). From baseline to pre-surgery, the difference-in-difference (DID) for EX showed a significant improvement in 6MWT of 50.7 m (P=0.05) compared to UC [mean (SD): 522.1 m (+/-104.3) to 582.1 m (+/-108) vs. 497.5 m (+/-106.3) to 506.0 m (+/-140.4). There was no statistically significant DID for secondary outcome measures.Conclusions:This community exercise prehabilitation programme significantly improves physical fitness for surgery, is feasible and provides a standardized framework for the prescription of exercise in oesophagogastric cancer patients undergoing NCT.

Abstract Background Nutrition is a modifiable risk factor impacting surgical outcomes in OG cancer. Its key role influencing health related quality of life is emerging with improved survivorship. Guidelines depicting optimal timing and type of dietetic intervention for this patient group are unclear. In order to best direct dietetic care, optimise timing of nutritional interventions and understand demand for service it is important to reflect on current provision. This audit aimed to describe the dietetic outpatient service to patients undergoing OG Surgery for cancer in a national centre for treatment of oesophageal cancer. Method A retrospective review of dietetic records and statistics. Patients who underwent oesophagectomy (O), gastrectomy (G) or subtotal gastrectomy (STG) for cancer between May 2022- May 2023 were included. Results 63 patients were included: 38 O, 17 TG, 8 STG. 11 were seen by the dietitian at first visit to OG Clinic (9 O, 1 TG, 1 STG) – 6 had an elective feeding tube (FT) inserted for neoadjuvant treatment (5 O, 1 STG). 83% attended a surgical pre-assessment dietetic appointment (36 O, 14 TG, 2 STG). 86% were reviewed within 1 month post O or TG, 75% post STG. 258 dietetic interventions occurred in the first year post-op (median 3.5, range 0-14). 64% in the first 3 months(m) post op, 16% at 3-6m, 10% at 6-9m, 10% at 9-12m. Conclusion In this high nutritional risk group only 18% are assessed by a dietitian at first visit to UGI MDT clinic. There is a successful pathway for immediate peri-operative dietetic care in patients post O and TG. The pathway for STG is less well established. Dietetic interventions are concentrated in the first 3 months after surgery. There is no established protocol to support longer term nutritional needs into survivorship. To inform practice a measure of patient experience and needs would be useful, to explore best delivery format and access routes to future services.