Unmet needs in survivorship: Increased anxiety post oesophago-gastric cancer surgery

INTRODUCTION

Despite significant surgical advancements in the treatment of oesophago-gastric cancer (OGC), patients often experience a considerable decline in health-related quality of life postoperatively. Psychological factors, such as hypervigilance and symptom-specific anxiety, may contribute to this. This study aimed to investigate the prevalence and trend of hypervigilance and symptom-specific anxiety in OGC survivors across treatment stages.

MATERIALS AND METHODS

103 patients with either gastric or oesophageal cancer, treated with surgery (and/or neoadjuvant chemotherapy), completed a specialist measure of oesophageal hypersensitivity (Oesophageal Anxiety and Hypervigilance Scale) at five time-points: spanning from diagnostic clinics to 6 months post-hospital discharge.

RESULTS

The results indicate a trend of rising symptom-specific anxiety and hypervigilance scores over time post-hospital discharge. Total scores showed variations over time; elevated at diagnosis, decreasing between pre-operative assessment and 2-4 weeks post-hospital discharge, and rising again at between 3 and 6 months post-discharge, exceeding the average score at diagnosis. The patterns for the subscale scores for symptom-specific anxiety and hypervigilance followed a similar trend, though anxiety scores consistently exceeded hypervigilance scores at previous time-points.

CONCLUSION

In noting the presence and variations of symptom-specific anxiety and hypervigilance in patients with OGC, this study directs attention to the previously unexplored significant psychological distress. Although specific conclusions from the data are restricted due to the study's design, it indicates the importance of assessing and addressing these psychological factors for effective management of patients with OGC.

National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma

Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett's oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett's oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett's oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett's-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett's oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.

Multicentre validation of CT grey-level co-occurrence matrix features for overall survival in primary oesophageal adenocarcinoma

BACKGROUND

Personalising management of primary oesophageal adenocarcinoma requires better risk stratification. Lack of independent validation of proposed imaging biomarkers has hampered clinical translation. We aimed to prospectively validate previously identified prognostic grey-level co-occurrence matrix (GLCM) CT features for 3-year overall survival.

METHODS

Following ethical approval, clinical and contrast-enhanced CT data were acquired from participants from five institutions. Data from three institutions were used for training and two for testing. Survival classifiers were modelled on prespecified variables ('Clinical' model: age, clinical T-stage, clinical N-stage; 'ClinVol' model: clinical features + CT tumour volume; 'ClinRad' model: ClinVol features + GLCM_Correlation and GLCM_Contrast). To reflect current clinical practice, baseline stage was also modelled as a univariate predictor ('Stage'). Discrimination was assessed by area under the receiver operating curve (AUC) analysis; calibration by Brier scores; and clinical relevance by thresholding risk scores to achieve 90% sensitivity for 3-year mortality.

RESULTS

A total of 162 participants were included (144 male; median 67 years [IQR 59, 72]; training, 95 participants; testing, 67 participants). Median survival was 998 days [IQR 486, 1594]. The ClinRad model yielded the greatest test discrimination (AUC, 0.68 [95% CI 0.54, 0.81]) that outperformed Stage (ΔAUC, 0.12 [95% CI 0.01, 0.23]; p = .04). The Clinical and ClinVol models yielded comparable test discrimination (AUC, 0.66 [95% CI 0.51, 0.80] vs. 0.65 [95% CI 0.50, 0.79]; p > .05). Test sensitivity of 90% was achieved by ClinRad and Stage models only.

CONCLUSIONS

Compared to Stage, multivariable models of prespecified clinical and radiomic variables yielded improved prediction of 3-year overall survival.

CLINICAL RELEVANCE STATEMENT

Previously identified radiomic features are prognostic but may not substantially improve risk stratification on their own.

KEY POINTS

• Better risk stratification is needed in primary oesophageal cancer to personalise management. • Previously identified CT features-GLCM_Correlation and GLCM_Contrast-contain incremental prognostic information to age and clinical stage. • Compared to staging, multivariable clinicoradiomic models improve discrimination of 3-year overall survival.

Long Term Survival of Heritable Pulmonary Arterial Hypertension Associated with Hereditary Hemorrhagic Telangiectasia: A Case Series

Hereditary hemorrhagic telangiectasia (HHT) is a hereditary disease characterized by recurrent epistaxis, mucocutaneous telangiectasias, and visceral arteriovenous malformations. Multiple genetic mutations have been linked to this rare disease, including ENG, ALK1 (ACVRL1), and MADH4. Pulmonary hypertension is a potential complication of HHT, with the most common phenotypes being World Health Organization (WHO) group 1 heritable pulmonary arterial hypertension (PAH), which is typically associated with ALK1 mutation; WHO group 2 pulmonary hypertension due to high output heart failure from hepatic arteriovenous malformations and/or anemia; and WHO group 2 due to high pulmonary artery wedge pressure. There is scarce evidence to help guide treatment of heritable PAH in HHT, and observational literature suggests that patients with HHT and heritable PAH have a worse prognosis compared to patients with idiopathic PAH. We describe the diagnosis, pulmonary hemodynamics, and detailed treatment courses of three patients with ALK1-associated HHT and PAH, who all exhibited objective clinical improvement with parenteral prostacyclins and oral agents.

EAES Multidisciplinary Rapid Guideline: systematic review, meta-analysis, GRADE assessment and evidence-informed recommendations on the surgical management of paraesophageal hernias

BACKGROUND

New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations.

OBJECTIVE

To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders.

METHODS

We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey.

RESULTS

The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn .

CONCLUSION

An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process.

GUIDELINE REGISTRATION NUMBER

PREPARE-2023CN018.

Multicenter, Prospective Cohort Study of Oesophageal Injuries and Related Clinical Outcomes (MUSOIC study)

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.

Delayed Surgical Intervention After Chemoradiotherapy in Esophageal Cancer: (DICE) Study

OBJECTIVE

To determine the impact of delayed surgical intervention following chemoradiotherapy (CRT) on survival from esophageal cancer.

BACKGROUND

CRT is a core component of multimodality treatment for locally advanced esophageal cancer. The timing of surgery following CRT may influence the probability of performing an oncological resection and the associated operative morbidity.

METHODS

This was an international, multicenter, cohort study, including patients from 17 centers who received CRT followed by surgery between 2010 and 2020. In the main analysis, patients were divided into 4 groups based upon the interval between CRT and surgery (0-50, 51-100, 101-200, and >200 days) to assess the impact upon 90-day mortality and 5-year overall survival. Multivariable logistic and Cox regression provided hazard ratios (HRs) with 95% CIs adjusted for relevant patient, oncological, and pathologic confounding factors.

RESULTS

A total of 2867 patients who underwent esophagectomy after CRT were included. After adjustment for relevant confounders, prolonged interval following CRT was associated with an increased 90-day mortality compared with 0 to 50 days (reference): 51 to 100 days (HR=1.54, 95% CI: 1.04-2.29), 101 to 200 days (HR=2.14, 95% CI: 1.37-3.35), and >200 days (HR=3.06, 95% CI: 1.64-5.69). Similarly, a poorer 5-year overall survival was also observed with prolonged interval following CRT compared with 0 to 50 days (reference): 101 to 200 days (HR=1.41, 95% CI: 1.17-1.70), and >200 days (HR=1.64, 95% CI: 1.24-2.17).

CONCLUSIONS

Prolonged interval following CRT before esophagectomy is associated with increased 90-day mortality and poorer long-term survival. Further investigation is needed to understand the mechanism that underpins these adverse outcomes observed with a prolonged interval to surgery.

Multiple staging investigations may not change management in patients with high-grade dysplasia or early esophageal adenocarcinoma

The clinical value of multiple staging investigations for high-grade dysplasia or early adenocarcinoma of the esophagus is unclear. A single-center prospective cohort of patients treated for early esophageal cancer between 2000 and 2019 was analyzed. This coincided with a transition period from esophagectomy to endoscopic mucosal resection (EMR) as the treatment of choice. Patients were staged with computed tomography (CT), endoscopic ultrasound (EUS) and 2-deoxy-2-[18F]fluoro-d-glucose (FDG) positron emission tomography(PET)/CT. The aim of this study was to assess their accuracy and impact on clinical management. 297 patients with high-grade dysplasia or early adenocarcinoma were included (endoscopic therapy/EMR n = 184; esophagectomy n = 113 [of which a 'combined' group had surgery preceded by endoscopic therapy n = 23]). Staging accuracy was low (accurate staging EMR: CT 40.1%, EUS 29.6%, FDG-PET/CT 11.0%; Esophagectomy: CT 43.3%, EUS 59.7%, FDG-PET/CT 29.6%; Combined: CT 28.6%, EUS46.2%, FDG-PET/CT 30.0%). Staging inaccuracies across all groups that could have changed management by missing T2 disease were CT 12%, EUS 12% and FDG-PET/CT 1.6%. The sensitivity of all techniques for detecting nodal disease was low (CT 12.5%, EUS 12.5%, FDG-PET/CT0.0%). Overall, FDG-PET/CT and EUS changed decision-making in only 3.2% of patients with an early cancer on CT and low-risk histology. The accuracy of staging with EUS, CT and FDG-PET/CT in patients with high-grade dysplasia or early adenocarcinoma of the esophagus is low. EUS and FDG-PET/CT added relevant staging information over standard CT in very few cases, and therefore, these investigations should be used selectively. Factors predicting the need for esophagectomy are predominantly obtained from EMR histology rather than staging investigations.

Extended Wireless pH Monitoring Significantly Increases Gastroesophageal Reflux Disease Diagnoses in Patients With a Normal pH Impedance Study

Background/Aims

Extended wireless pH monitoring (WPM) is used to investigate gastroesophageal reflux disease (GERD) as subsequent or alternative investigation to 24-hour catheter-based studies. However, false negative catheter studies may occur in patients with intermittent reflux or due to catheter-induced discomfort or altered behavior. We aim to investigate the diagnostic yield of WPM after a negative 24-hour multichannel intraluminal impedance pH (MII-pH) monitoring study and to determine predictors of GERD on WPM given a negative MII-pH.

Methods

Consecutive adult patients (> 18 years) who underwent WPM for further investigation of suspected GERD following a negative 24-hour MII-pH and upper endoscopy between January 2010 and December 2019 were retrospectively included. Clinical data, endoscopy, MII-pH, and WPM results were retrieved. Fisher's exact test, Wilcoxon rank sum test, or Student's t test were used to compare data. Logistic regression analysis was used to investigate predictors of positive WMP.

Results

One hundred and eighty-one consecutive patients underwent WPM following a negative MII-pH study. On average and worst day analysis, 33.7% (61/181) and 34.2% (62/181) of the patients negative for GERD on MII-pH were given a diagnosis of GERD following WPM, respectively. On a stepwise multiple logistic regression analysis, the basal respiratory minimum pressure of the lower esophageal sphincter was a significant predictor of GERD with OR = 0.95 (0.90-1.00, P = 0.041).

Conclusions

WPM increases GERD diagnostic yield in patients with a negative MII-pH selected for further testing based on clinical suspicion. Further studies are needed to assess the role of WPM as a first line investigation in patients with GERD symptoms.

1296 DEMOGRAPHIC AND MORTALITY EVALUATION OF URGENT COMMUNITY RESPONSE REFERRALS THAT ARE MANAGED IN COMMUNITY VS THOSE HOSPITALISED

Introduction

Demographic evaluation of urgent community response teams [UCR] is important to ensure equity of access and clinical outcomes for patients from all socio-demographic groups using such services. This retrospective descriptive study aimed to evaluate demographic and mortality differences between patients referred to UCR in terms of those managed in the community [Group1] versus those subsequently hospitalised [Group2].

Methods

Data was obtained over a 12-month period [2021-2022] for all new patients referred to a 7-day consultant-led UCR that serves a multi-ethnic, inner-city population. Data included demographic details, source of referral, urgency of referral and mortality within 60 days.

Results

Of 995 patients, 75.6%[n=752] were in Group 1; 24.4%[243] were in Group 2. The two groups were comparable in terms of age [mean(SD): 80.1(12.6) vs 80.0(11.4), p=ns] and gender [males:39.4% vs 42.4%,p=ns]. There were similar proportion of Black and minority ethnic patients within the two groups [21.0% (158) vs 24.7% (60), p=ns]. Source of referral were comparable between the two groups[p=ns]; overall, 67.7%[674] were from GP practices, 5.6%[56] Community Practitioners, 4.7%[47] NHS111, 2.7%[27] Ambulance, 32%[32] Palliative care, 5.9%[59] Emergency department, 10.1%[100] post-hospitalisation. Compared to Group 1 [46.9% (353)], significantly more patients in Group 2 were referred for urgent assessment within 2 hours [65.4% (159), p<0.001]. More patients died in Group2 within 60 days [22.2% (54) vs 11.3% (85), p<0.001].

Discussion

This large survey has described age, gender and ethnic similarities between the two groups, demonstrating equity of provision irrespective of protected characteristics. As might be clinically expected, patients referred for hospitalisation were assessed more urgently and had higher mortality rates compared to those managed in the community. This study provides valuable information for clinicians and researchers of similar UCR services in future.

SX-ELLA biodegradable stent for benign oesophageal strictures: a systematic review and proportion meta-analysis

Background

This systematic review aimed to analyse the use of the SX-ELLA biodegradable stent (BDS) for benign oesophageal strictures through the assessment of clinical and technical success, differences in pre- and post-BDS insertion dysphagia scores, rates of stent migration, and safety.

Methods

A systematic review was reported according to PRISMA guidelines, with a prospectively registered protocol. The databases PubMed, Embase, SCOPUS, and ClinicalTrials.gov were searched up to March 2022. Studies assessing the use of the SX-ELLA BDS in adults with benign oesophageal strictures were included. A pooled data analysis was conducted to analyse the clinical and technical success associated with BDS use, rate of stent migration, and safety.

Results

Of the 1509 articles identified, 16 studies treating 246 patients were eligible for inclusion. BDS was clinically successful in 41.9% of cases (95% CI = 35.7 – 48.1%), defined as those who experienced complete symptom resolution following BDS insertion. Technical success was achieved in 97.2% of patients (95% CI = 95.1 – 99.3%). A pooled analysis concluded a decrease in mean dysphagia score of 1.8 points (95% CI = 1.68 – 1.91) following BDS insertion. Re-intervention was required in 89 patients (36.2%, 95% CI = 30.2 – 42.2%), whilst stent migration occurred in 6.5% of patients (95% CI = 3.4 – 9.6%). A total of 37 major clinical complications related to BDS insertion were reported (15.0%, 95% CI = 10.5 – 19.5%).

Conclusion

The pooled data analysis demonstrates the high technical and moderate clinical success of the SX-ELLA biodegradable stent, supporting its use for benign oesophageal strictures in adults. However, greater evidence is required for more robust conclusions to be made in terms of success when compared to alternative methods of intervention, such as endoscopic dilation.

OGC O02 The prognostic effect of pathological lymph node regression after neoadjuvant chemotherapy for oesophageal adenocarcinoma – a multicentre study

Background

The prognostic benefits of primary tumour and lymph node (LN) downstaging after neoadjuvant chemotherapy for oesophageal adenocarcinoma are well described. Pathological primary tumour regression grading (TRG) is widely used in the assessment of response to chemotherapy and has been shown to have prognostic value in this patient group. However, there is a lack of robust evidence regarding the prognostic effect of pathological response in LN despite emerging evidence of a discrepancy, up to 25% of patients in some studies, between TRG in the primary tumour and response in regional LNs. Although primary tumour regression is routinely documented as part of the standard pathological reporting of oesophagectomy specimens, LN regression is generally overlooked despite it's potential prognostic value. The aim of this study was to investigate the relationship between pathological response in LN, tumour recurrence and survival.

Methods

Multicentre cohort study including 763 patients with oesophageal adenocarcinoma treated with neoadjuvant chemotherapy followed by surgery at Guy's and St Thomas’ NHS Foundation Trust (NHS-FT), The Royal Marsden NHS-FT, University Hospitals Birmingham NHS-FT, University Hospital Southampton NHS-FT and Belfast Health and Social Care Trust. Tumour regression was assessed in the primary tumour (as described by Mandard) and, retrospectively, in LNs retrieved from oesophagectomy specimens. LN were graded according to the proportion of fibrosis and residual tumour providing a LN regression score (LNRS). LNRS 1, complete response; LNRS 2, < 10% remaining tumour; LNRS 3, 10–50% remaining tumour; LNRS 4, > 50% viable tumour; LNRS 5, no evidence of response. Regression was defined as a LNRS of 1–3. Patients were classified as LN negative (no evidence of tumour or regression in any LN), complete LN-responders (evidence of regression ≥1 LN, no residual tumour in any LN), partial LN-responders (evidence of regression ≥1 LN with residual tumour ≥1 LN) and LN non-responders (no or minimal regression in any LN). Survival analysis was performed using multivariable Cox regression providing hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, gender, chemotherapy regimen, clinical stage, tumour grade, lympho-vascular invasion and primary tumour response.

Results

Mean age was 63 years with the majority male (86.2%). In total, 17,930 LN from 763 patients were analysed for evidence of response to chemotherapy. Overall, 243 (31.8%) patients were classified as LN negative, 62 (8.1%) as complete LN-responders, 155 (20.3%) as partial LN-responders and 303 (39.7%) as LN non-responders. Less than half (322/763, 42.2%) of patients demonstrated a pathological response in the primary tumour (Mandard score 1–3). Some patients had a LN response in the absence of a response in the primary tumour (97/431, 22.5%). Multivariable Cox regression survival analysis demonstrated improved overall survival in complete LN-responders (HR 0.37 95% CI 0.24–0.58), partial LN-responders (HR 0.70 95% CI 0.55–0.89) and LN negative patients (HR 0.34 95% CI 0.26–0.44) compared to LN non-responders. Similar results were observed for disease-free survival (complete LN-responders, HR 0.34 95% CI 0.22–0.53; partial LN-responders, HR 0.74 95% CI 0.58–0.93; LN negative, HR 0.33 95% CI 0.25–0.42). Rates of tumour recurrence were lower in patients who demonstrated a LN response or had negative LN (LN negative 23.0% vs complete LN-responders 19.4% vs partial LN-responders 50.3% vs LN non-responders 66.7%, p<0.001).

Conclusions

In this cohort of patients with oeosphageal adenocarcinoma treated with neoadjuvant chemotherapy prior to surgical resection, LN regression was a strong predictive factor for better survival. This relationship was independent of primary tumour response, which was discordant in a significant number of patients. Complete LN-responders had equivalent survival to those with negative LN. Complete and partial LN-responders had better survival than LN non-responders. Evaluation and documentation of LN regression should be considered during the standard pathological reporting of oesophagectomy specimens.

A O05 MUlti-center cohort Study of Oesophageal Injuries and related Clinical outcomes (MUSOIC) study

Background

Perforation of the oesophagus (OP) represent a potentially lethal yet poorly managed clinical condition due to its rarity, variation in clinical presentation and little consensus on the optimal management of these patients. Previous studies have shown that timely and appropriate treatment of OPs is the most important determinant of patient outcomes, and a delay in initiating the correct management within 24 hours increased the mortality rate from 10% to over 60%. Historically, patients have been managed based on the personal experience and preference of the surgeon, and accordingly most patients underwent surgical management based on data from small retrospective case series. Depending on the cause of injury, location of perforation and status of the patient, options include conservative management; endoscopy (stenting or clipping); and surgery (drainage, diversion, primary repair, or oesophagectomy). Currently, there are no recent large-scale studies investigating the outcomes in oesophageal perforation, leading to a paucity of high-grade evidence on the management of oesophageal injuries. This study aims to characterise the variation in the management of OPs, update its epidemiology in the UK; and evaluate the mortality and morbidity outcomes of surgical and non-surgical modalities in managing OP.

Methods

This was a multi-centred cohort study involving eligible centers from the Association of Upper Gastro-intestinal Surgeons for Great Britain and Ireland (AUGIS) research network. All adult patients who were admitted with a diagnosis of esophageal perforation (iatrogenic, spontaneous or traumatic causes) and managed as an inpatient for more than 24 hours were included in the study. Exclusion criteria were as follows: pediatric population; OP due to anastomotic leaks post-esophagectomy; and unavailability of data matching primary outcome measures. The time period for inclusion of patients was from January 2016 to December 2020. Investigators were asked to actively monitor patients and their electronic medical records to identify post-intervention complications up to 90 days from time of intervention if appropriate. The primary outcome was 90-day mortality. Other secondary outcomes included the incidence of complications secondary to OP or interventions; incidence of 30-day re-intervention; length of hospital stay (LOS) and intensive care unit (ICU) stay; readmission within 30 days; and recurrence.

Results

During the study period 369 patients with oesophageal perforation from eight centres and were included in the study. The mean age of the population was 63 (18) years, body mass index was 25 (9)kg/m2, 60% were male, 30% were ASA grade 3, and 41% ECOG performance status 0. The aetiology of OP was spontaneous in 57% and iatrogenic in 37%. The mean time from presentation to referral and intervention were 37 hours and 111 hours respectively. In patients transferred from a district general to a tertiary hospital the mean time from presentation to transfer was 100 hours. Surgery was used as the primary treatment approach in 31%, endoscopic intervention in 10% and conservative management in 56%. Thoractomy and laparotomy was used in 20% and 24% respectively, endosponge and endoscopic stent used in 11% and 7% respectively.

90-day mortality was 20% across the cohort, 30-day re-admission rate was 18%, mean ICU stay, and LOS were 10 days and 37 days respectively. 90-day mortality was significantly reduced in the surgery group (9%) when compared with endoscopic (24%) and conservative management groups (28%) (p<0.001). Multivariate analyses identified key patient, procedural, and treatment factors associated with mortality from oesophageal perforation.

Conclusions

In a centralised oesophageal and gastric cancer service, the management of complex upper gastrointestinal conditions including oesophageal perforation is most commonly centralised to oesophageal and gastric cancer centres. This large multi-centre collaborative study provides robust data concerning modern practices of the management of oesophageal perforation in the UK. Through a detailed and highly granular dataset, we have examined factors associated with the patient pathway, presentation and treatment that are associated with mortality following oesophageal perforation.

A O04 Identifying Predictive Factors for Prolonged use of Nutritional Support After Oesophagogastric Cancer Resections

Background

In the era of evidence-based practice, there remains significant variation in peri-operative nutritional strategies for patients undergoing oesophagogastric (OG) cancer resections. Although dietary support is accepted as essential for this patient group, the use of feeding adjuncts, such as parenteral nutrition (PN) or enteral feeding tubes, varies widely.

In addition, the clinical benefit of peri-operative supplementary feeding remains uncertain, especially since the evolution to minimally invasive OG surgery, introduction of ERAS and drive for early oral intake. Despite improvements in peri-operative nutrition pathways, risks associated with feeding adjuncts remain. There are also increased financial costs associated with peri-operative nutritional support which require consideration. After analysing unit peri-operative outcomes, it was hypothesised that routine feeding adjunct use may be unnecessary for most patients who meet oral nutritional goals early and should instead be reserved for patients with an increased risk of supplementary post-operative nutritional requirement.The primary aim of this study was to evaluate which clinicopathological factors were associated with prolonged use of PN after OG surgery. The secondary aim was to evaluate the associated morbidity and healthcare costs of PN use.

Methods

A retrospective cohort study of 518 patients undergoing oesophagectomy or total gastrectomy for cancer at Guy's and St Thomas’ NHS Foundation Trust, London, UK, between 2015 and 2021. The standard feeding regimen after oeosphagectomy or total gastrectomy at St Thomas’ involves PN for a median of eight days post-operatively. Oral intake is initiated after a contrast swallow is performed on day three for uncomplicated patients. The primary outcome was prolonged use of post-operative PN, defined as nine-days or more PN during the index admission.

Clinicopathological characteristics were compared using the Chi square test. The relationship between these characteristics and PN use was evaluated using logistic regression analysis, providing odds ratios (OR) with 95% confidence intervals (CI) adjusting for age, sex, BMI, comorbidities, histology, anastomosis location, surgical access, pre-operative weight loss, pre-operative supplementary feeding. The prognostic ability of clinicopathological characteristics to predict prolonged PN use were compared using receiver operator characteristic (ROC) analysis to calculate area under the curve (AUC). An economic model was developed using described PN related complication rates from the published literature and 2021 NHS tariffs.

Results

Predictive factors for prolonged PN use on adjusted analysis included age over 65 (HR 1.70 95% CI 1.14–2.52), pre-operative weight loss (0–10%: HR 1.67 95% CI 1.09–2.56, >10%: HR 2.21 95% CI 1.05–4.66), open surgery (HR 1.64 95% CI 1.03–2.62) and an OG anastomosis located in the neck (HR 2.50 95% CI 1.35–4.65). Patients with a BMI over 25 had a lower chance of prolonged PN use (HR 0.65 95% CI 0.43–0.98). Other characteristics were not prognostic.

ROC curve analysis demonstrated that anastomosis location (AUC 0.59), age (AUC 0.57) and surgical access (AUC 0.56) were the most prognostic factors. The combination of parameters included in the adjusted model provided an AUC of 0.67. Potential PN and line related complications included: deranged liver biochemistry (18.0%), deranged blood sugars (9%), line infection (1.4%) and line thrombus (0.8%). An eight-day course of PN was calculated to cost £884 with average treatment related complication costs of £176 per patient. Using the mean number of patients treated per year over the past three years (N = 112) the projected service savings were £75,912 per year if PN was reserved for patients with high-risk characteristics.

Conclusions

This study has demonstrated that several patient and treatment related factors are associated with an increased risk of needing prolonged adjunctive nutritional support after OG surgery. As surgical practice has evolved to minimally invasive surgery and ERAS with subsequently low peri-operative complication rates, the clinical benefits of short course adjuvant feeding may not be seen in patients who progress promptly to appropriate oral intake. Therefore, we propose the introduction of a tailored treatment pathway, based on pre-operative characteristics which excludes the routine use of post-operative feeding for low-risk patients. The study also demonstrates that a change in practice can lead to considerable cost savings.

The model demonstrated in this study can be applied to all feeding adjuncts and can therefore be universally adopted in any UK/global unit regardless of supplementary feeding route preference. It will encourage high-performance by promoting a patient-centred and individualised approach to peri-operative nutrition which is currently lacking in many aspects of our clinical practice. Further work in the form of a randomised trial may be explored to better understand the need and benefit of supplementary feeding methods after OG resection as the specialty continues to evolve.

OGC P20 Metabolic tumour and nodal response to neoadjuvant chemotherapy on FDG PET-CT as a predictor of pathological response and survival in patients undergoing surgical resection for locally advanced oesophageal adenocarcinoma

Background

18F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG PET-CT) is routinely used for staging of oesophageal cancer and has an emerging role in assessing response to neoadjuvant therapy. Several studies have demonstrated that a reduction in FDG avidity of the primary tumour and loco-regional lymph nodes following neoadjuvant chemotherapy predicts pathological response and survival in this patient group. However, no studies have evaluated the prognostic significance of metabolic parameters with respect to pathological response in lymph nodes.

Change in primary tumour maximum standardised uptake value (SUVmax) is the most widely used FDG PET-CT parameter to define metabolic response, with various thresholds described. The most commonly utilised are a 35% reduction in SUVmax (MUNICON), and a 30% reduction in SUVmax (PERCIST). However, there is no consensus regarding the optimal classification; the MUNICON threshold was derived from only 40 patients and PERCIST is not tumour specific. The primary aim of this study was to evaluate the ability of FDG PET-CT to predict pathological response in the primary tumour (pTR) and lymph nodes (pNR) in patients with oesophageal adenocarcinoma undergoing neoadjuvant chemotherapy before surgery. Secondary aims were to assess the prognostic effect of metabolic and pathological response and evaluate the predictive ability of response classifications.

Methods

Cohort study of 75 patients with locally advanced oesophageal or oesophago-gastric junctional adenocarcinoma who underwent FDG-PET-CT before and after neoadjuvant chemotherapy, prior to surgical resection at Guy's and St Thomas’ NHS Foundation Trust, London, UK, between 2017–2020. SUV metrics related to the primary tumour and loco-regional lymph nodes were derived on pre- and post- treatment FDG PET-CT. pTR and pNR were evaluated using the Mandard classification. Patients with Mandard scores of 1–3 were classified as pathological responders and those with Mandard scores of 4–5 as non-responders. Clinicopathological characteristics were compared using the Chi-squared test. Receiver operator characteristic (ROC) analysis was performed and area under the curve (AUC) calculated to determine optimum SUVmax thresholds for metabolic response in the primary tumour (mTR) and lymph nodes (mNR). Survival curves were created using the Kaplan-Meier method, with subgroups compared using the log-rank test. Survival analysis was performed using Cox proportional hazards regression providing hazard ratios (HR) with 95% confidence intervals (CI) adjusted for age (continuous), sex (male or female), chemotherapy regimen (ECX or FLOT), cT stage (cT1–2 or cT3–4), cN stage (cN0 or cN+), tumour grade (well / moderately differentiated or poorly differentiated) and presence of signet ring cells (yes or no).

Results

Mean age was 63 years with the majority male (86.7%). Almost two thirds received FLOT (48/75, 64.0%) with the remainder receiving ECX chemotherapy. There was discordance between pathological response in the primary tumour and lymph nodes in several patients, including 23.1% (6/26) who demonstrated a lymph node response in the absence of a response in the primary tumour. ROC analysis demonstrated an optimum tumour SUVmax decrease of 51.2% for predicting pTR. Using a pragmatic cut-off of 50% this provided better prediction of pTR (AUC 0.714, sensitivity 73.5%, specificity 69.2%, p<0.001) than PERCIST (AUC 0.631, sensitivity 87.8%, specificity 38.5%, p=0.008) and MUNICON (AUC 0.659, sensitivity 85.7%, specificity 46.2%, p=0.003) criteria. ROC analysis demonstrated an optimum nodal SUVmax decrease of 32.6% for predicting pNR or pathological node negativity. Using a pragmatic 30% SUVmax cut-off and excluding metabolically negative nodes, mNR demonstrated high sensitivity but low specificity (AUC 0.749, sensitivity 92.6%, specificity 57.1%, p=0.010) for predicting pNR. pTR, mTR, pNR and mNR were independent predictive factors for overall survival on adjusted analysis (pTR responder HR 0.10 95% CI 0.03–0.34; mTR responder HR 0.17 95% CI 0.06–0.48; pNR responder HR 0.17 95% CI 0.06–0.54; mNR responder HR 0.13 95% CI 0.02–0.66).

Conclusions

In this study metabolic response on FDG PET-CT after neoadjuvant chemotherapy was predictive of pathological response in both the primary tumour and lymph node metastases of patients with oesophageal adenocarcinoma. Patients who had a favourable metabolic or pathological response in the primary tumour or lymph nodes had improved survival compared to non-responders. It has been suggested that commonly utilised thresholds of SUVmax are not optimal for response assessment in this patient group. This is supported by the results of the present study which suggest a reduction in SUVmax of 50% in the primary tumour was not only a better predictor of pathologic response, but also tumour recurrence and survival compared with PERCIST and MUNICON criteria. No previous studies have evaluated the ability of FDG PET-CT to predict pathologic nodal response despite recent findings suggesting it is an independent predictor of survival and evidence of a discrepancy, in some patients, who demostrate a nodal response in the absence of a response in the primary tumour. The use of FDG PET-CT in assessing response to neoadjuvant chemotherapy remains an under researched area and further evaluation is needed to establish whether it could be used to tailor individualised treatment strategies.

OGC P27 A Review of Minimally Invasive Oesophagogastric Cancer Surgery in a High-Volume UK Unit

Background

Oesophagogastric (OG) cancer resections are technically challenging and associated with peri-operative morbidity.

Practice has evolved from open to minimally invasive surgery (MIS), with ERAS has seen peri-operative outcomes improve. OG surgeons have not transitioned to MIS at the rate of others; 2021 NOGCA results showed that 17.6% of oesophagectomies and 17% of gastrectomies were performed as MIS. Concerns regarding the technical ability to perform safe anastomoses and appropriate oncological clearance have been cited as common reasons for surgeons not transitioning to MIS. GSTT is a high-volume OG unit which has transitioned from a fully open to predominantly MIS practice. The unit has performed over 100 minimally invasive Ivor Lewis oesophagectomies and 97 laparoscopic gastrectomies, it was therefore decided to analyse the unit's peri-operative outcomes to ensure that appropriate standards were maintained during this change in practice. The primary aim of this study was to examine a decade of peri-operative outcomes for Ivor Lewis oesophagectomy and gastrectomies, comparing parallel open and MIS cohorts. The secondary aim is to perform a sequential cumulative sum control chart (CUSM) analysis of the cohort to determine whether a learning curve effect for OG MIS can be demonstrated.

Methods

A retrospective analysis of a prospectively maintained comprehensive local database was performed. The results were cross-checked with NOCGA data, and a notes review was performed to capture any missing data.All Ivor Lewis oesophagectomy and gastrectomy (total, extended total and subtotal) performed for adenocarcinoma, squamous cell carcinoma, neuroendocrine tumours and high grade dysplasia at Guy's and St Thomas’ NHS Foundation Trust, London, UK over a ten-year period (January 2012- December 2021) were included. MIS for oesophagectomy was defined as an Ivor Lewis oesophagectomy performed with both laparoscopic and thoracoscopic phases. A hybrid (laparoscopic abdomen and open chest phase) oesophagectomy was grouped with a two-phase open procedure to create an open cohort. Laparoscopic gastrectomy (with a laparoscopic oesophago-jejunostomy or gastro-jejunostomy for sub-total gastrectomy) was used as the definition of MIS. The cohorts were compared for: age, sex, BMI and use of neoadjuvant therapy. Temporal trends in surgical approaches were compared as were Individual surgeon (n=4) volumes. Peri-operative clinical and oncological outcomes including length of stay, anastomotic leak, return to theatre, chest complications, resection margins and lymph node harvest were all examined. A CUSM analysis is currently being completed to further analyse surgeon performance over time.

Results

596 patients underwent resection in well matched cohorts, 197 patients had an oesophagectomy (100 MIO), 339 had a gastrectomy (97 laparoscopic). MIS rates increased with no operations being performed as MIS in 2012 compared to 81% of oesophagectomy and 67% of gastrectomy performed as MIS in 2021. Two surgeons performed over 170 resections with MIS rate over 40%. OR of MIS performed by a high-volume surgeon was 3.01 (p<0.001). Lower volume MIS surgeons were more likely to have two consultants present, OR 1.4 (p=0.16).

Anastomotic leak rates following gastrectomy were 2% in both groups (p=0.66), 9% following open oesophagectomy and 11% after MIO (p=0.77). 10% of laparoscopic gastrectomy patients experienced a chest complication, 26% after open surgery, 22% MIO and 24% open (p=0.65). Mean length of stay was significantly reduced after MIS. An R0 rate of 96% was seen after laparoscopic gastrectomy, 90% after open (p=0.08). 68% of MIO patients had R0 resection compared to 70% after open. Positive CRM was 29% after MIO. The mean lymph node harvest was 29 after laparoscopic gastrectomy and 26 after open (p=0.24), 29 following MIO, 30 after open oesophagectomy. 97% of MIO harvested over 15 nodes.

Conclusions

This study demonstrates that a transition from open to MIS practice is achievable in the UK. Outcomes demonstrated similar peri-operative clinical and oncological outcomes between MIS and open surgery which addresses the concerns that prohibited the widespread uptake of MIS in UK centres. Developing a reliable surgical technique for lymphadenectomy and anastomoses that transitioned from open to hybrid and now MIS allowed for appropriate outcomes to be maintained. Unit outcomes compare well to both NOGCA/ECCG data with complication rates following MIO being significantly lower when compared to ECCG. Lymph node harvests were significantly higher in unit MIOs when compared to NOGCA (p=0.01). Volume played an important role in surgeons performing independent MIS. This should be considered when planning unit workload or a transition to MIS. It will be further explored in the CUSM analysis. A positive CRM was seen in more cases (29%) when compared to NOGCA (24%) and may be related to the preferred neoadjuvant regime being chemotherapy over chemoradiotherapy.

The future of OG is moving towards robotic surgery. It is proposed that the evolution from open to MIS will make a second transition to robotics less challenging as the strategies needed to perform MIS have been addressed.

Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS)/Perioperative Quality Initiative (POQI) consensus statement on intraoperative and postoperative interventions to reduce pulmonary complications after oesophagectomy

BACKGROUND

Pulmonary complications are the most common morbidity after oesophagectomy, contributing to mortality and prolonged postoperative recovery, and have a negative impact on health-related quality of life. A variety of single or bundled interventions in the perioperative setting have been developed to reduce the incidence of pulmonary complications. Significant variation in practice exists across the UK. The aim of this modified Delphi consensus was to deliver clear evidence-based consensus recommendations regarding intraoperative and postoperative care that may reduce pulmonary complications after oesophagectomy.

METHODS

With input from a multidisciplinary group of 23 experts in the perioperative management of patients undergoing surgery for oesophageal cancer, a modified Delphi method was employed. Following an initial systematic review of relevant literature, a range of anaesthetic, surgical, and postoperative care interventions were identified. These were then discussed during a two-part virtual conference. Recommendation statements were drafted, refined, and agreed by all attendees. The level of evidence supporting each statement was considered.

RESULTS

Consensus was reached on 12 statements on topics including operative approach, pyloric drainage strategies, intraoperative fluid and ventilation strategies, perioperative analgesia, postoperative feeding plans, and physiotherapy interventions. Seven additional questions concerning the perioperative management of patients undergoing oesophagectomy were highlighted to guide future research.

CONCLUSION

Clear consensus recommendations regarding intraoperative and postoperative interventions that may reduce pulmonary complications after oesophagectomy are presented.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Exercise prehabilitation during neoadjuvant chemotherapy may enhance tumour regression in oesophageal cancer: results from a prospective non-randomised trial

BACKGROUND

There is increasing evidence for the use of exercise in cancer patients and data supporting enhanced tumour volume reduction following chemotherapy in animal models. To date, there is no reported histopathological evidence of a similar oncological benefit in oesophageal cancer.

METHODS

A prospective non-randomised trial compared a structured prehabilitation exercise intervention during neoadjuvant chemotherapy and surgery versus conventional best-practice for oesophageal cancer patients. Biochemical and body composition analyses were performed at multiple time points. Outcome measures included radiological and pathological markers of disease regression. Logistic regression calculated ORs with 95% CI for the likelihood of pathological response adjusting for chemotherapy regimen and chemotherapy delivery.

RESULTS

Comparison of the Intervention (n=21) and Control (n=19) groups indicated the Intervention group had higher rates of tumour regression (Mandard TRG 1-3 Intervention n=15/20 (75%) vs Control n=7/19 (36.8%) p=0.025) including adjusted analyses (OR 6.57; 95% CI 1.52 to 28.30). Combined tumour and node downstaging (Intervention n=9 (42.9%) vs Control n=3 (15.8%) p=0.089) and Fat Free Mass index were also improved (Intervention 17.8 vs 18.7 kg/m²; Control 16.3 vs 14.7 kg/m², p=0.026). Differences in markers of immunity (CD-3 and CD-8) and inflammation (IL-6, VEGF, INF-y, TNFa, MCP-1 and EGF) were observed.

CONCLUSION

The results suggest improved tumour regression and downstaging in the exercise intervention group and should prompt larger studies on this topic.

TRIAL REGISTRATION NUMBER

NCT03626610.

P-OGC21 Patient perspectives on symptoms of importance and preferences for follow-up after major upper gastro-intestinal cancer surgery

Background

Long-lasting symptoms and reductions in quality of life are common after oesophago-gastric surgery. Post-operative follow-up has traditionally focussed on tumour recurrence and survival, but there is a growing need to also identify and treat functional sequelae to improve patients’ recovery.

Methods

An electronic survey was circulated via a British national charity for patients undergoing oesophago-gastric surgery and their families. Patients were asked about post-operative symptoms they deemed important to their quality of life, as well as satisfaction and preferences for post-operative follow-up.   Differences between satisfied and dissatisfied patients with reference to follow-up were assessed.

Results

Among 362 respondents with a median follow-up of 58 months since surgery (range 3-412), 36 different symptoms were reported as being important to recovery and quality of life after surgery, with a median 13 symptoms per patient. Most (84%) respondents indicated satisfaction with follow-up. Unsatisfied patients were more likely to have received shorter follow-up than 5 years  (27% among unsatisfied patient vs. 60% among satisfied patients, p &lt; 0.001and were less likely to have seen a dietitian as part of routine follow-up (37% vs. 58%, p = 0.005).

Conclusions

This patient survey highlights preferences with regard to follow-up after oesophago-gastrectomy. Longer follow-up and dietician involvement improved patient satisfaction. Patients reported being concerned by a large number of gastrointestinal and non-gastrointestinal symptoms, highlighting the need for multidisciplinary input and a consensus on how to manage the poly-symptomatic patient.  

P-OGC67 Gastric GISTs: Can presentation, Location and Radiological Features predict behaviour? – Experience in a UK cohort

Background

Gastrointestinal stromal tumours (GISTs) most commonly arise in the stomach, vary significantly in behaviour and can be difficult to risk stratify accurately pre-operatively. They are increasingly being identified incidentally during endoscopies or cross-sectional imaging. They have malignant potential and but vary from very low to high-risk. Pre-operatively, histological diagnosis can be achieved by performing endoscopic ultrasound (EUS) guided fine-needle aspirate or biopsy, but samples often contain insufficient material. This study aims to assess other features help identify aggressiveness of GISTs pre-operatively to help guide management decisions.

Methods

This is a retrospective cohort study analysing patients treated surgically for GIST from 2011-2020 at a UK tertiary centre. Exclusion criteria were non-gastric GISTs and patients who received a different diagnosis post-operatively. Hospital electronic patient record and e-noting systems were used to collect data. Risk groups were stratified according to the NCCN risk classification for GIST. ‘Very low risk’ and ‘low risk’ groups were combined in the analysis to form the ‘lower risk’ group; ‘moderate risk’ and ‘high risk’ categories combined to form the ‘higher risk’ group. Statistical analyses were conducted using STATA version 15.

Results

171 patients were included in total. OGD diagnosed gist on histology if ulcerated in 14.7% of cases. EUS biopsy was performed in 39% of cases pre-operatively – 84.6% of these were diagnostic. There was a higher proportion of higher risk GISTs in the GOJ/cardia region than lower risk GISTs (16.2% versus 6.7%), though this did not reach statistically significance (p = 0.32). A greater proportion of higher risk tumours were irregular in outline (p=.26),  heterogenous (p = 0.003) and necrotic (p = 0.001) than lower risk tumours. In addition, higher risk tumours were significantly more likely to be exophytic than lower risk tumours, which were significantly more endophytic (p = 0.05). A ROC curve including all the variables had an AUC of 0.8971.

Conclusions

This is the largest analysis of gastric GISTs in a UK population. This study found that a higher proportion of higher risk tumours were irregular, heterogenous and necrotic than lower risk tumours. In this study, a greater proportion of higher risk tumours arose in the GOJ/cardia. In keeping with muscularis origin, endoscopic biopsy was found to be a poor diagnostic tool unless ulcerated. EUS and FNA biopsies had a much higher rate of histological confirmation. This knowledge might help facilitate a more individualised approach with non-operative surveillance in lower risk tumours or expedited surgery in higher risk lesions.

P-OGC22 Incidence and relevance of clinically indeterminate non-regional lymph nodes in the treatment of oesophageal cancer

Background

Metastatic involvement of non-regional supraclavicular or superior mediastinal lymph nodes in distal oesophageal cancer is rare, but has important implications for prognosis and management.  The management of non-regional lymph nodes which appear indeterminate on CT and FDG PET-CT (subcentimetre nodes or those with preserved normal morphology, but increased FDG avidity) can present a diagnostic dilemma. This study investigates the incidence, work-up, and clinical significance of non-regional clinically indeterminate FDG avid lymph nodes.

Methods

A single centre retrospective review of all FDG PET-CT scans conducted over 5 years was conducted.  Patients with mid- or distal oesophageal cancer with non-regional FDG avid nodes were identified.  Subsequent work-up, management, and outcomes were retrieved from electronic health records.

Results

Reports for 1189 PET-CT scans were reviewed.  A total of 79 patients met the inclusion criteria.  Of these, 18 (23%) were deemed to have disease and performance status potentially amenable to radical surgery, and underwent further assessment.  The indeterminate lymph nodes were successfully sampled via endobronchial ultrasound (EBUS) or ultrasound-guided fine needle aspiration (US-FNA) in 100% of cases.  15/18 (83.3%) of samples were benign and proceeded to surgery.  Outcomes for patients who proceeded to surgery were similar to other cohorts.  None had pathology suggesting false negative lymph node sampling.

Conclusions

EBUS and US-FNA are effective means of sampling clinically indeterminate non-regional lymph nodes, and can significantly impact prognosis, and management. Further investigations in this context are of value in this cohort and should be pursued.

P-OGC09 Evaluating the Availability of Services for Cancer Patients Following Surgical Resection of Esophago-Gastric Tumours

Background

Upper gastrointestinal (UGI) cancers account for 11% of cancers in the UK, with oesophago-gastric cancers having the highest incidence rate in males. Since publication of the NHS Cancer Plan in 2001, mortality rates of oesophago-gastric cancer patients following curative surgery have been decreasing, causing an increased demand for services, particularly during follow-up post-operatively. Current guidelines recommend that patients are treated by specialised multi-disciplinary teams, involving both cancer nurse specialists and dieticians. However, the integration of these workers into patient care is still ongoing in UGI, with no national recommendations for trusts on the minimum requirements needed to run adequate services.

Methods

This was a retrospective observational study from October 2020 to April 2021. Cancer nurse specialists from all cancer trusts in England and Wales carrying out surgical resection of oesophago-gastric tumours were identified and contacted to complete a survey. The survey was divided into 4 main themes: the organisational setup of the trust, the follow-up of patients, the dietetic input and post-operative symptoms and survivorship.

Results

A total of 12 trusts out of 38 returned a completed survey. Differences were observed in the number of CNSs and UGI dieticians available across trusts. 50% of responders felt that the number of CNSs at their trust was not adequate to run efficient services for patients. In 42% of cases, the CNS was solely responsible for long-term follow-up of patients, up to 5-years in the majority of trusts. 11 trusts routinely follow-up patients with a dietician, integrated into MDT clinics. 75% of trusts had an associated patient group that could provide additional support to patients.

Conclusions

Differences in the availabilities of services and staff for oesophago-gastric cancer patients are present across trusts in England, which can lead to inequalities in patient care. Further longitudinal studies are needed to evaluate the impact of these differences on patient surgical outcomes and mortality.

P-OGC48 Definitive Chemoradiotherapy versus Neoadjuvant Chemoradiotherapy Followed by Radical Surgery for Locally Advanced Esophageal Squamous Cell Carcinoma: Systematic Review and Meta-analysis

Background

Debate exists surrounding definitive chemoradiotherapy (dCRT) over neoadjuvant chemoradiotherapy and surgery (nCRS) as a primary treatment for esophageal squamous cell carcinoma (ESCC) owing to the heterogeneity in the quality of current evidence. This study aimed to compare long-term survival of dCRT with nCRT for ESCC from high-quality studies.

Methods

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 23rd July 2021. Primary outcome was overall survival (OS) and secondary outcomes were disease-free survival (DFS) and recurrence rates. A meta-analysis was conducted using random-effects modelling to determine pooled adjusted multivariable hazard ratios (HRs).

Results

This review included ten high-quality studies including 14,092 patients, of which 30% received nCRT. Three studies were randomized controlled trials (RCT), six studies were single-center. dCRT and nCRT regimens were reported in six studies and surgical quality control were reported in two studies. Outcomes for OS and DFS were reported in eight and three studies, respectively. nCRT had significantly longer OS (HR: 0.68, CI95%: 0.54 - 0.87, p &lt; 0.001) and DFS (HR: 0.50, CI95%: 0.36 - 0.70, p &lt; 0.001) than dCRT.

Conclusions

nCRS followed by planned esophagectomy appears to remain the optimum curative treatment regime in patients with loco-regional ESCC. Thus, surgery remains an integral component of the management of patients with ESCC. As adjuvant and immunotherapy treatment regimens develop, ongoing prospective assessment of the role of radiotherapy in combination with modern treatment modalities should be studied

P-OGC07 The Role of Carbohydrate Loading on Lactate and Glucose Levels in Upper GI Cancer Surgery

Background

Surgical stress is a significant factor in metabolic dysregulation in the perioperative setting. Its impact on insulin resistance is regarded as one of the most detrimental effects, contributing to post-operative complications and poor outcomes. Clinical markers of this include glucose and lactate levels, with hyperglycaemia and hyperlactataemia the predicted responses by the body. One way of minimising the impact of surgical stress is pre-operative carbohydrate loading, which in theory will provide more substrate for metabolism. Our aim was to investigate whether carbohydrate loading had any impact on lactate and glucose levels in patients undergoing upper gastrointestinal cancer resections.

Methods

A retrospective observational feasibility study was performed looking at 42 patients who had undergone either an oesophagectomy or gastrectomy. Patients were divided depending on whether they received pre-operative carbohydrate loading. Lactate and glucose levels both intra-operatively and post-operatively were collected. Mean difference was compared between the two groups at 4 hours intra-operatively, 2 hours post-operatively and 12 hours post-operatively using unpaired t tests, with significance at P &lt; 0.05. Variance between the two groups was analysed. Secondary outcomes included analysis based on type of operation, anastomotic leaks, and post-operative intravenous fluid use in the first 24 hours.

Results

There was no statistically significant difference in lactate levels between the two test groups at any time point. Mean difference at intra-operative 4 hours 0.0408mmol/L (+/- 0.2537, P = 0.8731); post-operative 2 hours 0.2697mmol/L (+/- 0.3008, P = 0.3754); post-operative 12 hours 0.2327mmol/L (+/- 0.2368, P = 0.3318). Glucose levels at the same time points were not significantly different: intra-operative 4 hours 0.068mmol/L (+/- 0.5322, P = 0.5746); post-operative 2 hours -0.2649mmol/L (+/- 0.4679, P = 0.5746); post-operative 12 hours 0.3773mmol/L (+/- 0.3629, P = 0.305). Secondary outcomes did not show any statistically significant differences between analysed groups.

Conclusions

Pre-operative carbohydrate loading does not seem to influence lactate or glucose levels in these patients either intra-operatively or post-operatively. The lack of significant differences between the two cohorts may be due to underpowering of the sample size, as this is a small feasibility study. We assume that carbohydrate loading would reduce insulin resistance and therefore lactate and glucose levels. However, could it be that carbohydrate loading is not having as much of an effect on patient metabolism as we think? A larger prospective study is recommended to investigate its impact on clinical biochemistry and patient outcomes.

P-OGC12 Nasogastric tube drainage and pyloric intervention after oesophageal resection: UK practice variation and effect on outcomes

Background

Over 1,500 patients with oesophageal cancer undergo a resection in the UK each year. At surgery, patients commonly have a nasogastric tube (NGT) placed and may undergo a pyloric intervention. There is conflicting evidence on the use of both NGTs and pyloric interventions during oesophageal resections. We performed a national survey of oesophageal centres and assessed practice variation.

Methods

An electronic survey was distributed to all resection centres in England, Wales and Scotland. Variations in practice regarding NGTs and pyloric intervention were assessed, and compared to nationally reported centre volumes and length-of-stay data

Results

Most centres (31/39, 79%) responded to the survey. All centres reported routine NGT use. The majority of centres (19/31, 61%) did not perform pyloric interventions. When used, surgical pyloroplasty was the most frequent strategy (8/31, 26%). Routine post-operative radiological assessment was utilised in 9/31 (29%) of centres. Criteria for NGT removal and dietary progression was highly variable, with every centre reporting different protocols. There were no significant differences in practice between high and low volume centres. There were also no trends seen when comparing centres above vs at-or-below the median length-of-stay. The majority (68%) of centres were willing to take part in a trial assessing NGT use and pyloric interventions.

Conclusions

Pyloric intervention use varies widely, with no clear link to outcomes. NGT use remains standard practice despite evidence for safe omission. Surgeons require and recognise the need for a trial to assess requirement for NGTs and pyloric intervention after oesophageal resection.

P-OGC13 Chest drainage after oesophageal resection: A systematic review

Background

Modern enhanced recovery protocols discourage drain use due to negative impacts on patient comfort, mobility, and recovery, and lack of proven clinical benefit. After oesophagectomy, however, drains are still routinely placed. This review aimed to assess the evidence for, and how best to use chest drains after oesophageal surgery.

Methods

A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases. Studies reporting outcomes for different types or uses of thoracic drainage, or outcomes related to drains after trans-thoracic oesophagectomy were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed with Newcastle-Ottawa and Jadad scores.

Results

Among 434 potentially relevant studies, 27 studies met the inclusion criteria and these included 2564 patients. Studies that examined the number of drains showed pain reduction with a single drain compared to multiple drains (3 studies, n = 103), and transhiatal placement compared to intercostal (6 studies, n = 425). Amylase levels may aid diagnosis of anastomotic leak (9 studies, n = 888). Narrow calibre Blake drains may effectively drain both air and fluid (2 studies, n = 163). Drain removal criteria by daily drainage volumes of up to 300ml did not impact subsequent effusion rates (2 studies, n = 130). Complications related directly to drains were reported by 3 studies (n = 59).

Conclusions

Available evidence on the impact of thoracic drainage after oesophagectomy is limited, but has the potential to negatively affect outcomes. Further research is required to determine optimum drainage strategies.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Consensus recommendations for the standardized histopathological evaluation and reporting after radical oesophago-gastrectomy (HERO consensus)

BACKGROUND

Variation in the approach, radicality, and quality of gastroesophageal surgery impacts patient outcomes. Pathological outcomes such as lymph node yield are routinely used as surrogate markers of surgical quality, but are subject to significant variations in histopathological evaluation and reporting. A multi-society consensus group was convened to develop evidence-based recommendations for the standardized assessment of gastroesophageal cancer specimens.

METHODS

A consensus group comprised of surgeons, pathologists, and oncologists was convened on behalf of the Association of Upper Gastrointestinal Surgery of Great Britain & Ireland. Literature was reviewed for 17 key questions. Draft recommendations were voted upon via an anonymous Delphi process. Consensus was considered achieved where >70% of participants were in agreement.

RESULTS

Consensus was achieved on 18 statements for all 17 questions. Twelve strong recommendations regarding preparation and assessment of lymph nodes, margins, and reporting methods were made. Importantly, there was 100% agreement that the all specimens should be reported using the Royal College of Pathologists Guidelines as the minimum acceptable dataset. In addition, two weak recommendations regarding method and duration of specimen fixation were made. Four topics lacked sufficient evidence and no recommendation was made.

CONCLUSIONS

These consensus recommendations provide explicit guidance for gastroesophageal cancer specimen preparation and assessment, to provide maximum benefit for patient care and standardize reporting to allow benchmarking and improvement of surgical quality.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Protocol for LAsting Symptoms after Oesophageal Resectional Surgery (LASORS): multicentre validation cohort study

INTRODUCTION

Surgery is the primary curative treatment for oesophageal cancer, with considerable recent improvements in long-term survival. However, surgery has a long-lasting impact on patient's health-related quality of life (HRQOL). Through a multicentre European study, our research group was able to identify key symptoms that affect patient's HRQOL. These symptoms were combined to produce a tool to identify poor HRQOL following oesophagectomy (LAsting Symptoms after Oesophageal Resection (LASOR) tool). The objective of this multicentre study is to validate a six-symptom clinical tool to identify patients with poor HRQOL for use in everyday clinical practice.

METHODS AND ANALYSIS

Included patients will: (1) be aged 18 years or older, (2) have undergone an oesophagectomy for cancer between 2015 and 2019, and (3) be at least 12 months after the completion of adjuvant oncological treatments. Patients will be given the previously created LASOR questionnaire. Each symptom from the LASOR questionnaire will be graded according to impact on quality of life and frequency of the symptom, with a composite score from 0 to 5. The previously developed LASOR symptom tool will be validated against HRQOL as measured by the European Organisation for Research and Treatment of Cancer QLQC30 and OG25.

SAMPLE SIZE

With a predicted prevalence of poor HRQOL of 45%, based on the previously generated LASOR clinical symptom tool, to validate this tool with a sensitivity and specificity of 80%, respectively, a minimum of 640 patients will need to be recruited to the study.

ETHICS AND DISSEMINATION

NHS Health Research Authority (North East-York Research Ethics Committee) approval was gained 8 November 2019 (REC reference 19/NE/0352). Multiple platforms will be used for the dissemination of the research data, including international clinical and patient group presentations and publication of research outputs in a high impact clinical journal.

The Influence of Comorbidity on Health-Related Quality of Life After Esophageal Cancer Surgery

BACKGROUND

Esophageal cancer surgery reduces patients' health-related quality of life (HRQoL). This study examined whether comorbidities influence HRQoL in these patients.

METHODS

This prospective cohort study included esophageal cancer patients having undergone curatively intended esophagectomy at St Thomas' Hospital London in 2011-2015. Clinical data were collected from patient reports and medical records. Well-validated cancer-specific and esophageal cancer-specific questionnaires (EORTC QLQ-C30 and QLQ-OG25) were used to assess HRQoL before and 6 months after esophagectomy. Number of comorbidities, American Society of Anesthesiologists physical status classification (ASA), and specific comorbidities were analyzed in relation to HRQoL aspects using multivariable linear regression models. Mean score differences with 95% confidence intervals were adjusted for potential confounders.

RESULTS

Among 136 patients, those with three or more comorbidities at the time of surgery had poorer global quality of life and physical function and more fatigue compared with those with no comorbidity. Patients with ASA III-IV reported more problems with the above HRQoL aspects and worse social function and pain compared with those with ASA I-II. Cardiac comorbidity was associated with worse global quality of life and dyspnea, while pulmonary comorbidities were related to coughing. Patients assessed both before and 6 months after surgery (n = 80) deteriorated in most HRQoL aspects regardless of comorbidity status, but patients with several comorbidities had worse physical function and fatigue and more trouble with coughing compared with those with fewer comorbidities.

CONCLUSION

Comorbidity appears to negatively influence HRQoL before esophagectomy, but appears not to severely impact 6-month recovery of HRQoL.

Pan-cancer analysis of whole genomes

Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale1-3. Here we report the integrative analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter4; identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation5,6; analyses timings and patterns of tumour evolution7; describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity8,9; and evaluates a range of more-specialized features of cancer genomes8,10-18.

Study protocol for a multicenter prospective cohort study on esophagogastric anastomoses and anastomotic leak (the Oesophago-Gastric Anastomosis Audit/OGAA)

Esophagectomy is a mainstay in curative treatment for esophageal cancer; however, the reported techniques and outcomes can vary greatly. Thirty-day mortality of patients with an intact anastomosis is 2-3% as compared to 17-35% in patients who have an anastomotic leak. The subsequent management of leaks postesophagectomy has great global variability with little consensus on a gold standard of practice. The aim of this multicentre prospective audit is to analyze current techniques of esophagogastric anastomosis to determine the effect on the anastomotic leak rate. Leak rates and leak management will be assessed to determine their impact on patient outcomes. A 12-month international multicentre prospective audit started in April 2018 and is coordinated by a team from the West Midlands Research Collaborative. This will include patients undergoing esophagectomy over 9 months and encompassing a 90-day follow-up period. A pilot data collection period occurred at four UK centers in 2017 to trial the data collection form. The audit standards will include anastomotic leak and the conduit necrosis rate should be less than 13% and major postoperative morbidity (Clavien-Dindo Grade III or more) should be less than 35%. The 30-day mortality rate should be less than 5% and the 90-day mortality rate should be less than 8%. This will be a trainee-led international audit of esophagectomy practice. Key support will be given by consultant colleagues and anesthetists. Individualized unit data will be distributed to the respective contributing sites. An overall anonymized report will be made available to contributing units. Results of the audit will be published in peer-reviewed journals with all collaborators fully acknowledged. The key information and results from the audit will be disseminated at relevant scientific meetings.

International Variation in Surgical Practices in Units Performing Oesophagectomy for Oesophageal Cancer: A Unit Survey from the Oesophago-Gastric Anastomosis Audit (OGAA)

BACKGROUND

Anastomotic leaks are associated with significant risk of morbidity, mortality and treatment costs after oesophagectomy. The aim of this study was to evaluate international variation in unit-level clinical practice and resource availability for the prevention and management of anastomotic leak following oesophagectomy.

METHOD

The Oesophago-Gastric Anastomosis Audit (OGAA) is an international research collaboration focussed on improving the care and outcomes of patients undergoing oesophagectomy. Any unit performing oesophagectomy worldwide can register to participate in OGAA studies. An online unit survey was developed and disseminated to lead surgeons at each unit registered to participate in OGAA. High-income country (HIC) and low/middle-income country (LMIC) were defined according to the World Bank whilst unit volume were defined as < 20 versus 20-59 versus ≥60 cases/year in the unit.

RESULTS

Responses were received from 141 units, a 77% (141/182) response rate. Median annual oesophagectomy caseload was reported to be 26 (inter-quartile range 12-50). Only 48% (68/141) and 22% (31/141) of units had an Enhanced Recovery After Surgery (ERAS) program and ERAS nurse, respectively. HIC units had significantly higher rates of stapled anastomosis compared to LMIC units (66 vs 31%, p = 0.005). Routine post-operative contrast-swallow anastomotic assessment was performed in 52% (73/141) units. Stent placement and interventional radiology drainage for anastomotic leak management were more commonly available in HICs than LMICs (99 vs 59%, p < 0.001 and 99 vs 83%, p < 0.001).

CONCLUSIONS

This international survey highlighted variation in surgical technique and management of anastomotic leak based on case volume and country income level. Further research is needed to understand the impact of this variation on patient outcomes.

The Prognostic Role of Pre-operative Positron Emission Tomography-Computed Tomography and Endoscopic Ultrasound Parameters in Oesophageal Adenocarcinoma

Background: To evaluate the prognostic role of Positron Emission Tomography/Computed Tomography (PET/CT) and Endoscopic Ultrasound (EUS) performed before neoadjuvant chemotherapy (NAC) and surgery for oesophageal adenocarcinoma (OAC) patients, focusing on lymph node (LN) assessment. Methods: OAC patients treated in a single tertiary center during January 2008 until December 2014 were retrospectively studied. All patients had PET/CT and EUS before NAC and oesophagectomy. PET-FDG-avid local LNs and maximum standardized uptake value (SUVmax) of the primary tumour, EUS positive LNs and EUS tumour length were recorded. Univariate, multivariate and survival analyses were performed. Results: Following exclusions 151consecutive patients met the inclusion criteria, (median age 62 years). PET/CT and EUS sensitivity for local LNs metastasis was 39.2% and 88.6%, with specificities of 83.33% and 19.15% respectively. No overall survival (OS) difference was found between patients with PET/CT FDG-avid LNs and those with negative LNs (p=0.347). SUVmax uptake was divided into high and low (median cut-off value: 10) with no significant difference in OS between groups (p=0.141). EUS tumour length was not prognostic (OS, p=0.455). Conclusions: Initial LN staging in OA is inaccurate. Although PET/CT and EUS assessments may be complimentary, none independently predicted survival.

A longitudinal assessment of psychological distress after oesophageal cancer surgery

BACKGROUND

Psychological distress is common among patients with oesophageal cancer. However, little is known about the course and predictors of psychological distress among patients treated with curative intent. Therefore, the aim of this study was to explore the prevalence, course and predictors of anxiety and depression in patients operated for oesophageal cancer, from prior to surgery to 12 months post-operatively.

METHODS

A prospective cohort of patients with oesophageal cancer (n = 218) were recruited from one high-volume specialist oesophago-gastric treatment centre (St Thomas' Hospital, London, UK). Anxiety and depression were assessed prior to surgery, 6 and 12 months post-operatively. Mixed-effects modelling was performed to investigate changes over time and to estimate the association between clinical and socio-demographic predictor variables and anxiety and depression symptoms.

RESULTS

The proportion of patients with anxiety was 33% prior to surgery, 28% at 6 months, and 37% at 12 months. Prior to surgery, 20% reported depression, 27% at 6 months, and 32% at 12-month follow-up. Anxiety symptoms remained stable over time whereas depression symptoms appeared to increase from pre-surgery to 6 months, levelling off between 6 and 12 months. Younger age, female sex, living alone and more severe self-reported dysphagia (i.e., difficulty swallowing) predicted higher anxiety symptoms. In-hospital complications, greater limitations in activity status and more severe self-reported dysphagia were predictive of higher depression.

CONCLUSIONS

Many patients report psychological distress during the first year following oesophageal cancer surgery. Whether improving the experience of swallowing difficulties may also reduce distress among these patients warrants further study.

Prevalence and predictors of anxiety and depression among esophageal cancer patients prior to surgery

This study aims to establish the prevalence and predictors of anxiety and depression among esophageal cancer patients, post-diagnosis but prior to curatively intended surgery. This was a cross-sectional study using data from a hospital-based prospective cohort study, carried out at St Thomas' Hospital, London. Potential predictor variables were retrieved from medical charts and self-report questionnaires. Anxiety and depression were measured prior to esophageal cancer surgery, using the Hospital Anxiety and Depression Scale. Prevalence of anxiety and depression was calculated using the established cutoff (scores ≥8 on each subscale) indicating cases of 'possible-probable' anxiety or depression, and multivariable logistic regression analyses were performed to examine predictors of emotional distress. Among the 106 included patients, 36 (34%) scored above the cutoff (≥8) for anxiety and 24 (23%) for depression. Women were more likely to report anxiety than men (odds ratio 4.04, 95% confidence interval 1.45-11.16), and patients reporting limitations in their activity status had more than five times greater odds of reporting depression (odds ratio 6.07, 95% confidence interval 1.53-24.10). A substantial proportion of esophageal cancer patients report anxiety and/or depression prior to surgery, particularly women and those with limited activity status, which highlights a need for qualified emotional support.

Extent of Lymphadenectomy and Prognosis After Esophageal Cancer Surgery

IMPORTANCE

The prognostic role of the extent of lymphadenectomy during surgery for esophageal cancer is uncertain and requires clarification.

OBJECTIVE

To clarify whether the number of removed lymph nodes influences mortality following surgery for esophageal cancer.

DESIGN, SETTING, AND PARTICIPANTS

Conducted from January 1, 2000, to January 31, 2014, this was a cohort study of patients who underwent esophagectomy for cancer in 2000-2012 at a high-volume hospital for esophageal cancer surgery, with follow-up until 2014.

EXPOSURES

The main exposure was the number of resected lymph nodes. Secondary exposures were the number of metastatic lymph nodes and positive to negative lymph node ratio.

MAIN OUTCOMES AND MEASURES

The independent role of the extent of lymphadenectomy in relation to all-cause and disease-specific 5-year mortality was analyzed using Cox proportional hazard regression models, providing hazard ratios (HRs) with 95% CIs. The HRs were adjusted for age, pathological T category, tumor differentiation, margin status, calendar period of surgery, and response to preoperative chemotherapy.

RESULTS

Among 606 included patients, 506 (83.5%) had adenocarcinoma of the esophagus, 323 (53%) died within 5 years of surgery, and 235 (39%) died of tumor recurrence. The extent of lymphadenectomy was not statistically significantly associated with all-cause or disease-specific mortality, independent of the categorization of lymphadenectomy or stratification for T category, calendar period, or chemotherapy. Patients in the fourth quartile of the number of removed nodes (21-52 nodes) did not demonstrate a statistically significant reduction in all-cause 5-year mortality compared with those in the lowest quartile (0-10 nodes) (HR, 0.86; 95% CI, 0.63-1.17), particularly not in the most recent calendar period (HR, 0.98; 95% CI, 0.57-1.66 for years 2007-2012). A greater number of metastatic nodes and a higher positive to negative node ratio was associated with increased mortality rates, and these associations showed dose-response associations.

CONCLUSIONS AND RELEVANCE

This study indicated that the extent of lymphadenectomy during surgery for esophageal cancer might not influence 5-year all-cause or disease-specific survival. These results challenge current clinical guidelines.