bluuebunny/crossref_metadata_2025 huggingface dataset:
OGC P03 A protocol for investigation and management of late effects after Upper GI surgery
Authors: Pecorella Ilaria , Grimes Sam , Sunderland Nicola , Wong Leslie , Warren Sophie , Chinyama Nyarai , Smith Ben , Bennett John , Hardwick Richard , Sarker Anita , Modolell Ines , Roberts Geoffrey
Published: November 2023

Background

Upper GI surgery, and particularly upper GI cancer surgery can result in quality of life limiting symptoms months and years later. While some of these symptoms may be unavoidable, there are a number of conditions which can be treated with the intention of improving quality of life. We developed and assessed the impact of a CNS and dietitian-led protocol for the investigation and management of late effects after upper GI cancer surgery at Addenbrooke’s Hospital, Cambridge.

Methods

A multi-disciplinary team including nurses, dietitians, pharmacists and with medical input from surgery, gastroenterology and clinical biochemistry produced a pragmatic guideline for the investigation and management of gastrointestinal, nutritional and endocrinological late effects. The protocol was instituted then retrospectively assessed for impact.

The patients were divided in two groups, according to the beginning of their investigations: before or after the introduction of the protocol. Key measures were: proportion of patients being investigated for late effects, the time from presentation of symptoms to diagnosis and which late effects patients were diagnosed.

Results

In the analysis we included a total of 63 patients, 43 from the pre-protocol group and 20 from the post-protocol group. Patients investigated more than once have been interpreted individually making 51 cases pre-protocol and 22 post-protocol. In the pre-protocol group, 78.43% of patients were investigated for late effects. Among them 55% were diagnosed SIBO, 22.9% PEI. In the post-protocol group, 36.36% of patients were investigated for late effects. Among them 50% were diagnosed SIBO and 37.5% PEI. The average time from symptoms to diagnosis in the pre-protocol group was 10 months while in the post-protocol group 2 months.

Conclusions

The protocol has proved a popular adjunct to AHP-led follow-up clinics. The time from symptom onset to diagnosis has significantly improved from 10 to 2 months with the new protocol. Interestingly, the protocol appears to have reduced the number of patients investigated, however as the proportion of patients with SIBO has not changed, suggesting some patients may not be being identified. However, this may reflect the small study numbers and will likely change over time. We are keen to demonstrate our early experience with this standardised, nurse/dietitian-led approach to management of symptoms after Upper GI cancer surgery.
OGC P04 Total Gastrectomy is associated with greater Overall Survival than Subtotal Gastrectomy in Stage III Gastric Adenocarcinoma with Signet Rings
Authors: Patel Nikhil , Doyle Joseph , Al-Hasan Yousef , Patel Pranav , Bhogal Ricky , Allum William , Asif Chaudry Mohammed , Kumar Sacheen
Published: November 2023

Background

Presence of signet rings is a poor prognostic factor in advanced gastric adenocarcinoma (GAc), and is associated with lower chemo(radio)sensitivity, higher locoregional and distant recurrence rates, and lower overall survival (O.S) rates than non-signet ring gastric Ac. Incidence of signet ring GAc is increasing in Europe, Asia and USA, accounting for 35-45% of new cases of GAc. D2 lymphadenectomy and perioperative chemo(immuno)therapy enable better locoregional and systemic disease control, and reduced rate of cancer-related death in GAc. We hypothesise that total gastrectomy is associated with greater O.S than subtotal gastrectomy in signet ring positive GAc.

Methods

All patients who underwent elective gastrectomy for signet ring positive GAc from October 2013 - February 2023 at a single, tertiary, specialist cancer centre in the UK were included in this study. Demographic details including age, BMI, tumour staging (TNM classification), Charlson co-morbidity score, and use of neo(adjuvant) chemo(immuno)therapy were collected. Post-operative histopathology including tumour differentiation, lymphovascular invasion, lymph node yield, recurrence and survival time since surgery were collected. Statistical analyses were performed on matched data subsets using the Datatab platform, including Chi-squared, Student’s T-test and Fisher’s exact tests. Log-rank tests were performed on survival data.

Results

A total of 51 patients (32 male, 19 female) underwent elective total or subtotal gastrectomy for GAc with signet rings (27 total, 24 subtotal gastrectomy). There was no significant difference in mean age, BMI, tumour differentiation, nodal (N) or metastasis (M) stage between these two cohorts. A total of 14/24 (58.3%) patients underwent neoadjuvant chemo(immuno)therapy before subtotal gastrectomy, compared to 21/27 (77.8%) of patients who underwent total gastrectomy (p=0.135). Overall survival was greater among patients that underwent subtotal gastrectomy for stage I cancer (p=0.08), whereas total gastrectomy led to better survival in stage III disease (p=0.131).

Conclusions

This study demonstrates a trend towards greater O.S with total gastrectomy for stage III signet ring positive gastric adenocarcinoma. We suggest total gastrectomy enables better locoregional disease control in advanced cases which have higher risk of lymph node spread. The potential oncological and survival benefits of this methodology need to be weighed up against the increased morbidity and quality of life implications of total gastrectomy.
OGC P05 18FDG-PET-CT is superior to CT in detecting locoregional and distant recurrence after oesophago-gastrectomy for distal oesophageal/gastro-oesophageal junctional cancer
Authors: Patel Nikhil , Doyle Joseph , Al-Hasan Yousef , Patel Pranav , Bhogal Ricky , Allum William , Asif Chaudry Mohammed , Kumar Sacheen
Published: November 2023

Background

Recurrent oesophageal and gastro-oesophageal junctional cancers (OGJC) are associated with poor survival. Evaluation of symptoms, monitoring of tumour markers, and spiral computed tomography (CT) can be used in postoperative surveillance to identify potential recurrence. 18FDG-PET-CT may be used when CT is equivocal despite positive clinical and biochemical markers, and may enable early diagnosis of recurrent disease. We hypothesise that 18FDG-PET-CT is superior to CT in identifying recurrent OGJC and may have a role in routine surveillance post-oesophago-gastrectomy.

Methods

Patients with recurrent OGJC after two-stage oesophago-gastrectomy performed in a single, tertiary, specialist UK cancer centre, who were investigated for suspected recurrence with 18FDG-PET-CT and CT within 1 month of each other, up to 5 years after primary resection were included. Demographic details including age, tumour staging (TNM classification), histological subtype, resection margin status, and serum CA19-9 and CEA levels at the time of recurrence were collected. Radiology reports were reviewed to determine whether recurrence was identified on CT, 18FDG-PET-CT or both. Statistical analyses were performed on the Datatab platform. Sensitivity of both imaging modalities at identifying recurrence was calculated.

Results

A total of n=65 (58 male, 7 female) patients were included. Locoregional, distant, and both locoregional and distant recurrence were identified in n=17 (26.2%), n=22 (33.8%) and n=26 (40.0%) patients respectively. 18FDG-PET-CT (63/65, 96.9% sensitivity) was superior to CT (57/63, 87.7% sensitivity) in detecting all recurrence (p=0.02) and distant recurrence (100% compared to 81.8% sensitivity). Eight patients had recurrence identified on 18FDG-PET-CT, but not by CT (n=4 distant recurrence, n=1 locoregional recurrence, n=3 distant and locoregional recurrence). Of n=5 patients who received treatment for recurrence, n=3 had single-site recurrence. Median survival following detection in this subgroup was 2 years.

Conclusions

This study demonstrated that 18FDG-PET-CT was significantly more sensitive than CT in detecting all recurrent OGJC, and distant recurrence. This modality may have a role in surveillance following oesophago-gastrectomy for OGJC. Its greater sensitivity may enable early diagnosis of recurrence when performed following identification of clinical or biochemical features suspicious for recurrent disease. This could enable appropriate patients to undergo further systemic anti-cancer therapy to treat recurrence, prevent further disease progression and improve survival. Further studies considering economic and logistical factors including availability of equipment to perform a higher volume of scans are required to support these findings.
OGC P07 The utility of cardiopulmonary exercise testing (CPEX) in the management of patients with oesophago-gastric cancer
Authors: D’Sa Shalyn J , Koshy Renol , O' Packham Andrew , Bowrey David
Published: November 2023

Background

The assessment of fitness for surgery of patients with oesophago-gastric (OG) cancer remains a challenge. Accurately “triaging” patients is vital in determining which patients with potentially operable cancer go forward for surgery. Over the last decade, CPEX has been introduced at most centres, although its utility remains unclear.

Methods

Between 2015-2020, 346 patients with OG cancer underwent pre-operative CPEX testing. The (i) anaerobic threshold (AT), (ii) maximum oxygen uptake at peak exercise (V ̇O2peak) and (iii) ventilatory equivalent for CO2 (VE/V CO2) were determined, and their influence on treatment outcomes ascertained.

Results

The MDT 'triaged' 27% of patients unfit for surgery based on their poor CPEX measures (AT: 11.2 vs. 10.2, p=0.002; VO2 peak: 20.3 vs. 17.1, p=0.001; VE/VE CO2: 1.81 vs. 1.58, p=0.001).

60/165 (36%) patients resected, suffered a Clavien-Dindo grade»3 complication, with no association with preoperative CPEX-derived variables (AT:10.9 vs 11.25, p=0.314; VO2 peak: 19.4 vs 19.4, p=0.825; VE/VECO2: 36.3 vs. 37.2, p=0.35).

Multi-variate analysis demonstrated significant associations between poorer CPEX-derived measures and longer HDU stay (AT: p=0.016; VO2 peak: p=0.04), longer hospital stay (AT: p=0.027; VO2 peak: p=0.02) and higher 90-day mortality (AT: p=0.012; VO2 peak: p=0.04).

Conclusions

CPEX testing was a useful adjunct to the MDT algorithm in helping clinicians to triage patients for surgery. It was however not useful in identifying an “at risk” group within the subset considered fit for surgery.
OGC P08 Siewert type III gastro-oesophageal junction adenocarcinoma; total gastrectomy vs. oesophagectomy
Authors: Walmsley James , Browning Matthew , Ariyarathenam Arun , Berrisford Richard , Humphreys Lee , Sanders Grant , Chung Tham Ji , Wheatley Tim , Chan David S Y
Published: November 2023

Background

Tumours of the gastro-oesophageal junction are amenable to different surgical resections. There is an increasing body of evidence to suggest Siewert type III tumours should be managed as gastric cancers and hence may be more appropriately resected via total gastrectomy.

The aim of this study was to compare the outcomes of total gastrectomy and oesophagectomy in patients diagnosed with Siewert type III gastro-oesophageal junction (GOJ) adenocarcinoma.

Methods

Consecutive patients who underwent curative surgery [total gastrectomy (n=42) or oesophagectomy (n=35)] between 1 January 2010 – 03 April 2023 for Siewert type III GOJ adenocarcinoma were analysed prospectively [median age 68 years, (range 43-83 years), 76.6% male, neo-adjuvant treatment 74.0%]. The primary outcome measure was overall 5 and 10-year survival. Secondary outcomes included: 30- and 90-day mortality, lymph node harvest, positive node harvest, margin involvement, anastomotic leak and length of stay.

Results

Demographic details between both groups of patients were similar. Patients undergoing total gastrectomy had a significantly shorter length of hospital stay compared with patients undergoing oesophagectomy (median 8 vs. 10 days, p<0.006). Distal margin involvement was significantly higher in patients undergoing oesophagectomy (0% vs. 12.1 %, p=0.027). Overall, 5 and 10-year survival was significantly higher in patients undergoing total gastrectomy (62% and 52% vs. 36% and 22% respectively, p=0.013). There were no significant differences in lymph node harvest (median 29.5 vs. 33.0 nodes), anastomotic leak rates (2.4% vs. 11.4%), 30- (2.4% vs 0%) and 90-day (2.4% vs 2.9%) mortality.

Conclusions

Patients undergoing total gastrectomy have improved short and long-term outcomes compared with patients undergoing oesophagectomy for Siewert type III GOJ adenocarcinoma.
OGC P09 Benchmarking of OG cancer care across the United Kingdom: a collaboration of 2 national clinical audit systems
Authors: Forshaw Matthew , Anderson David , Urquhart Christine , Cromwell David
Published: November 2023

Background

Clinical audit plays an important role in benchmarking cancer services to ensure the delivery of high-quality care. The UK has 2 separate clinical audits (NOGCA in England and Wales, and QPI data in Scotland) analysing the process and outcomes of care for oesophagogastric (OG) cancer patients. Both cover the care pathway from diagnosis to the end of primary treatment. Comparative analysis has not previously been undertaken between these 2 audits. We aim to demonstrate that the 2 systems can be interrogated to provide valuable population and benchmarking data, and present the results of a successful collaborative project.

Methods

Data was extracted from the 2 audits for all epithelial OG cancers diagnosed between 01/01/17 and 31/12/19 (n=34,584). Analysis was then undertaken, with a particular focus on: 1) disease stage at presentation; 2) proportion of patients undergoing CT staging 3) proportion of patients receiving curative/non-curative treatment; 4) Curative treatment patterns; and 5) short-term outcome measures (adjusted mortality, key pathology outcomes). Descriptive statistics were derived for each country and stratified by patient/tumour characteristics. Mortality rates and longitudinal margins were adjusted for case-mix using multiple logistic regression. Statistical tests were 2-sided; threshold of significance set at p<0.05.

Results

Baseline demographics were similar. Staging CTs were less commonly performed in England (83.1%; Scotland=98.5%; Wales=92.2%). Metastatic disease at presentation was highest in Scotland (40%-42%; England=30%-34%; Wales=36%-39%). England (40%) had highest proportion of MDT derived curative treatment plans (compared to Scotland=29% and Wales=34%). However, actual curative treatment rates (24-31%) were more similar and these differences narrowed after correction for population and staging differences. Curative treatment patterns are shown in Table 1. Mortality rates were similar in the 3 nations. Longitudinal margin positivity was significantly lower in Scotland (2.4%; England=5.4% and Wales=8.2%). Excision of >15 lymph nodes was highest in England.

Conclusions

The 2 audit systems used in the UK to analyse the care and outcomes for patients diagnosed with OG cancer share sufficient data definitions and overlap to allow meaningful comparison. The data presented here represents an important benchmark of current UK OG practice. Most results were similar although some important differences were highlighted which require further exploration.
OGC P12 The Current Landscape of Nutritional Care in Oesophahgogastric Cancer: Insights from The National Oesophagogastric Nutrition Audit (NONA)
Authors: Casey Patrick , Gossage James , Ford Kate , Huddy Fiona , Owen Kellie , Markar Sheraz , McLaughlin John , Sultan Javed
Published: November 2023

Background

Specialist nutritional support is important during treatment for oesophagogastric (OG) cancer yet current practice remains unstandardised across the UK. The National Oesophagogastric Nutrition Audit (NONA) aimed to describe the current landscape of OG dietetic services in the UK and Ireland, with a specific focus on resource allocation, barriers to dietetic support, and the provision of support throughout the cancer pathway.

Methods

Tertiary cancer units, secondary care, and community services across the UK and Ireland were invited to complete a 28-point electronic questionnaire. Team leaders and senior specialist OG dietitians were the target respondents. All data points were peer-reviewed, piloted, and revised by the NONA steering committee before distribution. Data points covered a range of areas related to resources, skill mix, provision of support throughout the cancer pathway, and involvement with national audit and research.

Results

Complete responses were received from 50 units (surgical units, n=35 and oncology units, n=10). Secondary care/community services were underrepresented (n=5). The majority (77%) of tertiary surgical units agreed or strongly agreed they were able to provide adequate nutritional care in the post-operative period. However, confidence dropped significantly during the early diagnostic phase and in the neoadjuvant period, with 52% and 67% of units disagreeing that they could provide adequate dietetic support, respectively. Inadequate funding, understaffing, and prioritisation of inpatients were commonly reported barriers. There was significant variation in practice regarding nutritional service structure, and staffing resources across specialist units.

Conclusions

The NONA survey provides a ‘real-world’ landscape of nutritional care for patients with OG cancer. Lack of funding, resource, and evidence-base may explain the variation seen in services provided across the UK. Further research and consensus is required to help standardise nutritional care, guide service specification, and improve nutritional outcomes for patients with OG cancer. Further national consensus frameworks to standardise care in the UK are currently underway.
OGC P15 Analysing the Impact of Prehabilitation on Patient Outcomes in Oesophagogastric Cancer Surgery: Combined Data from Four prospective Clinical Trials performed across the UK and Ireland
Authors: Barman Sowrav , Walker Robert , Knight William , Baker Cara , Kelly Mark , Gossage James , Allen Sophie , Preston Shaun , Sultan Javed , Rockall Timothy , Robb William , Tully Roisin , Underwood Tim , West Malcom , Jack Sandy , Levett Denny , Grocott Mike , Leggett Samantha , Davies Andrew
Published: November 2023

Background

Prehabilitation is increasingly being used in patients undergoing multi-modality treatment for oesophago-gastric (OG) cancer. Most studies to date have been small, single centre trials lacking statistical power. The results of larger randomised trials are still awaited. There remain considerable uncertainties regarding the outcome measures that may benefit from prehabilitation, the exact nature of the intervention and the mechanisms behind any observed benefit. This collaborative study sought to combine data from four prospective clinical prehabilitation trials performed in the UK and Ireland to determine the overall impact of the intervention on patient outcomes following oesophagogastric cancer surgery.

Methods

Anonymised data from four prospective prehabilitation trials conducted in the UK and Ireland (Southampton, Guildford, Dublin, and St Thomas’, London) in patients undergoing multi-modality treatment for oesophagogastric cancer was combined. The studies included two randomized and two non-randomized clinical trials. The primary outcome measures were differences in complications and length of stay. Secondary outcomes were changes in BMI, fitness (VO2 max), chemotherapy completion rates and tumour regression. In total, 180 patients were included from four studies, with 93 patients in the prehabilitation group and 87 patients in the control group.

Results

Severe complications (Clavien Dindo >=3) were observed less frequently in the prehabilitation group (19% vs 34%; p=0.038). Hospital length of stay also favoured prehabilitation (10 vs 11 days) albeit not statistically significant. Chemotherapy completion rates were significantly higher following prehabilitation (96% vs 63%; p<0.001). There were non-significant improvements in VO2 max change following neo-adjuvant therapy (delta 1.35 vs 2.39; p=0.25), anaerobic threshold change (delta 1.20 vs 2.20; p=0.11) and chemotherapy response (Mandard 1-3 57% vs 44%; p=0.178).

Conclusions

Despite some limitations in terms of heterogeneity of study methodology and prehabilitation interventions, this study has highlighted a willingness of individual units to collaborate and tangible clinical benefits across a range of outcome measures in a larger OG patient population. Current initiatives to agree national standards for delivering prehabilitation and the results of on-going trials will help to further refine this important intervention and expand the evidence base to support the widespread adoption and implementation of prehabilitation programs.
OGC P17 Reporting nutritional outcomes following gastrectomy: A systematic mapping review
Authors: Patel Minal , Waheed Unaiza , Khan Shiraz , Alkhaffaf Bilal
Published: November 2023

Background

Following an international consensus agreement of patients and healthcare professionals (GASTROS Study), ‘nutritional outcomes’ have been identified as critically important to report in surgical trials for gastric cancer. A previous review has demonstrated that nutritional outcomes are rarely reported by trials, and little is known about how best to measure them. In preparation for future work on establishing an optimum approach to report and measure nutritional outcomes, a mapping review was undertaken to examine current approaches used by researchers in this field.

Methods

We conducted a systematic literature search (using MEDLINE, Embase, CINAHL, Cochrane and PsychInfo) and included randomised control trials and prospective studies reporting any form of nutritional outcome in patients following gastrectomy, between 2012 and 2022. The review was conducted using PRISMA guidelines and registered on the PROSPERO database (CRD42022365652). Full text reviews and data extraction were completed independently by three reviewers. Datapoints of interest included general trial and surgery characteristics, study types, duration and frequency of nutritional outcomes and the utility of nutritional screening measurement tools. Data collection and analysis was conducted on Microsoft Excel.

Results

3288 abstracts were screened, yielding 87 studies (17220 patients) eligible for inclusion. 90% of trials were based in East Asia. 24% of trials reported biochemical, anthropometric, and weight-based outcomes. 21 different biochemical tests were reported by 74% trials, the most common marker being ‘albumin’. Anthropometric measurements were heterogenous with BMI and skeletal muscle index being the most frequently reported. 66% of studies reported patient weight as an outcome. 28% studies reported both nutritional screening and assessment. 48% of trials utilised screening tools. The frequency and time points at which nutritional outcomes were measured varied greatly.

Conclusions

This mapping review highlights significant variation in the reporting of nutritional outcomes. Consensus agreement is required to establish the optimum approach to use in trials and clinical practice.
OGC P18 10-year survival following oesophagectomy and 2-field lymphadenectomy: a retrospective cohort study
Authors: Linder Cortland , Kaushal Devesh , Tan LamChin , Malik Amman
Published: November 2023

Background

Only 12.6% of patients with oesophageal cancer in the UK will survive over 10 years. While oesophagectomy remains the best option for resectable oesophageal cancers, there is debate about the extent of lymphadenectomy during surgery and its impact on short and long-term outcomes. We analyzed the outcomes, including 5- and 10-year survivals, for patients undergoing oesophagectomy and radical lymphadenectomy by a single surgeon.

Methods

All patients who underwent oesophagectomy for any stage of oesophageal cancer in a single tertiary centre in the United Kingdom, with or without neoadjuvant chemotherapy, were identified from a prospectively maintained database from 2006-2017. We describe long term survival by number of lymph nodes resected and lymph node ratio (the ratio between the number of positive nodes and total nodes resected).

Results

Median survival following oesophagectomy was 66.3 months (95% CI: 53-71) with a minimum follow-up of 5 years. Most patients had adenocarcinomas (85.9%) followed by squamous carcinomas (8.5%). For all histologies, overall 5-year survival was 54% and 10-year survival was 40%. For patients with adenocarcinoma, resecting ≥24 lymph nodes improved survival compared with <24 nodes (median 73 months and 59 months respectively, p<0.038). The number of lymph nodes resected was an independent predictor of survival (p<0.001). For patients with any histology, a lower lymph node ratio indicated better survival (p<0.01).

Conclusions

This study demonstrates an improved long-term survival following oesophagectomy combined with lymphadenectomy of ≥24 nodes. We did not have any loss to follow-up with a long follow-up period, strengthening reported results.
OGC P24 The impact of early enteral feed composition on the rate of chyle leak post-oesophagectomy
Authors: Pan Sally , Bushra Raisa , Cheah Lilyanne , Ribbits Alexander , Grimes Sam , O’Neill J Robert
Published: November 2023

Background

Patients undergoing oesophagectomy are at significant risk of malnutrition and benefit from peri-operative enteral feeding. Chyle leak presents in up to 20% of patients undergoing an oesophageal resection and is associated with immunosuppression, malnutrition and increased complications. Early enteral feeding can increase the rate of chyle leak in these patients. Enteral feed with a high percentage of fat as medium chain triglycerides (MCT) is more easily absorbed and can reduce chyle production. We evaluated the impact of early enteral MCT-rich feed on the prevalence and severity of chyle leak post-oesophagectomy. Secondary outcomes include length stay, and post-operative weight change.

Methods

Retrospective review of records from consecutive patients undergoing oesophagectomy at a single tertiary centre between January 2015 and December 2022. Following specialist dietician input, patients received enteral feed on post-operative day 1 – 5 with Nutrison Protein Plus Energy (standard; 5.8% total fat, 0.9% (MCT)) (2015-June 2021) or Nutrison Peptisorb Plus HEHP (HEHP; 5% total fat and 3% MCT) enteral feed (June 2021 to Dec 2022). All patients transitioned to standard feed on post-operative day 6 onwards and were discharged on IDDSI level 4 diet and supplemental jejunal feeding.

Patients who did not commence early enteral feeding were excluded from analysis.

Results

A total of 329 patients were included. Patients who received early enteral HEHP feed had fewer chyle leaks (5/52; 9.6%) compared to patients who received early enteral standard feed (68/277; 24.5% p=0.017). The proportion of ECCG grade I and II leaks was similar between groups. No patients required surgical intervention for a chyle leak during the study period. The HEHP group had a shorter critical care (p<0.001) and total length of hospital stay (p=0.011). Weight change from pre-operative baseline was equivalent in both groups at 6 weeks (standard; -4.5%, HEHP; -2.3%, P=0.066) and 3 months (standard; -5.6%, HEHP -4.0%, P=0.400).

Conclusions

In the context of routine jejunostomy use and early enteral feeding post-oesophagectomy, HEHP feed on post-operative day 1- day 5 was associated with a significantly lower chyle leak rate with corresponding shorter length of stay compared to standard feed. No difference was noted in post-operative weight change between groups which was relatively well preserved up to 3 months post-operatively.
OGC P25 Impact of minimally-invasive oesophagectomy on post-operative analgesia and surrogate outcomes
Authors: Ribbits Alexander , Bushra Raisa , Pan Sally , Cheah Lilyanne , O’Neill Robert
Published: November 2023

Background

Minimally invasive oesophagectomy (MIO) via either two (MIO2) or three phases (MIO3) has been proposed to reduce post-operative pain and correspondingly improve patient recovery compared to open Ivor-lewis (ILO), Left thoracoabdominal oesophagectomy (LTA) or hybrid-ILO (lap abdomen, open thoracotomy). The primary aim of this study was to audit analgesia outcomes according to surgical approach via maximum daily pain score, daily and total post-operative opiate usage. Secondary outcomes included return of GI function, mobility, and rates of post-operative pneumonia, escalation in ward care or re-intubation due to respiratory failure.

Methods

Retrospective review of records from consecutive patients undergoing oesophagectomy at a single tertiary centre between January 2015 and December 2022. Post-operative analgesia consisted of thoracic epidural and patient controlled analgesia (PCA) for patients undergoing thoracotomy and PCA+/- paravertebral analgesia for those undergoing MIO. Patients remaining ventilated due to early post-operative complications were excluded from analysis.

Opioid usage was converted to oral morphine equivalents for comparison. Patient mobility was prospectively recorded by a physiotherapist using the Manchester Mobility Score (MMS). Pneumonia was defined as either rising inflammatory makers or fever and any new respiratory symptom, oxygen requirement or pulmonary imaging changes.

Results

Of a total 328 eligible patients, 225 underwent open oesophagectomy, 80 MIO, and 23 hybrid-ILO. Pain scores were similar on post-operative day 0-5 across approaches. MIO was associated with a significantly lower median total opioid usage (MIO2-624mg, MIO3-720mg) compared to open (ILO-1608mg, LTA-1984mg ) and hybrid-ILO-1977mg (P<0.001).

There was no significant difference in pneumonia, escalation or reintubation rates between the different approaches. MIO was associated with an earlier return of bowel function (P<0.001) and patients undergoing MIO achieved the maximum MMS score earlier than those undergoing thoracotomy (P<0.001).

Conclusions

Equivalent post-operative analgesia can be achieved between open and minimally invasive oesophagectomy when multimodal approaches including epidural anaesthesia are employed. MIO is however, associated with an approximately threefold reduction in opiate use with corresponding earlier return of gut function, and improved post-operative mobility compared to ILO, LTA or hybrid-ILO. Where feasible and can safely be employed, suitable patients may benefit from a minimally invasive oesophagectomy over open or hybrid approaches as part of an enhanced recovery pathway supported by a multidisciplinary team.
OGC P27 Resection margin strategy in gastric cancer surgery: the European REMARCS (Resection MARgin for Cancer of the Stomach) survey
Authors: Chevallay Mickael , Berlth Felix , De Manzoni Giovanni , Piessen Guillaume , Davies Andrew , Koessler Thibaud , Meyer Hans-Joachim , Möhler Markus , Grabsch Heike , Grimminger Peter , Allum William , Pera Manuel , Hölscher Arnulf , Mönig Stefan
Published: November 2023

Background

Surgery with negative resection margins and appropriate lymphadenectomy is the only curative treatment for gastric cancer. The adequate proximal resection margins length in European guidelines is between 5 to 8 centimeters depending on the histological subtype. However, these recommendations are based on outdated studies with limited data. The peri-operative treatment modalities have evolved, and the application of these resection margin cut-offs may not be as uniform as before. The aim of our study was to assess the current European practice in gastric cancer surgery with particular attention to resection margins.

Methods

A panel of 13 international experts composed of surgeons, pathologists, and oncologists developed a web-based survey containing 45 questions about center demographic, resection margin strategy, and post-operative care. The survey was distributed to Upper Gastrointestinal (UGI) surgeons through UGI and visceral surgical societies mailing lists and social media between February and June 2022. Participants were excluded if they did not answer a minimum of 80% completion of the questionary).

Results

172 surgeons from 154 centers in 19 countries responded to the survey. The most represented countries were Germany 60 (35%), Switzerland 30 (18%) and Italy 16 (9%). The mean surgical years’ experience of the responders was 20.8 and their caseload was 23.2 cases per year. For intestinal type gastric tumor, a proximal resection margin length of a minimum of 5 centimeters was advocated by 119 (77%) of the responders. For diffuse, a resection margin of a minimum of 8 cm was applied by 98 (63%) of the surgeons. Macroscopic inspection of the specimen was routinely performed by 110 respondents (64%).

Conclusions

The real-world data from our questionnaire shows that the length of resection margins proposed by actual guidelines are not strictly applied in European centers. Further data from clinical research are needed to standardize resection margin cut-off. This could help European surgeons to propose more organ-sparing strategies to their patients.
OGC P29 Cost of complications after Upper Gastrointestinal Cancer surgery: the case for pre-habilitation illustrated
Authors: Herbert Geraint L , Robinson David , Powell Arfon G , Barlow Rachael , Abdelrahman Tarig , Khalid Usman , Lewis Wyn G
Published: November 2023

Background

Upper Gastro Intestinal (UGI) cancer surgery carries considerable risk and cost in terms of human and financial resource. Reported complication rates after oesophagectomy and gastrectomy are 65% and 42% respectively and can range from relatively minor morbidity to major life-threatening events, all with the potential to increase Length of Stay (LoS) and cost which can be graded by the Clavien-Dindo (CD) system. This study aimed to study the impact of complications on LoS and quantify the associated economic costs.

Methods

Consecutive 754 patients with UGI cancer (420 oesophageal, 334 gastric), undergoing potentially curative treatment (median age 67 yr., 590 m, 164 f, 684 Adeno Ca, 36 SCC, 205 Ivor-Lewis oesophagectomy, 146 Trans Hiatal oesophagectomy, 142 total gastrectomy, 134 subtotal gastrectomy, 97 open and close, 11 Three-stage oesophagectomy, 10 salvage resections, 8 oesophagogastrectomy) were studied. The cost of each night’s stay was limited to direct costs, including ward and medical staff expenditure.

Results

Median LoS was 13 (IQR-7) days. The number of patients related to CD score were; Zero-326, I-41, II-224, IIIa-44, IIIb-28, IVa-36, IVb-4 and V-16, with median LoS of 11, 14, 14, 23, 25, 32, 44 and 9 days respectively. The added LoS for each complication cohort was 3 days for CD I and II, then 12, 14, 21, and 33 days for CD IIIa, IIIb, IVa and IVb respectively. Average added cost for each grade of complication per patient was £844.44 for CD I and II, £3,377.76 for IIIa, £8,519.40 for IIIb, £14,927.70 for IVa and £36,047.85 for IVb.

Conclusions

Overall hospital and CC LoS increased related to complication grade, other than CD V, with an average ward cost per additional day of £281.48 and CC cost of £1426.15. Average cost of an uncomplicated oesophagectomy or gastrectomy was estimated to be £16,544. As well as the adverse impact on patients’ recovery and well-being, complications have a large fiscal impact on healthcare systems and in many cases can dwarf the first treatment cost. These findings illustrate a strong clinical and business case for investment in effective strategies to boost complication free surgery including pre-habilitation.
OGC P35 A clinical audit looking at how efficient the current pathways are for detecting upper oesophageal cancer
Authors: Siempis Timoleon , Harris Andrew , McCain Scott , Kennedy Ray , MacAulay Graeme , Gray Ronan , Kennedy Andrew
Published: November 2023

Background

Dysphagia is a red flag symptom of possible oesophageal cancer. Patients are referred to gastroenterology, Upper GI Surgery or Otolaryngology. The referral pathway is determined by whether the symptoms are thought to be oropharyngeal or oesophageal in nature. Often, correlation between patient’s perception of the level of dysphagia and the anatomical location of the underlying cause is unreliable. This can result in a number of patients receiving either a delayed complete examination of the oesophagus or not receiving one at all. Our aim was to identify potential delays in the diagnostic pathway of patients with suspected upper oesophageal malignancy.

Methods

A retrospective analysis of 348 patients with a confirmed histological diagnosis of oesophageal cancer between January 2021 – March 2023 was performed. Only patients with cervical oesophageal cancer up to 20cm were included. The time between GP referral and commencement of treatment was compared against NHS England standards. The initial investigation ordered for those patients after being referred to the specialist was reviewed in order to identify any diagnostic delays. According to NICE guidelines, all patients with dysphagia should be referred for oesophago-gastro-duodenoscopy (OGD) urgently. Barium swallow should not be the first line investigation for suspected oesophageal cancer.

Results

14 cervical oesophageal cancer cases were identified. 5 cases discussed at UGI Multidisciplinary meeting with incidental diagnosis were excluded. All remaining 9 cases were discussed at both Head and Neck and UGI MDMs. 6/9 patients were first referred to ENT with dysphagia. The remaining 3/9 were referred to either Gastroenterology or UGI. 4/9 patients had OGD whereas 5/9 had barium swallow and 7/9 rigid oesophagoscopy organized by ENT. Interestingly, 4/5 barium swallow tests were the first line investigation. Median interval from GP referral till start of treatment was 108 days which is almost double compared to the standards (62 days).

Conclusions

This study highlights significant delays in the diagnostic pathway of patients referred from GP with dysphagia and suspected cervical oesophageal cancer. It appears that this group of patients enters a pathway without a clear diagnostic consensus. Patients with red flag dysphagia symptoms for suspected malignancy should have direct visualisation of the oesophagus irrespective of whether the initial assessment occurs within head and neck or upper gastrointestinal suspected cancer pathways.
OGC P38 The impact of hospital experience in bariatric surgery on short-term outcomes after minimally invasive oesophagectomy: a nationwide analysis
Authors: Janssen Henricus , Geraerdts Tessa , Simkens Geert , Visser Maurits , de Hingh Ignace , van Det Marc , Nieuwenhuijzen Grard , van Hillegersberg Richard , Luyer Misha , Nienhuijs Simon
Published: November 2023

Background

Minimally invasive oesophagectomy (MIO) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIO.

Methods

Data on oesophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Dutch institutions have a mandatory annual threshold of 200 bariatric and 20 oesophagectomy procedures. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case-mix.

Results

Of 3371 patients undergoing oesophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIO. Bariatric hospitals (N=6) accounted for 1057 (43.1%) MIO. Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P<0.001). Bariatric hospitals were associated with a reduced risk of overall complications (OR 0.72 [95%CI 0.60-0.87]), length of hospital (OR 0.73 [95%CI 0.61-0.87]) and ICU stay (OR 0.83 [95%CI 0.69-1.00] (P=0.046)) after MIO. Surgical radicality did not differ. Lymph node yield (≥15) was lower in bariatric hospitals (90.0% vs. 94.7%, P<0.001). Several short-term outcomes showed a significantly improving trend over the years in bariatric, but not non-bariatric hospitals.

Conclusions

In this nationwide analysis, bariatric hospitals were associated with improved short-term outcomes after MIO and further improved over the years. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify.
OGC P39 The accuracy of Hospital Acquired Pneumonia (HAP) Diagnosis after Oesophagectomy
Authors: Waheed Unaiza , Alvi Quraishi Rumaysa , Patel Minal , Worthington Lucy , Fidler David , Heal Calvin , Alkhaffaf Bilal
Published: November 2023

Background

Oesophagectomy is a high-risk intervention associated with significant rates of morbidity. Pneumonia is a complex spectrum of infective and non-infective aetiology, varying in severity and is common after oesophagectomy. Inconsistent definitions of pulmonary complications pose significant challenges in both the clinical and research setting. The internal Esophageal Consensus Complications Group (ECCG) have adopted the Centre for Disease Control (CDC) criteria for HAP diagnosis to address this. However, other validated diagnostic criteria are also available. This study aimed to better understand the incidence of HAP after oesophagectomy, and the accuracy of four validated diagnostic tools.

Methods

This was a retrospective review of all consecutive oesophagectomies undertaken at a regional OG centre serving a population of 3.5 million patients between 2014-2022. Datapoints included patient demographics; comorbidities; post-operative course and re-admissions. The timing of pneumonia diagnosis was determined in the post-operative period, alongside observations and Computed Tomography (CT) and Chest X-Ray (CXR) reports. Four diagnostic criteria (Centres for Disease control- CDC, American Thoracic Society - ATS, Utrecht and Clinical Pulmonary Infection Score - CPIS) were applied to determine the incidence of HAP in comparison to patients treated for HAP. Statistical tests were performed in STATA.

Results

460 patients were included, 356 (77.40%) were male. 223 (48.5%) were treated for HAP between 2014-2022. 56 (12.2%) met the CDC criteria. Mean days to diagnosis was 5 days (SD +/- 3.72). Diagnostic sensitivity and specificity for HAP was 88.89%, and 50.15% respectively. The ATS criteria were met by 79 patients (17.2%), showing a similar sensitivity (97.53%) and specificity (92.02%) to the CDC criteria. The Utrecht criteria had the lowest specificity (75.20%) for HAP diagnosis. 192 patients had sputum samples; 158 (82.29%) were culture positive. 52 patients were re-intubated, of which 29 (55.8%) were reintubated due to respiratory failure.

Conclusions

HAP is a complex and nuanced diagnosis with high inter-observer variation. Currently available and validated diagnostic tools result in different rates of HAP diagnosis. These findings highlight the importance of adopting robust approaches to diagnosing HAP to avoid unnecessary treatments and to more accurately determine the effectiveness of protocolised management (such as ERAS) that target HAP. The findings also highlight important implications on outcome reporting in research, particularly with interventions (e.g. minimally invasive and robotic surgery) which aim to reduce the burden of post-operative morbidity. Further widescale studies are required to validate these findings.
OGC P43 Is surgery (gastrectomy) alone more effective than surgery combined with adjuvant chemotherapy for the treatment of Stage I-III gastric adenocarcinoma?
Authors: Kaur Rikhraj Naveena
Published: November 2023

Background

Gastric adenocarcinoma, the malignant proliferation of glandular cells in stomach epithelium, is a type of gastric cancer with statistical disease-burden of the 5th most common global and 17th most common cancer in the UK. Gastric adenocarcinoma at different stages (Stage I-IV) present with different prognoses. Particularly promising subset is patients with Stage I-III gastric adenocarcinoma, presenting with 5-year survival rates up to 71.8%, warranting early diagnosis and effective treatment can be vital. There are several treatment modalities, currently surgery being gold-standard. However, understanding pathological nature of tumour development, combination treatments, such as adjuvant chemotherapy after surgery can maximise patient outcomes.

Methods

The study aimed to investigate patients with Stage I-III (non-advanced) gastric adenocarcinoma, in understanding whether adjuvant chemotherapy combined with surgery provides (1) greater disease-free/disease-specific/cause-specific survival, (2) overall survival, (3) decreased recurrence rates or improved recurrence-free survival, compared to surgery alone.

17 (3 randomised-control, 10 cohort, 4 case-control) English-language, full-text, Level I-III, peer-reviewed studies from MEDLINE and Embase databases, in past 10 years were reviewed. No age/sex/ethnicity/country restrictions applied and dimension of interest limited to Stage I-III gastric adenocarcinoma patients who had undergone tumour resection via surgery, and received chemotherapy as the only adjuvant therapy.

Results

7/17 (41.2%) of studies have at least one statistical outcome measure (DFS/OS/RFS, measured by p-values and HR/OR) that supports, with statistical significance, that adjuvant chemotherapy combined with surgery has benefit over surgery alone for the treatment of Stage I-III gastric adenocarcinoma. Majority of studies, 10/17 (58.8%) do not show statistically significant benefit of adjuvant chemotherapy.

Conclusions

In conclusion, findings of this study are limited by sample size and bias present in individual studies reviewed. Thus, findings are different when compared to prior large-scale meta-analyses and ongoing research is needed in the field (with consideration to advances in interventions i.e. surgical technique and new chemotherapeutic combinations) to fully understand whether adjuvant chemotherapy is effective when combined with surgery for treatment of gastric adenocarcinoma.
OGC P50 Evaluating the outcomes of routine level one ward care post major oesphago-gastric surgery
Authors: Johnson Courtney , Walmsley James , Berrisford Richard , Chan David S Y , Humphreys Lee , Sanders Grant , Wheatley Tim , Ariyarathenam Arun
Published: November 2023

Background

Oesophago-gastric cancer resections are complex operations. Many centres routinely manage patients in higher acuity settings such as surgical HDU, ITU or fast track beds.

The UK has 2.4 critical care beds per 1000, compared to an average of 5 per 1000 across OECD-EU nations. The COVID-19 pandemic has also had a significant impact on availability of these beds.

Patients in our unit are routinely admitted to a standard level one surgical bed with continuous non-invasive cardiac monitoring and nursing care ratio of 1 to 5. This has been in practice for over 10 years with good outcomes.

Methods

Consecutive major oesophago-gastric resections between April 2020 and March 2023 in a single tertiary unit were included.

Patients were split into two groups:

Patients who were admitted directly to the surgical ward or had a planned admission to ITU based on pre-operative assessment and routine Integrated Cardiopulmonary Exercise Testing (CPEX) outcomes were considered to have completed a standard pathway.

The primary outcome was unplanned ITU admission rate. Secondary outcomes included: total length of stay (TLOS), 30- and 90-day mortality.

Results

238 patients (187 M: 51 F) were identified with a median age of 69 (33 – 84 years).

The resections performed were Ivor Lewis oesophago-gastrectomy (ILGO) (n=196, 81%), total/extended total (n=30), subtotal (n=10) or distal gastrectomy (n=3). 34 patients were admitted to ITU, of which 23 were unplanned (9.2%) and all had undergone an ILGO. The median TLOS and mortality data are outlined in Table 1, with <1% 30 and 90-day mortality for patients on the standard pathway.

The median ITU length of stay was 5 days (1 – 48 days) with reasons for admission listed in Table 2.

Conclusions

Major oesophago-gastric cancer resections can be managed safely in the early post-operative period, outside of higher acuity care settings with good outcomes.