Risk factors for and treatment of anastomotic strictures after Ivor Lewis esophagectomy.

INTRODUCTION: Anastomotic strictures following esophagectomy occur frequently and impact on nutrition and quality of life. Although strictures are often attributed to ischemia and anastomotic leaks, the role of anastomosis size and pyloroplasty is not well evaluated. Our study aims to assess the rate of and risk factors for anastomotic stricture following esophagectomy, and the impact of treatment with regular endoscopic balloon dilatations. METHODS: Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, surgical outcomes and anastomotic strictures were recorded. Relationship of anastomotic strictures with circular stapler size, pyloroplasty and anastomotic leak was analyzed. Treatment of strictures with endoscopic balloon dilatation was reviewed and percentage weight loss at 1 year was evaluated. RESULTS: Anastomotic strictures occurred in 17.4% of patients. Patient demographics between those with and without stricture were similar. Stricture rate was similar in patients with or without pyloroplasty (13.9% vs 21.7%, respectively, p = 0.14) and in those with or without an anastomotic leak (25.0% vs 16.6%, respectively, p = 0.345). Stricture risk increased with smaller sized stapler (25 mm = 33.3%, 28 mm = 15.3%, 31 mm = 4.8%; p = 0.027). The median number of dilatations required to fully treat strictures was 2 (IQR: 1-3). The median length of time from surgery to first dilatation was 2.9 months (IQR: 2.0-4.7) and to last dilatation was 6.1 months (IQR: 4.8-10.0). Median maximum dilatation diameter was 20 mm (IQR: 18.0-20.0). There were no complications from dilatations. Percentage weight loss at 1 year in patients with strictures was similar to those without strictures (8.7% vs 11.1%, respectively, p = 0.090). CONCLUSIONS: Post-esophagectomy anastomotic strictures are common and not necessarily related to anastomotic leaks or absence of pyloroplasty. Smaller anastomosis size was strongly linked with stricture formation. A driven approach with regular endoscopic balloon dilation is safe and effective in treating these strictures with no excess weight loss at 1 year once treated.

Effect of pyloroplasty on clinical outcomes following esophagectomy.

INTRODUCTION: The role of concurrent pyloroplasty with esophagectomy is unclear. Available literature on the impact of pyloroplasty during esophagectomy on complications and weight loss is varied. Data on the need for further pyloric intervention are scarce. Our study compares the clinical outcomes after esophagectomy with or without pyloroplasty and investigates the role of post-operative pyloric dilatation. METHODS: Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, mortality rate, anastomotic leak, respiratory complications (Clavien-Dindo grade ≥ 3), anastomotic stricture rate, and percentage weight loss at 1 and 2 year post-operatively were evaluated. For weight analysis at 1 and 2 year post-operatively, patients were excluded if they had been diagnosed with recurrence or died prior to the 1 or 2 year timepoints. RESULTS: Ninety-two patients did not have a pyloroplasty, and 115 patients had a pyloroplasty. There were no complications resulting from pyloroplasty. There was no significant demographic difference between the groups except for age. Mortality rate, anastomotic leak, respiratory complications, anastomotic stricture rate, and percentage weight loss at 1 and 2 years were statistically similar between the two groups. However, 14.1% of patients without pyloroplasty required post-operative endoscopic pyloric balloon dilatation to treat respiratory complications or gastroparesis. Subgroup analysis of patients without pyloroplasty indicated that patients requiring dilatation had greater weight loss at 1 year (15.8% vs 9.4%, p = 0.02) and higher respiratory complications rate (27.3% vs 4.7%, p = 0.038). CONCLUSIONS: Overall results from our study that pyloroplasty during Ivor Lewis esophagectomy is safe and useful to prevent the need for post-operative pyloric dilatation.

The Cancer Hub Approach for Upper Gastrointestinal Surgery During COVID-19 Pandemic: Outcomes from a UK Cancer Centre.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused unprecedented disruption to global healthcare delivery. In England, the majority of elective surgery was postponed or cancelled to increase intensive care capacity. Our unit instituted the 'RM Partners Cancer Hub' at the Royal Marsden Hospital in London, to deliver ongoing cancer surgery in a 'COVID-lite' setting. This article describes the operational set-up and outcomes for upper gastrointestinal (UGI) cancer resections performed during this period. METHODS: From April 2020 to April 2021, the Royal Marsden Hospital formed the RM Partners Cancer Hub. This approach was designed to coordinate resources and provide as much oncological treatment as feasible for patients across the RM Partners West London Cancer Alliance. A UGI surgical case prioritisation strategy, along with strict infection control pathways and pre-operative screening protocols, was adopted. RESULTS: A total of 231 patients underwent surgery for confirmed or suspected UGI cancer during the RM Partners Cancer Hub, with 213 completed resections and combined 90-day mortality rate of 3.5%. Good short-term survival outcomes were demonstrated with 2-year disease free survival (DFS) and overall survival (OS) for oesophageal (70.8% and 72.9%), gastric (66.7% and 83.3%) and pancreatic cancer resections (68.0% and 88.0%). One patient who developed perioperative COVID-19 during the RM Partners Cancer Hub operation made a full recovery with no lasting clinical sequelae. CONCLUSION: Our experience demonstrates that the RM Partners Cancer Hub approach is a safe strategy for continuing upper gastrointestinal (GI) resectional surgery during future periods of healthcare service disruption.

Is Re-introducing Major Open and Minimally Invasive Surgery during COVID-19 Safe for Patients and Healthcare Workers? An International, Multi-centre Cohort Study in the Field of Oesophago-gastric Surgery.

INTRODUCTION: The COVID-19 pandemic has resulted in unparalleled changes to patient care, including the suspension of cancer surgery. Concerns regarding COVID-19-related risks to patients and healthcare workers with the re-introduction of major complex minimally invasive and open surgery have been raised. This study examines the COVID-19 related risks to patients and healthcare workers following the re-introduction of major oesophago-gastric (EG) surgery. PATIENTS AND METHODS: This was an international, multi-centre, observational study of consecutive patients treated by open and minimally invasive oesophagectomy and gastrectomy for malignant or benign disease. Patients were recruited from nine European centres serving regions with a high population incidence of COVID-19 between 1 May and 1 July 2020. The primary endpoint was 30-day COVID-19-related mortality. All staff involved in the operative care of patients were invited to complete a health-related survey to assess the incidence of COVID-19 in this group. RESULTS: In total, 158 patients were included in the study (71 oesophagectomy, 82 gastrectomy). Overall, 87 patients (57%) underwent MIS (59 oesophagectomy, 28 gastrectomy). A total of 403 staff were eligible for inclusion, of whom 313 (78%) completed the health survey. Approaches to mitigate against the risks of COVID-19 for patients and staff varied amongst centres. No patients developed COVID-19 in the post-operative period. Two healthcare workers developed self-limiting COVID-19. CONCLUSIONS: Precautions to minimise the risk of COVID-19 infection have enabled the safe re-introduction of minimally invasive and open EG surgery for both patients and staff. Further studies are necessary to determine the minimum requirements for mitigations against COVID-19.

High-Throughput Breath Volatile Organic Compound Analysis Using Thermal Desorption Proton Transfer Reaction Time-of-Flight Mass Spectrometry.

Breath analysis is highly acceptable to patients and health care professionals, but its implementation in clinical practice remains challenging. Clinical trials and routine practice require a robust system for collection, storage, and processing of large numbers of samples. This work describes a platform based upon the hyphenation of thermal desorption (TD) with proton transfer reaction time-of-flight mass spectrometry (PTR-ToF-MS), coupled by means of an original modification of the TD interface. The performance of TD-PTR-ToF-MS was tested against seven oxygenated volatile organic compounds (VOCs), belonging to three chemical classes (i.e., fatty acids, aldehydes, and phenols), previously identified as possible biomarkers of colorectal and esophago-gastric adenocarcinoma. Limits of detection and quantification were on the order of 0.2-0.9 and 0.3-1.5 parts per billion by volume (ppbV), respectively. Analytical recoveries from TD tubes were 80% or higher, linear response was in the low- to mid-ppbV range ( R2 = 0.98-0.99), and coefficients of variation were within 20% of mean values. The usability of the platform was evaluated in the analysis of a set of breath samples of clinical origin, allowing for a throughput of nearly 100 TD tubes for 24 h of continuous operation. All of these characteristics enhance the implementation of TD-PTR-ToF-MS for large-scale clinical studies.

The Diagnostic Accuracy of 18 F-FGD-PET/CT for Cancer of the Gallbladder: A Retrospective Study.

Background Gallbladder cancer has a poor prognosis and imaging can have variable diagnostic accuracy. We assessed the ability of preoperative 18 F-fluorodeoxyglucose positron emission tomography computed tomography ( 18 F-FDG-PET/CT) imaging to predict a postoperative histological diagnosis of gallbladder cancer. Method A retrospective analysis was undertaken in a cohort of patients, who had suspected gallbladder cancer on cross-sectional imaging and that underwent preoperative FDG-PET/CT scan. The discriminatory power of FDG-PET/CT was determined in receiver operator characteristic (ROC) analysis and diagnostic accuracy parameters were estimated at different thresholds of maximum standard unit value (SUV max ) . Results Twenty-two patients were included in the study; 7 had malignant and 15 benign diagnoses. There was no statistically significant difference between the measured SUV max between the two groups ( p = 0.71). With an area under the curve of 0.486, the ROC curve did not indicate any discriminatory power of FDG-PET/CT at any potential threshold of SUV max. Conclusion This study indicates that the diagnosis of primary gallbladder cancer cannot be accurately confirmed with FDG PET/CT scanning.

Dual-modality emergency management of a rare cause of an aorto-oesophageal fistula: a case report.

Aorto-oesophageal fistula (AOF) is a life-threatening condition that usually presents with upper gastro-intestinal haemorrhage. This case report details the emergency presentation and management of a 51-year-old male who presented with hematemesis secondary to an impacted denture (ingested two years previously) in the oesophagus that had led to an AOF. This necessitated urgent thoracic endovascular aortic repair followed by thoracotomy, oesophagotomy, T-tube insertion and oesophagostomy. This is the first documentation in the literature of the dual-modality management for this rare cause of AOF and demonstrates the multidisciplinary approach to successful management of this complex yet rare presentation.

Auto-deconvolution and molecular networking of gas chromatography-mass spectrometry data.

We engineered a machine learning approach, MSHub, to enable auto-deconvolution of gas chromatography-mass spectrometry (GC-MS) data. We then designed workflows to enable the community to store, process, share, annotate, compare and perform molecular networking of GC-MS data within the Global Natural Product Social (GNPS) Molecular Networking analysis platform. MSHub/GNPS performs auto-deconvolution of compound fragmentation patterns via unsupervised non-negative matrix factorization and quantifies the reproducibility of fragmentation patterns across samples.

Cross-platform mass spectrometry annotation in breathomics of oesophageal-gastric cancer.

Disease breathomics is gaining importance nowadays due to its usefulness as non-invasive early cancer detection. Mass spectrometry (MS) technique is often used for analysis of volatile organic compounds (VOCs) associated with cancer in the exhaled breath but a long-standing challenge is the uncertainty in mass peak annotation for potential volatile biomarkers. This work describes a cross-platform MS strategy employing selected-ion flow tube mass spectrometry (SIFT-MS), high resolution gas chromatography-mass spectrometry (GC-MS) retrofitted with electron ionisation (EI) and GC-MS retrofitted with positive chemical ionisation (PCI) as orthogonal analytical approaches in order to provide facile identification of the oxygenated VOCs from breath of cancer patients. In addition, water infusion was applied as novel efficient PCI reagent in breathomics analysis, depicting unique diagnostic ions M+ or [M-17]+ for VOC identification. Identity confirmation of breath VOCs was deduced using the proposed multi-platform workflow, which reveals variation in breath oxygenated VOC composition of oesophageal-gastric (OG) cancer patients with dominantly ketones, followed by aldehydes, alcohols, acids and phenols in decreasing order of relative abundance. Accurate VOC identification provided by cross-platform approach would be valuable for the refinement of diagnostic VOC models and the understanding of molecular drivers of VOC production.

Optimisation of sampling parameters for standardised exhaled breath sampling.

The lack of standardisation of breath sampling is a major contributing factor to the poor repeatability of results and hence represents a barrier to the adoption of breath tests in clinical practice. On-line and bag breath sampling have advantages but do not suit multicentre clinical studies whereas storage and robust transport are essential for the conduct of wide-scale studies. Several devices have been developed to control sampling parameters and to concentrate volatile organic compounds (VOCs) onto thermal desorption (TD) tubes and subsequently transport those tubes for laboratory analysis. We conducted three experiments to investigate (i) the fraction of breath sampled (whole versus lower expiratory exhaled breath); (ii) breath sample volume (125, 250, 500 and 1000 ml); and (iii) breath sample flow rate (400, 200, 100 and 50 ml min-1). The target VOCs were acetone and potential volatile biomarkers for oesophago-gastric cancer belonging to the aldehyde, fatty acids and phenol chemical classes. We also examined the collection execution time and the impact of environmental contamination. The experiments showed that the use of exhaled breath-sampling devices requires the selection of optimum sampling parameters. The increase in sample volume has improved the levels of VOCs detected. However, the influence of the fraction of exhaled breath and the flow rate depends on the target VOCs measured. The concentration of potential volatile biomarkers for oesophago-gastric cancer was not significantly different between the whole and lower airway exhaled breath. While the recovery of phenols and acetone from TD tubes was lower when breath sampling was performed at a higher flow rate, other VOCs were not affected. A dedicated 'clean air supply' reduces the contamination from ambient air, but the breath collection device itself can be a source of contaminants. In clinical studies using VOCs to elicit potential biomarkers of gastro-oesophageal cancer, the optimum parameters are 500 mls sample volume of whole breath with a flow rate of 200 ml min-1.

Enhanced recovery protocols after oesophagectomy.

The feasibility and safety of enhanced recovery protocols (ERP) have been demonstrated in a large number of surgical specialties. Several studies have shown improved post-operative outcomes and economic benefit from the use of ERPs in oesophageal cancer surgery. However, these improvements are not always translated more widely into clinical practice due to variation in protocols, poor compliance and failure to implement a robust implementation strategy. ERP implementation strategies should reflect the fact that these are complex interventions that are influenced by a wide range of social, organizational and cultural factors.