Circumferential resection margin rates in esophageal cancer resection- oncological equivalency and comparable clinical outcomes between open versus minimally invasive techniques: A retrospective cohort study.

BACKGROUND: Radical surgery for esophageal cancer requires macroscopic and microscopic clearance of all malignant tissue. A critical element of the procedure is achieving a negative circumferential margin (CRM) to minimize local recurrence. The utility of minimally invasive surgery poses challenges in replicating techniques developed in open surgery, particularly for hiatal dissection in esophago-gastrectomy. In this study, the technical approach and clinical and oncological outcomes for open and laparoscopic esophago-gastrectomy are described with particular reference to CRM involvement. MATERIALS AND METHODS: This cohort study included all patients undergoing either open or laparoscopic esophago-gastrectomy between January 2004 to June 2022 in a single tertiary center. A standard surgical technique for hiatal dissection of the esophago-gastric junction developed in open surgery was adapted for a laparoscopic approach. Clinical parameters, length of stay (LOS), post-operative complications and mortality data were collected and analyzed by a Mann-Whitney U or Fisher's exact method. RESULTS: Overall 447 patients underwent an esophago-gastrectomy in the study with 219 open and 228 laparoscopic procedures. The CRM involvement was 18.8% in open surgery and 13.6% in laparoscopic surgery. The 90-day-mortality for open surgery was 4.1% compared with 2.2% for laparoscopic procedures. Median Intensive care unit (ITU), inpatient LOS and 30-day readmission rates were shorter for laparoscopic compared with open esophago-gastrectomy (ITU: 5 versus 8 days, P=0.0004; LOS: 14 versus 20 days, P=0.022; 30-day re-admission 7.46% versus 10.50%). Post-operative complication rates were comparable across both cohorts. The rates of starting adjuvant chemotherapy were 51.8% after open and 74.4% in laparoscopic esophago-gastrectomy. CONCLUSION: This study presents a standardized surgical approach to hiatal dissection for esophageal cancer. We present equivalence between open and laparoscopic esophago-gastrectomy in clinical, oncological and survival outcomes with similar rates of CRM involvement. We also observe a significantly shorter hospital length of stay with the minimally invasive approach.

Radiomic applications in upper gastrointestinal cancer surgery.

INTRODUCTION: Cross-sectional imaging plays an integral role in the management of upper gastrointestinal (UGI) cancer, from initial diagnosis and staging to determining appropriate treatment strategies. Subjective imaging interpretation has known limitations. The field of radiomics has evolved to extract quantitative data from medical imaging and relate these to biological processes. The key concept behind radiomics is that the high-throughput analysis of quantitative imaging features can provide predictive or prognostic information, with the goal of providing individualised care. OBJECTIVE: Radiomic studies have shown promising utility in upper gastrointestinal oncology, highlighting a potential role in determining stage of disease and degree of tumour differentiation and predicting recurrence-free survival. This narrative review aims to provide an insight into the concepts underpinning radiomics, as well as its potential applications for guiding treatment and surgical decision-making in upper gastrointestinal malignancy. CONCLUSION: Outcomes from studies to date have been promising; however, further standardisation and collaboration are required. Large prospective studies with external validation and evaluation of radiomic integration into clinical pathways are needed. Future research should now focus on translating the promising utility of radiomics into meaningful patient outcomes.

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.

Neoadjuvant Chemotherapy-Chemoradiation for Borderline-Resectable Pancreatic Adenocarcinoma: A UK Tertiary Surgical Oncology Centre Series.

BACKGROUND: Patients with borderline-resectable pancreatic ductal adenocarcinoma (BR-PDAC) have historically poor survival, even after curative pancreatic resection and adjuvant chemotherapy. Emerging evidence suggests that neoadjuvant chemoradiation (NCR) improves R0 resection rates in BR-PDAC patients. We evaluated the R0 resection rate, disease-free survival (DFS) and overall survival (OS) in our patients who underwent NCR for BR-PDAC at our institution. METHODS: All patients who underwent NCR for BR-PDAC from January 2010 to March 2020 were included in the study. The patients received a variety of NCR regimens during the study period, and in patients with radiological evidence of tumour stability or regression, pancreatic resection was performed. The primary endpoint was the OS, and the secondary endpoints included patient morbidity, the R0 resection rate, histological parameters and the DFS. RESULTS: The study included 29 patients (16 men and 13 women), with a median age of 65 years (range 46-74 years). Of these 29 patients, 17 received FOLFIRINOX and 12 received gemcitabine (GEM)-based NCR regimens. All patients received chemoradiation at the end of chemotherapy (range 45-56 Gy). R0 resection was achieved in 75% of the patients, with a higher rate noted in the FOLFIRINOX group. The median DFS was 22 months for the whole cohort but higher in the FOLFIRINOX group (34 months). The median OS for the cohort was 29 months, with a higher median OS noted for the FOLFIRINOX cohort versus the GEM cohort (42 versus 28 months). CONCLUSION: NCR, particularly FOLFIRINOX-based treatment, for BR-PDAC results in higher rates of R0 resection and an increased median DFS and OS, supporting its continued use in this patient group.

Mini-mesohepatectomy for tumours at the hepatocaval confluence: A cases series and review of the literature.

Liver lesions located adjacent to the middle hepatic vein (MHV) at the hepatocaval confluence are rare. Mini-mesohepatectomy (MMH) allows resection of these lesions with preservation of liver parenchymal volume thus reducing the risk of post-hepatectomy liver failure (PHLF). We evaluated our experience of MMH at our institution and assessed post-operative complications, disease free survival (DFS) and overall survival (OS). All patients undergoing MMH at our institution were included in the study. Intra-operative parameters, histopathological data, DFS and OS were evaluated. 11 patients with colorectal liver metastasis underwent MMH between Jan 2012 and Dec 2020. MMH resulted in R0 resection rate in all patients with no PHLF. There were 1 post-operative bile leaks but no mortality following MMH. Median DFS was 13.5 months with OS being 60 months. MMH offers safe oncological resection of lesions at the MHV at the hepatocaval confluence and should be considered in patients presenting with such lesions.

Effect of peri-operative chemotherapy regimen on survival in the treatment of locally advanced oesophago-gastric adenocarcinoma - A comparison of the FLOT and 'MAGIC' regimens.

BACKGROUND: Peri-operative chemotherapy improves survival in patients with locally advanced oesophago-gastric adenocarcinoma. Two regimens with proven survival benefits are epirubicin, cisplatin plus capecitabine or fluorouracil (Medical Research Council Adjuvant Gastric Infusional Chemotherapy, MAGIC) and fluorouracil plus leucovorin, oxaliplatin, and docetaxel (FLOT). This study aimed to compare the effect of these regimens on survival (primary aim) and pathological response, surgical complications, adverse events and chemotherapy completion rates. METHODS: Cohort study including 946 patients treated with FLOT (n = 257) or MAGIC (n = 689) who underwent surgical resection for oesophageal (n = 743) or gastric (n = 203) adenocarcinoma between 2002 and 2021 at St Thomas' Hospital or The Royal Marsden Hospital, London, UK. Survival analysis was performed using multivariable Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted for age, sex, clinical T-stage, clinical N-stage, tumour grade and presence of signet ring cells. RESULTS: Patients treated with FLOT had better overall survival (HR = 0.69, 95% CI 0.50-0.94) and disease-free survival (HR = 0.75, 95% CI 0.58-0.98) than MAGIC. Patients treated with FLOT were more likely to have a complete pathological response (9.5% FLOT versus 5.5% MAGIC, p = 0.027) and were less likely to have a positive resection margin (19.1% FLOT versus 32.2% MAGIC, p < 0.001). The stratified analysis revealed similar results for oesophageal and gastric tumours. Rates of surgical complications, chemotherapy-associated adverse events and completion were similarly distributed between treatment groups. CONCLUSIONS: Patients with oesophageal or gastric adenocarcinoma treated with peri-operative FLOT had better survival and pathological response than those treated with peri-operative MAGIC. Rates of surgical complications, adverse events and chemotherapy completion were comparable.

A rare case of small bowel volvulus after jenjunoileal bariatric bypass requiring emergency surgery: a case report.

INTRODUCTION: Bariatric surgery is on the increase throughout the world. Jejunoileal bypass bariatric procedures have fallen out of favor in western surgical centers due to the high rate of associated complications. They are, however, performed routinely in other centers and as a consequence of health tourism, management of complications related to these procedures may still be encountered. CASE PRESENTATION: We describe a rare case of small bowel obstruction in a 45-year-old British Caucasian woman, secondary to a volvulus of the jejunoileal anastomosis following bariatric bypass surgery. The pre-operative diagnosis was confirmed by radiology. We describe a successful surgical technique for this rare complication. CONCLUSIONS: Bariatric surgery may be complicated by bowel obstruction. Early imaging is vital for diagnosis and effective management. The use of our surgical technique provides a simple and effective approach for the successful management of this bariatric complication.

Endoscopic laser fragmentation and removal of a nonremovable metal esophageal stent for persistent dysphagia: a technical note.

BACKGROUND: Self-expanding metal stents are widely used in the palliation of esophageal diseases (Todd, N Engl J Med 344(22):1681-1687, 2001). The majority are inserted for end-stage malignancy and are not designed to be removed. METHODS: We report the first recorded successful endoscopic removal of an "irremovable" stent by laser fragmentation after its placement became redundant. A 72-year-old man who had persistent dysphagia after esophageal stent insertion for Boerhaave's syndrome had his stent removed by Nd-YAG laser fragmentation at staged endoscopies. RESULTS: The stent was removed in its entirety and the patients' symptoms resolved. CONCLUSIONS: We describe a successful technique for the removal of a nonretrievable stent using laser fracture and endoscopic retrieval. This method of stent removal has not been previously reported.