Endoscopic management of ingested toothpick resulting in duodeno-ureteric fistula.

Toothpicks are commonly used but rarely ingested. Unlike most foreign bodies, if accidentally swallowed these rarely spontaneously pass. The duodenum has been reported as the most common site of toothpick foreign body lodgement in the upper gastrointestinal tract. We report the case of a 57-year-old presenting with recurrent urosepsis after non recognition of a toothpick impaction in the duodenum with fistulisation into the right renal pelvis. Endoscopic removal of the foreign body was successful in management of the urosepsis.

Small bowel obstruction secondary to barbed sutures in bariatric surgery: a cautionary tale.

BACKGROUND: Laparoscopic bariatric surgery relies on technically challenging intracorporeal suturing for critical parts of the operation. Barbed sutures have been developed to provide an alternative to suturing for certain manoeuvres within a procedure. Barbed sutures theoretically negate the need for knot tying and allow for continuous application of tension; however the barbs can unintentionally adhere to surrounding tissues. We describe a case series of three patients who developed V-Loc™ (barbed) suture related small bowel obstruction (SBO) to promote awareness of this unusual but preventable complication. METHODS: Medical records of patients diagnosed with V-Loc™ related SBO between 2018 and 2021 at a tertiary centre were reviewed. Data regarding presentation, diagnosis, management and outcomes were obtained. RESULTS: Three patients were identified where V-Loc™ sutures were aetiologically related to early post-surgical small bowel obstruction secondary to small bowel adherence to barbed suture tail or adhesions between barbed suture tail and unintended viscera. In these cases, non-absorbable V-Loc™ sutures were used to close the small bowel mesenteric defect at Roux-en-Y gastric bypass surgery. All patients required adhesiolysis at re-look laparoscopy prior to resolution. All patients were discharged home well after relook laparoscopy. CONCLUSION: Overly long or exposed V-Loc™ suture tails can result in SBO following laparoscopic bariatric surgery. Cutting the suture tail as close as practical to the final throw of the suture and/or covering exposed suture ends may prevent this complication.

The effect of bariatric surgery on the expression of gastrointestinal taste receptors: A systematic review.

Gastrointestinal nutrient sensing via taste receptors may contribute to weight loss, metabolic improvements, and a reduced preference for sweet and fatty foods following bariatric surgery. This review aimed to investigate the effect of bariatric surgery on the expression of oral and post-oral gastrointestinal taste receptors and associations between taste receptor alterations and clinical outcomes of bariatric surgery. A systematic review was conducted to capture data from both human and animal studies on changes in the expression of taste receptors in oral or post-oral gastrointestinal tissue following any type of bariatric surgery. Databases searched included Medline, Embase, Emcare, APA PsychInfo, Cochrane Library, and CINAHL. Two human and 21 animal studies were included. Bariatric surgery alters the quantity of many sweet, umami, and fatty acid taste receptors in the gastrointestinal tract. Changes to the expression of sweet and amino acid receptors occur most often in intestinal segments surgically repositioned more proximally, such as the alimentary limb after gastric bypass. Conversely, changes to fatty acid receptors were observed more frequently in the colon than in the small intestine. Significant heterogeneity in the methodology of included studies limited conclusions regarding the direction of change in taste receptor expression induced by bariatric surgeries. Few studies have investigated associations between taste receptor expression and clinical outcomes of bariatric surgery. As such, future studies should look to investigate the relationship between bariatric surgery-induced changes to gut taste receptor expression and function and the impact of surgery on taste preferences, food palatability, and eating behaviour.Registration code in PROSPERO: CRD42022313992.

Defining Physiological Ketosis Following Very-Low-Calorie Diets.

INTRODUCTION: Very low-calorie diets (VLCDs) are used preoperatively in bariatric-metabolic surgery; however, this can lead to physiological ketosis. Euglycemic ketoacidosis is an increasingly recognized complication in diabetic patients on sodium-glucose-cotransporter-2 inhibitors (SGLT2i) undergoing surgery and requires assessment of ketones for diagnosis and monitoring. VLCD induced ketosis may confound monitoring in this group. We aimed to evaluate the influence of VLCD, compared to standard fasting, on perioperative ketone levels and acid-base balance. MATERIALS AND METHODS: Twenty-seven patients were prospectively recruited to the intervention group and 26 to the control group from two tertiary referral centres in Melbourne, Australia. Intervention group patients were severely obese (body mass index) (BMI) (≥35), undergoing bariatric-metabolic surgery, and prescribed 2 wk of VLCD preoperatively. Control group patients underwent general surgical procedures and prescribed standard procedural fasting only. Patients were excluded if diabetic or prescribed SGLT2i. Ketone and acid-base measurements were taken at regular intervals. Univariate and multivariate regression was utilised with significance defined as P < 0.005. CLINICALTRIALS: gov ID: NCT05442918. RESULTS: Patients on VLCD, compared to standard fasting, had an increased median preoperative (0.60 versus 0.21 mmol/L), immediate postoperative (0.99 versus 0.34 mmol/L) and day 1 postoperative (0.69 versus 0.21 mmol/L) ketone level (P < 0.001). Preoperative acid-base balance was normal in both groups, however VLCD patients were found to have a metabolic acidosis immediately postoperatively (pH 7.29 versus pH 7.35) (P = 0.019). Acid-base balance had normalized in VLCD patients on postoperative day 1. CONCLUSIONS: Preoperative VLCD resulted in increased pre- and postoperative ketone levels with immediate postoperative values consistent with metabolic ketoacidosis. This should be considered particularly when monitoring diabetic patients prescribed SGLT2i.

A Convoluted Picture of Diabetic Myonecrosis.

INTRODUCTION: A patient with well-controlled type 2 diabetes was found to have diabetic myonecrosis, a rare condition associated with poorly controlled type 2 diabetes. Diagnosis was masked by concern for lumbosacral plexopathy from a history of spinal cord infarct. CASE PRESENTATION: A 49-year-old African American woman with type 2 diabetes and paraplegia secondary to spinal cord infarct presented to the emergency department with left leg swelling and weakness from her hip to toes. Hemoglobin A1c was 6.0%, and there was no leukocytosis or elevated inflammatory markers. Computed tomography showed evidence of infectious process or possible diabetic myonecrosis. DISCUSSION: Recent reviews show fewer than 200 reports of diabetic myonecrosis since first described in 1965. It typically is seen in poorly controlled types 1 and 2 diabetes, with average hemoglobin A1c of 9.34% at time of diagnosis. CONCLUSIONS: Diabetic myonecrosis should be considered in diabetic patients with unexplained swelling and pain - particularly in the thigh - even with unremarkable lab values.

C-reactive protein is a predictor of severe infective complications following gastrectomy-a retrospective analysis.

Background: Post-operative complications are the main contributing factor to increased length of stay, increased cost of care and short-term mortality experienced by patients following gastrectomy. The purpose of this study was to determine the diagnostic accuracy of C-reactive protein (CRP) in predicting complications following gastrectomy. This may assist clinicians to make better informed clinical decisions in the post-operative period. Methods: A retrospective analysis of a prospectively maintained database was performed. Sixty patients who underwent gastrectomy for gastric cancer were included. Demographic information, operative data and post-operative details such as complications, unplanned intensive care unit (ICU) admission and readmission to hospital were analysed. Complications were further analysed based on whether they were either infective or non-infective in nature. Receiver operator characteristic (ROC) analysis was performed to examine the association between CRP and post-operative morbidity. Optimum cut-offs were determined using the Youden's index. Results: From the second post-operative day (POD), CRP levels were able to predict subsequent severe infective (SI) complications following gastrectomy [area under the curve (AUC): 0.789, 95% CI : 0.636-0.941]. An optimum cut-off of 180 mg/L resulted in a sensitivity of 87.50%. The negative predictive value (NPV) at this point was 96.30%. Conclusions: CRP is a strong negative predicter of SI complications following gastrectomy. This suggests early CRP values may be useful in prompting early investigation or facilitating safer, earlier discharge from hospital. Health services may benefit by determining similar cut-offs based on their own unique patient populations.

Learning curve of laparoscopic inguinal hernia repair: systematic review, meta-analysis, and meta-regression.

BACKGROUND: Laparoscopic inguinal hernia repair has a long learning curve. It can be a technically challenging procedure and initially presents an unfamiliar view of inguinal anatomy. The aim of this review was to evaluate published literature relating to the learning curve of laparoscopic inguinal hernia repair and identify the number of cases required for proficiency. The secondary aim was to compare outcomes between surgeons before and after this learning curve threshold had been attained. METHODS: A systematic literature search was conducted in databases of PubMed, Medline, Embase, Web of Science, and Cochrane Library, to identify studies that evaluated the learning curve of laparoscopic inguinal hernia repair. A meta-regression analysis was undertaken to identify the number of cases to achieve surgical proficiency, and a meta-analysis was performed to compare outcomes between cases that were undertaken during a surgeon's learning phase and experienced phase of the curve. RESULTS: Twenty-two studies were included in this review, with 19 studies included in the meta-regression analysis, and 11 studies included in the meta-analysis. Mixed-effects Poisson regression demonstrated that there was a non-linear trend in the number of cases required to achieve surgical proficiency, with a 2.7% year-on-year decrease. The predicted number of cases to achieve surgical proficiency in 2020 was 32.5 (p < 0.01). The meta-analysis determined that surgeons in their learning phase may experience a higher rate of conversions to open (OR 4.43, 95% CI 1.65, 11.88), postoperative complications (OR 1.61, 95% CI 1.07, 2.42), and recurrences (OR 1.32, 95% CI 0.40, 4.30). CONCLUSION: Laparoscopic inguinal hernia repair has a well-defined learning curve. While learning surgeons demonstrated reasonable outcomes, supervision during this period may be appropriate given the increased risk of conversion to open surgery. These data may benefit learning surgeons in the skill development of minimally invasive inguinal hernia repairs.

Tumor-Infiltrating Neutrophils after Neoadjuvant Therapy are Associated with Poor Prognosis in Esophageal Cancer.

BACKGROUND: In esophageal cancer (EC), there is a paucity of knowledge regarding the interplay between the tumor immune microenvironment and response to neoadjuvant treatment and, therefore, which factors may influence outcomes. Thus, our goal was to investigate the changes in the immune microenvironment with neoadjuvant treatment in EC by assessing the expression of immune related genes and their association with prognosis. METHODS: We examined the transcriptome of paired pre- and post-neoadjuvant treated EC specimens. Based on these findings, we validated the presence of tumor-infiltrating neutrophils using CD15+ immunohistochemistry in a discovery cohort of patients with residual pathologic disease. We developed a nomogram as a predictor of progression-free survival (PFS) incorporating the variables CD15+ cell count, tumor regression grade, and tumor grade. RESULTS: After neoadjuvant treatment, there was an increase in genes related to myeloid cell differentiation and a poor prognosis associated with high neutrophil (CD15+) counts. Our nomogram incorporating CD15+ cell count was predictive of PFS with a C-index of 0.80 (95% confidence interval [CI] 0.68-0.9) and a concordance probability estimate (CPE) of 0.77 (95% CI 0.69-0.86), which indicates high prognostic ability. The C-index and CPE of the validation cohort were 0.81 (95% CI 0.69-0.91) and 0.78 (95% CI 0.7-0.86), respectively. CONCLUSIONS: Our nomogram incorporating CD15+ cell count can potentially be used to identify patients at high risk of recurrent disease and thus stratify patients who will benefit most from adjuvant treatment.

Oesophageal neuroendocrine tumours-case series of a rare malignancy.

Oesophageal neuroendocrine neoplasms (NENs) are rare tumours. Neuroendocrine carcinomas (NECs) are the highest grade of NENs, with aggressive biological behaviour and poor outcomes. No standardized treatment pathways exist for these tumours, with management being individualized based on patient and tumour factors. We present five cases, four men and one women between 63 and 68 years old, who were diagnosed with symptomatic primary oesophageal NECs. Three were diagnosed with localized disease, and two were diagnosed with metastatic disease. Endoscopy, biopsy and staging scan results are outlined. Two patients received neoadjuvant chemotherapy. Three patients with localized disease underwent oesophagectomy. Two of these patients received neoadjuvant chemotherapy. Four patients have succumbed to their disease, with a median survival following a diagnosis of 18 months (5-34 months). This case series highlights the variability of presentation and stage at diagnosis of oesophageal NECs. Multimodal treatment is commonly utilized; however, outcomes are universally poor. Further research is required to determine the optimal treatment regimen for oesophageal NENS.

Economic burden of complications and readmission following oesophageal cancer surgery.

BACKGROUND: Oesophageal cancer is the seventh most prevalent malignancy globally, and the sixth most common cause of cancer-related death. Oesophageal cancer is also one of the most costly cancers to treat. The aim of this study was to assess the financial impact of post-operative morbidity and hospital readmissions following oesophagectomy for oesophageal cancer. METHODS: A retrospective analysis was performed on a prospectively maintained database of patients with oesophageal cancer who underwent an oesophagectomy at a single centre between July 2014 and June 2019 (N = 56). Readmission costs were also assessed in this cohort for 12 months post-operatively. RESULTS: The total median cost for oesophagectomy in this cohort was AU$57 250. Major complications occurred in 40% of patients, with a median total admission cost of AU$74 606, significantly higher than patients with either minor or no complications (median admission cost of AU$52 713, P < 0.001). Patients whose operation was complicated by an anastomotic leak had a higher median admission cost than those without a leak (AU$104 328 and AU$54 972 respectively, P < 0.001). Cost centres representing the greatest proportion of costs were theatre resources and surgical ward care (medical and nursing). A total of 110 readmissions in 25 patients were recorded in the 12 months post-operatively, the majority for gastroscopy and dilatation of anastomotic stricture. CONCLUSION: Post-oesophagectomy morbidity greatly increases cost of care. In addition to the clinical benefits, interventions to minimize post-operative complications are likely to result in substantial cost savings.

Telemedicine versus face-to-face follow up in general surgery: a randomized controlled trial.

BACKGROUND: Telemedicine provides healthcare to patients at a distance from their treating clinician. There is a lack of high-quality evidence to support the safety and acceptability of telemedicine for postoperative outpatient follow-up. This randomized controlled trial-conducted before the COVID-19 pandemic-aimed to assess patient satisfaction and safety (as determined by readmission, reoperation and complication rates) by telephone compared to face-to-face follow-up after uncomplicated general surgical procedures. METHODS: Patients following laparoscopic appendicectomy or cholecystectomy and laparoscopic or open umbilical or inguinal hernia repairs were randomized to a telephone or face-to-face outpatient clinic. Patient demographics, perioperative details and postoperative outcomes were compared. Patient satisfaction was assessed via a standardized Likert-style scale. RESULTS: One hundred and twenty-three patients were randomized over 12 months. Mean consultation times were significantly shorter for telemedicine than face-to-face clinics (telemedicine 10.52 ± 7.2 min, face-to-face 15.95 ± 9.96 min, P = 0.0021). There was no difference between groups in the attendance rates, nor the incidence or detection of postoperative complications. Of the 58 patients randomized to the telemedicine arm, 40% reported high, and 60% reported very high satisfaction with the method of clinic follow-up. CONCLUSION: Telemedicine postoperative follow-up is safe and acceptable to patients and could be considered in patients undergoing uncomplicated benign general surgery.

Respiratory Function and Racial Health Disparities With Residential Proximity to Coal Power Plants in Wisconsin.

BACKGROUND: Burning fossil fuels, including coal, is the primary source of greenhouse gas emissions driving anthropogenic climate change and its associated health harms. Coal-fired power plants supply 23% of electricity nationally and 42% for Wisconsin, contributing to air pollution and associated respiratory diseases, cancers, and cardiovascular and neurologic disorders, especially for vulnerable populations. Authors seek to quantify residential distance from coal-fired power plants, pulmonary function of Wisconsin residents, and demographics. METHODS: Data from 2,327 adults aged 21-74 years was obtained from the Survey of the Health of Wisconsin database from 2008 through 2013. Pulmonary function was measured by expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) as a ratio of FEV1/FVC. An average of at least 3 FEV1/FVC readings less than 80% was considered abnormal. RESULTS: Adults living near 1 of 11 coal-fired power plants may have worse pulmonary function. The odds ratio of FEV1/FVC values below 80% for those living within 35 km of a coal-fired power plant was 1.24 (95% CI, 0.90-1.70) when compared to those living greater than 35 km from a plant. While Black individuals made up 4.8% of the total sample population, they accounted for 13.3% of individuals living within 35 km of coal-fired power plants. Similarly, Hispanic populations accounted for 4.8% of those living within 35 km of a plant, while making up 2.8% of the sample population. INTERPRETATION: Significant disparities were found in residential proximity to Wisconsin coal-fired power plants for Black and Hispanic populations, with trends that support worse pulmonary function when living within 35 km of these plants. When linked with socioeconomic and racial/ethnic factors, closing down coal-fired power plants becomes a necessity to reduce disparities and address environmental injustices.

Body Composition Differences Between Excess Weight Loss ≥ 50% and < 50% at 12 Months Following Bariatric Surgery.

BACKGROUND: The relationship between weight loss and body composition is undefined after bariatric surgery. The objective of this study was to compare body composition changes in patients with excess weight loss ≥ 50% (EWL ≥ 50) and < 50% at 12 months post-operatively (EWL < 50). METHODS: A prospective cohort study was completed on patients undergoing bariatric surgery at two tertiary hospitals between 2017 and 2021. Body composition was measured with dual-energy X-ray absorptiometry immediately before surgery, and at 1, 6, and 12 months post-operatively. Body mass index (BMI), fat mass (FM), lean body mass (LBM), and skeletal muscle index (SMI) trajectories were analysed between patients with EWL ≥ 50% and EWL < 50%. RESULTS: Thirty-seven patients were included in this series (EWL ≥ 50% n = 25, EWL < 50% n = 12), comprising of both primary and revisional bariatric surgery cases, undergoing a sleeve gastrectomy (62.2%), Roux-en-Y gastric bypass (32.4%), or one anastomosis gastric bypass (5.4%). The EWL ≥ 50% group demonstrated a more optimal mean FM-to-LBM loss ratio than the EWL < 50% group. EWL ≥ 50% patients lost 2.0 kg more FM than EWL < 50% patients for each 1 kg of LBM lost. EWL ≥ 50% was also associated with an increase in mean SMI% over 12 months (5.5 vs. 2.4%; p < 0.0009). Across the whole cohort, the first month after surgery accounted for 67.4% of the total LBM reduction that occurred during the 12-month post-operative period. CONCLUSION: This data suggests EWL ≥ 50% is associated with a more optimal body composition outcome than EWL < 50%. LBM reduction occurs predominantly in the early post-operative period.

Potential Clinical Utility of a Targeted Circulating Tumor DNA Assay in Esophageal Adenocarcinoma.

OBJECTIVE: To explore the clinical utility of circulating tumor DNA (ctDNA) in esophageal adenocarcinoma (EAC) by developing a cost-effective and rapid technique utilising targeted amplicon sequencing. SUMMARY OF BACKGROUND DATA: Emerging evidence suggests that levels of ctDNA in the blood can be used to monitor treatment response and in the detection of disease recurrence in various cancer types. Current staging modalities for EAC such as computerised tomography of the chest/abdomen/pelvis (CT) and positron emission tomography (PET) do not reliably detect occult micro-metastatic disease, the presence of which signifies a poor prognosis. After curative-intent treatment, some patients are still at high risk of recurrent disease, and there is no widely accepted optimal surveillance tool for patients with EAC. METHODS: Sixty-two patients with EAC were investigated for the presence of ctDNA using a tumor-informed approach. We designed a custom targeted amplicon sequencing panel of target specific primers covering mutational foci in 9 of the most commonly mutated genes in EAC. Serial blood samples were taken before and after neoadjuvant treatment (NAT), and during surveillance. RESULTS: Somatic mutations were detected in pre-treatment biopsy samples of 55 out of 62 (89%) EAC patients. Mutations in TP53 (80%) were the most common. Out of these 55 patients, 20 (36%) had detectable ctDNA at baseline. The majority (90%) of patients with detectable ctDNA had either locally advanced tumors, nodal involvement or metastatic disease. In patients with locally advanced tumors, disease free survival (DFS) was more accurately stratified using pre-treatment ctDNA status [HR 4.34 (95% CI 0.93-20.21); P = 0.05] compared to nodal status on PET-CT. In an exploratory subgroup analysis, patients who are node negative but ctDNA positive have inferior DFS [HR 11.71 (95% CI 1.16-118.80) P = 0.04]. In blood samples taken before and following NAT, clearance of ctDNA after NAT was associated with a favourable response to treatment. Furthermore, patients who are ctDNA positive during post-treatment surveillance are at high risk of relapse. CONCLUSIONS: Our study shows that ctDNA has potential to provide additional prognostication over conventional staging investigation such as CT and PET. It may also have clinical utility in the assessment of response to NAT and as a biomarker for the surveillance of recurrent disease.

Identifying the limitations of cardiopulmonary exercise testing prior to esophagectomy using a pooled analysis of patient-level data.

Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of aerobic fitness in patients undergoing surgery. While peak oxygen uptake during exercise (VO2peak) and anaerobic threshold have demonstrated a moderate correlation with the development of complications following esophagectomy, no clinically useful threshold values have been defined. By pooling patient level data from existing studies, we aimed to define optimal thresholds for preoperative CPET parameters to predict patients at high risk of postoperative complications. Studies reporting on the relationship between preoperative CPET variables and post-esophagectomy complications were determined from a comprehensive literature search. Patient-level data were obtained from six contributing centers for pooled-analyses. Outcomes of interest included cardiopulmonary and non-cardiopulmonary complications, unplanned intensive care unit readmission, and 90-day and 12-month all-cause mortality. Receiver operating characteristic curves and logistic regression models estimated the predictive value of CPET parameters for each individual outcome of interest. This analysis comprised of 621 patients who underwent CPET prior to esophagectomy during the period from January 2004 to March 2017. For both anaerobic threshold and VO2peak, none of the receiver operating characteristic curves achieved an area under the curve value > 0.66 for the outcomes of interest. The discriminatory ability of CPET for determining high-risk patients was found to be poor in patients undergoing an esophagectomy. CPET may only carry an adjunct role to clinical decision-making.

Pre-operative low muscle mass is associated with major complications and lower recurrence-free survival after gastric cancer surgery.

BACKGROUND: Low muscle mass (LMM) has been associated with post-operative morbidity. This study aimed to examine the relationship between pre-operative LMM and major post-operative complications and survival in patients undergoing curative resection for gastric cancer. METHODS: A single-centre retrospective cohort study was conducted on consecutive patients who underwent surgical resection for gastric adenocarcinoma between 2008 and 2018. Patient demographics, radiological parameters, pathological data and complications were recorded. Skeletal muscle index was calculated using OsiriX software by manually measuring the cross-sectional skeletal muscle area at the third lumbar vertebra and correcting to the patient's height. Univariate and multivariate analyses were used to identify the risk factors associated with the outcomes. RESULTS: A total of 62 patients (36 males, mean age 68.3 ± 1.5 years) met the inclusion criteria. Twenty-six (41.9%) patients had LMM pre-operatively. Demographic data in the non-LMM and LMM groups were equally matched except for body mass index (27.6 ± 0.8 kg/m2 versus 24.3 ± 1.1 kg/m2 ; P = 0.012) and serum albumin (36.7 ± 0.7 g/L versus 33.8 ± 1.0 g/L; P = 0.017), which were higher in the non-LMM. LMM was associated with higher incidence of total (35.5% versus 64.5%; P = 0.006), minor (40% versus 60%; P = 0.030), major (9.1% versus 90.9%; P = 0.004) post-operative complications and decreased recurrence-free survival (hazard ratio 2.29; 95% confidence interval 1.10-4.77; P = 0.027). CONCLUSION: LMM is a significant independent risk factor for major post-operative complications and recurrence-free survival after gastrectomy. Pre-operative identification of LMM could be a useful tool for prognostication and may identify a group suitable for prehabilitation.

Health economic analysis of curative-intent gastrectomy for gastric carcinoma and the costs related to post-operative complications.

BACKGROUND: The management of post-gastrectomy complications requires considerable resources and is likely associated with a substantial economic burden. The objectives of this study were to perform a cost analysis of admissions following gastrectomy for gastric carcinoma and then to quantify the financial impact of post-operative complications. METHODS: A retrospective analysis was conducted in patients that underwent a gastrectomy from 2008 to 2019. Demographic data, operative information, post-operative complications and facility costs were compared. RESULTS: A total of 74 patients underwent a curative-intent gastrectomy during the study period. The 36 (48.6%) patients that had no complications had a median total admission cost of AU$29 228. A total of 21 (28.4%) patients had a minor complication and 17 (23.0%) patients had a major complication, with a median total admission cost of AU$36 592 and AU$71 808, respectively. The difference across all three groups was statistically significant. In patients who had major complications compared to those without complications, there was a significant increase in the cost of intensive care services, theatre resources and nursing care. Across the whole cohort, the principal cost centres accounting for the largest proportion of total cost were theatre equipment and resources (33.9%), nursing care on the ward (23.0%) and staffing time of the surgical team (16.7%). CONCLUSION: The surgical management of gastric cancer carries a substantial cost burden. The presence and severity of post-operative complications is strongly associated with increasing cost. Minimizing complications, in addition to obvious clinical benefits, enables a large reduction in costs of care.