Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis.

Esophagectomy for esophageal cancer is associated with high morbidity. It remains unclear whether prehabilitation, a strategy aimed at optimizing patients' physical and mental functioning prior to surgery, improves postoperative outcomes. A systematic review and meta-analysis was conducted to evaluate the effect of prehabilitation on post-operative outcomes after esophagectomy. Data sources included Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, and PEDro, with information from 1 January 2000 to 5 August 2023. The analysis included randomized controlled trials and observational studies that compared prehabilitation interventions to standard care prior to esophagectomy. A random effects model was used to generate a pooled estimate for pairwise meta-analysis, meta-analysis of proportions, and meta-analysis of means. A total of 1803 patients were included with 584 in randomized controlled trials (RCTs) and 1219 in observational studies. In the randomized evidence, there were no significant differences between prehabilitation and control in the odds of postoperative pneumonia (15.0 vs. 18.9%, odds ratio (OR) 1.06 [95% confidence interval (CI): 0.66;1.72]) or pulmonary complications (14 vs. 25.6%, OR 0.68 [95% CI: 0.32;1.45]). In the observational data, there was a reduction in both postoperative pneumonia (22.5 vs. 32.9%, OR 0.48 [95% CI: 0.28;0.83]) and pulmonary complications (26.1 vs. 52.3%, OR 0.35 [95% CI: 0.17;0.75]) with prehabilitation. Hospital and intensive care unit length of stay (days), operative mortality, and severe complications (Clavien-Dindo ≥ 3) did not differ between groups in both the randomized data and observational data. Prehabilitation demonstrated reductions in postoperative pneumonia and pulmonary complications in observational studies, but not RCTs. The overall certainty of these findings is limited by the low quality of the available evidence.

Robotic enucleation of oesophageal leiomyoma technique and surgical outcomes.

INTRODUCTION: Complete enucleation of oesophageal leiomyoma is the treatment of choice, traditionally performed by open surgery. Minimally invasive thoracoscopic approaches have been proposed as an alternative to thoracotomy. Robotic surgical systems with improved dexterity, tremor filtration and stereoscopic vision are advancement over conventional thoracoscopy and may make the preservation of mucosal integrity relatively easier. We present herein our technique of robotic-assisted thoracoscopic (RATS) enucleation of oesophageal leiomyoma along with surgical outcomes and intermediate follow-up of 11 cases. MATERIALS AND METHODS: The present study retrospectively reviews patients undergoing robotic portal oesophageal leiomyomectomy from March 2012 to October 2019. The collected data were analysed for demographic details, clinical presentation, size, shape, tumour location, operating time, post-operative complications, length of hospital stay and recurrence on follow-up. RESULTS: Twelve patients underwent robotic portal oesophageal leiomyomectomy with a clinical diagnosis of oesophageal leiomyoma. Of these, 11 patients were included in the study. The average operative time was 110 min, with a mean blood loss of 26 ml. There was no conversion in this series. At a median follow-up of 44 months (range 6-78 months), all patients were symptom-free with no recurrence or diverticula. CONCLUSION: Our series demonstrates the safety and feasibility of RATS oesophageal enucleation with good short and intermediate outcomes. In our opinion, the robotic system's technical advantages are particularly beneficial for oesophageal leiomyoma enucleation.

The role of surgery after prolonged primary chemotherapy for advanced oesophageal adenocarcinoma.

BACKGROUND: Most patients presenting with oesophageal cancer do so with advanced disease not suitable for surgery. However, there are examples of encouraging survival following surgery in highly selected patients who respond well to chemotherapy. METHODS: This was a retrospective cohort study of patients who presented with advanced but nonvisceral metastatic oesophageal cancer. Consecutive patients on a prolonged primary chemotherapy pathway who underwent surgical resection following a favourable response to chemotherapy were included. Survival and recurrence rates were analysed using Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS: A total of 57 patients included in the cohort operated between 2007 and 2015, the overall median survival was 44 months and the 5-year survival was 42%. Prechemotherapy cN0/cN1 (HR: 0.27, 95% CI: 0.12-0.62) conferred an independent survival advantage compared to cN2 and cN3 disease. Poor differentiation (HR: 2.46, 95% CI: 1.11-5.42), R1 resection (HR: 2.43, 95% CI: 1.14-5.19) and advanced nodal status (HR: 3.28, 95% CI: 1.44-7.47) predicted worse survival on univariable analysis. Poor differentiation (HR: 3.93, 95% CI: 1.62-9.56) was independently associated with poor survival when adjusted for other variables. CONCLUSION: Patients who present with advanced inoperable oesophageal cancer who have a favourable response to chemotherapy represent a limited group of patients who may benefit from surgery.

Using simple interrupted suture anastomoses may impair translatability of experimental rodent oesophageal surgery.

Background/purpose: Irreproducibility and missing translatability are major drawbacks in experimental animal studies. Hand-sewn anastomoses in oesophageal surgery are usually continuous, whereas those in experimental oesophageal surgery are widely performed using the simple interrupted technique. It has been implicated to be inferior in tolerating anastomotic tension, which we aimed to test in rats due to their importance as an animal model in oesophageal surgery.Methods: We determined linear breaking strengths for the native oesophagus (n = 10), the simple interrupted suture anastomosis (n = 11), and the simple stitch (n = 9) in 8-week old Sprague-Dawley rats. Experiments were powered to a margin of error of 10% around the results of exploratory investigations. The comparison of anastomotic resilience between native organ and simple interrupted suture anastomosis was a priori powered to 99%.Results: Native oesophagi sustained traction forces of 4.25 N (95% CI: 4.03-4.58 N), but the simple interrupted suture anastomosis had only 38.6% (Δ= -2.78 N, 95% CI: -2.46 to -3.11 N, p < .0001) of the resilience of native oesophagi.Conclusions: Oesophageal division and re-anastomosis markedly decreases resilience to traction forces compared to the native organ. This effect is even more pronounced in rats compared to other species and might impair transferability of results.

Delayed diagnosis: An important prognostic factor for oesophageal atresia in developing countries.

AIM: The aim of this study is to analyse the effect of delayed diagnosis on mortality rates, and evaluate the role of delayed diagnosis as a new prognostic factor in patients with oesophageal atresia (OA), especially in developing countries. METHODS: The records of 80 consecutive patients with OA (2008-2013) were reviewed. Patients were divided into two groups according to the time of diagnosis. As we demonstrated the effect of delayed diagnosis on mortality, we decided to develop a new classification that will be utilised to predict the prognosis of OA. The discrimination ability of the new prognostic classification was compared with those of the Waterston, Montreal and Spitz classifications using the area under the curve. RESULTS: The parameters of the new prognostic classification were birth weight less than 2000 g, the presence of major cardiac/life-threatening anomalies and delay in diagnosis. Class I consisted of patients with none or one of these parameters. Class II consisted of patients with two or three of these parameters. The area under the curve of the new classification was better than those of the other classifications in determining the prognosis of patients with OA. CONCLUSIONS: Delayed diagnosis of OA significantly led to morbidity and mortality. Although delayed diagnosis is not a characteristic of newborn or a marker of severity for OA and is a health care system issue in developing countries, we here point out that it is a prognostic factor in its own right. Our new classification has a superior discriminatory ability compared to the above-mentioned classifications.

Topography and extent of pulmonary vagus nerve supply with respect to transthoracic oesophagectomy.

Pulmonary complications are frequently observed after transthoracic oesophagectomy. These complications may be reduced by sparing the vagus nerve branches to the lung. However, current descriptions of the regional anatomy are insufficient. Therefore, we aimed to provide a highly detailed description of the course of the pulmonary vagus nerve branches. In six fixed adult human cadavers, bilateral microscopic dissection of the vagus nerve branches to the lungs was performed. The level of branching and the number, calibre and distribution of nerve branches were described. Nerve fibres were identified using neurofilament immunohistochemistry, and the nerve calibre was measured using computerized image analysis. Both lungs were supplied by a predominant posterior and a smaller anterior nerve plexus. The right lung was supplied by 13 (10-18) posterior and 3 (2-3) anterior branches containing 77% (62-100%) and 23% (0-38%) of the lung nerve supply, respectively. The left lung was supplied by a median of 12 (8-13) posterior and 3 (2-4) anterior branches containing 74% (60-84%) and 26% (16-40%) of the left lung nerve supply, respectively. During transthoracic oesophagectomy with en bloc lymphadenectomy and transection of the vagus nerves at the level of the azygos vein, 68-100% of the right lung nerve supply and 86-100% of the inferior left lung lobe nerve supply were severed. When vagotomy was performed distally to the last large pulmonary branch, 0-8% and 0-13% of the nerve branches to the right middle/inferior lobes and left inferior lobe, respectively, were lost. In conclusion, this study provides a detailed description of the extensive pulmonary nerve supply provided by the vagus nerves. During oesophagectomy, extensive mediastinal lymphadenectomy denervates the lung to a great extent; however, this can be prevented by performing the vagotomy distal to the caudalmost large pulmonary branch. Further research is required to determine the feasibility of sparing the pulmonary vagus nerve branches without compromising the completeness of lymphadenectomy.

Gastric neo-adenocarcinoma arising in a gastric tube after Ivor Lewis oesophagectomy for oesophageal adenocarcinoma.

A 69-year-old man, seven years post Ivor-Lewis oesophagectomy for oesophageal adenocarcinoma, was diagnosed to have a moderately differentiated 4 cm, malignant ulcer within the gastric tube remnant on an endoscopic biopsy. His original presentation was with a T1N0 oesophageal adenocarcinoma, histologically intestinal in type with inflammatory features. He presented with anaemia and melena due to a malignant ulcer in the mid body of his gastric tube on an endoscopy which was confirmed to be a gastric neo-adenocarcinoma on biopsy. He underwent right posterolateral thoracotomy and a wedge resection of the gastric tube including the tumour. Pathology confirmed a T3 N0 (0/7 lymph nodes) with clear margins moderately differentiated adenocarcinoma of intestinal phenotype with papillary features and was reported to be a histopathologically new tumour. Proposed surgical treatments in such patients are dependent on patient's fitness for major resection and may vary from Endoscopic Mucosal Resection to partial resection with preservation of right gastroepiploic vessels or total gastrectomy with intestinal interposition via a retromediastinal route. We suggest that regular endoscopic surveillance may be indicated in such post-oesophagectomy patients as the number of patients developing gastric tube cancers may increase with improve survival of those patients.

Online tools to predict individualised survival for primary oesophageal cancer patients with and without pathological complete response after neoadjuvant therapy followed by oesophagectomy: development and external validation of two independent nomograms.

OBJECTIVE: This study aimed to develop and validate robust predictive models for patients with oesophageal cancer who achieved a pathological complete response (pCR) and those who did not (non-pCR) after neoadjuvant therapy and oesophagectomy. DESIGN: Clinicopathological data of 6517 primary oesophageal cancer patients who underwent neoadjuvant therapy and oesophagectomy were obtained from the National Cancer Database for the training cohort. An independent cohort of 444 Chinese patients served as the validation set. Two distinct multivariable Cox models of overall survival (OS) were constructed for pCR and non-pCR patients, respectively, and were presented using web-based dynamic nomograms (graphical representation of predicted OS based on the clinical characteristics that a patient could input into the website). The calibration plot, concordance index and decision curve analysis were employed to assess calibration, discrimination and clinical usefulness of the predictive models. RESULTS: In total, 13 and 15 variables were used to predict OS for pCR and non-pCR patients undergoing neoadjuvant therapy followed by oesophagectomy, respectively. Key predictors included demographic characteristics, pretreatment clinical stage, surgical approach, pathological information and postoperative treatments. The predictive models for pCR and non-pCR patients demonstrated good calibration and clinical utility, with acceptable discrimination that surpassed that of the current tumour, node, metastases staging system. CONCLUSIONS: The web-based dynamic nomograms for pCR (https://predict-survival.shinyapps.io/pCR-eso/) and non-pCR patients (https://predict-survival.shinyapps.io/non-pCR-eso/) developed in this study can facilitate the calculation of OS probability for individual patients undergoing neoadjuvant therapy and radical oesophagectomy, aiding clinicians and patients in making personalised treatment decisions.

Laproendoscopic single site oesophageal diverticulectomy.

Epiphrenic divericula are uncommon disorders of the lower oesophagus, which are symptomatic in only 15-20% of cases. The optimum treatment modality for such cases remains an oesophageal diverticulectomy with long myotomy with or without an antireflux operation. Recently, this is increasingly being done through the laparoscopic approach. Here we describe the first reported case of oesophageal diverticulectomy through the laparoendoscopic single site approach. A 57-year-old man presented to us with 6 months history of dysphagia and regurgitation. Patient was investigated with upper gastrointestinal (UGI) endoscopy, barium swallow, CECT chest and abdomen, oesophageal manometry and 24 hour pH study. He was diagnosed to have lower oesophageal diverticulum with mildly elevated pressure readings in manometric studies with normal peristalsis. Based on his symptoms, he was taken up for surgery. A laparoscopic transhiatal oesophageal diverticulectomy with myotomy was done through laparoendoscopic single site technique. The procedure lasted 160 min. There was no intraoperative complication. Gastrograffin study was done on postoperative day 2 following which he was started on liquids. He made an uneventful recovery and was discharged on fourth day. He remained asymptomatic on follow up. Oesophageal diverticulectomy is possible through laparoendoscopic single site approach if necessary expertise is available.

A pilot randomized controlled trial on the utility of gastric conditioning in the prevention of esophagogastric anastomotic leak after Ivor Lewis esophagectomy. The APIL_2013 Trial.

BACKGROUND: Anastomotic leakage (AL) after Ivor Lewis esophagectomy is associated with high morbidity and mortality. Preoperative gastric conditioning (GC) improves blood perfusion of the gastroplasty, one of the most important factors for anastomotic viability. This pilot randomized controlled trial aimed to evaluate the feasibility of GC before oesophageal surgery in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer, who required an Ivor Lewis esophagectomy. MATERIALS AND METHODS: This was a randomized (1:1), open-label, single-centre, controlled, parallel-group, pilot clinical trial. Two study groups: 1) GC-group: patients who underwent an Ivor Lewis esophagectomy and GC before surgery; 2) Surgery alone (SA)-group: patients who underwent only Ivor Lewis esophagectomy. Feasibility was assessed by means of the number of patients in whom a GC was performed, and the cumulative incidence of postoperative AL. Secondary endpoints were conduit necrosis (CN), hospital stay, morbidity, mortality, and anastomotic stricture. RESULTS: Between 2015 and 2018, 38 patients were randomized and analysed: 20 to GC-group and 18 to SA-group. 17 GCs (85%) were successfully performed, right gastric artery occlusion failed in three patients. Morbidity after GC occurred in 5/22 patients (all Clavien-Dindo ≤ IIIa). The cumulative incidence of AL was 15.0% (3/20, 95%CI: 5.2-36.0%) in GC-group and 33.3% (6/18, 95%CI: 16.3-56.3%) in SA-group, p-value: 0.184. CN: 0/20 vs. 1/18 (p-value: 0.474); surgical morbidity (Clavien-Dindo III-V): 7/20 vs. 12/18 (p-value: 0.070); hospital stay (median [range] days): 12 [9-45] vs. 27.5 [10-166] (p-value: 0.067). When only successful GCs (three arteries) were included for analysis, ischemia-related gastric conduit failure (AL and CN) was lower in the GC group (p-value: 0.041). CONCLUSIONS: Preoperative arteriographic GC before Ivor Lewis esophagectomy is a feasible and safe procedure and seems it may reduce AL in patients with oesophageal cancer or Siewert I-II esophagogastric junction cancer.

Clinical outcome of patients after recurrent laryngeal nerve lymph node dissection for oesophageal squamous cell carcinoma.

OBJECTIVES: Recurrent laryngeal nerve lymph node dissection (LND) has been incorporated into oesophagectomy for patients with oesophageal squamous cell carcinoma, but with uncertain oncological efficacy. METHODS: The data of patients with oesophageal squamous cell carcinoma, including who underwent upfront surgery (surgery group) and those who received neoadjuvant therapy followed by surgery (neoadjuvant chemoradiotherapy group), were retrospectively examined. The overall survival (OS) and disease-free survival (DFS) were compared between patients with and without recurrent laryngeal nerve LND. RESULTS: Among the 312 patients, no significant differences were found in 3-year OS and DFS between patients with and without recurrent laryngeal nerve LND in the entire cohort (OS: 57% vs 52%, P = 0.33; DFS: 47% vs 41%, P = 0.186), or the surgery group (n = 173, OS: 69% vs 58%, P = 0.43; DFS: 52% vs. 48%, P = 0.30) and the neoadjuvant chemoradiotherapy group (n = 139, OS: 44% vs 43%, P = 0.44; DFS: 39% vs 32%, P = 0.27). However, among patients with clinical positive recurrent laryngeal nerve lymph node involvement before treatment, there was significant OS and DFS differences between patients with and without recurrent laryngeal nerve LND (OS: 62% vs 33%, P = 0.029; DFS: 49% vs 26%, P = 0.031). CONCLUSIONS: Recurrent laryngeal nerve LND is not a significant prognostic factor in patients with oesophageal squamous cell carcinoma; however, it is associated with better outcomes in patients with pre-treatment radiological evidence of recurrent laryngeal nerve lymph node involvement.

Learning curve for minimally invasive oesophagectomy of oesophageal cancer and survival analysis.

PURPOSE: Minimally invasive oesophagectomy is a technically demanding procedure, and the learning curve for this procedure should be explored. A survival analysis should also be performed. METHODS: A total of 214 consecutive patients who underwent minimally invasive oesophagectomy were retrospectively reviewed. To evaluate the development of thoracoscopic-laparoscopic oesophagectomy and compare mature minimally invasive oesophagectomy and open oesophagectomy, we comprehensively studied the clinical and surgical parameters. The cumulative sum (CUSUM) plot was used to evaluate the learning curve for systemic lymphadenectomy. Cox proportional hazards regression analysis was performed to explore the clinical factors affecting survival. RESULTS: The bleeding volume, operation time, and postoperative mortality within 3 months significantly decreased after 20 patients. The rise point for node dissection was visually determined to occur at patient 57 in the CUSUM plots. Patients who underwent mature thoracoscopic-laparoscopic oesophagectomy had better surgical data and short-term benefits than patients who underwent an open procedure. Cox proportional hazards regression analysis showed that the maximum diameter of the tumour cross-sectional area and the number of positive nodes significantly influenced survival. CONCLUSIONS: The results suggest that thoracoscopic-laparoscopic oesophagectomy has short-term benefits. There was no evidence that it was associated with a significantly better prognosis for patients with oesophageal cancer. ClinicalTrials Gov ID: NCT04217239; January 2, 2020 retrospectively registered.

Modern oncological and operative outcomes in oesophageal cancer: the St. James's hospital experience.

BACKGROUND: Oesophageal cancer has a reputation for poor survival, and a relatively high risk of major postoperative morbidity and mortality. Encouragingly, a recent international cancer registry study reports a doubling of survival outcomes in Ireland over the last 20 years. This study focused on both oncologic and operative outcomes in patients treated with curative intent requiring surgery at a high-volume center. METHODS: All patients undergoing surgery or multimodal therapy with curative intent from 2009 to 2018 were studied. All data was recorded prospectively and maintained internally. The period 2009-2013 was compared with 2014-2018 to monitor any change in trends. RESULTS: Four hundred and seventy-five patients (adenocarcinoma 77%, mean age 65; 76% male; 64% neoadjuvant therapy) underwent open surgical resection, 54% via en bloc 2-stage, 19.8% en bloc 3-stage, and 26.5% by a transhiatal approach. New onset atrial fibrillation was the commonest index complication, in 108 (22.7%), 80 (18%) developed suspected pneumonia/respiratory tract infection, 20 (4.2%) an anastomotic leak, and 25 (5.2%) a chyle leak. The 90-day mortality rate was 1.2% and 0.8% at 30 days. The median survival was 77.17 months, with a 5-year survival of 56%. CONCLUSION: Consistent with registry data on population survival for oesophageal cancer, this study highlights markedly improved survival outcomes in patients treated curatively, reflecting international trends, as well as low mortality rates; however, cardiorespiratory complications remain significant.

Using multidimensional scaling in model choice for congenital oesophageal atresia: similarity analysis of human autopsy organ weights with those from a comparative assessment of Aachen Minipig and Pietrain piglets.

Swine models had been popular in paediatric oesophageal surgery in the past. Although being largely replaced by rodent models, swine experienced a revival with the establishment of minipig models. However, none of them has ever been investigated for similarity to humans. We conducted a pilot study to determine whether three-week old Pietrain piglets and three-month old Aachen Minipigs are suitable for experimental paediatric oesophageal atresia surgery. We tested the operation's feasibility, performed a necropsy, weighed organs, measured organ length and calculated relative weights and lengths, and measured laboratory parameters. We used multidimensional scaling to assess the similarity of the swine breeds with previously published human data. Pietrain piglets had a higher a priori bodyweight than Aachen Minipigs (Δ = 1.31 kg, 95% confidence interval (CI): 0.37-2.23, p = 0.015), while snout-to-tail length was similar. Pietrain piglets had higher absolute and relative oesophageal lengths (Δ = 5.43 cm, 95% CI: 2.2-8.6; p = 0.0062, q1* = 0.0083 and Δ = 11.4%, 95% CI: 5.1-17.6; p = 0.0025, q3* = 0.0053). Likewise, absolute and relative small intestinal lengths were higher in Pietrains, but all other parameters did not differ, with the exception of minor differences in laboratory parameters. Multidimensional scaling revealed three-week old Pietrain piglets to be similar to two-month old humans based on their thoracoabdominal organ weights. This result indicates three-week old Pietrain piglets are a suitable model of paediatric oesophageal atresia surgery, because clinically many procedures are performed at around eight weeks age. Three-month old Aachen Minipigs were more dissimilar to eight-week old humans than three-week old Pietrain piglets.

Semimechanical anastomosis during oesophagectomy reduces leaks and stenosis: a propensity score matched analysis.

OBJECTIVES: Several techniques for oesophageal anastomosis during oesophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the notable morbidity of oesophageal fistula, reducing its incidence is of paramount importance. We report our single-centre experience with the semimechanical (SM) technique as compared to a totally manual (TM) technique. METHODS: Three hundred and twelve partial and subtotal oesophagectomies performed between January 1998 and April 2018 were analysed. The series was split into a training period (January 1998-September 2015), when both TM and SM techniques were used, and a validation period (October 2015-April 2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding. RESULTS: The training period included 212 oesophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction in both leak (0.8% vs 12%; P < 0.001) and stricture rate (0% vs 7%; P = 0.005). After propensity score matching, the difference in leak (0% vs 14%; P = 0.013) and stricture rate (0% vs 10%; P = 0.022) was confirmed. During the validation period, which included 100 oesophagectomies performed with SM anastomosis, 1 leak (1%) and 1 stricture (1%) were observed. CONCLUSIONS: SM technique for oesophageal anastomosis outperforms TM technique and allows achieving very low complication rates.

First UK experience of endoscopic vacuum therapy for the management of oesophageal perforations and postoperative leaks.

Oesophageal perforations and anastomotic leaks are associated with high morbidity and mortality. Endoscopic vacuum therapy (EVT) is a promising novel treatment that promotes healing and avoids sepsis. There are no data reporting its use in the UK. We report the first British experience of EVT in two elderly frail patients. Two patients were treated in our institution with EVT using Eso-SPONGE®. One patient had spontaneous oesophageal perforation and the other had anastomotic leakage post-Merendino oesophageal reconstruction (oesophagogastric continuity with jejunal interposition anastomosis). Both patients were over 65 years of age. One patient had 13 endoscopic Eso-SPONGE® exchanges over 8 weeks, while the other one had 6 exchanges over 4 weeks. Complete resolution of oesophageal leakage was achieved in both cases. EVT should be considered in the management of patients with oesophageal perforations and postoperative leaks. This novel therapeutic intervention has the potential to significantly reduce morbidity and mortality in these patients.

The surgical management of non-malignant aerodigestive fistula.

BACKGROUND: Acquired aerodigestive fistula (ADF) are rare, but associated with significant morbidity. Surgery affords the best prospect of cure. We present our experience of the surgical management of ADFs at a specialist unit, highlighting operative techniques, challenges and assess clinical outcomes following intervention. We also illustrate findings of a Hospital Episodes Statistics search for ADFs. METHODS: A prospectively-maintained database was searched to identify all patients diagnosed with an ADF who were managed at our institution. Of 48 patients with an ADF, eight underwent surgical intervention. RESULTS: Four patients underwent an exploration of the ADF with primary repair of the defect. Two of these patients had proximal ADFs, amenable to repair through a neck incision, and two required a thoracotomy. Two patients suffered fistulae secondary to endoscopic therapy and underwent oesophageal exclusion surgery, with subsequent staged reconstruction. Two patients with previous Tuberculosis had a lung segmentectomy and lobectomy respectively, and a further patient in remission after treatment for lymphoma underwent oesophageal resection with synchronous reconstruction. Three patients suffered a complication, with one post-operative mortality. The remaining seven patients all achieved normal oral alimentation, with no evidence of ADF recurrence at a median follow-up of 32 months. CONCLUSIONS: Surgery to manage ADFs is effective in restoring normal alimentation and alleviates soiling of the airway, with a very low risk of recurrence. Several operative techniques can be utilised dependent on the features of the ADF. Early referral to specialist units is advocated, where the expertise to facilitate the complete management of patients is present, within a multi-disciplinary setting.

'How well, not how much': The life and career of Maksymilian Rutkowski (1867-1947).

Maksymilian Rutkowski (1867-1947) was a distinguished graduate of the Jagiellonian University and a pioneer in the early days of surgery in interwar Poland. He was a long-standing leader in both clinical and academic surgery. In addition, he played an important role in the founding of the School for Nurses and Healthcare Workers in Cracow supported by the Rockefeller Foundation. Among his best known surgical techniques, one may list the novel procedure of bladder exstrophy, new techniques of gastroenterostomy and plastic restoration of the oesophagus. Although Rutkowski's reputation as a medical figure is well established within Polish medical history, his achievements are hardly recognized by international scholars. Thus, in the absence of adequate historical information on this eminent surgeon, we have researched the main facts about his life and seminal contribution to Polish and international surgery.

Time interval between neoadjuvant chemoradiotherapy and surgery for oesophageal or junctional cancer: A nationwide study.

INTRODUCTION: The optimal time between end of neoadjuvant chemoradiotherapy (nCRT) and oesophagectomy is unknown. The aim of this study was to assess the association between this interval and pathologic complete response rate (pCR), morbidity and 30-day/in-hospital mortality. METHODS: Patients with oesophageal cancer treated with nCRT and surgery between 2011 and 2016 were selected from a national database: the Dutch Upper Gastrointestinal Cancer Audit (DUCA). The interval between end of nCRT and surgery was divided into six periods: 0-5 weeks (n = 157;A), 6-7 weeks (n = 878;B), 8-9 weeks (n = 972;C), 10-12 weeks (n = 720;D), 13-14 weeks (n = 195;E) and 15 or more weeks (n = 180;F). The association between these interval groups and outcomes was investigated using univariable and multivariable analysis with group C (8-9 weeks) as reference. RESULTS: In total, 3102 patients were included. The pCR rate for the groups A to F was 31%, 28%, 26%, 31%, 40% and 37%, respectively. A longer interval was associated with a higher probability of pCR (≥10 weeks for adenocarcinoma: odds ratio [95% confidence interval]: 1.35 [1.00-1.83], 1.95 [1.24-3.07], 1.64 [0.99-2.71] and ≥13 weeks for squamous cell carcinoma: 2.86 [1.23-6.65], 2.67 [1.29-5.55]. Patients operated ≥10 weeks after nCRT had the same probability for intraoperative/postoperative complications. Patients from groups D and F had a higher 30-day/in-hospital mortality (1.80 [1.08-3.00], 3.19 [1.66-6.14]). CONCLUSION: An interval of ≥10 weeks for adenocarcinoma and ≥13 weeks for squamous cell carcinoma between nCRT and oesophagectomy was associated with a higher probability of having a pCR. Longer intervals were not associated with intraoperative/postoperative complications. The 30-day/in-hospital mortality was higher in patients with extended intervals (10-12 and ≥15 weeks); however, this might have been due to residual confounding.