Background. Esophagectomy is a technically demanding procedure associated with high levels of morbidity. Anastomotic leak (AL) is a common complication with potentially major ramifications for patients. It has also been associated with poorer long-term overall survival (OS) and disease recurrence. Objective. The aim of this study was to determine whether AL contributes to poor OS and recurrence-free survival (RFS) for patients with esophageal cancer. Methods. Consecutive patients undergoing a two-stage, two-field transthoracic esophagectomy from a single highvolume unit between 1997 and 2016 were evaluated. Clinicopathologic characteristics, along with oncological and postoperative outcomes, were stratified by no AL versus non-severe leak (NSL) versus severe esophageal AL (SEAL). SEAL was defined as ALs associated with Clavien-Dindo grade III/IV complications. Results. This study included 1063 patients, of whom 8% (87/1063) developed AL; 45% of those who developed AL were SEALs (39/87). SEAL was associated with a prolonged critical care stay (median 8 vs. 3 vs. 2 days; p \ 0.001) and prolonged hospital stay (median 43 vs. 27 vs. 15 days; p \ 0.001) compared with NSL or no AL. There were no significant differences in number of lymph nodes harvested and rates of R1 resection between groups. OS and RFS were not affected by either NSL or SEAL, and Cox multivariate regression showed NSL and SEAL were not independently associated with OS and RFS. Sensitivity analysis in patients receiving neoadjuvant therapy followed by esophagectomy demonstrated similar findings. Conclusion. These results demonstrate that AL leads to prolonged critical care and in-hospital length of stay; however, contrary to previous reports, our results do not compromise long-term outcomes and are unlikely to have a detrimental oncological impact. Esophagectomy remains a key component of treatment for patients with potentially curable esophageal cancer. While mortality levels from the procedure have fallen dramatically over the last 30 years, esophagectomy is still associated with high levels of morbidity. 1-3 Anastomotic leak (AL) is a commonly seen complication that has historically been associated with high mortality rates. 4 The Esophagectomy Complications Consensus Group (ECCG) defined AL as a full-thickness defect involving the esophagus, anastomosis, staple line or conduit, irrespective of the presentation or method of identification. 5 The classification further divided leaks into the management strategy employed: type I, those that require no change in treatment; type II, leaks that require intervention, but not surgery; and type III, leaks that require surgical intervention. The incidence of AL has been reported at between 3 and 30%. 6,7 This can result in a prolonged hospital stay, a need for reoperation, anastomotic stricturing that requires repeated dilations, and potentially poorer long-term survival. 8,9 A French multicenter study, which defined severe

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Background The Oesophago-Gastric Anastomosis Audit (OGAA) is an international collaborative group set up to study anastomotic leak outcomes after oesophagectomy for cancer. This Delphi study aimed to prioritize future research areas of unmet clinical need in RCTs to reduce anastomotic leaks. Methods A modified Delphi process was overseen by the OGAA committee, national leads, and engaged clinicians from high-income countries (HICs) and low/middle-income countries (LMICs). A three-stage iterative process was used to prioritize research topics, including a scoping systematic review (stage 1), and two rounds of anonymous electronic voting (stages 2 and 3) addressing research priority and ability to recruit. Stratified analyses were performed by country income. Results In stage 1, the steering committee proposed research topics across six domains: preoperative optimization, surgical oncology, technical approach, anastomotic technique, enhanced recovery and nutrition, and management of leaks. In stages 2 and stage 3, 192 and 171 respondents respectively participated in online voting. Prioritized research topics include prehabilitation, anastomotic technique, and timing of surgery after neoadjuvant chemo(radio)therapy. Stratified analyses by country income demonstrated no significant differences in research priorities between HICs and LMICs. However, for ability to recruit, there were significant differences between LMICs and HICs for themes related to the technical approach (minimally invasive, width of gastric tube, ischaemic preconditioning) and location of the anastomosis. Conclusion Several areas of research priority are consistent across LMICs and HICs, but discrepancies in ability to recruit by country income will inform future study design.

An analysis by Dandy in 1926 showed that 25 cases of -spinal osteomyelitis with extradural abscess had been reported up to that time. Only two of the patients recovered, and except in one case there was " no evidence to indicate that the nature of the lesion was more than roughly guessed" (Taylor and Kennedy, 1923). -The concluding words are also of interest: "Whether an epidural abscess may eventually be diagnosed before implication of the spinal cord and before the appearance of a spinal block remains to be seen."Numerous authors since that date have recorded cases successfully diagnosed and surgically treated (Abrahamson, McConnell, and Wilson, 1934; Stammers, 1938;Browder and Meyers, 1941).As late as 1944, however, when the clinical syndrome had long been accurately defined in the literature, Boger states: " From the literature, as we have reviewed it, there are 84 operated cases with a mortality of 35%." All authors agree that in non-operated cases the disease is invariably fatal. The mortality, then, can reasonably be associated with delay in making the diagnosis-a state of affairs less likely to obtain when the clinical syndrome of fever, spinal muscle spasm, and pain in the back of rapid onset and in a site where alternative possibilities are rare gains more general recognition. The coincident osteomyelitis of the spine and incipient neurological signs are indications for surgery without delay.The surgical technique, when reported, has been that common for all abscesses-namely, incision (by an extensive laminectomy to the limits of the extradural abscess) and drainage, either by repeated packing or by a large-bore drainage-tube (Stammers, 1938;Mixter and Smithwick, 1932 Jan. 20.-Temperature, pulse, and respiration normal. The left paralaminal musculature opposite L 3-4 was more acutely tender than on the previous day and showed slight swelling and increase in local heat. There was no tenderness over the spinous processes. A diminution was noted in the left ankle-jerk.Jan. 21.-An exploration by needling showed thick creamy pus in the paravertebral groove deep to the area of tenderness. Skiagrams failed to demonstrate any bony lesion in the lumbo-sacral vertebrae and there was no distortion of the psoas shadow. As the left ankle-jerk was still noticeably weaker than the right a diagnosis was made of osteomyelitis of the lumbar spine with cxtradural abscess.Jan. 22.-The bacteriological report showed that Staphylococcus aureus had been isolated in the pus. No tubercle bacilli were seen in Ziehl-Neelsen films. Operation was therefore undertaken without delay. A midline incision was made from L 2 to S 1. Thick creamy pus was found in considerable quantity deep to both erector spinae muscles. The laminae of L 3, 4, and 5 were soft and necrotic and were removed, releasing an extradural abscess of thick pus, extending up to L 2 and down to S 1. It had not separated the close dural attachment to the posterior common ligament except inferiorly. The dura over an equivalent area was covered by fleshy greyish-red gra...