Background: The impact of anastomotic leak (AL) on long-term outcomes after gastrectomy for gastric adenocarcinoma is poorly understood. This study determined whether AL contributes to poor overall survival. Methods: Consecutive patients undergoing gastrectomy in a single high-volume unit between 1997 and 2016 were evaluated. Clinicopathological characteristics, oncological and postoperative outcomes were stratified according to whether patients had no AL, non-severe AL or severe AL. Severe AL was defined as anastomotic leakage associated with Clavien-Dindo Grade III-IV complications. Results: The study included 969 patients, of whom 58 (6⋅0 per cent) developed AL; 15 of the 58 patients developed severe leakage. Severe AL was associated with prolonged hospital stay (median 50, 30 and 13 days for patients with severe AL, non-severe AL and no AL respectively; P < 0⋅001) and critical care stay (median 11, 0 and 0 days; P < 0⋅001). There were no significant differences between groups in number of lymph nodes harvested (median 29, 30 and 28; P = 0⋅528) and R1 resection rates (7, 5 and 6⋅5 per cent; P = 0⋅891). Cox multivariable regression analysis showed that severe AL was independently associated with overall survival (hazard ratio 3⋅96, 95 per cent c.i. 2⋅11 to 7⋅44; P < 0⋅001) but not recurrence-free survival. In sensitivity analysis, the results for patients who had neoadjuvant therapy then gastrectomy were similar to those for the entire cohort. Conclusion: AL prolongs hospital stay and is associated with compromised long-term overall survival.

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.

Background Esophagectomy is associated with a high rate of morbidity and mortality. Preoperative cardiopulmonary fitness has been correlated with outcomes of major surgery. Variables derived from cardiopulmonary exercise testing (CPET) have been associated with postoperative outcomes. It is unclear whether preoperative cardiorespiratory fitness of patients undergoing esophagectomy is associated with long-term survival. This study aimed to evaluate whether any of the CPET variables routinely derived from patients with esophageal cancer may aid in predicting long-term survival after esophagectomy. Methods Patients undergoing CPET followed by trans-thoracic esophagectomy for esophageal cancer with curative intent between January 2013 and January 2017 from single high-volume center were retrospectively analyzed. The relationship between predictive co-variables, including CPET variables and survival, was studied with a Cox proportional hazard model. Receiver operation curve (ROC) analysis was performed to find cutoff values for CPET variables predictive of 3-year survival. Results The study analyzed 313 patients. The ventilatory equivalent for carbon dioxide (VE/VCO2) at the anerobic threshold was the only CPET variable independently predictive of long-term survival in the multivariable analysis (hazard ratio [HR], 1.049; 95% confidence interval [CI], 1.011–1.088; p = 0.011). Pathologic stages 3 and 4 disease was the other co-variable found to be independently predictive of survival. An ROC analysis of the VE/VCO2 failed to demonstrate a predictive cutoff value of 3-year survival (area under the curve, 0.564; 95% CI, 0.499–0.629; p = 0.056). Conclusions A high VE/VCO2 before esophagectomy for malignant disease is an independent predictor of long-term survival and may be an important variable for clinicians to consider when counseling patients.

Background Minimally invasive techniques are increasingly used in the treatment of esophageal cancer. The learning curve for minimally invasive oesophagectomy (MIO) is variable and can impact on patient outcomes. The aim of this study was to review the current evidence on learning curves in MIO and identify which parameters are used for benchmarking. Methods A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to February 2020. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if an assessment of the learning curve was reported on, regardless of which (if any) statistical method was used.  Results Twenty-nine studies comprising 3741 patients were included. Twenty-two studies reported on a combination of thoracoscopic, hybrid and total MIO, 6 studies reported robotic assisted MIO (RAMIE) alone and 1 study evaluated both RAMIE and thoracoscopic esophagectomies. Operating time was the most frequently used parameter to determine learning curve progression (23/39 studies), with number of resected lymph nodes, morbidity and blood loss also frequently used. Learning curves were found to plateau at 7-60 cases for thoracoscopic esophagectomy, 12-175 cases for total and thoracoscopic/hybrid esophagectomy and 9-85 cases for RAMIE.  Conclusions Multiple parameters are employed to gauge MIO learning curve progression. However, there are no validated or approved sets of outcomes. Further work is required to determine the optimum parameters that should be utilised to ensure best patient outcomes and required length of proctoring.