Tim Bright

Treatment of luminal gastrointestinal malignancies with curative intent has traditionally required a combination of systemic treatments and complex surgical resections, which carry risks to function and quality of life. Organ‐sparing approaches to treating gastrointestinal malignancies have advanced significantly. With increasing efficacy of upfront systemic and radiation therapies, select patients can safely avoid radical surgery while maintaining oncologic outcomes. This review discusses current and future organ‐sparing approaches in the management of gastro‐oesophageal, colon, rectal and anal cancers.

Background: In Europe, the lowest perioperative mortality is seen when oesophagectomies are performed in high‐volume hospitals. In Australia, the optimum annual volume for the lowest mortality has been shown to be 21+. The objective was to evaluate regional variation in hospital mortality following oesophagectomy from a prospective database using univariate and multivariable logistic regression models. Methods: The Australia and New Zealand Intensive Care Society Adult Patient Database was used to identify patients undergoing oesophagectomy for cancer in Australia from 2012 to 2021. The hospital mortality for each jurisdiction per year was determined, and a three‐level mixed‐effects logistic model was used to assess hospital volume versus hospital mortality. Results: 4189 patients underwent oesophagectomy in 124 hospitals. Regions with the highest number of hospitals performing oesophagectomies were NSW/ACT (44) and VIC/TAS (38). The jurisdiction with the highest proportion of operations in high‐volume hospitals (21+ operations per year) was Queensland (39.7%), followed by Western Australia (39.6%) and South Australia (31.8%). Mortality rates were 1.4% in Queensland, 2.5% in South Australia, 3.3% in Western Australia, 3.8% in VIC/TAS and 5.4% in NSW/ACT. The differences in mortality between jurisdictions were primarily driven by differences in surgical volume across hospitals within each jurisdiction, accounting for 73.9% of the between‐hospital variance, with higher volume associated with lower mortality. Conclusions: Differences exist between jurisdictions in Australia for outcomes following oesophagectomy. Perioperative mortality was lower in regions where surgery was more commonly undertaken in a higher‐volume hospital. Hospital mortality in Australia might be reduced if oesophagectomies are uniformly centralised to high‐volume hospitals.

Background: In Australian and Aotearoa New Zealand (ANZ), it is unclear whether minimally invasive transthoracic Ivor Lewis esophagectomy (MIO) is superior to open techniques with regards to perioperative and oncological outcomes. Most evidence on this topic have been derived from high‐volume centers prior to the advent of perioperative FLOT chemotherapy. How these findings are applicable to the ANZ context, where oesophagectomies are typically performed in low‐moderate volume centers, is unknown. This study compares perioperative outcomes and long‐term survival between patients undergoing transthoracic open versus hybrid and total MIO following neoadjuvant FLOT chemotherapy across multiple ANZ centers. Methods: Retrospective analysis of transthoracic oesophagectomies undertaken between 2017 and 2022 following neoadjuvant FLOT chemotherapy from 22 ANZ centers. The primary endpoint was the rate of major (Clavien‐Dindo grade ≥ 3) postoperative complication. Secondary endpoints included nodal yield, surgery time, length‐of‐stay, and rates of perioperative complications, positive resection margins, ICU readmissions, in‐hospital mortality, 30‐day hospital readmissions, textbook outcome, adjuvant chemotherapy delivered, as well as disease free (DFS) and overall survival (OS). Results: Open esophagectomy, hybrid MIO and total MIO was performed in 155 (62.5%), 61 (24.6%), and 32 (12.9%) patients, respectively. From open to total MIO, there was a stepwise decrease in the rate of major postoperative complications (Open: 38.7%, hybrid MIO: 29.5%, total MIO: 15.6%, p = 0.032). This was associated with reduced length‐of‐stay [Median(IQR), Open: 14 (11–23), hybrid MIO: 13 (11–23), total MIO: 10 (8–12), p = 0.031], and lower rates of pulmonary (Open: 49.0%, hybrid MIO: 42.6%, total MIO: 28.1%, p = 0.031), cardiac (Open: 20.0%, hybrid MIO: 6.6%, total MIO: 3.1%, p = 0.006), sepsis (Open: 18.7%, hybrid MIO: 8.2%, total MIO: 3.1%, p = 0.022), and wound (Open: 12.3%, hybrid MIO: 3.3%, total MIO: 0.0%, p = 0.019) complications. No significant differences were observed in other perioperative endpoints. Moreover, institutional factors including enhanced recovery after surgery programs and hospital case volume interacted with surgical technique to influence postoperative complication rates. Importantly, adjusted DFS and OS were comparable between the three groups. Conclusions: In ANZ, MIO was associated with fewer complications and comparable survival compared to open transthoracic esophagectomy. These findings support the safety of MIO in lower‐volume settings in the era of perioperative FLOT chemotherapy.

Background: Patients undergoing cancer treatment incur significant out‐of‐pocket costs attributed to both medical and non‐medical expenditure. We quantified out‐of‐pocket costs for patients receiving surgical treatment for oesophageal cancer and their financial toxicity. Methods: Patients who had undergone oesophagectomy for cancer completed an out‐of‐pocket questionnaire which determined medical costs (e.g., gap payments and medications), non‐medical costs (e.g., travel, accommodation, wage loss) and carer costs (travel and wage loss). Financial toxicity was assessed using the validated Comprehensive Score for Financial Toxicity (COST) questionnaire. Out‐of‐pocket costs and financial toxicity were summarised using medians with bootstrapped 95% confidence intervals (CIs) (1000 resamples). Between‐group comparisons were assessed with Wilcoxon rank‐sum and Kruskal–Wallis tests and associations with income percentiles using Spearman's correlation. Results: Seventy individuals completed the survey (43.3% response rate). The majority were male (85.7%), aged 60–79 (76.5%) and 0–5 years post‐cancer diagnosis (55.7%). Median out‐of‐pocket expenditure was $1352 and was mainly attributed to wage loss (64.7%), followed by carer cost (23.7%). Out‐of‐pocket costs were higher for younger age groups (40–59 years) compared to those aged 60–79 years ( p = 0.003). There was no statistically significant difference in out‐of‐pocket costs between public versus privately insured patients. Median out‐of‐pocket costs trended higher for rural ($1696) versus urban located patients ($1235), but this was not statistically significantly different ( p = 0.140). The median financial toxicity score was 23.5 (95% CI: 21.0–27.5), indicating moderate financial toxicity. Financial toxicity did not differ significantly by age, gender, country of birth, education or location. A lower income percentile was associated with greater financial toxicity ( ρ = −0.30, p = 0.012). Conclusion: Patients facing oesophagectomy for cancer incur many out‐of‐pocket costs, mostly due to wage loss from time spent away from work for both patients and carers. Younger patients and those with lower income face proportionately greater financial burdens, highlighting a need for targeted support to reduce financial stress.

Indocyanine green fluorescence guided video‐assisted thoracoscopic ligation of the thoracic duct.

Mucosal impedance is a marker of esophageal mucosal integrity and a novel technique for assessing esophageal function and pathology. This article highlights its development and clinical application for gastroesophageal reflux disease (GERD), Barrett’s esophagus, and eosinophilic esophagitis. A narrative review of key publications describing the development and use of mucosal impedance in clinical practice was conducted. A low mean nocturnal baseline impedance (MNBI) has been shown to be an independent predictor of response to anti-reflux therapy. MNBI predicts medication-responsive heartburn better than distal esophageal acid exposure time. Patients with equivocal evidence of GERD using conventional methods, with a low MNBI, had an improvement in symptoms following the initiation of PPI therapy compared to those with a normal MNBI. A similar trend was seen in a post fundoplication cohort. Strong clinical utility for the use of mucosal impedance in assessing eosinophilic esophagitis has been repeatedly demonstrated; however, there is minimal direction for application in Barrett’s esophagus. The authors conclude that mucosal impedance has potential clinical utility for the assessment and diagnosis of GERD, particularly when conventional investigations have yielded equivocal results.

The biomarker development field within molecular medicine remains limited by the methods that are available for building predictive models. We developed an efficient method for conservatively estimating confidence intervals for the cross validation-derived prediction errors of biomarker models. This new method was investigated for its ability to improve the capacity of our previously developed method, StaVarSel, for selecting stable biomarkers. Compared with the standard cross validation method, StaVarSel markedly improved the estimated generalisable predictive capacity of serum miRNA biomarkers for the detection of disease states that are at increased risk of progressing to oesophageal adenocarcinoma. The incorporation of our new method for conservatively estimating confidence intervals into StaVarSel resulted in the selection of less complex models with increased stability and improved or similar predictive capacities. The methods developed in this study have the potential to improve progress from biomarker discovery to biomarker driven translational research.

Background. Rectal foreign bodies form a surprisingly frequent cause of presentation to the emergency department. The materials inserted constitute a wide range of size, shape, and texture with each presenting a unique set of challenges. Despite a seemingly innocuous presentation, if not recognised early and managed accordingly, significant complications can develop including obstruction, perforation, and sphincteric injury. The existing doctrines advocate endoscopic intervention after simple measures fail and advise against the use of laxative therapy due to concerns for complications that may arise. The authors of this study challenge this notion, provided certain conditions are met. Case Presentation. We report the case of a 14-year-old boy who inserted a golf ball into his rectum, which subsequently migrated proximally into the sigmoid colon on plain radiographic films. The patient was asymptomatic on presentation, and there was no clinical evidence of bowel injury or mechanical bowel obstruction. Endoscopic removal of the golf ball was pursued under general anaesthesia. Despite protracted efforts, the golf ball was not able to be retrieved endoscopically. In an attempt to avoid aggressive surgery, volume laxatives were administered with successful passage of the golf ball several hours later. Conclusions. This case discusses the unique technical challenges, which may be encountered when attempting to retrieve a large, spherical, and non-confirming foreign body entrapped above the rectosigmoid junction and how these factors can complicate endoscopic retrieval. The authors advocate that in the absence of a mechanical bowel obstruction, patients with foreign bodies possessing physical properties that are amenable to spontaneous passage, a trial of strong aperients, should be considered first line. The authors contention is that direct escalation to removal of foreign body in theatre can be resource draining and may expose the patient to additional risk.

Pneumatic balloon dilatation for the treatment of achalasia has been used for over a century and continues to have a role. Although relatively simple to perform, there are multiple steps that should be followed to deliver the treatment safely and effectively, and these are detailed. The results of pneumatic dilatation have been compared to those of laparoscopic cardiomyotomy and to per-oral endoscopic myotomy (POEM) and suggest that, provided multiple balloon dilatations are performed, acceptable results can be attained. In patients treated with a previous myotomy, or with anatomical challenges in accessing the hiatus, pneumatic dilatation is a useful option in the treatment of achalasia.

Antireflux surgery aims to improve quality of life. However, whether patients and clinicians agree on what this means, and what is an acceptable outcome following fundoplication, is unknown. This study used clinical scenarios pertinent to laparoscopic fundoplication for gastroesophageal reflux to define acceptable outcomes from the perspective of patients, surgeons, and general practitioners (GPs). Patients who had previously undergone a laparoscopic fundoplication, general practitioners, and esophagogastric surgeons were invited to rank 11 clinical scenarios of outcomes following laparoscopic fundoplication for acceptability. Clinicopathological and practice variables were collated for patients and clinicians, respectively. GPs and esophagogastric surgeons additionally were asked to estimate postfundoplication outcome probabilities. Descriptive and multivariate statistical analyses were undertaken to examine for associations with acceptability. Reponses were received from 331 patients (36.4% response rate), 93 GPs (13.4% response), and 60 surgeons (36.4% response). Bloating and inability to belch was less acceptable and dysphagia requiring intervention more acceptable to patients compared to clinicians. On regression analysis, female patients found bloating to be less acceptable (OR: 0.51 [95%CI: 0.29–0.91]; P = 0.022), but dysphagia more acceptable (OR: 1.93 [95%CI: 1.17–3.21]; P = 0.011). Postfundoplication estimation of reflux resolution was higher and that of bloating was lower for GPs compared to esophagogastric surgeons. Patients and clinicians have different appreciations of an acceptable outcome following antireflux surgery. Female patients are more concerned about wind-related side effects than male patients. The opposite holds true for dysphagia. Surgeons and GPs differ in their estimation of event probability for patient recovery following antireflux surgery, and this might explain their differing considerations of acceptable outcomes.