Paul Turner

In our department patients with oesophago-gastric junctional adenocarcinomas with signet ring differentiation undergo a second endoscopy for gastric mapping biopsies to investigate the extent of tumour extension into the proximal stomach. This is due to the perceived aggressive morphology and to avoid a R1 (microscopic positive) resection at the distal margin. Our aim was to elucidate whether gastric mapping endoscopic biopsies are necessary prior to resection in signet ring adenocarcinomas of the oesophago-gastric junction (OGJ). Patients with operable OGJ adenocarcinomas with signet ring morphology were retrospectively analysed from 2011–2021 from our databank of completed oesophagectomies at our upper gastrointestinal cancer surgical department. From 2014–2021, OGJ adenocarcinomas identified with signet ring differentiation were subjected to a second invasive endoscopy with gastric mapping biopsies to determine the distal ex-tent of microscopic invasion into the cardia and beyond. These were analysed to determine the histopathological yield from gastric mapping biopsies and the number of cases with a positive (R1) distal resection margin. From 2014, 322 oesophagectomy cases were completed and these were analysed further. Of these, 21.7% (n = 70) were found pre-operatively to have signet ring differentiation and thus underwent a second gastric mapping endoscopy. Within the signet ring morphology cohort, only one patient (1.4%) was found to involve a R1 resection margin which necessitated a second operation involving gastric resection and colonic interposition. Our results suggest that patients with signet ring adenocarcinoma of the OGJ do not need gastric mapping biopsies to determine the distal margin prior to resection. Although considered a more aggressive subtype of adenocarcinoma, radial infiltration from the tumour does not seem to affect conventional surgical oncological margins.

Oesophageal cancer is clinically staged using the TNM classification by modalities such as CT, PET-CT and endoscopic ultrasound. This is used to assess and guide oncological treatment in the form of neoadjuvant chemotherapy, radiotherapy and surgery. Following neoadjuvant therapy and/or surgery the resected specimen is analysed and given a final histological stage. The purpose of this study was to evaluate the accuracy and variation in pre-operative (radiological) stage from the final histopathological stage. This retrospective study was conducted using an electronic database containing pre- and post-operative TNM staging information on all patients undergoing elective oesophagectomies from April 2009 to December 2021 at a single tertiary upper gastrointestinal cancer centre. 568 patients underwent Ivor Lewis oesophagectomies. The median age was 63 years old (45–82) with M:F 1.78:1. The median length of stay (LOS) was 13 (3–148) days. Results on table attached. Based on our data, there is an observed significant down-staging amongst tumours with higher T and N stages from their predicted pre-operative stage to the final TNM stage allocated after histopathology review. This reflects the continued value of neoadjuvant chemo(radio)therapy. Early T1N0 tumours still appear challenging to accurately stage pre-operatively, hence adjuncts such as endoscopic ultrasound remain crucial in guiding management.

Delayed gastric emptying (DGE) is a known complication following oesophagectomy with gastric conduit reconstruction. Pyloroplasty is often performed to mitigate the consequences of DGE. It remains contentious whether performing a pyloroplasty has a significant role in reducing DGE. We discuss our twelve-year experience at a single centre routinely performing Heineke-Mikulicz pyloroplasty for all oesophagectomies. This retrospective study employed an electronic database containing information on all patients who underwent elective Ivor Lewis oesophagectomies from April 2009 to December 2021 in a tertiary upper gastrointestinal cancer centre. Across six surgeons in the centre, a standardised pyloroplasty technique was performed. DGE was defined as patients who had high nasogastric output (> 1.5 litres per day) after ten post-operative days or required endoscopic pyloric balloon dilatation within one year following oesophagectomy. 578 patients underwent Ivor Lewis oesophagectomy during the study period. The mean age was sixty years and the male to female ratio was 1.8:1. The median length of stay was 13 days (3–148). DGE was seen in 9.9% (n = 57) patients. Of these patients, 39.7% (n = 29) cases required oesophageal dilatation within 12 months after their oesophagectomy. 50.8% (n = 21) required in-patient endoscopic dilatation, 14.0% (n = 8) required out-patient endoscopic dilatation. From those who developed DGE, the 30- and 90-day mortality was nil. There were 1.2% (n = 7) leaks specifically from the pyloroplasty which were all managed conservatively. The rate of delayed gastric emptying is reported to be approximately 15% (Zhang & Zhang, 2018). Our study demonstrates that performing a pyloroplasty reduces this risk to 9.9% and is worthwhile as the complication rate from pyloroplasty is low. Although there are various methods employed in overcoming pyloric sphincter denervation following oesophagectomy (pyloroplasty, pyloromyotomy, digital or instrumental pyloric stretching or intra-operative balloon dilatation), the most effective method of reducing DGE warrants a randomised control trial.

Background: With the SARS-CoV-2 pandemic gripping most of the globe, healthcare and economic recovery strategies are being explored currently as a matter of urgency. The underpinning rationale of this paper is that we believe that health and care services are provided locally, therefore, local implications of national policy need to be reflected when informing national responses to the SARS-CoV-2 pandemic. Methods: We adopted the assumptions underlying the United Kingdom government’s national epidemiological model which influences the national policy response to the SARS-CoV-2 pandemic. We used these in a local context and show projections in terms of presentations of symptomatic patients differ in a variety of settings. Setting: North of England, United Kingdom, population modelled at four local constituent levels which aggregated gives a total population of 3.2m . Results: We clearly demonstrate that there is significant difference in the way the national modelling outputs are replicated at local levels. Specifically, in terms of projected increased levels of demand for services on the local health and care systems. Conclusions: We present significant evidence of differing timelines specifically in terms of subsequent projected peak demands. Additionally, it clearly indicates varying levels of such demand throughout the four modelled localities. These idiosyncrasies are ‘masked’ by both regional and national approaches to modelling. We urge readers to ensure that any national policy is appropriately adopted through the use of complementary bottom up approach, to suit local health and care systems. Finally, we share our methodology to ensure other professionals could replicate this study elsewhere.

I t is estimated that 79 million people in the United States (35% of adults ≥ 20 years of age and 50% of adults ≥ 65 years of age) have mild degrees of hyperglycemia and are thereby at risk for developing type 2 diabetes.1 Scientific jargon such as “impaired glucose tolerance” (IGT), “impaired fasting glucose” (IFG), and “elevated A1C” may be too technical or cumbersome to use with most patients. Accordingly, preferred terminologies such as “prediabetes” and “at high risk for diabetes” have entered the clinical lexicon and are felt to be simple enough to be understood by the average patient and also sufficiently motivating to encourage lifestyle change to prevent further deterioration to type 2 diabetes. However, there is debate in the literature regarding which term is most suitable to describe this stage in the development of diabetes. In 2009, the International Expert Committee criticized the term “prediabetes” because it suggests unequivocal progression to diabetes—not an inevitable occurrence2—and advocated for use of the “high risk” terminology instead. The American Diabetes Association, however, has continued to use “prediabetes,” considering it an appropriate description of this at-risk category.3 Other groups, including the World Health Organization and the International Diabetes Federation, have been using different terms for increased diabetes risk, such as “intermediate hyperglycemia,” as well as the more technical IGT and IFG.4,5 However, those descriptors are not routinely used by practitioners in the United States. The American Association of Clinical Endocrinologists preferred “prediabetes” in its 2011 guidelines.6 Prediabetes is usually an asymptomatic state. However, it has been associated with certain morbidities, including early stages of neuropathy and macrovascular disease.7 For health care providers (HCPs), recognition of this stage is essential because it provides opportunities for patient education about the importance of initiating …