Oesophagogastric Cancer Surgery Research Articles

590. RESOLUTION OF SYMPTOMS AFTER OESOPHAGO-GASTRIC CANCER RESECTION (RESTORED)–STANDARDISING GASTROINTESTINAL SYMPTOMS AND CONDITIONS AFTER SURGERY: A MULTI-DISCIPLINARY EXPERT DELPHI STUDY

Abstract Background Oesophago-gastric cancer surgery negatively affects quality of life with a high post-operative symptom burden. Several conditions that may be diagnosed and treated after surgery are recognised. However, consensus regarding their definition and management is lacking. We aimed to develop consensus regarding the definition, investigation and management of the common symptoms and conditions, and triggers to consider disease recurrence, as a foundation for improving management and quality of life in these patients. Design Modified 2-round Delphi consensus study of a multidisciplinary expert panel. Results 86/127(67.7%) and 77/100(77.0%) responses were received in rounds 1 and 2. Consensus was achieved in defining 26 symptoms. For 10 conditions (anastomotic stricture, acid reflux, non-acid reflux, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption), definitions, diagnostic criteria, first and second-line investigation and first-line treatments were agreed. Consensus was not reached for third line investigation of some conditions, nor for second, third or fourth-line treatments for others. 12 of 14(85.7%) symptoms were agreed as triggers to consider cancer recurrence, during the early (< 1 year) and late (> 1 year) post-operative periods. Conclusion Expert consensus regarding symptoms, conditions and triggers to consider investigation for recurrence after oesophago-gastric cancer surgery was achieved. This will allow standardisation and timely diagnosis and treatment of post-operative conditions, reducing variation in care. It will facilitate comparative, prospective research to establish the incidence and response to treatment of these conditions, helping develop robust evidence to optimise patients’ quality of life.

355 Predictors of Textbook Outcome Following Oesophagogastric Cancer Surgery: A Single-Centre Analysis

Abstract Aim Textbook outcome (TO) is a multidimensional composite measure representing an ideal perioperative course, which has been utilised to assess the quality of care in oesophagogastric cancer surgery. We aim to determine TO rates among oesophagogastric cancer patients in a UK tertiary centre, investigate predictors of TO attainment, and evaluate the relationship between TO and survival. Method A retrospective analysis of a prospectively collected departmental database between 2006-2021 was conducted. Patients that underwent radical oesophagogastric cancer surgery with curative intent were included. TO attainment required margin-negative resection, adequate lymphadenectomy, uncomplicated postoperative course, and no hospital readmission. Predictors of TO were investigated using multivariable logistic regression. The association between TO and survival was evaluated using Kaplan-Meier analysis and Cox regression modelling. Results 667 oesophageal cancer and 312 gastric cancer patients were included. TO was achieved in 35.1% of oesophagectomy patients and 51.3% of gastrectomy patients. Several factors were independently associated with a low likelihood of TO attainment: T3 stage (OR:0.41, 95% CI [0.22-0.79], p=0.008) and T4 stage (OR:0.26, 95% CI [0.08-0.72], p=0.013) in the oesophagectomy cohort and high BMI (OR:0.93, 95% CI [0.88-0.98], p=0.011) in the gastrectomy cohort. TO attainment was associated with greater overall survival in oesophagectomy and gastrectomy cohorts, however, it was not associated with recurrence-free survival in the gastrectomy cohort. Conclusions TO is a relevant multidimensional metric that can be utilised to compare surgical quality between centres and investigate patients at risk of TO failure. Enhancement of preoperative care measures can improve TO rates and subsequently, long-term survival.

Predictors of textbook outcome following oesophagogastric cancer surgery.

Textbook outcome (TO) is a composite measure representing an ideal perioperative course, which has been utilized to assess the quality of care in oesophagogastric cancer (OGC) surgery. We aim to determine TO rates among OGC patients in a UK tertiary center, investigate predictors of TO attainment, and evaluate the relationship between TO and survival. A retrospective analysis of a prospectively collected departmental database between 2006 and 2021 was conducted. Patients that underwent radical OGC surgery with curative intent were included. TO attainment required margin-negative resection, adequate lymphadenectomy, uncomplicated postoperative course, and no hospital readmission. Predictors of TO were investigated using multivariable logistic regression. The association between TO and survival was evaluated using Kaplan-Meier analysis and Cox regression modeling. In sum, 667 esophageal cancer and 312 gastric cancer patients were included. TO was achieved in 35.1% of esophagectomy patients and 51.3% of gastrectomy patients. Several factors were independently associated with a low likelihood of TO attainment: T3 stage (odds ratio (OR): 0.41, 95% confidence interval (CI) [0.22-0.79], p = 0.008) and T4 stage (OR:0.26, 95% CI [0.08-0.72], p = 0.013) in the esophagectomy cohort and high BMI (OR:0.93, 95% CI [0.88-0.98], p = 0.011) in the gastrectomy cohort. TO attainment was associated with greater overall survival and recurrence-free survival in esophagectomy and gastrectomy cohorts. TO is a relevant quality metric that can be utilized to compare surgical performance between centers and investigate patients at risk of TO failure. Enhancement of preoperative care measures can improve TO rates and, subsequently, long-term survival.

O113: Predictors of textbook outcome following oesophagogastric cancer surgery

Abstract Textbook outcome (TO) is a multidimensional composite measure representing an ideal perioperative course, which has been utilised to assess the quality of care in oesophagogastric cancer surgery. We aim to determine TO rates among oesophagogastric cancer patients in a UK tertiary centre, investigate predictors of TO attainment, and evaluate the relationship between TO and survival. A retrospective analysis of a prospectively collected departmental database between 2006-2021 was conducted. Patients that underwent radical oesophagogastric cancer surgery with curative intent were included. TO attainment required margin-negative resection, adequate lymphadenectomy, uncomplicated postoperative course, and no hospital readmission. Predictors of TO were investigated using multivariable logistic regression. The association between TO and survival was evaluated using Kaplan-Meier analysis and Cox regression modelling. 667 oesophageal cancer and 312 gastric cancer patients were included. TO was achieved in 35.1% of oesophagectomy patients and 51.3% of gastrectomy patients. Several factors were independently associated with a low likelihood of TO attainment: T3 stage (OR:0.41, 95% CI [0.22-0.79], p=0.008) and T4 stage (OR:0.26, 95% CI [0.08-0.72], p=0.013) in the oesophagectomy cohort and high BMI (OR:0.93, 95% CI [0.88-0.98], p=0.011) in the gastrectomy cohort. TO attainment was associated with greater overall survival in oesophagectomy and gastrectomy cohorts, however, it was not associated with recurrence-free survival in the gastrectomy cohort. TO is a useful multidimensional quality improvement metric that can be utilised to compare surgical quality between centres and investigate patients at risk of TO failure. Implementation of preoperative care measures can improve rates of TO and long-term survival.

O101: Current guidelines on physical activity do not prevent skeletal muscle loss and physical decline prior to Oesophagogastric cancer surgery: a new benchmark for prehabilitation?

Abstract Prehabilitation is being widely adopted to optimise physical health prior to surgery. However, there remains a lack of consensus regarding exercise type and intensity with current guidance extrapolated from generic, non-cancer populations. The WHO and American College of Sports Medicine (ACSM) recommend 600-1200 Metabolic Equivalent minutes (MET-mins) per week of physical activity (PA) but the effectiveness of this recommendation in cancer populations is unknown. Patients undergoing treatment for Oesophagogastric cancer were prospectively recruited. International Physical Activity Questionnaire (IPAQ) quantified PA at baseline and throughout treatment. Two cohorts were defined (lowPA and highPA) based on ACSM cut-off of 1200 MET-mins/week. Outcome measures were physical function (1 minute sit-to-stand, 1mSTS), CT muscle mass, chemotoxicity, and failure to complete planned treatment. 38 patients completed all study assessments (highPA n=20, lowPA n=18) with no difference in baseline characteristics or disease stage between groups. LowPA group showed declines in 1mSTS performance following chemotherapy, whereas the highPA group improved (mean difference -4 versus +10, p=0.001). Whilst both saw a decline in skeletal muscle mass, the lowPA group lost significantly more (mean difference -5.1 versus -1.8, p=0.007). There were trends towards a lower incidence of severe chemotoxicity (30% vs 61%, p=0.054) and failure to complete planned treatment (15% versus 28%, p=.33) in the highPA group. Whilst further research is required to define the most effective prehabilitation strategy, this study is the first to suggest a new benchmark to preserve muscle mass and function is higher than current guidelines and should be considered when developing prehabilitation recommendations.

OGC P15 Analysing the Impact of Prehabilitation on Patient Outcomes in Oesophagogastric Cancer Surgery: Combined Data from Four prospective Clinical Trials performed across the UK and Ireland

Abstract Background Prehabilitation is increasingly being used in patients undergoing multi-modality treatment for oesophago-gastric (OG) cancer. Most studies to date have been small, single centre trials lacking statistical power. The results of larger randomised trials are still awaited. There remain considerable uncertainties regarding the outcome measures that may benefit from prehabilitation, the exact nature of the intervention and the mechanisms behind any observed benefit. This collaborative study sought to combine data from four prospective clinical prehabilitation trials performed in the UK and Ireland to determine the overall impact of the intervention on patient outcomes following oesophagogastric cancer surgery. Methods Anonymised data from four prospective prehabilitation trials conducted in the UK and Ireland (Southampton, Guildford, Dublin, and St Thomas’, London) in patients undergoing multi-modality treatment for oesophagogastric cancer was combined. The studies included two randomized and two non-randomized clinical trials. The primary outcome measures were differences in complications and length of stay. Secondary outcomes were changes in BMI, fitness (VO2 max), chemotherapy completion rates and tumour regression. In total, 180 patients were included from four studies, with 93 patients in the prehabilitation group and 87 patients in the control group. Results Severe complications (Clavien Dindo >=3) were observed less frequently in the prehabilitation group (19% vs 34%; p=0.038). Hospital length of stay also favoured prehabilitation (10 vs 11 days) albeit not statistically significant. Chemotherapy completion rates were significantly higher following prehabilitation (96% vs 63%; p<0.001). There were non-significant improvements in VO2 max change following neo-adjuvant therapy (delta 1.35 vs 2.39; p=0.25), anaerobic threshold change (delta 1.20 vs 2.20; p=0.11) and chemotherapy response (Mandard 1-3 57% vs 44%; p=0.178). Conclusions Despite some limitations in terms of heterogeneity of study methodology and prehabilitation interventions, this study has highlighted a willingness of individual units to collaborate and tangible clinical benefits across a range of outcome measures in a larger OG patient population. Current initiatives to agree national standards for delivering prehabilitation and the results of on-going trials will help to further refine this important intervention and expand the evidence base to support the widespread adoption and implementation of prehabilitation programs.

OGC P51 Development of a symptom response questionnaire following therapeutic interventions for patients recovering from oesophagogastric cancer resection

Abstract Background Patients frequently experience symptoms after major oesophagogastric (OG) cancer resection which can delay quality of life resolution. Multiple symptoms can arise simultaneously making diagnosis of the underlying problem(s) and subsequent treatment complex. While diagnostic tests can offer valuable insight, some conditions are treated empirically and a positive response to therapy can go some way to confirming the diagnosis. Whilst numerous baseline symptom questionnaires exist, there is currently no established questionnaire to assess treatment response to an intervention following OG cancer surgery. Methods A survey of 362 OG cancer patients in survivorship phase identified their most important symptoms after surgery. A questionnaire based on validated EORTC symptom questionnaires including those derived from EORTC QLQ- CR 29, Bil 21, C30, ST022, OES 18 and OG25 has been developed to assess intervention impact on symptoms. For each reported symptom the patient is asked to grade the degree to which the symptom affected them before and after the intervention on a Likert scale.This study reports the development of the questionnaire and patient feedback following pyloric dilatation for delayed gastric emptying at 2 and 4 weeks post-procedure. Results The development of the questionnaire incorporated the use of previously validated EORTC questions and two measures that compared the patient’s symptoms before and after therapeutic intervention. All 12 patients involved in the initial development and first-stage review of the questionnaire rated it as easy or very easy to complete. A subsequent consecutive validation cohort of 27 patients undergoing pyloric dilatation for delayed gastric emptying also described the questionnaire as easy or very easy in 100% of cases. Conclusions Symptom response to an intervention is not routinely collected in a prospective setting despite potentially offering important clues as to accuracy of underlying diagnosis and documenting efficacy of the treatment. Patient recall of response to treatment retrospectively may be inaccurate and susceptible to bias. To best of our knowledge, this is the first questionnaire to detail symptomatic responses to therapeutic interventions in patients after OG cancer surgery. The questionnaire appears to be acceptable to patients and easy to complete. Further validation is needed before the questionnaire can be widely used, including testing with various interventions and on a digital platform.

OGC P61 Audit of diagnosis and treatment of early pneumonia after elective oesophagogastric resections

Abstract Background Respiratory complications after oesophagogastric (OG) cancer surgery are common and present as some of the most severe. Post-operative respiratory complications reduce disease free and overall survival. Incorrect use of antibiotics can have negative outcomes. Are the diagnosis criteria clear and do such patients receive the correct management? This audit assesses diagnoses of pneumonia against the US Centers for Disease Control (CDC) criteria and antibiotic choice against National Institute for Health and Care Excellence (NICE) guidelines in a regional OG cancer surgery centre (which may be replicated in many other OG centres). Methods We examined records of 109 patients who underwent elective OG surgery at University College Hospital London between July 2021 and June 2022. The post-operative period was defined as 7 days from the initial operation. Results 30.2% of all patients were treated with antibiotics for pneumonia in the post-operative period. 42.4% of these patients had a sputum sample taken at the time of clinical suspicion of pneumonia, and 42.8% of these grew one or more relevant organisms. 69.7% of treated patients were prescribed a NICE-approved antibiotic. 17.4% of all patients developed pneumonia per the US CDC criteria and these patients had a longer stay in ICU (10.6 days compared to 5.3 days) and hospital (29.4 days compared to 14.3 days) than those who did not. 30-day mortality rate was 0% in this group. Conclusions This audit identified variability in diagnosis and antibiotic prescribing in post-operative pneumoniae. Sputum analysis was used inconsistently to diagnose and guide antibiotic therapies; cultures were often taken after antimicrobials were initiated, with patients treated symptomatically rather than based on microbiology results. Recommendations following this audit comprised; the use of CDC criteria to promote accurate diagnosis in the post-operative period, and regular multidisciplinary review of antibiotic agents prescribed to ensure appropriate targeted treatment.

OGC P13 CNS and Dietitian led clinical follow-up with support from a survivorship multi-disciplinary team meeting: A model of care for patients after oesophago-gastric (OG) cancer surgery

Abstract Background Major upper gastro-intestinal (UGI) cancer surgery in combination with chemotherapy offers the best chance of cure for patients with oesophageal and gastric cancer. However, these treatments have significant long-term side-effects resulting in a high symptom burden in this patient group. This adversely affects quality of life and places significant demands on healthcare after surgery. There is a large variation in follow-up services nationally, with little guidance on optimal practice. Methods A clinical nurse specialist (CNS) and Dietitian led clinic has been utilised in this patient group for 12 years at St Thomas’ hospital, with UGI surgeon support as required. In 2021, a survivorship multi-disciplinary team meeting (MDM) consisting of CNS, Dietitian, Gastroenterologist, UGI surgeon and psychologist was introduced. This aimed to support the clinic by discussing management of complex cases. Results Since 2011, approximately 3000 patient consults have been undertaken in the survivorship clinic. These patients benefited from specialist follow-up, expertise in symptom management, holistic needs assessments, recurrence surveillance and specialist dietetic advice. These patients were removed from surgical and oncology out-patient clinics, creating greater capacity in these services. Patient feedback has consistently supported this model of follow-up. Complex patients are discussed in the survivorship MDM which supports the clinic. Conclusions CNS and Dietitian led clinics, alongside a survivorship MDM, may provide a better model of follow-up compared to traditional surgical clinics by offering a greater breadth of expertise and consistency of follow-up. Evaluation of patient centred outcomes and economic analysis, in addition to on-going national initiatives to standardise the investigation and management of symptoms following major UGI surgery, would support replicating this model in other centres.

EGS P04 Recent ten year experience of Boerhaave’s Syndrome Management in a tertiary Oesophago-gastric Surgery Centre

Abstract Background Oesophageal Perforation (OP) is a low incidence, high complexity gastrointestinal surgical emergency with associated high mortality rates. A consequence of UK centralisation of oesophago-gastric (OG) cancer surgery is passive centralisation of OG surgical emergencies leading to reduced mortality for OP and lower threshold for surgical intervention by high volume OG cancer surgeons. Boerhaave's Syndrome characterised by Mackler’s Triad (vomiting, thoracic pain and subcutaneous emphysema) represents 30% of OP. UCLH has an OG surgery catchment population of 3 million. We present our experience of managing Boerhaave’s syndrome as an OG cancer centre with a dedicated OG Consultant on-call rota. Methods A retrospective review of electronic health records of all adult patients with a radiological diagnosis of OP over a 10 year period from 01/01/2013 to 31/12/2022) at our institution was performed. The inclusion criteria were adult patients with a clinical and radiological diagnosis of Boerhaave’s syndrome. Those with OP due to malignancy, endoscopic, or foreign body perforation were excluded from further analysis. The primary outcome measure was 90-day mortality and the secondary outcome measures were length of stay and reintervention rate. Results 41 patients with Boerhaave’s syndrome were identified (31 male, 10 female) with median age of 62 (46 - 71). 17 (41.5%) patients presented directly to our institution and 24 (58.5%) were transferred from other hospitals. Primary intervention was surgical in 31 (75.6%), endoscopic in 3 (7.3%) and conservative in 7 (17.1%) patients respectively. Overall 90-day mortality was 12.2% but 6.5% in the surgically managed group. Median length of stay was 58 days (22 - 70). 9 patients had reintervention – 7 (17.1%) had a thoracotomy/thoracoscopic surgery for intrathoracic collections and 2 patients (9.8%) had endoscopic intervention. Conclusions This is a report of the experience of managing Boerhaave’s syndrome in a high volume tertiary OG centre. A favourable 90-day mortality rate of 12.2% compares to 38.8% described in a previous UK cohort is likely a result of management in a tertiary centre with appropriate multidisciplinary infrastructure to manage complex patients and provide a consistently high level of perioperative care. The lower mortality rate (6.5%) in the operatively managed group is likely due to patient selection and surgical techniques honed from familiarity with complex cancer and benign oesophageal surgery and working as part of an effective multidisciplinary team.

Continuous glucose monitoring and low-glycaemic index diet in the management of postprandial hypoglycaemia after oesophagogastric cancer surgery.

Continuous glucose monitoring and low-glycaemic index diet in the management of postprandial hypoglycaemia after oesophagogastric cancer surgery.

584 Extended VTE Prophylaxis in Patients Undergoing Oesophagogastric Cancer Surgery

Abstract Aim Venous thromboembolism (VTE) is a life-threatening complication in cancer patients undergoing surgery. NICE recommends VTE-prophylaxis to 28days for patients undergoing major abdominal cancer surgery. The efficacy of in-hospital VTE-prophylaxis is well-documented, but the optimal duration of postoperative VTE-prophylaxis remains controversial. Patients undergoing oesophagogastric cancer surgery have a higher risk of VTE due to suboptimal oral intake, dehydration, need for adjuvant and neoadjuvant chemotherapy. Hence in 2014, extended VTE-prophylaxis to 28days from hospital discharge (HD) was adopted as a departmental policy. This study aims to evaluate its effectiveness, prescribing compliance and safety. Method This is a 10-year retrospective study from July 2012-2022. All patients who underwent cardio-oesophagectomy or gastrectomy for oesophagogastric cancers were included. Patients who died during the index admission, benign oesophagogastric surgery including excision of GIST, and central line associated VTE were excluded. The primary outcome is prescribing compliance with 28-day VTE prophylaxis from HD. The secondary outcome includes the incidence of VTE and bleeding complications requiring hospital readmission within 28days from HD. Results 582 patients were included in our study. Since 2014, 423/490patients (86.3%) have been discharged with 28days VTE-prophylaxis from HD compared to pre-2014 (13/92patients,14.1%). There was a statistically significant difference in improving prescribing compliance following the introduction of this policy (p<0.05). No patient was readmitted due to bleeding complications. Only 1 patient (1/582,0.17%) developed VTE within 28days from HD. Conclusions We recommend extending VTE-prophylaxis for 28days from hospital discharge for all patients undergoing oesophagogastric cancer surgery. This improves prescribing compliance, reduces the incidence of post-discharge VTE and is safe.

The prognostic impact of pre-treatment cachexia in resectional surgery for oesophagogastric cancer: a meta-analysis and meta-regression.

Cancer cachexia is not purely an end-stage phenomenon and can influence the outcomes of patients with potentially curable disease. This review examines the effect of pre-treatment cachexia on overall survival, in patients undergoing surgical resection of oesophagogastric cancer. A systematic literature search of MEDLINE, EMBASE and Cochrane Library databases was conducted, from January 2000 to May 2022, to identify studies reporting the influence of cachexia on patients undergoing an oesophagogastric resection for cancer with curative intent. Meta-analyses of the primary (overall survival) and secondary (disease-free survival and postoperative mortality) outcomes were performed using random-effects modelling. Meta-regression was used to examine disease stage as a potential confounder. Ten non-randomized studies, comprising 7186 patients, were eligible for inclusion. The prevalence of pre-treatment cachexia was 35 per cent (95 per cent c.i.: 24-47 per cent). Pooled adjusted hazard ratios showed that cachexia was adversely associated with overall survival (HR 1.46, 95 per cent c.i.: 1.31-1.60, P < 0.001). Meta-analysis of proportions identified decreased overall survival at 1-, 3- and 5-years in cachectic cohorts. Pre-treatment cachexia was not a predictor of disease-free survival and further data are required to establish its influence on postoperative mortality. The proportion of patients with stage III/IV disease was a significant moderator of between-study heterogeneity. Cachexia may have a greater influence on overall survival in studies where more patients have a locally advanced malignancy. Pre-treatment cachexia adversely influences overall survival following resection of an oesophagogastric malignancy.

Malnutrition defined by GLIM criteria identifies a higher incidence of malnutrition and is associated with pulmonary complications after oesophagogastric cancer surgery, compared to ICD-10-defined malnutrition.

Low muscle mass, measured using computed tomography (CT), is associated with poor surgical outcomes. We aimed to include CT-muscle mass in malnutrition diagnosis using the Global Leadership Initiative on Malnutrition (GLIM) criteria, compare it to the International Classification of Diseases 10th Revision (ICD-10) criteria, and assess the impact on postoperative outcomes after oesophagogastric (OG) cancer surgery. One hundred and eight patients who underwent radical OG cancer surgery and had preoperative abdominal CT imaging were included. GLIM and ICD-10 malnutrition data were assessed against complication and survival outcomes. Low CT-muscle mass was determined using predefined cut-points. GLIM-defined malnutrition prevalence was significantly higher than ICD-10-malnutrition (72.2% vs. 40.7%, p < 0.001). Of the 78 patients with GLIM-defined malnutrition, low muscle mass (84.6%) was the predominant phenotypic criterion. GLIM-defined malnutrition was associated with pneumonia (26.9% vs. 6.7%, p = 0.010) and pleural effusions (12.8% vs. 0%, p = 0.029). Postoperative complications did not correlate with ICD-10 malnutrition. Severe GLIM (HR: 2.51, p = 0.014) and ICD-10 (HR: 2.15, p = 0.039) malnutrition were independently associated with poorer 5-year survival. GLIM criteria appear to identify more malnourished patients and more closely relate to surgical risk than ICD-10 malnutrition, likely due to incorporating objective muscle mass assessment.

Understanding Potentially Preventable Mortality Following Oesophago-Gastric Cancer Surgery: Analysis of a National Audit of Surgical Mortality

IntroductionAt a national level, understanding preventable mortality after oesophago-gastric cancer surgery can direct quality-improvement efforts. Accordingly, utilizing the Australian and New Zealand Audit of Surgical Mortality (ANZASM), we aimed to: (1) determine the causes of death following oesophago-gastric cancer resections in Australia, (2) quantify the proportion of potentially preventable deaths, and (3) identify clinical management issues contributing to preventable mortality.MethodsAll in-hospital mortalities following oesophago-gastric cancer surgery from 1 January 2010 to 31 December 2020 were analysed using ANZASM data. Potentially preventable and non-preventable cases were compared. Thematic analysis with a data-driven approach was used to classify clinical management issues.ResultsOverall, 636 complications and 123 clinical management issues were identified in 105 mortalities. The most common causes of death were cardio-respiratory in aetiology. Forty-nine (46.7%) deaths were potentially preventable. These cases were characterized by higher rates of sepsis (59.2% vs 33.9%, p = 0.011), multiorgan dysfunction syndrome (40.8% vs 25.0%, p = 0.042), re-operation (63.3% vs 41.1%, p = 0.031) and other complications compared with non-preventable mortality. Potentially preventable mortalities also had more clinical management issues per patient [median (IQR): 2 (1–3) vs 0 (0–1), p < 0.001), which adversely impacted preoperative (30.6% vs 7.1%, p = 0.002), intraoperative (18.4% vs 5.4%, p = 0.037) and postoperative (51.0% vs 17.9%, p < 0.001) care. Thematic analysis highlighted recurrent areas of deficiency with preoperative, intraoperative and postoperative patient management.ConclusionsAlmost 50% of deaths following oesophago-gastric cancer resections were potentially preventable. These were characterized by higher complication rates and clinical management issues. We highlight recurrent themes in patient management to improve future quality of care.

OGC P25 Outcomes of Laparoscopic Vs Open Oesophagectomy in a single high volume centre

Abstract Background Oesophageal cancer has a poor 5 year survival and surgery is the mainstay of curative treatment for the majority of cases. Minimally invasive surgery is practiced in a number of formats (open thorax/open abdomen, open thorax/lap abdomen, thoracoscopic/lap abdomen) and its benefits have been subject to a number of trials. Methods We interrogated a prospectively recorded database of oesophagogastric cancer surgery from a large single centre to compare oesophagectomy cases performed with curative intent comparing laparoscopic abdomen plus open thorax versus a totally open operation. Transhiatal oesophagectomies were excluded. Baseline data was compared to establish whether groups were equally matched and outcomes of length of stay, any complication, anastomotic leak, number of lymph nodes yielded, 30 day mortality and 90 day mortality were subject to statistical analysis. Missing data was not imputed. Results Sixty-nine hybrid oesophagectomies (laparoscopic abdomen, open thoracic phase) and 373 totally open procedures were performed between January 2017-May 2022. Both groups were equally matched in terms of age, performance status, ASA, tumour site, gender ratio and histology. LOS was 11.6 vs 13.5 (lap vs open / days), P=0.72. Complication rate was 33.3% v 37.3% (lap vs open) P= 0.53. Anastomotic leak rate was 10.1% vs 8.9% (lap vs open) P=0.73. Number of lymph nodes yielded was 25.8 ± 2.17 vs 24 ± 0.59 (lap vs open, mean ± s.e). Thirty day mortality was 2.9% vs 2.17% (lap vs open) P=0.66. Ninety day mortality was 7.25% vs 4.19% (lap vs open) P=0.27. Conclusions This 5 year dataset of equally matched laparoscopic abdominal phase vs totally open oesophagectomy procedures shows no statistically significant difference in the outcomes that were measured. The laparoscopic approach would be expected to inflict a lesser stress response than open surgery. Oesophagectomy along with possible complications may inflict a stress response that masks the benefits from laparoscopic surgery. This data supports the notion that the laparoscopic abdomen approach is not inferior to an open procedure. Interrogation of a larger 10 year dataset would be worthwhile to confirm this. Furthermore, this current study may be merely be reflective of the learning curve for the laparoscopic approach and a prospective study of our practice will be worthwhile.

OGC P36 Unmet needs in survivorship: Increased anxiety post oesophago-gastric cancer surgery

Abstract Background Oesophago-Gastric (OG) cancer is an aggressive malignant disease, and patients are offered extensive surgical treatment often in combination with neoadjuvant and adjuvant oncological intervention. The treatment process is emotionally demanding and affects treatment outcomes (Fangand, &amp; Schnoll, 2002). However, the available research is concentrated on generalised anxiety and depression (Hellstadius et al, 2017), despite the unique concerns of this cohort. This study examines the trajectory of patients’ unique OG symptoms related anxiety through utilising a specialist measure. Methods The Oesophageal Anxiety and Hypervigilence Scale (EHAS) is a newly validated self-report questionnaire that detects oesophageal anxiety in patience with GI disorders. It has been shown to demonstrate good internal consistency and validity (Taft et al, 2018). Patients with oesophageal cancer were recruited from at Guy's and St Thomas’ Hospital, London. As part of their routine clinic appointments between September 2021-February 2022, patients completed the EHAS measure across four key time points within their treatment trajectory; diagnosis (Time 1), pre-operatively (Time 2), two weeks post operatively (Time 3), and 6–12 months post operatively, often termed ‘survivorship’ (Time 4). Results A total of 106 EHAS measures were completed by 83 patients (79% male, 20% female, mean age = 64) at different stages within their treatment trajectory, representing a between-subjects design. 61% of patients underwent oesophagectomy, 22% total gastrectomy, 10% subtotal gastrectomy and 7% underwent other surgeries including sigmoid colectomy, and jejunal resection. Pooling the sample z-score, the cut off score for clinical significance was calculated at 33. The EHAS outcomes revealed high anxiety at Time 1 (T1 mean = 28/33) which decreased by 32% from to Time 2 (T2 mean = 19/33). Anxiety remained low in the period between Time 2 to Time 3 (T3 mean = 21/33). Surprisingly, anxiety scores increased by 42% from Time 3 to Time 4 (T4 mean = 29/33), matching the elevated levels observed at Time 1. Other important findings related to the proportion of patients that scored above clinical cut off. Whilst 12% of patients scored above cut off at Time 1, this rose to 32% at Time 4, indicating marked anxiety during the phase of recovery greater than that experienced at diagnosis. At this level of analysis there is no evidence to indicate a relationship between type of surgery and elevated anxiety. Conclusions With the use of a specialist anxiety measure, we demonstrate that oesophageal anxiety is common among OG cancer patient cohort. The trajectory of anxiety observed in this study has clinical implications for the timing of support and enhanced recovery programme; this study revealed that OG anxiety fluctuated across the treatment pathway, and peaked at two distinct time points; diagnosis and survivorship. This challenges the often held assumption that patients anxiety increases pre-operatively (Hellstadius et al, 2017), and instead refocuses the need for input at both the diagnosis and survivorship periods. The high anxiety observed at the survivorship stage may also affect patients’ ability to process and adhere to treatment advice, further exacerbating their symptoms and jeopardising their physical recovery. Patients are monitored less during their survivorship period as the intensity of treatment cease, however the results indicate need for continued input.

OGC P27 A Review of Minimally Invasive Oesophagogastric Cancer Surgery in a High-Volume UK Unit

Abstract Background Oesophagogastric (OG) cancer resections are technically challenging and associated with peri-operative morbidity. Practice has evolved from open to minimally invasive surgery (MIS), with ERAS has seen peri-operative outcomes improve. OG surgeons have not transitioned to MIS at the rate of others; 2021 NOGCA results showed that 17.6% of oesophagectomies and 17% of gastrectomies were performed as MIS. Concerns regarding the technical ability to perform safe anastomoses and appropriate oncological clearance have been cited as common reasons for surgeons not transitioning to MIS. GSTT is a high-volume OG unit which has transitioned from a fully open to predominantly MIS practice. The unit has performed over 100 minimally invasive Ivor Lewis oesophagectomies and 97 laparoscopic gastrectomies, it was therefore decided to analyse the unit's peri-operative outcomes to ensure that appropriate standards were maintained during this change in practice. The primary aim of this study was to examine a decade of peri-operative outcomes for Ivor Lewis oesophagectomy and gastrectomies, comparing parallel open and MIS cohorts. The secondary aim is to perform a sequential cumulative sum control chart (CUSM) analysis of the cohort to determine whether a learning curve effect for OG MIS can be demonstrated. Methods A retrospective analysis of a prospectively maintained comprehensive local database was performed. The results were cross-checked with NOCGA data, and a notes review was performed to capture any missing data.All Ivor Lewis oesophagectomy and gastrectomy (total, extended total and subtotal) performed for adenocarcinoma, squamous cell carcinoma, neuroendocrine tumours and high grade dysplasia at Guy's and St Thomas’ NHS Foundation Trust, London, UK over a ten-year period (January 2012- December 2021) were included. MIS for oesophagectomy was defined as an Ivor Lewis oesophagectomy performed with both laparoscopic and thoracoscopic phases. A hybrid (laparoscopic abdomen and open chest phase) oesophagectomy was grouped with a two-phase open procedure to create an open cohort. Laparoscopic gastrectomy (with a laparoscopic oesophago-jejunostomy or gastro-jejunostomy for sub-total gastrectomy) was used as the definition of MIS. The cohorts were compared for: age, sex, BMI and use of neoadjuvant therapy. Temporal trends in surgical approaches were compared as were Individual surgeon (n=4) volumes. Peri-operative clinical and oncological outcomes including length of stay, anastomotic leak, return to theatre, chest complications, resection margins and lymph node harvest were all examined. A CUSM analysis is currently being completed to further analyse surgeon performance over time. Results 596 patients underwent resection in well matched cohorts, 197 patients had an oesophagectomy (100 MIO), 339 had a gastrectomy (97 laparoscopic). MIS rates increased with no operations being performed as MIS in 2012 compared to 81% of oesophagectomy and 67% of gastrectomy performed as MIS in 2021. Two surgeons performed over 170 resections with MIS rate over 40%. OR of MIS performed by a high-volume surgeon was 3.01 (p&amp;lt;0.001). Lower volume MIS surgeons were more likely to have two consultants present, OR 1.4 (p=0.16). Anastomotic leak rates following gastrectomy were 2% in both groups (p=0.66), 9% following open oesophagectomy and 11% after MIO (p=0.77). 10% of laparoscopic gastrectomy patients experienced a chest complication, 26% after open surgery, 22% MIO and 24% open (p=0.65). Mean length of stay was significantly reduced after MIS. An R0 rate of 96% was seen after laparoscopic gastrectomy, 90% after open (p=0.08). 68% of MIO patients had R0 resection compared to 70% after open. Positive CRM was 29% after MIO. The mean lymph node harvest was 29 after laparoscopic gastrectomy and 26 after open (p=0.24), 29 following MIO, 30 after open oesophagectomy. 97% of MIO harvested over 15 nodes. Conclusions This study demonstrates that a transition from open to MIS practice is achievable in the UK. Outcomes demonstrated similar peri-operative clinical and oncological outcomes between MIS and open surgery which addresses the concerns that prohibited the widespread uptake of MIS in UK centres. Developing a reliable surgical technique for lymphadenectomy and anastomoses that transitioned from open to hybrid and now MIS allowed for appropriate outcomes to be maintained. Unit outcomes compare well to both NOGCA/ECCG data with complication rates following MIO being significantly lower when compared to ECCG. Lymph node harvests were significantly higher in unit MIOs when compared to NOGCA (p=0.01). Volume played an important role in surgeons performing independent MIS. This should be considered when planning unit workload or a transition to MIS. It will be further explored in the CUSM analysis. A positive CRM was seen in more cases (29%) when compared to NOGCA (24%) and may be related to the preferred neoadjuvant regime being chemotherapy over chemoradiotherapy. The future of OG is moving towards robotic surgery. It is proposed that the evolution from open to MIS will make a second transition to robotics less challenging as the strategies needed to perform MIS have been addressed.

261. MALNUTRITION DEFINED BY GLIM CRITERIA ASSOCIATES WITH INCREASED RISK OF ADVERSE OUTCOME AFTER OESOPHAGO-GASTRIC CANCER SURGERY

Abstract Low muscle mass is associated with postoperative complications after oesophago-gastric (OG) cancer surgery, but data demonstrating a negative impact on long-term survival is limited. Clinical tools to accurately stratify risk based on nutritional status would be of considerable value. The Global Leadership Initiative on Malnutrition (GLIM) is a consensus framework for diagnosing malnutrition. We aimed to assess the prevalence of malnutrition defined by GLIM and the impact on postoperative outcomes after OG cancer surgery. Patients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Retrospective collection of preoperative data identified malnutrition using the GLIM definition. The phenotypic criterion includes body mass index (BMI), unintentional weight loss, and muscle mass. All patients had a malignant disease and met the aetiologic criterion of an inflammatory condition. Nutrition status was categorised as no malnutrition, mild–moderate, and severe. Malnutrition diagnosis was assessed against oncological, surgical, and survival data. Low skeletal muscle index (cm2/m2) measured by CT was determined using predefined cut-points.1 Cox regression analysis determined predictors of overall survival. One-hundred and eight patients were included. Malnutrition using GLIM criteria was present in 72% of patients (n = 78), including mild–moderate (n = 45) and severe malnutrition (n = 33). The predominant phenotypic criterion for GLIM malnutrition was low muscle mass (n = 66, 61%), followed by preoperative weight loss (n = 46, 43%) and low BMI (n = 11, 10%). Malnutrition was associated with postoperative pneumonia (26.9% vs 6.7% well-nourished, p = 0.010). Severe malnutrition was associated with poorer 5-year overall survival (p = 0.022) (Figure 1) and, along with stage 4 disease, higher age, and severe postoperative complications, remained an independent predictor of survival after multivariate analysis (OR 2.51, 95% CI 1.20–5.24, p = 0.014). Malnutrition defined by GLIM is highly prevalent and is associated with postoperative pneumonia. Severe malnutrition is an independent predictor of poorer overall survival. Muscle mass is a key phenotypic GLIM criterion, and the GLIM diagnostic framework is potentially a practical and valuable component of preoperative risk stratification in OG cancer surgery.

A feasibility trial of prehabilitation before oesophagogastric cancer surgery using a multi-component home-based exercise programme: the ChemoFit study

BackgroundTreatment for locally advanced oesophagogastric adenocarcinoma involves neoadjuvant chemotherapy which has a negative impact on patient fitness. Using ‘prehabilitation’ to increase activity levels and fitness may affect physiology, postoperative outcomes and improve patient wellbeing and quality of life. The aims of the trial were to address the feasibility and acceptability of recruiting participants to a home-based prehabilitation programme and provide data to allow design of future studies.MethodsWe recruited patients to a single-arm feasibility trial of home-based exercise prehabilitation. Eligible patients were aged ≥18years, had operable oesophageal or gastric adenocarcinoma and were receiving neoadjuvant chemotherapy at our tertiary referral hospital. All participants commenced a home-based exercise programme utilising pedometers and step counting to target daily aerobic exercise sessions alongside daily strengthening exercises. A weekly telephone consultation directed the exercise programme and facilitated weekly data collection. The primary (feasibility) outcomes for the trial were (a) recruitment rate, (b) completion rate, (c) engagement with the programme (use of pedometers, recording step counts, telephone consultations) and (d) compliance with exercise sessions, exercise intensity and strengthening exercises.ResultsThere were 42 patients recruited, and the recruitment rate was 72.4% (42/58). 92.3% (36/39) of patients completed the exercise programme. There was 98.7% (IQR 93.2–100.0%) compliance with wearing a pedometer and recording data, and 100.0% (IQR 93.1–100.0%) compliance with a weekly telephone consultation. Exercise sessions and strengthening exercises were completed 70.2% (IQR 53.1–88.9%) and 69.4% (IQR 52.1–84.3%) of the time, respectively. Appropriate exercise intensity was recorded 96% (IQR 85.4–99.4%) of the time. There were no adverse events. Participants were enrolled in the exercise programme for a median of 91 days (IQR 84 to 105 days).ConclusionsThe results of this trial support the feasibility and acceptability of recruiting participants to an appropriately powered randomised controlled trial of prehabilitation.Trial registrationClinicaltrials.gov NCT04194463. Registered on 11th December 2019—retrospectively registered.