Publications by authors named "Markar S"

234 Publications

Wearable Activity Monitors in Home Based Exercise Therapy for Patients with Intermittent Claudication: A Systematic Review.

Eur J Vasc Endovasc Surg 2021 04 12;61(4):676-687. Epub 2021 Jan 12.

Department of Surgery and Cancer, Imperial College London, London, UK; Institute of Global Health Innovation, Imperial College London, London, UK; Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK.

Objective: Intermittent claudication (IC) can severely limit functional capacity and quality of life. Supervised exercise therapy is the recommended first line management; however, this is often limited by accessibility, compliance and cost. As such, there has been an increased interest in the use of wearable activity monitors (WAMs) in home based telemonitoring exercise programmes for claudicants. This review aims to evaluate the efficacy of WAM as a feedback and monitoring tool in home based exercise programmes for patients with IC.

Data Sources: A search strategy was devised. The databases MEDLINE, EMBASE, and Web of Science were searched through to April 2020.

Review Methods: Randomised trials and prospective trials were included. Eligible trials had to incorporate WAMs as a feedback tool to target walking/exercise behaviour. The primary outcome was the change in walking ability. Study quality was assessed with risk of bias tool.

Results: A total of 1148 records were retrieved. Of these, eight randomised controlled trials and one prospective cohort study, all of which compared a WAM intervention against standard care and/or supervised exercise, met the inclusion criteria. Owing to heterogeneity between studies, no meta-analysis was conducted. WAM interventions improved measures of walking ability (heterogeneous outcomes such as maximum walking distance, claudication distance and six minute walk distance), increased daily walking activity (steps/day), cardiovascular metrics (maximum oxygen consumption), and quality of life.

Conclusion: There is some evidence that home based WAM interventions are beneficial for improving walking ability and quality of life in patients with IC. However, existing studies are limited by inadequate sample size, duration, and appropriate power. Achieving consensus on outcome reporting and study methods, as well as maximising device adherence, is needed.
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http://dx.doi.org/10.1016/j.ejvs.2020.11.044DOI Listing
April 2021

Quality of life and symptom assessment in paraesophageal hernias: a systematic literature review of reporting standards.

Dis Esophagus 2021 Jul;34(7)

Department of Surgery and Cancer, Imperial College London, London, UK.

Background: Paraesophageal hernias (PEH) present with a range of symptoms affecting physical and mental health. This systematic review aims to assess the quality of reporting standards for patients with PEH, identify the most frequently used quality of life (QOL) and symptom severity assessment tools in PEH and to ascertain additional symptoms reported by these patients not captured by these tools.

Methods: A systematic literature review according to PRISMA protocols was carried out following a literature search of MEDLINE, Embase and Cochrane databases for studies published between January 1960 and May 2020. Published abstracts from conference proceedings were included. Data on QOL tools used and reported symptoms were extracted.

Results: This review included 220 studies reporting on 28 353 patients. A total of 46 different QOL and symptom severity tools were used across all studies, and 89 different symptoms were reported. The most frequently utilized QOL tool was the Gastro-Esophageal Reflux Disease-Health related quality of life questionnaire symptom severity instrument (47.7%), 57.2% of studies utilized more than 2 QOL tools and 'dysphagia' was the most frequently reported symptom, in 55.0% of studies. Notably, respiratory and cardiovascular symptoms, although less common than GI symptoms, were reported and included 'dyspnea' reported in 35 studies (15.9%).

Conclusions: There lacks a QOL assessment tool that captures the range of symptoms associated with PEH. Reporting standards for this cohort must be improved to compare patient outcomes before and after surgery. Further investigations must seek to develop a PEH specific tool, that encompasses the relative importance of symptoms when considering surgical intervention and assessing symptomatic improvement following surgery.
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http://dx.doi.org/10.1093/dote/doaa134DOI Listing
July 2021

Gastroesophageal Reflux Disease: A Review.

JAMA 2020 12;324(24):2536-2547

Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.

Importance: Gastroesophageal reflux disease (GERD) is defined by recurrent and troublesome heartburn and regurgitation or GERD-specific complications and affects approximately 20% of the adult population in high-income countries.

Observations: GERD can influence patients' health-related quality of life and is associated with an increased risk of esophagitis, esophageal strictures, Barrett esophagus, and esophageal adenocarcinoma. Obesity, tobacco smoking, and genetic predisposition increase the risk of developing GERD. Typical GERD symptoms are often sufficient to determine the diagnosis, but less common symptoms and signs, such as dysphagia and chronic cough, may occur. Patients with typical GERD symptoms can be medicated empirically with a proton pump inhibitor (PPI). Among patients who do not respond to such treatment or if the diagnosis is unclear, endoscopy, esophageal manometry, and esophageal pH monitoring are recommended. Patients with GERD symptoms combined with warning symptoms of malignancy (eg, dysphagia, weight loss, bleeding) and those with other main risk factors for esophageal adenocarcinoma, such as older age, male sex, and obesity, should undergo endoscopy. Lifestyle changes, medication, and surgery are the main treatment options for GERD. Weight loss and smoking cessation are often useful. Medication with a PPI is the most common treatment, and after initial full-dose therapy, which usually is omeprazole 20 mg once daily, the aim is to use the lowest effective dose. Observational studies have suggested several adverse effects after long-term PPI, but these findings need to be confirmed before influencing clinical decision making. Surgery with laparoscopic fundoplication is an invasive treatment alternative in select patients after thorough and objective assessments, particularly if they are young and healthy. Endoscopic and less invasive surgical techniques are emerging, which may reduce the use of long-term PPI and fundoplication, but the long-term safety and efficacy remain to be scientifically established.

Conclusions And Relevance: The clinical management of GERD influences the lives of many individuals and is responsible for substantial consumption of health care and societal resources. Treatments include lifestyle modification, PPI medication, and laparoscopic fundoplication. New endoscopic and less invasive surgical procedures are evolving. PPI use remains the dominant treatment, but long-term therapy requires follow-up and reevaluation for potential adverse effects.
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http://dx.doi.org/10.1001/jama.2020.21360DOI Listing
December 2020

Gastroesophageal Reflux Disease.

JAMA 2020 12;324(24):2565

Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, and Karolinska University Hospital, Stockholm, Sweden.

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http://dx.doi.org/10.1001/jama.2020.21573DOI Listing
December 2020

New geographic model of care to manage the post-COVID-19 elective surgery aftershock in England: a retrospective observational study.

BMJ Open 2020 10 31;10(10):e042392. Epub 2020 Oct 31.

Department of Surgery and Cancer, Imperial College of Science, Technology and Medicine, London, UK.

Objectives: The suspension of elective surgery during the COVID-19 pandemic is unprecedented and has resulted in record volumes of patients waiting for operations. Novel approaches that maximise capacity and efficiency of surgical care are urgently required. This study applies Markov multiscale community detection (MMCD), an unsupervised graph-based clustering framework, to identify new surgical care models based on pooled waiting-lists delivered across an expanded network of surgical providers.

Design: Retrospective observational study using Hospital Episode Statistics.

Setting: Public and private hospitals providing surgical care to National Health Service (NHS) patients in England.

Participants: All adult patients resident in England undergoing NHS-funded planned surgical procedures between 1 April 2017 and 31 March 2018.

Main Outcome Measures: The identification of the most common planned surgical procedures in England (high-volume procedures (HVP)) and proportion of low, medium and high-risk patients undergoing each HVP. The mapping of hospitals providing surgical care onto optimised groupings based on patient usage data.

Results: A total of 7 811 891 planned operations were identified in 4 284 925 adults during the 1-year period of our study. The 28 most common surgical procedures accounted for a combined 3 907 474 operations (50.0% of the total). 2 412 613 (61.7%) of these most common procedures involved 'low risk' patients. Patients travelled an average of 11.3 km for these procedures. Based on the data, MMCD partitioned England into 45, 16 and 7 mutually exclusive and collectively exhaustive natural surgical communities of increasing coarseness. The coarser partitions into 16 and seven surgical communities were shown to be associated with balanced supply and demand for surgical care within communities.

Conclusions: Pooled waiting-lists for low-risk elective procedures and patients across integrated, expanded natural surgical community networks have the potential to increase efficiency by innovatively flexing existing supply to better match demand.
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http://dx.doi.org/10.1136/bmjopen-2020-042392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783383PMC
October 2020

Defining Domains of Survivorship.

Ann Surg 2020 12;272(6):935-936

Department of Surgery and Cancer, Imperial College London, London, UK.

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http://dx.doi.org/10.1097/SLA.0000000000003988DOI Listing
December 2020

Health-related quality of life following total minimally invasive, hybrid minimally invasive or open oesophagectomy: a population-based cohort study.

Br J Surg 2020 Oct 9. Epub 2020 Oct 9.

Surgical Care Science, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.

Background: Minimally invasive oesophagectomy has been shown to reduce the risk of pulmonary complications compared with open oesophagectomy, but the effects on health-related quality of life (HRQoL) and oesophageal cancer survivorship remain unclear. The aim of this study was to assess the longitudinal effects of minimally invasive compared with open oesophagectomy for cancer on HRQoL.

Methods: All patients who had surgery for oesophageal cancer in Sweden from January 2013 to April 2018 were identified. The exposure was total or hybrid minimally invasive oesophagectomy, compared with open surgery. The study outcome was HRQoL, evaluated by means of the European Organisation for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-OG25 at 1 and 2 years after surgery. Mean differences and 95 per cent confidence intervals were adjusted for confounders.

Results: Of the 246 patients recruited, 153 underwent minimally invasive oesophagectomy, of which 75 were hybrid minimally invasive and 78 were total minimally invasive procedures. After adjustment for age, sex, Charlson Co-morbidity Index score, pathological tumour stage and neoadjuvant therapy, there were no clinically and statistically significant differences in overall or disease-specific HRQoL after oesophagectomy between hybrid minimally invasive and total minimally invasive surgical technique versus open surgery.

Conclusion: In this population-based nationwide Swedish study, longitudinal HRQoL after minimally invasive oesophagectomy was similar to that of the open surgical approach.
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http://dx.doi.org/10.1002/bjs.11998DOI Listing
October 2020

Insights from a global snapshot of the change in elective colorectal practice due to the COVID-19 pandemic.

PLoS One 2020 8;15(10):e0240397. Epub 2020 Oct 8.

Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

Background: There is a need to understand the impact of COVID-19 on colorectal cancer care globally and determine drivers of variation.

Objective: To evaluate COVID-19 impact on colorectal cancer services globally and identify predictors for behaviour change.

Design: An online survey of colorectal cancer service change globally in May and June 2020.

Participants: Attending or consultant surgeons involved in the care of patients with colorectal cancer.

Main Outcome Measures: Changes in the delivery of diagnostics (diagnostic endoscopy), imaging for staging, therapeutics and surgical technique in the management of colorectal cancer. Predictors of change included increased hospital bed stress, critical care bed stress, mortality and world region.

Results: 191 responses were included from surgeons in 159 centers across 46 countries, demonstrating widespread service reduction with global variation. Diagnostic endoscopy was reduced in 93% of responses, even with low hospital stress and mortality; whilst rising critical care bed stress triggered complete cessation (p = 0.02). Availability of CT and MRI fell by 40-41%, with MRI significantly reduced with high hospital stress. Neoadjuvant therapy use in rectal cancer changed in 48% of responses, where centers which had ceased surgery increased its use (62 vs 30%, p = 0.04) as did those with extended delays to surgery (p<0.001). High hospital and critical care bed stresses were associated with surgeons forming more stomas (p<0.04), using more experienced operators (p<0.003) and decreased laparoscopy use (critical care bed stress only, p<0.001). Patients were also more actively prioritized for resection, with increased importance of co-morbidities and ICU need.

Conclusions: The COVID-19 pandemic was associated with severe restrictions in the availability of colorectal cancer services on a global scale, with significant variation in behaviours which cannot be fully accounted for by hospital burden or mortality.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240397PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7544024PMC
October 2020

What Has Been the Impact of Covid-19 on Safety Culture? A Case Study from a Large Metropolitan Healthcare Trust.

Int J Environ Res Public Health 2020 09 25;17(19). Epub 2020 Sep 25.

Department of Surgery and Cancer, Imperial College, London SW7 2AZ, UK.

Covid-19 has placed an unprecedented demand on healthcare systems worldwide. A positive safety culture is associated with improved patient safety and, in turn, with patient outcomes. To date, no study has evaluated the impact of Covid-19 on safety culture. The Safety Attitudes Questionnaire (SAQ) was used to investigate safety culture at a large UK healthcare trust during Covid-19. Findings were compared with baseline data from 2017. Incident reporting from the year preceding the pandemic was also examined. SAQ scores of doctors and "other clinical staff", were relatively higher than the nursing group. During Covid-19, on univariate regression analysis, female gender, age 40-49 years, non-White ethnicity, and nursing job role were all associated with lower SAQ scores. Training and support for redeployment were associated with higher SAQ scores. On multivariate analysis, non-disclosed gender (-0.13), non-disclosed ethnicity (-0.11), nursing role (-0.15), and support (0.29) persisted to a level of significance. A significant decrease ( < 0.003) was seen in error reporting after the onset of the Covid-19 pandemic. This is the first study to investigate SAQ during Covid-19. Differences in SAQ scores were observed during Covid-19 between professional groups when compared to baseline. Reductions in incident reporting were also seen. These changes may reflect perception of risk, changes in volume or nature of work. High-quality support for redeployed staff may be associated with improved safety perception during future pandemics.
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http://dx.doi.org/10.3390/ijerph17197034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7579589PMC
September 2020

Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus.

Dis Esophagus 2021 Jun;34(6)

Department of General Thoracic and Esophageal Surgery, Heart and Lung Centre, Helsinki University Hospital, Helsinki, Finland.

There are no internationally recognized criteria available to determine preparedness for hospital discharge after esophagectomy. This study aims to achieve international consensus using Delphi methodology. The expert panel consisted of 40 esophageal surgeons spanning 16 countries and 4 continents. During a 3-round, web-based Delphi process, experts voted for discharge criteria using 5-point Likert scales. Data were analyzed using descriptive statistics. Consensus was reached if agreement was ≥75% in round 3. Consensus was achieved for the following basic criteria: nutritional requirements are met by oral intake of at least liquids with optional supplementary nutrition via jejunal feeding tube. The patient should have passed flatus and does not require oxygen during mobilization or at rest. Central venous catheters should be removed. Adequate analgesia at rest and during mobilization is achieved using both oral opioid and non-opioid analgesics. All vital signs should be normal unless abnormal preoperatively. Inflammatory parameters should be trending down and close to normal (leucocyte count ≤12G/l and C-reactive protein ≤80 mg/dl). This multinational Delphi survey represents the first expert-led process for consensus criteria to determine 'fit-for-discharge' status after esophagectomy. Results of this Delphi survey may be applied to clinical outcomes research as an objective measure of short-term recovery. Furthermore, standardized endpoints identified through this process may be used in clinical practice to guide decisions regarding patient discharge and may help to reduce the risk of premature discharge or prolonged admission.
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http://dx.doi.org/10.1093/dote/doaa101DOI Listing
June 2021

Reply to B. P. L. Wijnhoven et al and F. Nuytens et al.

J Clin Oncol 2021 01 18;39(1):92-93. Epub 2020 Sep 18.

Sheraz R. Markar, MRCS(Eng), MSc, MA, MBBChir, Department of Surgery and Cancer, Imperial College London, United Kingdom; and Mark I. van Berge Henegouwen, MD, PhD, Department of Surgery, Amsterdam University Medical Center, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.

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http://dx.doi.org/10.1200/JCO.20.02354DOI Listing
January 2021

Effect of anastomotic leaks on long-term survival after oesophagectomy for oesophageal cancer: systematic review and meta-analysis.

Dis Esophagus 2021 Mar;34(3)

Department of Surgery & Cancer, Imperial College London, London, UK.

Introduction: Long-term survival after curative surgery for oesophageal cancer surgery remains poor, and the prognostic impact of anastomotic leak (AL) remains unknown. A meta-analysis was conducted to investigate the impact of AL on long-term survival.

Methods: A systematic electronic search for articles was performed for studies published between 2001 and 2020 evaluating the long-term oncological impact of AL. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute hazard ratios and 95% confidence intervals.

Results: Nineteen studies met the inclusion criteria, yielding a total of 9885 patients. Long-term survival was significantly reduced after AL (HR: 1.79, 95% CI: 1.33-2.43). AL was associated with significantly reduced overall survival in studies within hospital volume Quintile 1 (HR: 1.35, 95% CI: 1.12-1.63) and Quintile 2 (HR: 1.83, 95% CI: 1.35-2.47). However, no significant association was found for studies within Quintile 3 (HR: 2.24, 95% CI: 0.85-5.88), Quintile 4 (HR: 2.59, 95% CI: 0.67-10.07), and Quintile 5 (HR: 1.29, 95% CI: 0.92-1.81). AL was significantly associated with poor long-term survival in patients with associated overall Clavien Dindo Grades 1-5 (HR: 2.17, 95% CI: 1.31-3.59) and severe Clavien Dindo Grades 3-5 (HR: 1.42, 95% CI: 1.14-1.78) complications.

Conclusions: AL has a negative prognostic impact on long-term survival after restorative resection of oesophageal cancers, particularly in low-volume centers. Future efforts must be focused on strategies to minimize the septic and immunological response to AL with early recognition and treatment thus reducing the impact on long-term survival.
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http://dx.doi.org/10.1093/dote/doaa085DOI Listing
March 2021

Definitive Chemoradiotherapy Compared to Neoadjuvant Chemoradiotherapy With Esophagectomy for Locoregional Esophageal Cancer: National Population-Based Cohort Study.

Ann Surg 2020 May 19. Epub 2020 May 19.

*Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle-Upon-Tyne, United Kingdom †Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, Tyne and Wear, United Kingdom ‡School of Medical Education, Newcastle University, Newcastle upon Tyne, Tyne and Wear, United Kingdom §Department of Surgery & Cancer, Imperial College London, London, United Kingdom ¶Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA ||Department of Molecular Medicine & Surgery, Karolinska Institutet, Stockholm, Sweden.

Aim: Ongoing randomized controlled trials seek to evaluate the potential organ-preservation strategy of definitive chemoradiotherapy as a primary treatment for esophageal cancer. This population-based cohort study aimed to assess survival following definitive chemoradiotherapy (DCR) with or without salvage esophagectomy (SALV) in the treatment of esophageal cancer.

Patients And Methods: Data from the National Cancer Database (NCDB) from 2004 to 2015, was used to identify patients with nonmetastatic esophageal cancer receiving either DCR (n = 5977) or neoadjuvant chemoradiotherapy with planned esophagectomy (NCRS) (n = 13,555). Propensity score matching and multivariable analyses were used to account for treatment selection bias. Subset analyses compared patients receiving SALV after DCR with NCRS.

Results: Comparison of baseline demographics of the unmatched cohort revealed that patients receiving NCRS were younger, had a lower burden of medical comorbidities, lower proportion of squamous cell carcinoma (SCC), and more positive lymph nodes. Following matching, NCRS was associated with significantly improved survival compared with DCR [hazard ratio (HR): 0.60, 95% confidence Interval (CI): 0.57-0.63, P < 0.001], which persisted in subset analyses of patients with adenocarcinoma (HR: 0.60, 95% CI: 0.56-0.63, P < 0.001) and SCC (HR: 0.58, 95% CI: 0.53-0.63, P < 0.001). Of 829 receiving SALV after DCR, 823 patients were matched to 1643 NCRS. There was no difference in overall survival between SALV and NCRS (HR: 1.00, 95% CI: 0.90-1.11, P = 1.0).

Conclusions: Surgery remains an integral component of the management of patients with esophageal cancer. Neoadjuvant therapy followed by planned esophagectomy appears to remain the optimum curative treatment regime in patients with locoregional esophageal cancer.
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http://dx.doi.org/10.1097/SLA.0000000000003941DOI Listing
May 2020

Protocol of an interdisciplinary consensus project aiming to develop an AGREE II extension for guidelines in surgery.

BMJ Open 2020 08 11;10(8):e037107. Epub 2020 Aug 11.

Medical School, European University Cyprus, Nicosia, Cyprus.

Introduction: Appraisal of Guidelines for Research and Evaluation (AGREE II) is an instrument that informs development, reporting and assessment of clinical practice guidelines. Previous research has demonstrated the need for improvement in methodological and reporting quality of clinical practice guidelines specifically in surgery. We aimed to develop an AGREE II extension document for application in surgical guidelines.

Methods And Analysis: We have performed a structured literature review and assessment of guidelines in surgery using the AGREE II instrument. In exploratory analyses, we have identified factors associated with guideline quality. We have performed reliability and factor analyses to inform the development of an extension document. We will summarise this information and present it to a Delphi panel of stakeholders. We will perform iterative Delphi rounds and we will summarise the final results to develop the extension instrument in a dedicated consensus conference.

Ethics And Dissemination: Funding bodies will not be involved in the development of the instrument. Research ethics committee and Health Research Authority approval was waived, since this is a professional staff study only and no duty of care lies with the National Health Service to any of the participants. Conflicts of interest, if any, will be addressed by reassigning functions or replacing participants with relevant conflicts. The results will be disseminated through publication in peer reviewed journals, the funders' websites, social media and direct contact with guideline development organisations and peer-reviewed journals that publish guidelines.
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http://dx.doi.org/10.1136/bmjopen-2020-037107DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7418673PMC
August 2020

Surgical challenges and research priorities in the era of the COVID-19 pandemic: EAES membership survey.

Surg Endosc 2020 10 4;34(10):4225-4232. Epub 2020 Aug 4.

Griffin Institute (Northwick Park Institute of Medical Research), Northwick Park Hospital, Harrow, HA1 3UJ, UK.

Background: Healthcare systems and general surgeons are being challenged by the current pandemic. The European Association for Endoscopic Surgery (EAES) aimed to evaluate surgeons' experiences and perspectives, to identify gaps in knowledge, to record shortcomings in resources and to register research priorities.

Methods: An ad hoc web-based survey of EAES members and affiliates was developed by the EAES Research Committee. The questionnaire consisted of 69 items divided into the following sections: (Ι) demographics, (II) institutional burdens and management strategies, and (III) analysis of resource, knowledge, and evidence gaps. Descriptive statistics were summarized as frequencies, medians, ranges,, and interquartile ranges, as appropriate.

Results: The survey took place between March 25th and April 16th with a total of 550 surgeons from 79 countries. Eighty-one percent had to postpone elective cases or suspend their practice and 35% assumed roles not related to their primary expertise. One-fourth of respondents reported having encountered abdominal pathologies in COVID-19-positive patients, most frequently acute appendicitis (47% of respondents). The effect of protective measures in surgical or endoscopic procedures on infected patients, the effect of endoscopic surgery on infected patients, and the infectivity of positive patients undergoing laparoscopic surgery were prioritized as knowledge gaps and research priorities.

Conclusions: Perspectives and priorities of EAES members in the era of the pandemic are hereto summarized. Research evidence is urgently needed to effectively respond to challenges arisen from the pandemic.
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http://dx.doi.org/10.1007/s00464-020-07835-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7402075PMC
October 2020

Association of bariatric surgery with all-cause mortality and incidence of obesity-related disease at a population level: A systematic review and meta-analysis.

PLoS Med 2020 07 28;17(7):e1003206. Epub 2020 Jul 28.

Department of Surgery and Cancer, Imperial College London, London, United Kingdom.

Background: Previous clinical trials and institutional studies have demonstrated that surgery for the treatment of obesity (termed bariatric or metabolic surgery) reduces all-cause mortality and the development of obesity-related diseases such as type 2 diabetes mellitus (T2DM), hypertension, and dyslipidaemia. The current study analysed large-scale population studies to assess the association of bariatric surgery with long-term mortality and incidence of new-onset obesity-related disease at a national level.

Methods And Findings: A systematic literature search of Medline (via PubMed), Embase, and Web of Science was performed. Articles were included if they were national or regional administrative database cohort studies reporting comparative risk of long-term mortality or incident obesity-related diseases for patients who have undergone any form of bariatric surgery compared with an appropriate control group with a minimum follow-up period of 18 months. Meta-analysis of hazard ratios (HRs) was performed for mortality risk, and pooled odds ratios (PORs) were calculated for discrete variables relating to incident disease. Eighteen studies were identified as suitable for inclusion. There were 1,539,904 patients included in the analysis, with 269,818 receiving bariatric surgery and 1,270,086 control patients. Bariatric surgery was associated with a reduced rate of all-cause mortality (POR 0.62, 95% CI 0.55 to 0.69, p < 0.001) and cardiovascular mortality (POR 0.50, 95% CI 0.35 to 0.71, p < 0.001). Bariatric surgery was strongly associated with reduced incidence of T2DM (POR 0.39, 95% CI 0.18 to 0.83, p = 0.010), hypertension (POR 0.36, 95% CI 0.32 to 0.40, p < 0.001), dyslipidaemia (POR 0.33, 95% CI 0.14 to 0.80, p = 0.010), and ischemic heart disease (POR 0.46, 95% CI 0.29 to 0.73, p = 0.001). Limitations of the study include that it was not possible to account for unmeasured variables, which may not have been equally distributed between patient groups given the non-randomised design of the studies included. There was also heterogeneity between studies in the nature of the control group utilised, and potential adverse outcomes related to bariatric surgery were not specifically examined due to a lack of available data.

Conclusions: This pooled analysis suggests that bariatric surgery is associated with reduced long-term all-cause mortality and incidence of obesity-related disease in patients with obesity for the whole operated population. The results suggest that broader access to bariatric surgery for people with obesity may reduce the long-term sequelae of this disease and provide population-level benefits.
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http://dx.doi.org/10.1371/journal.pmed.1003206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386646PMC
July 2020

Hospital volume of esophageal cancer surgery in relation to outcomes from primary anti-reflux surgery.

Dis Esophagus 2021 Jan;34(1)

Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden and.

No previous study has sought to identify the effect of hospital volume of esophagectomy on anti-reflux surgery outcomes. The hypothesis under investigation was hospitals performing esophagectomies, particularly those of higher annual volume, have better outcomes from primary anti-reflux surgery. This population-based cohort study included adult individuals (≥18 years) in Sweden receiving primary anti-reflux surgery for a recorded gastro-esophageal reflux disease in 1997-2010, with follow-up until 2013 The 'exposure' was hospital volume of esophagectomy, with hospitals conducting esophagectomies divided into 0, >0-1, >1-3 and ≥ 4 based on annual volume, and hospitals not conducting esophagectomies were the reference category. The outcomes were 30-day re-intervention and surgical re-intervention during the entire follow-up after anti-reflux surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, type of anti-reflux surgery, and year of anti-reflux surgery. Among 10,959 participants having undergone primary anti-reflux surgery, the 30-day re-intervention rate was 1.1%, and the rate of surgical re-intervention during the entire follow-up was 6.8%. Compared with hospitals not performing esophagectomy, hospitals in the highest volume group of esophagectomy showed no decreased risks of 30-day re-intervention (HR = 1.46, 95% CI 0.89-2.39) or surgical re-intervention (HR = 1.21, 95%CI 0.91-1.60) during follow-up. Similarly, the intermediate hospital volume categories of esophageal cancer surgery had no decreased risk of surgical re-interventions after anti-reflux surgery. This study provides no evidence for centralization of primary anti-reflux surgery to centers for esophageal cancer surgery.
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http://dx.doi.org/10.1093/dote/doaa075DOI Listing
January 2021

Practice patterns of diagnostic upper gastrointestinal endoscopy during the initial COVID-19 outbreak in England.

Lancet Gastroenterol Hepatol 2020 09 16;5(9):804-805. Epub 2020 Jul 16.

Department of Surgery and Cancer, Imperial College London, London W2 1NY, UK.

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http://dx.doi.org/10.1016/S2468-1253(20)30236-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365623PMC
September 2020

Is Local Endoscopic Resection a Viable Therapeutic Option for Early Clinical Stage T1a and T1b Esophageal Adenocarcinoma?: A Propensity-Matched Analysis.

Ann Surg 2020 Jun 11. Epub 2020 Jun 11.

Department of Surgery & Cancer, Imperial College London, London, UK.

Objective: The aim of this study was to evaluate the outcome of endoscopic resection (ER) versus esophagectomy in node-negative cT1a and cT1b esophageal adenocarcinoma.

Summary Of Background Data: The role of ER in the management of subsets of clinical T1N0 esophageal adenocarcinoma is controversial.

Methods: Data from the National Cancer Database (2010-2015) were used to identify patients with clinical T1aN0 (n = 2545) and T1bN0 (n = 1281) esophageal adenocarcinoma that received either ER (cT1a, n = 1581; cT1b, n = 335) or esophagectomy (cT1a, n = 964; cT1b, n = 946). Propensity score matching and Cox analyses were used to account for treatment selection bias.

Results: ER for cT1a and cT1b disease was performed more commonly over time. The rates of node-positive disease in patients with cT1a and cT1b esophageal adenocarcinoma were 4% and 15%, respectively. In the matched cohort for cT1a cancers, ER had similar survival to esophagectomy [hazard ratio (HR): 0.85, 95% confidence interval (CI): 0.70-1.04, P = 0.1]. The corresponding 5-year survival for ER and esophagectomy were 70% and 74% (P = 0.1), respectively. For cT1b cancers, there was no statistically significant difference in overall survival between the treatment groups (HR: 0.87, 95% CI: 0.66-1.14, P = 0.3). The corresponding 5-year survival for ER and esophagectomy were 53% versus 61% (P = 0.3), respectively.

Conclusions: This study demonstrates ER has comparable long-term outcomes for clinical T1aN0 and T1bN0 esophageal adenocarcinoma. However, 15% of patients with cT1b esophageal cancer were found to have positive nodal disease. Future research should seek to identify the subset of T1b cancers at high risk of nodal metastasis and thus would benefit from esophagectomy with lymphadenectomy.
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http://dx.doi.org/10.1097/SLA.0000000000004038DOI Listing
June 2020

The influence of the SARS-CoV-2 pandemic on esophagogastric cancer services: an international survey of esophagogastric surgeons.

Dis Esophagus 2020 Jun 5. Epub 2020 Jun 5.

Department of Upper Gastrointestinal Surgery, Queen Elizabeth Hospital, Birmingham, UK.

Background: Several guidelines to guide clinical practice among esophagogastric surgeons during the COVID-19 pandemic were produced. However, none provide reflection of current service provision. This international survey aimed to clarify the changes observed in esophageal and gastric cancer management and surgery during the COVID-19 pandemic.

Methods: An online survey covering key areas for esophagogastric cancer services, including staging investigations and oncological and surgical therapy before and during (at two separate time-points-24th March 2020 and 18th April 2020) the COVID-19 pandemic were developed.

Results: A total of 234 respondents from 225 centers and 49 countries spanning six continents completed the first round of the online survey, of which 79% (n = 184) completed round 2. There was variation in the availability of staging investigations ranging from 26.5% for endoscopic ultrasound to 62.8% for spiral computed tomography scan. Definitive chemoradiotherapy was offered in 14.8% (adenocarcinoma) and 47.0% (squamous cell carcinoma) of respondents and significantly increased by almost three-fold and two-fold, respectively, in both round 1 and 2. There were uncertainty and heterogeneity surrounding prioritization of patients undergoing cancer resections. Of the surgeons symptomatic with COVID-19, only 40.2% (33/82) had routine access to COVID-19 polymerase chain reaction testing for staff. Of those who had testing available (n = 33), only 12.1% (4/33) had tested positive.

Conclusions: These data highlight management challenges and several practice variations in caring for patients with esophagogastric cancers. Therefore, there is a need for clear consistent guidelines to be in place in the event of a further pandemic to ensure a standardized level of oncological care for patients with esophagogastric cancers.
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http://dx.doi.org/10.1093/dote/doaa054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314222PMC
June 2020

Protocol for LAsting Symptoms after Oesophageal Resectional Surgery (LASORS): multicentre validation cohort study.

BMJ Open 2020 06 3;10(6):e034897. Epub 2020 Jun 3.

Faculty of Medicine, Department of Surgery & Cancer, Imperial College, London, UK.

Introduction: Surgery is the primary curative treatment for oesophageal cancer, with considerable recent improvements in long-term survival. However, surgery has a long-lasting impact on patient's health-related quality of life (HRQOL). Through a multicentre European study, our research group was able to identify key symptoms that affect patient's HRQOL. These symptoms were combined to produce a tool to identify poor HRQOL following oesophagectomy (LAsting Symptoms after Oesophageal Resection (LASOR) tool). The objective of this multicentre study is to validate a six-symptom clinical tool to identify patients with poor HRQOL for use in everyday clinical practice.

Methods And Analysis: Included patients will: (1) be aged 18 years or older, (2) have undergone an oesophagectomy for cancer between 2015 and 2019, and (3) be at least 12 months after the completion of adjuvant oncological treatments. Patients will be given the previously created LASOR questionnaire. Each symptom from the LASOR questionnaire will be graded according to impact on quality of life and frequency of the symptom, with a composite score from 0 to 5. The previously developed LASOR symptom tool will be validated against HRQOL as measured by the European Organisation for Research and Treatment of Cancer QLQC30 and OG25.

Sample Size: With a predicted prevalence of poor HRQOL of 45%, based on the previously generated LASOR clinical symptom tool, to validate this tool with a sensitivity and specificity of 80%, respectively, a minimum of 640 patients will need to be recruited to the study.

Ethics And Dissemination: NHS Health Research Authority (North East-York Research Ethics Committee) approval was gained 8 November 2019 (REC reference 19/NE/0352). Multiple platforms will be used for the dissemination of the research data, including international clinical and patient group presentations and publication of research outputs in a high impact clinical journal.
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http://dx.doi.org/10.1136/bmjopen-2019-034897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7279661PMC
June 2020

Implementation of Minimally Invasive Esophagectomy From a Randomized Controlled Trial Setting to National Practice.

J Clin Oncol 2020 07 18;38(19):2130-2139. Epub 2020 May 18.

Department of Surgery, Amsterdam University Medical Centers, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.

Purpose: The aim of this study was to examine the external validity of the randomized TIME trial, when minimally invasive esophagectomy (MIE) was implemented nationally in the Netherlands, using data from the Dutch Upper GI Cancer Audit (DUCA) for transthoracic esophagectomy.

Methods: Original patient data from the TIME trial were extracted along with data from the DUCA dataset (2011-2017). Multivariate analysis, with adjustment for patient factors, tumor factors, and year of surgery, was performed for the effect of MIE versus open esophagectomy on clinical outcomes.

Results: One hundred fifteen patients from the TIME trial (59 MIE 56 open) and 4,605 patients from the DUCA dataset (2,652 MIE 1,953 open) were included. In the TIME trial, univariate analysis showed that MIE reduced pulmonary complications and length of hospital stay. On the contrary, in the DUCA dataset, MIE was associated with increased total and pulmonary complications and reoperations; however, benefits included increased proportion of R0 margin and lymph nodes harvested, and reduced 30-day mortality. Multivariate analysis from the TIME trial showed that MIE reduced pulmonary complications (odds ratio [OR], 0.19; 95% CI, 0.06 to 0.61). In the DUCA dataset, MIE was associated with increased total complications (OR, 1.36; 95% CI, 1.19 to 1.57), pulmonary complications (OR, 1.50; 95% CI, 1.29 to 1.74), reoperations (OR, 1.74; 95% CI, 1.42 to 2.14), and length of hospital stay. Multivariate analysis of the combined and MIE datasets showed that inclusion in the TIME trial was associated with a reduction in reoperations, Clavien-Dindo grade > 1 complications, and length of hospital stay.

Conclusion: When adopted nationally outside the TIME trial, MIE was associated with an increase in total and pulmonary complications and reoperation rate. This may reflect nonexpert surgeons outside of high-volume centers performing this minimally invasive technique in a nonstandardized fashion outside of a controlled environment.
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http://dx.doi.org/10.1200/JCO.19.02483DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7325364PMC
July 2020

Lasting Symptoms After Esophageal Resection (LASER): European Multicenter Cross-sectional Study.

Ann Surg 2020 Nov 17. Epub 2020 Nov 17.

Department of Upper GI Surgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

Objective: To identify the most prevalent symptoms and those with greatest impact upon health-related quality of life (HRQOL) among esophageal cancer survivors.

Background: Long-term symptom burden after esophagectomy, and associations with HRQOL, are poorly understood.

Patients And Methods: Between 2010 and 2016, patients from 20 European Centers who underwent esophageal cancer surgery, and were disease-free at least 1 year postoperatively were asked to complete LASER, EORTC-QLQ-C30, and QLQ-OG25 questionnaires. Specific symptom questionnaire items that were associated with poor HRQOL as identified by EORTC QLQ-C30 and QLQ-OG25 were identified by multivariable regression analysis and combined to form a tool.

Results: A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had symptoms associated with their esophagectomy. Ongoing weight loss was reported by 10.4% of patients, and only 13.8% returned to work with the same activities.Three LASER symptoms were correlated with poor HRQOL on multivariable analysis; pain on scars on chest (odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81 ± 0.02 and 0.82 ± 0.09 respectively.

Conclusion: Two-thirds of patients experience significant symptoms more than 1 year after surgery. The 3 key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased support.
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http://dx.doi.org/10.1097/SLA.0000000000003917DOI Listing
November 2020

The effect of time between procedures upon the proficiency gain period for minimally invasive esophagectomy.

Surg Endosc 2020 06 20;34(6):2703-2708. Epub 2020 Apr 20.

Division of Surgery, Department Surgery & Cancer, Imperial College London, 10th Floor QEQM Building, London, UK.

Background: Complex surgical procedures including minimally invasive esophagectomy (MIE) are commonly associated with a period of proficiency gain. We aim to study the effect of reduced procedural interval upon the number of cases required to gain proficiency and adverse patient outcomes during this period from MIE.

Methods: All adult patients undergoing MIE for esophageal cancer in England from 2002 to 2012 were identified from Hospital Episode Statistics database. Outcomes evaluated included conversion rate from MIE to open esophagectomy, 30-day re-intervention, 30-day and 90-day mortality. Regression models investigated relationships between procedural interval and the number of cases and clinical outcomes during proficiency gain period.

Results: The MIE dataset comprised of 1696 patents in total, with procedures carried out by 148 surgeons. Thresholds for procedural interval extracted from change-point modeling were found to be 60 days for conversion, 80 days for 30-day re-intervention, 80 days for 30-day mortality and 110 days for 90-day mortality. Procedural interval of MIEs did not influence the number of cases required for proficiency gain. However, reduced MIE procedural interval was associated with significant reductions in conversions (0.16 vs. 0.07; P < 0.001), re-interventions (0.15 vs. 0.09; P < 0.01), 30-day (0.12 vs. 0.05; P < 0.01) and 90-day (0.14 vs. 0.06; P < 0.01) mortality during the period of proficiency gain.

Conclusions: This national study has demonstrated that the introduction of MIE is associated with a period of proficiency gain and adverse patient outcomes. The absolute effect of this period of proficiency gain upon patient morbidity and mortality may be reduced by reduced procedural interval of MIE practice within specialized esophageal cancer centers.
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http://dx.doi.org/10.1007/s00464-019-06692-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7214481PMC
June 2020

Assessment of chest wall movement following thoracotomy: a systematic review.

J Thorac Dis 2020 Mar;12(3):1031-1040

Department of Surgery and Cancer, Imperial College London, London, UK.

Thoracotomy is a major cause of respiratory impairment, increasing the risk of postoperative pulmonary complications (PPC). Systems assessing ribcage kinematics may detect changes in chest expansion following thoracotomy and may thus aid in the development of patient-tailored chest physiotherapy. Hence, we aimed to identify studies assessing changes in chest wall movement following thoracotomy using objective measures. The Cochrane library, MEDLINE, EMBASE, Scopus and Web of Science databases were searched to find relevant articles providing an objective assessment of chest wall movement following thoracotomy. Methodological quality of included studies concerning chest wall movement following thoracotomy was assessed by use of QUADAS-2 tool. A total of 12 articles were included for the assessment of chest wall changes following thoracotomy using objective measures. Four studies measured changes in the cross-sectional area of the ribcage and abdomen using the respiratory inductive plethysmography (RIP), 1 study computed the chest wall compliance by monitoring the intra-pleural pressure, 3 studies measured changes in chest circumference with a simple tape measure and 4 articles performed a compartmental analysis of the chest wall volume by means of an optoelectronic plethysmography (OEP). There was no delay in the collection of data of the index test and reference standard, resulting in a low risk of bias for the flow and timing domain. Across all studies, participants underwent the same reference standard, resulting in a low risk of verification bias. Several objective measures were able to detect changes in chest wall displacement following thoracotomy and differed in the practical use and invasive nature. OEP allows a compartmental analysis of the chest wall volume. Hence, this system allows to assess chest wall movement changes following thoracotomy and the impact of different types of surgical approach. Furthermore, it could aid in the development of tailored physiotherapy.
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http://dx.doi.org/10.21037/jtd.2019.12.93DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139064PMC
March 2020

Learning curves and the influence of procedural volume for the treatment of dysplastic Barrett's esophagus.

Gastrointest Endosc 2020 09 5;92(3):543-550.e1. Epub 2020 Mar 5.

Research Department of Targeted Intervention, Division of Surgery and Interventional Science, University College London, London, United Kingdom; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom.

Background And Aims: Endoscopic resections and radiofrequency ablation (RFA) are the established treatments for Barrett's-associated dysplasia and early esophageal neoplasia. The UK RFA Registry collects patient outcomes from 24 centers treating patients in the United Kingdom and Ireland. Learning curves for treatment of Barrett's dysplasia and the impact of center caseload on patient outcomes is still unknown.

Methods: We examined outcomes of 678 patients treated with RFA in the UK Registry using risk-adjusted cumulative sum control chart (RA-CUSUM) analysis to identify change points in complete resolution of intestinal metaplasia (CR-IM) and complete resolution of dysplasia (CR-D) outcomes. We compared outcomes between those treated at high-volume (>100 enrolled patients), medium-volume (51-100), and low-volume (<50) centers.

Results: There was no association between center volume and CR-IM and CR-D rates, but recurrence rates were lower in high-volume versus low-volume centers (log rank P = .001). There was a significant change point for outcomes at 12 cases for CR-D (reduction from 24.5% to 10.4%; P < .001) and at 18 cases for CR-IM (30.7% to 18.6%; P < .001) from RA-CUSUM curve analysis.

Conclusion: Our data suggest that 18 supervised cases of endoscopic ablation may be required before competency in endoscopic treatment of Barrett's dysplasia can be achieved. The difference in outcomes between a high-volume and low-volume center does not support further centralization of services to only high-volume centers.
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http://dx.doi.org/10.1016/j.gie.2020.02.041DOI Listing
September 2020
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