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Introduction Enhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure. Methods A team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system. Results Thirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure. Conclusions The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.

Background The objectives of this national study were to examine the short-term safety and long-term survival benefit associated with surgical resection of hepatic metastases from gastric cancer. Methods Patients from the Hospital Episode Statistics database were classified by disease and treatment approach. Gastric cancer: 1. Without liver metastases treated by gastrectomy (GG). 2. With liver metastases treated by gastrectomy and hepatectomy (GGH). 3. With liver metastases treated by gastrectomy without hepatectomy (GGNH). 4. With liver metastases treated with no surgery (GNS). Propensity score matching and multivariable analyses were used to compensate for differences in some baseline characteristics. Results During the study period, 87,482 were patients diagnosed with gastric cancer, of whom 13,841 underwent partial or total gastrectomy. Of those who underwent gastrectomy, 336 had a diagnosis of liver metastases and 78 of these had a hepatectomy. Propensity-matched analysis showed no significant differences in 30- or 90-day mortality between the GGH and GG groups. The GGH group had significantly improved 1-year mortality (35.9 % vs. 50.0 %, p  = 0.049) and 5-year mortality (61.5 % vs. 75.7 %, p  = 0.031) compared to the GGNH group, and compared to the GNS group, the GCH group had 1-year mortality (35.9 % vs. 84.6 %, p  < 0.001) and 5-year mortality (61.5 % vs. 90.8 %, p  < 0.001). Conclusions This study showed that hepatectomy for synchronous gastric cancer hepatic metastases may carry survival benefits in selected patients. The data presented should not be a rationale to change current clinical practice but rather a stimulus to prospectively study the role of surgery in a selected group of patients who are currently treated with palliative chemotherapy.

With the military operations of Israeli occupation forces focused to the north and on Gaza City, 70% of Gaza's population of 2·2 million people has been forced southwards, yet civilians fleeing (or already displaced) to the south have not been spared.3 What is most concerning is the disregard for international humanitarian law, under which hospitals and medical personnel are specifically protected. Over 51% of Gaza's education facilities have been bombed, including facilities run by UNRWA, where thousands of displaced people are seeking shelter.3 The deliberate targeting of hospitals, water tanks, oxygen production facilities, and solar panels and generators, while minimising essential medical supplies, food, water, and fuel from entering Gaza, has led to a total collapse of the health-care system in Gaza.4 This collapse has meant amputations have been performed without anaesthesia, burns debrided without pain relief, and surgery taking place under light from mobile phones. There is intense fighting around the Al-Shifa and Al-Quds hospitals, and Israeli forces have raided Al-Shifa Hospital and are interrogating patients and medical staff.5 Little or no access to power and oxygen is a potential death sentence for ventilated patients and premature babies in incubators, and in Al-Shifa Hospital, 32 patients (including six premature babies) have already died.4 As a medical community, we know our first responsibility is to save lives, a pledge we work to uphold wherever we are.

Horton also seeks to condemn an “asymmetry of outrage”.1 We echo this sentiment but have drawn different conclusions of where and how this asymmetry has developed, with reference to persistent anti-Palestinian bias in reporting across influential media outlets, both in the past month,3 and extending across several decades.4 Of even greater concern are Horton's unsubstantiated claims that medical clinics in Gaza are “adorned with pictures of [Saddam Hussein and Osama bin Laden]”.1 This bizarre and dangerously timed statement risks encouraging people who seek to cause violence and attack essential health services. BK is a member of the Oxford Teaching Group; has travelled to Gaza to support medical education and training; and financially supports Medical Aid for Palestinians' medical and humanitarian work. NM is the Chairman of the board of trustees for the International Medical Education Trust (IMET) and receives contributions from IMET for travel to Gaza with the Oxford Teaching Group, and receives support from Medical Aid for Palestinians for travel to Gaza to conduct humanitarian work.

IntroductionThe risk of dysplasia and cancer increases with age in Barrett’s oesophagus. Advanced endoscopic therapy such as EMR and RFA is indicated in dysplasia and intramucosal cancer, but associated with higher risks in older patients. Little guidance is available as to when to stop endoscopic therapy and follow up. Here we summarise the outcomes of endoscopic therapy in the elderly (>80 years) in a tertiary centre.MethodsAll patients aged over 80 who underwent endoscopic therapy for Barrett’s since 2008 were selected. Their Electronic Patient Record (EPR) was searched to establish details and outcomes.ResultsSince 2008, 56 patients over 80 with Barrett’s underwent advanced endoscopic therapy after discussion at UGI MDT. Age range was 80 to 90 years. Only 14% of patients were female. Median Barrett’s length was C2M5. The majority of patients at the time of referral had high-grade dysplasia (57%). 13% had low grade dysplasia, 27% intramucosal cancer and 4% submucosal cancer. Histology at the time of first therapy showed that 8/56 (14%) had more invasive disease than expected and 8/56 (14%) had less invasive disease.75% underwent EMR first, 7% underwent RFA first and 18% had APC only. 18% were on anticoagulation with warfarin or DOAC, 4% on clopidogrel. There was no haemorrhage or perforation following therapy.59% achieved complete resolution of intestinal metaplasia (CR-IM) and 71% achieved complete resolution of dysplasia (CR-D) (table 1). of the 4 patients with submucosal cancer (2 identified pre-therapy and 2 identified post-therapy), 2 patients achieved complete resolution of dysplasia. 17 of the octogenarians died during the 14 year follow-up period with a median survival of 3 years after start of treatment. Only one died from oesophageal cancer and they presented with cancer at the time of first therapy.ConclusionsElderly patients were able to tolerate advanced endotherapy for Barrett’s well, with good resolution of metaplasia and/or dysplasia, similar to the UK Halo registry results in patients with a mean age of 67 years. In patients over 80 with advanced Barrett’s dysplasia or early cancer, in whom surgery is usually not suitable, advanced endotherapy should be considered in the context of their fitness and life expectancy.Abstract P141 Table 1Outcomes post therapy Total patients(n=56) Patients alive with continued follow-up(n=33) CR-IM 33 (59%) 27 (82%) CR-D 40 (71%) 29 (88%) Ongoing LGD 5 (9%) 2 (6%) Ongoing HGD 5 (9%) 2 (6%) Submucosal cancer 6 (11%) 1 (3%) Patient declined further OGD 2 (4%) - Endotherapy stopped due to clinical deterioration 4 (7%) - Lost to FU 2 (4%) - Died during FU period 17 (30%) -

BackgroundUpper gastrointestinal cancers are aggressive malignancies with poor prognosis, even following multimodality therapy. As such, they require timely and accurate diagnostic and surveillance strategies; however, such radiological workflows necessitate considerable expertise and resource to maintain. In order to lessen the workload upon already stretched health systems, there has been increasing focus on the development and use of artificial intelligence (AI)-centred diagnostic systems. This systematic review summarizes the clinical applicability and diagnostic performance of AI-centred systems in the diagnosis and surveillance of esophagogastric cancers.MethodsA systematic review was performed using the MEDLINE, EMBASE, Cochrane Review, and Scopus databases. Articles on the use of AI and radiomics for the diagnosis and surveillance of patients with esophageal cancer were evaluated, and quality assessment of studies was performed using the QUADAS-2 tool. A meta-analysis was performed to assess the diagnostic accuracy of sequencing methodologies.ResultsThirty-six studies that described the use of AI were included in the qualitative synthesis and six studies involving 1352 patients were included in the quantitative analysis. Of these six studies, four studies assessed the utility of AI in gastric cancer diagnosis, one study assessed its utility for diagnosing esophageal cancer, and one study assessed its utility for surveillance. The pooled sensitivity and specificity were 73.4% (64.6–80.7) and 89.7% (82.7–94.1), respectively.ConclusionsAI systems have shown promise in diagnosing and monitoring esophageal and gastric cancer, particularly when combined with existing diagnostic methods. Further work is needed to further develop systems of greater accuracy and greater consideration of the clinical workflows that they aim to integrate within.

Our paper highlights the use of artificial intelligence (AI) in oesophageal and gastric malignancies with acceptable levels of accuracy for both diagnostic and surveillance purposes. Here, we comment on the past, present and future work necessary for incorporating AI into the clinical framework and practice.

Background Motor neurone disease (MND) is a devastating illness which leads to muscle weakness and death, usually within 2-3 years of symptom onset. Respiratory insufficiency is a common cause of morbidity, particularly in later stages of MND and respiratory complications are the leading cause of mortality in MND patients. Non Invasive Ventilation (NIV) is the current standard therapy to manage respiratory insufficiency. Some MND patients however do not tolerate NIV due to a number of issues including mask interface problems and claustrophobia. In those that do tolerate NIV, eventually respiratory muscle weakness will progress to a point at which intermittent/overnight NIV is ineffective. The NeuRx RA/4 Diaphragm Pacing System was originally developed for patients with respiratory insufficiency and diaphragm paralysis secondary to stable high spinal cord injuries. The DiPALS study will assess the effect of diaphragm pacing (DP) when used to treat patients with MND and respiratory insufficiency. Method/Design 108 patients will be recruited to the study at 5 sites in the UK. Patients will be randomised to either receive NIV (current standard care) or receive DP in addition to NIV. Study participants will be required to complete outcome measures at 5 follow up time points (2, 3, 6, 9 and 12 months) plus an additional surgery and 1 week post operative visit for those in the DP group. 12 patients (and their carers) from the DP group will also be asked to complete 2 qualitative interviews. Discussion The primary objective of this trial will be to evaluate the effect of Diaphragm Pacing (DP) on survival over the study duration in patients with MND with respiratory muscle weakness. The project is funded by the National Institute for Health Research, Health Technology Assessment (HTA) Programme (project number 09/55/33) and the Motor Neurone Disease Association and the Henry Smith Charity. Trial Registration: Current controlled trials ISRCTN53817913. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS or the Department of Health.

AbstractObjectiveTo systematically document the patterns of war related injuries in Gaza, Palestine.DesignSurvey study of international healthcare workers, August 2024 to February 2025.SettingGaza, Palestine.Participants78 international healthcare workers deployed to Gaza.Main outcome measuresThe main outcome was the type of injuries observed by international healthcare workers during the conflict in Gaza. A Delphi informed survey was distributed through non-governmental organisation rosters and secure WhatsApp and email groups. Respondents completed the survey using contemporaneous logbooks and shift records.ResultsThe survey collected data on 12 anatomical regions, mechanisms of trauma, and general medical conditions. 78 healthcare workers reported 23 726 trauma related injuries and 6960 injuries related to weapons. The most common traumatic injuries were burns (n=4348, 18.3%), lower limb injuries (n=4258, 17.9%), and upper limb injuries (n=3534, 14.9%). Explosive injuries accounted for most of the weapon related trauma (n=4635, 66.6%), predominantly affecting the head (n=1289, 27.8%), whereas firearm injuries disproportionately affected the lower limbs (n=526, 22.6%). Healthcare workers reported 4188 people with chronic disease across 11 domains requiring long term treatment.ConclusionHealthcare workers deployed to Gaza reported an injury phenotype defined by extensive polytrauma (≥2 anatomical regions), complex blast injuries from high yield explosives, firearm related injuries to upper and lower limbs, and severe disruption to primary care and the treatment of chronic diseases. The results provide actionable insights to tailor humanitarian response and highlight the urgent need for structured, resilient clinical surveillance systems.Editor’s noteThis paper is based on research from an active war zone, where conventional research methods may be impossible to apply.