bluuebunny/crossref_metadata_2025 huggingface dataset:
274. ROBOTIC REVISIONAL HIATAL HERNIA REPAIR (R-RHR): DOES IT MAKE SENSE?
Authors: Vicente Christian Jose Herrero , Font Arantxa Clavell , Martín Ms Marta Viciano , Savall Elisenda Garsot
Published: September 2024

Background

The gastroesophageal reflux disease (GERD) is increasing among our population and Nissen Fundoplication still remains as the most widely performed technique. The robotic approach to the hiatal hernia repair has been proven to be safe and feasible.

Precision and comfort seem to be some reasons that it makes, at least, comparable to the laparoscopic approach.

Revisional hiatal hernia is a challenging situation to the operator due the adhesions and fibrosis of the tissues so our concern is that the best technology available is needed.

Methods

From June 2019 to November 2023 our division performed 14 cases of Robotic Revisional Hiatal Hernia Repair (R-RHR). Demographic items such as Gender, Age, Body Mass Index (BMI), Previous surgery, Time from first surgery and Postoperative outcomes as Operation Time, Length of stay (LOS), Mesh use, Complications and Readmissions were recorded.

Results

10 women and 4 men were recruited. In all cases the DaVinci robotic platform X and Xi (Intuitive) was used. Mean age resulted in 63.5 years old (sd 12.25). Mean BMI was 26.97 (sd 3.52). In 71.4% cases the Previous HH Surgery was Nissen Fundoplication. 49.3 months was the mean time from the first surgery to the revisional procedure.

163.5 (sd 83.7) minutes was the mean operation time. Mean Lenght Of Stay resulted in 3.4 days (sd 1.4). There were no conversions to the laparoscopic approach. In 5 patients (35.8%) a mesh was placed.

Pleural effusion was the only postoperative complication reported (1/14) and it was managed non-operatively. No other complications were recorded and mortality rate was 0.

Conclusions

To the authors knowledge, this is Spain’s largest Robotic - Revisional Hiatal Hernia Repair (R- RHR) series. The results lead us to conclude that the robotic approach, even the complexity of the surgery, is safe and feasible in trained teams with similar outcomes from the primary surgery that are published.
276. AI NAVIGATION SURGERY FOR ESOPHAGEAL CANCER
Authors: Takeuchi Masashi , Kawakubo Hirofumi , Furube Tasuku , Nakao Atsushi , Hisaoka Kazuhiko , Matsuda Satoru , Kitagawa Yuko
Published: September 2024

With recent technological innovations, artificial intelligence (AI) has begun to be used not only in endoscopic diagnosis and pathology diagnosis but also in the field of surgery. AI enables objective and consistent recognition and evaluation, making it suitable for surgical assistance in surgical operations as well as for the evaluation of surgical techniques and learning curves. First, an AI-assisted surgical procedure recognition system for robotic esophagectomy was developed. By focusing on surgical procedures, the system automatically recognizes surgical procedures with 84% accuracy using AI. In particular, more than 90% of accuracy was obtained in the phase for Left RLN lymph node dissection and Post-dissection to completion of surgery. In addition, as intraoperative navigation, a system for automatic recognition of critical organs such as the recurrent laryngeal nerve, trachea, and subclavian artery was developed, and its recognition accuracy is gradually improving, enabling organ recognition in real time. Currently, with data from more than 100 cases, the system is able to predict Intersection over Union (IoU) with an accuracy of 0.3-0.4.

Similar developments are underway in other areas, such as automatic recognition of the surgical process in robotic distal gastrectomy, and a surgical difficulty prediction system is being built using this technology. This system is expected to make it possible to automatically determine the degree of difficulty of surgery during the operation, leading to the decision to change the surgical team during the operation and the prediction of the operation completion time. These technologies can be useful not only for intraoperative navigation, but also surgical education and postoperative care. Using them, young surgeons have the opportunity to dive into authentic scenarios and acquire practical experience safely, bypassing the dangers inherent in real-life surgeries. Through the use of AI-powered interactive simulations, they can deeply grasp surgical methods, establishing the groundwork of crucial practical abilities needed for performing successful operations.

In the future, we intend to verify the external validity of these systems using data from multiple facilities, and further work on the development of a surgical support system that transcends fields, with the aim of obtaining regulatory approval as a medical device. In addition to the potential clinical applications of the systems under development, we would like to discuss the current status and future of AI-based surgical support systems in the surgical field.
277. FLUORESCENCE-GUIDED ANASTOMOSIS DURING SINGLE-PORT VATS IVOR LEWIS ESOPHAGECTOMY
Authors: Rajan Shiv , Kumar Vijay
Published: September 2024

Background

Minimally Invasive Esophagectomy (MIE) is the standard approach for esophageal cancer. The thoracic part is performed using multiple ports during video or robotic approach with CO2 inflation of 8-10 mmHg. There are recent publications of successful lung & thymic surgeries utilizing single port. This video describes our technique for performing ICG-guided intrathoracic anastomosis during single-port Ivor Lewis (IL) esophagectomy.

Methods

The surgery was performed on a 58-year-old male patient with Siwert type 1 adenocarcinoma (cT3, N0 M0). The patient underwent 4 cycles of neoadjuvant FLOT chemotherapy following a Multidisciplinary tumour board decision. Single-port Ivor Lewis (IL) esophagectomy was planned after three weeks of last cycle.

Results

Following the laparoscopic abdominal phase with extracorporeal gastric conduit formation and feeding jejunostomy, the patient was placed in a semiprone position. The thoracic phase was performed through single-port (4 cm in the 6th intercostal) VATS without CO2. The intrathoracic anastomosis was performed with a linear stapler in side-to-side manner under 1.5 ml indocyanine green (ICG) guidance. Thoracic phase time was 65 minutes. There were no intraoperative and postoperative complications. The pain score was three without opioid use. The patient was allowed orally on day five and discharged home on the eighth postoperative day.

Conclusion

Single port VATS IL MIE is a quick and safe surgical technique. Optics, instrumentations and surgical stapler maneuvering through a single port require a learning curve but are not difficult in our experience. A larger cohort and long-term follow-up are necessary for wider utilization of this approach.

https://wetransfer.com/downloads/21555d68e61e7f962f2c33ed061b72dc20240319163828/b0b0feeea6f7a7ba47a04bb26ac96c2220240319163854/83de2d
280. MANOMETRIC FINDINGS IN PATIENTS WITH GIANT HIATAL HERNIA: OESOPHAGEAL PHYSIOLOGY APPEARS TO IMPROVE WITH SURGERY
Authors: Khoma Oleksandr , Raichurkar Pratik , Falk Gregory
Published: September 2024

Background

High resolution manometry (HRM) is a gold standard test of oesophageal physiology. The use of HRM in patients with giant hiatus hernia (GHH) is limited by historical technical challenges as well as unclear clinical implications of the findings. The aim of this study is to demonstrate feasibility of HRM in patients with GHH and study effect of surgery on oesophageal physiology of patients undergoing GHH repair.

Methods

Data was extracted from a prospectively populated database of patients with giant (>30% stomach above diaphragm) hiatus hernias. All patients that underwent HRM before and after surgery were included. Manometric findings before and after surgery were analysed and compared. Patient symptoms were correlated with manometric findings.

Results

Inclusion criteria were met by 30 patients: 83% female, average age 74 (range 51-86), 93% had type III hernia containing on average 55% of stomach. All operations but one were performed laparoscopically. Pre-operatively average LOS length was 1.89cm which improved significantly to 2.19cm after surgery (p<0.05). Nine patients had ineffective oesophageal motility on index study which normalised post operatively in 4 patients. Lower oesophageal sphincter integrated relaxation pressure (IRP) increased post-operatively from 9.07mmHg to 11.52mmHg (p<0.05). Distal contractility improved post-operatively, however this was not significant. Most common presenting symptoms were dyspnoea, anaemia, retrosternal pain, and dysphagia. There was no association between dysphagia and manometric findings before or after surgery.

Conclusion

This study provides an insight into HRM findings in patients with GHH before and after surgery. Majority of the physiological parameters improved with surgery. There was no correlation of symptom of dysphagia with manometric findings.
281. PROTEOMIC, TRANSCRIPTOMIC AND GENOMIC ANALYSIS OF ESOPHAGEAL ADENOCARCINOMA UNCOVERS CANDIDATE THERAPEUTIC TARGETS AND CANCER-SELECTIVE POST-TRANSCRIPTIONAL REGULATION
Authors: O'Neill Rob , Mayordomo Marcos , Mitulovic Goran , Al Shboul Sofian , Bedran Georges , Faktor Jakub , Hernychova Lenka , Uhrik Lukas , Gomez-Herranz Maria , Kocikowski Mikolaj , Save Vicki , Vojtesek Borivoj , Arends Mark , OCCAMS The , Hupp Ted , Alfaro Javier
Published: September 2024

Background

Addressing the poor prognosis associated with esophageal adenocarcinoma (EAC) has been hindered by the absence of biomarkers for early disease detection and therapeutic targets. Despite extensive research on the somatic mutations associated with EAC, the impact of genomic aberrations on protein expression and cancer phenotype remains unclear.

Methods

We conducted a quantitative proteomic analysis using tumour tissue and patient-matched adjacent normal esophageal and gastric tissues from 23 patients undergoing resection for EAC. We further examined the relationship between transcript and protein levels using patient-matched whole transcriptome RNA sequencing and proteomic data from 7 patients and integrated these findings with data from a cohort of 264 EAC patients with RNA sequencing and 454 patients with whole-genome sequencing, as well as external published datasets.

Results

We quantified protein expression from 5897 genes in EAC and normal tissues. Several potential biomarkers showing selective expression in EAC, such as the transmembrane protein GPA33, were identified. We validated the EAC-specific expression of GPA33 in an external cohort of 115 patients, suggesting its utility as a diagnostic and therapeutic target. Additionally, integrated analysis of protein and RNA expression in EAC and normal tissues revealed genes with discordant protein and RNA levels, indicating post-transcriptional regulation of protein expression. These outlier genes, including SLC25A30, TAOK2, and AGMAT, exhibited rare somatic mutations, suggesting post-transcriptional mechanisms driving this EAC-specific phenotype. AGMAT, as an example, was found to be overexpressed at the protein level in EAC compared to adjacent normal tissues, with a proposed EAC-selective, post-transcriptional mechanism regulating protein abundance.

Conclusion

Through quantitative proteomic analysis, we identified GPA33 as a candidate EAC biomarker. Integrated analysis of the proteome, transcriptome, and genome in EAC uncovered genes with tumor-selective post-transcriptional regulation of protein expression, offering potential exploitable vulnerabilities for therapeutic intervention.
294. LEARNING CURVE OF MINIMALLY INVASIVE ESOPHAGECTOMY: OUR SERIES, SYSTEMATIC REVIEW OF THE LITERATURE AND META-ANALYSIS
Authors: Riccio Federica , Pierobon Elisa Sefora , Bellaio Luca , Scarton Alessia Scarton , De Pasqual Anna Laura , Zuin Irene Sole , Pittacolo Matteo , Moletta Lucia , Zanchettin Gianpietro , Capovilla Giovanni , Salvador Renato , Provenzano Luca , Valmasoni Michele
Published: September 2024

Background

Minimally invasive esophagectomy has demonstrated non-inferiority in terms of surgical and oncologic outcomes compared with open esophagectomy, with better short-term outcomes. The learning curve of this procedure is protracted before a plateau of ideal results is reached. The purpose of this study is to evaluate the safety and efficacy of implementing a totally minimally invasive esophagectomy program for cancer in a high-volume center and the impact of the learning curve on perioperative and oncologic outcomes.

Methods

This is a retrospective non-randomized control study. The study includes 199 patients who underwent surgery from June 2018 to October 2022. Patients undergoing MIE were assigned to the “MIE group” (n=61), while those undergoing Open Esophagectomy to the “OE group” (n=138). By comparing the perioperative and oncological outcomes between the two groups, we assessed the safety and efficacy of the MIE. Subsequently, the MIE group was divided into two subgroups: Early Experience (“EE”) and Late Experience (“LE”) group. By comparing the perioperative surgical outcomes between these two groups we evaluated the presence and the impact of a learning curve.

Results

Although longer surgical duration (p<0.001), MIE did not compromise surgical radicality (same rate of R0, p=0.345 and higher number of lymph node yields p<0.001). We observed a learning curve effect on postoperative outcomes, with decreasing complication rates (61% vs. 36.7%, p=0.054), and shorter ICU stay (1.6 ± 2.4 vs. 0.6 ± 1.5, p=0.049) and faster recovery in the LE group (19.6 ± 19.8 vs. 12.2 ± 5.9, p=0.055). Analysis of CUSUM plots reveals a decrease in total ICU and recovery starting with patient number 25. A meta-analysis confirms a trend towards lower anastomotic leak rates as the learning curve progresses.

Conclusion

The findings of this study support the safety and efficacy of implementing a totally MIE program for cancer in a high-volume center. The outcomes are not impaired by the learning curve effect and meet current standards. Comparing the outcomes of the early experience with those of the late experience, we discovered improving trends in postoperative complication and recovery rates. In our high-volume center's experience, improving these outcomes has required 25 to 30 cases.
299. SURGICAL STRATEGY FOR THE TREATMENT OF AORTOESOPHAGEAL FISTULA
Authors: Adachi Yukari , Goto Hironobu , Koterazawa Yasufumi , Sawada Ruichiro , Harada Hitoshi , Urakawa Naoki , Hasegawa Hiroshi , Kanaji Shingo , Yamashita Kimihiro , Matsuda Takeru , Oshikiri Taro , Kakeji Yoshihiro
Published: September 2024

Background

The number of thoracic endovascular aortic repair (TEVER) and artificial vessel replacement for thoracic aortic aneurysms is increasing. Aortoesophageal fistula (AEF) is one of the problems with long-term outcomes, and management of AEF needs immediate control of hemorrhage and infection. Bleeding control can be performed with artificial vessel replacement, but postoperative graft infection is inevitable in AEF. For infection control, removal of the diseased esophagus should be performed. In this study, we will clarify the surgical outcomes of esophagectomy for AEF.

Material and Methods

We evaluated 22 patients who underwent artificial vascular replacement and esophagectomy for AEF from 2007 to 2023 at Kobe University Hospital, retrospectively. The surgical approaches for esophagectomy were left open thoracotomy, median sternotomy or minimally invasive esophagectomy (MIE).

Results

In this study, all patients underwent simultaneous artificial vascular replacement and esophagectomy. According to the surgical approaches, 15 patients underwent left open thoracotomy, 6 patients underwent median sternotomy and 1 patient underwent left open thoracotomy + MIE. The male to female ratio was 15:7, and the median age was 72 (38-85) years. According to the type of reconstruction, 11 patients underwent pediculated jejunum reconstruction and 1 patient underwent ileocolic reconstruction. 12 patients (54.5%) were able to undergo reconstruction, 10 patients (45.5%) were not undergo reconstruction. 4 patients (18.2%) of died in the hospital.

Conclusion

Esophagectomy simultaneous with artificial vascular replacement could be a feasible treatment for AEF.
304. OUTCOMES OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY BEFORE AND AFTER IMPLEMENTATION OF ENDOSCOPIC VACUUM THERAPY IN A TERTIARY REFERRAL CENTER
Authors: Pattynama Lisanne , Pouw Roos , Gisbertz Suzanne , Daams Freek , Bergman Jacques , van Berge Henegouwen Mark , Eshuis Wietse
Published: September 2024

Background

Anastomotic leakage (AL) after esophagectomy is associated with severe morbidity and a high mortality. Endoscopic vacuum therapy (EVT) has recently been established as a promising endoscopic treatment option for AL, with success rates of higher than 80%. The aim of this study was to compare outcomes of AL after esophagectomy, before and after implementation of EVT.

Methods

For this cohort study, consecutive patients with AL after transthoracic esophagectomy with gastric conduit reconstruction with cervical or thoracic anastomosis from two different time periods (before the implementation phase of EVT [2013–2017, pre-EVT], and after [2020–2023, EVT]) were included. Data was collected from a prospectively maintained database. Outcome measures included initial treatment modality, re-operation, intensive care unit (ICU) admission, hospital stay, and complications, classified according to Clavien-Dindo.

Results

100 patients with AL were included, with 50 patients in the pre-EVT group and 50 patients in the EVT group. In the pre-EVT group, initial treatment of AL consisted of conservative therapy (n=20, 40%), endoscopic stenting (n=13, 26%), endoscopic drainage (n=6, 12%) or surgery (n=11, 22%). In the EVT group, initial treatment of AL consisted of conservative therapy (n=5, 10%), surgery (n=2, 4%) or EVT (n=43, 86%). Other baseline characteristics showed no differences. The EVT group had a significantly lower initial surgical treatment rate compared to the pre-EVT group (respectively 2 [4%] vs. 11 [22%], p=0.03). Furthermore, the EVT group had a significantly lower ICU admission rate than the pre-EVT group (respectively 16 [32%] vs. 35 [70%], p<0.001). Clavien-Dindo classification differed significantly between the two groups (p = 0.033), with less Grade IIIa and more Grade IVa in the pre-EVT group, compared to the EVT group. Reoperations occurred in 17 patients (34%) in the pre-EVT group and 9 (18%) in the EVT group, which was not statistically significant. No statistically significant difference was observed in length of hospital stay.

Conclusion

The implementation of EVT as treatment option for AL after esophagectomy in this tertiary referral center may have led to a lower ICU admission rate. Taking this into consideration, EVT may be associated with long term health benefits for the patient and reduced healthcare costs.
312. THE VALUE OF DETECTING THE GASTRIC TUBE PRESSURE AFTER MINIMALLY INVASIVE ESOPHAGECTOMY: A PROSPECTIVE, UNCONTROLLED EXPLORATORY STUDY
Authors: Wei Xiufeng , Chen Xiankai , Xu Lei , Kang Xiaozheng , Qi Shu , Luo Peng , Wang Ziyi , Qin Jianjun , Wang Zhen , Zhang Ruixiang , Li Yin
Published: September 2024

Background

With the increasing popularity of minimally invasive esophagectomy(MIE), the incidence of postoperative gastric conduit dilation has also shown an increasing trend. The main purpose of this study is to explore the relationship between postoperative tubular gastric dilation and internal gastric tube pressure.

Methods

In a prospective cohort study from November 2023 to February 2024, 54 patients undergoing MIE were enrolled. Based on postoperative chest X-ray, patients were categorized into acute gastric conduit dilation (Acd) and non-acute dilation (Non-Acd) groups. Gastric tube pressure, including static pressures(SP), peak pressures(PP), and median pressures (MP), was measured postoperatively. Acute gastric dilation was defined as the gastric tube occupying over 40% of the hemithorax on X-ray. We compared the incidence of postoperative complications, surgery-related mortality, readmission rates, and hospital stay durations.

Results

Of the patients, 19 experienced acute gastric dilation, while 35 did not. The Acd group showed significantly higher SP, PP, and MP (p<0.01). Univariate analysis identified SP, PP, MP, and upper mediastinal pleura reconstruction as risk factors for acute gastric dilation, with SP being a key predictor in multivariate analysis. Patients in the Acd group had longer hospital stays (median 13 days vs. 8 days for Non-Acd). No significant differences were noted in postoperative complications, surgery-related mortality or readmission rates.

Conclusion

Acute gastric conduit dilation post-MIE is linked to increased gastric tube pressure. Monitoring this pressure is both safe and feasible, offering insights into reducing acute gastric dilation through surgical improvements such as mediastinal pleura reconstruction.
314. TRANSORAL ANTEGRADE T-TUBE INSERTION FOR MANAGEMENT OF OESOPHAGEAL LEAKS FOLLOWING MINIMAL INVASIVE OESOPHAGECTOMY
Authors: Fong Kang Ler , Lyn Tiffany , Lee Zhen Jin , Tan Nan Guang , Lim Chin Hong , Lim Eugene Kee Wee , Eng Alvin Kim Hock , Chan Weng Hoong , Ong Hock Soo , Wong Wai Keong , Tan Jeremy Tian Hui
Published: September 2024

Introduction

Oesophageal leaks following minimal invasive oesophagectomy (MIE) present significant challenges to upper GI surgeons, with reported rates ranging from 11% to 21%. Management strategies include: conservative, endoscopic, and surgical interventions. These vary based on patient clinical status and institution. Here, we propose a hybrid approach involving thoracoscopic washout coupled with antegrade T-tube insertion via gastroscopy for managing these complex leaks.

Methods

We describe the case of a 66-year-old male who underwent MIE via the McKeown approach for Siewert 1 Gastro-oesophageal adenocarcinoma. His neoadjuvant chemotherapy had been interrupted by a complex ischiorectal abscess and thus a decision was made to proceed for surgery. The surgery proceeded with a cervical anastomosis using a linear stapled technique and closure with 3.0 PDS. Postoperatively, the patient deteriorated on day 2, necessitating intubation due to decreased oxygen saturation. The chest tube output looked slightly bile stained. A subsequent CT scan revealed mediastinal fluid accumulation, prompting urgent intervention.

Results

Diagnostic thoracoscopy revealed contamination of the right chest and posterior mediastinum, necessitating extensive washout. A 2cm necrotic patch and perforation were identified on the gastric side of the oesophago-gastric anastomosis. Intraoperative gastroscopy localized the leak with a positive air bubble test. A Maryland forceps was passed through the defect to confirm the defect. Subsequently, a guidewire was passed antegrade into the cavity using the gastroscope. Decision was made to purse-string the defect (around the guidewire) using 3.0 PDS and the T-tube was exchanged transorally via the guidewire into the cavity and exteriorized through a 5mm port to the skin. Existing large-bore chest and Blake drains were retained, and a feeding jejunostomy was established.

Conclusion

This hybrid management approach, combining endoscopy and thoracoscopic washout with T-tube insertion, offers an alternative for addressing complex anastomotic leaks following MIE. By avoiding resection and diversion, this technique potentially reduces morbidity. Follow-up scans demonstrated resolution of the leak allowing the patient to be discharged.

https://1drv.ms/v/s!Aghd8kXfo8oQlX6QyliVLgRDmIu-?e=EGN5YD
318. EFFICACY OF PROPHYLACTIC STEROID THERAPY OF INJECTION AND ADMINISTRATION AGAINST STRICTURE FOR SUBENTIRE CIRCUMFERENTIAL DEFECT AFTER ESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION
Authors: Kadota Tomohiro , Sasabe Maasa , Yamashita Hiroki , Inaba Atsushi , Sunakawa Hironori , Nakajo Keiichiro , Shinmura Kensuke , Yano Tomonori
Published: September 2024

Background

Esophageal stricture is a major problem after endoscopic submucosal dissection (ESD) for large superficial esophageal squamous cell carcinomas (SESCC). Local triamcinolone injection (LTI) has been reported as the standard prophylactic treatment against stricture, however, it showed that its efficacy was insufficient for subentire circumferential mucosal defect after ESD in the subgroup analysis of randomized controlled trial (JCOG1217). On the other hand, the usefulness of oral prednisolone administration (OPA) has also been reported. Thus, we aimed to compare the efficacy of LTI with combination of LTI and OPA in patients with subentire circumferential mucosal defect after esophageal ESD.

Methods

This retrospective study enrolled the patients with mucosal defect after ESD larger than 7/8th circumference and not spreading entire who treated with LTI or combination of LTI and OPA between July 2010 to January 2020. Triamcinolone acetonide (50-100 mg) was injected into ulcer bed immediately after ESD, and oral prednisolone (30 mg daily, tapered gradually for 8 weeks) was administrated. We defined as an esophageal stricture in case the endoscope could not pass through the stricture, and then endoscopic balloon dilation (EBD) was required. We evaluated stricture-free survival (SFS), and the number and duration of EBD.

Results

A total of 42 patients in the LTI group and 26 in the combination group were enrolled. The median longitudinal extension of the lesions was 4.5 cm (range; 2-7) in the LTI group and 4 cm (2-7) in the combination group. Finally, 18 patients (42.9%) in the LTI group and 7 (26.9%) in the combination group developed esophageal stricture, and 12-week SFS was 64.3% and 76.9%. The median number and duration of required ESD were 6 (2-10) in the LTI group and 4 (2-9) in the combination group, and 88 days (15-288) and 66 days (22-176).

Conclusion

The steroid combination therapy of local triamcinolone injection and oral prednisolone administration showed the effective outcomes comparing with local triamcinolone injection alone for subentire circumferential mucosal defect after esophageal ESD. Thus, this combination therapy can be the most promising treatment and should be compared in the randomized controlled trail with large sample size.
319. EXTENSIVE LYMPHADENECTOMY MAY IMPROVE SURVIVAL IN NODE NEGATIVE OESOPHAGEAL CANCER
Authors: Khoma Oleksandr , Paredes Steven , Park Jin-soo , Kennedy Catherine , Falk Gregory
Published: September 2024

Background

Lymph node metastases are a major prognostic factor in survival of patients with oesophageal cancer.

The number of lymph nodes removed during oesophagectomy has been previously proven to be associated with improved survival. The aim of this study was to examine the effect of lymph node harvest on survival specifically in pathologically node negative (pN0) patients with oesophageal cancer.

Methods

Data were extracted from a prospectively populated single-surgeon database of oesophageal resections for cancer. All consecutive patients with pN0 were included. Patient-specific risk adjusted analysis of overall and disease-free survival was performed to identify the number of lymph nodes associated with improved survival.

Results

Inclusion criteria were met by 137 patients (49 squamous cell carcinoma and 88 adenocarcinoma). Adjusted for cancer stage, tumour (histological type, degree of differentiation, lympho-vascular invasion, neo-adjuvant therapy) and patient related factors (age, sex), increased lymph node number was associated with significant improvement in overall (P = 0.045) and disease free (P = 0.030) survival. Lymph node count ≥ 17 was associated with improved overall and disease-free survival.

Conclusion

In this cohort of patients with pathologically node-negative oesophageal cancer, lymph node count of 17 or above was associated with significantly improved survival.
322. IMPACT OF POSTOPERATIVE NUTRITIONAL SUPPORT MODES ON CLINICAL AND PATIENT-REPORTED OUTCOMES IN ENHANCED RECOVERY AFTER ESOPHAGECTOMY FOR CANCER
Authors: Wang Kangning , Xie Qin , Huang Yixuan , Wei Xing , Shi Qiulin , Zhou Qiang , Leng Xuefeng , Miao Yan , Han Yongtao , Fang Qiang
Published: September 2024

Background

Enhanced Recovery After Surgery (ERAS) for esophagectomy has been demonstrated to be safe and effective. However, there is significant variation in the nutritional support treatment modes during the perioperative period. We have recently developed a novel ERAS nutritional support mode. In this study, we compared this new mode with the previous ERAS nutritional support treatment mode to assess their impact on clinical and Patient-Reported Outcomes (PROs), aiming to develop an optimal approach.

Methods

We enrolled 357 patients who underwent esophagectomy for esophageal thoracic cancer or esophagogastric junction cancer from June 2021 to August 2023. Two different ERAS nutritional support treatment protocols were used postoperatively: the control group previously received enteral nutrition by nasojejunal tube + parenteral nutrition + early oral diet after surgery, while the study group currently received parenteral nutrition + early oral diet. We compared the two groups in terms of clinical observation indicators, hematological analysis, serum protein changes and clinical outcomes. The comparison of quality of life on PROs was assessed using the MD Anderson Symptom Inventory. Symptom changes were analyzed using a mixed-effects model.

Results

A total of 324 patients successfully completed the ERAS nutritional support protocols. The success rates were 91% in the control group and 90.2% in the study group, with no statistically significant difference (p>0.05). The incidence of complications did not significantly differ between the two groups (p>0.05). Compared to the control group (n=223), the study group (n=101) significantly shortened the chest drain time (6.2±2.6 days vs. 6.6±1.5 days, p<0.05) and elevated the levels of serum total protein and albumin on the 4th postoperative day (53±5 g/L vs. 51±4 g/L, 30±2 g/L vs. 28±2 g/L, p<0.05). There were no statistically significant differences in the first flatus time, first defecation time, infusion time and postoperative hospital stay between the two groups (p>0.05). The comparison of hematological analysis, serum protein changes, changes in body weight during the perioperative period and 30-day readmission rate showed no statistically significant differences (p>0.05). In the MD Anderson Symptom Inventory, the study group had significantly better scores in sadness, dry mouth, enjoyment of life, and general activity dimensions compared to the control group (p=0.013, p<0.001, p=0.045, p=0.008).

Conclusion

Based on the similar rehabilitation outcomes, the simplified ERAS nutritional support treatment mode without postoperative enteral nutrition by nasojejunal tube is more optimized because it is physiological sound and significantly improves quality of life on PROs.
323. LONG-TERM SURVIVAL OUTCOME OF PATIENTS WITH EARLY ESOPHAGEAL CANCER AFTER ESD (ENDOSCOPIC SUBMUCOSAL DISSECTION) AND ESOPHAGECTOMY
Authors: Lin Yu-fu , Lee Jang-Ming , Lin M Mong-Wei , Huang Pei-Ming , Chen Ke-Cheng , Kuo Shuenn-Wen
Published: September 2024

Endoscopic submucosal dissection (ESD) has been gradually accepted as an effective treatment option for patients with early esophageal cancer. However, its long-term outcome is limited in literature.

Method

This study compare the overall survival for the patients with early esophageal cancer (T1N0M0) treated with ESD and esophagectomy. The tumor staging was confirmed with EUS, PET and CT imaging. The indication of ESD was T1aN0M0 in clinical staging studies. Three-field lymph node dissection with intrathoracic (Ivor Lewis) or cervical esophagogastrostomy (McKeown) was performed for the patients undergoing esophagectomy under thoracoscopic (minimally invasive esophagectomy) laparoscopic approaches.

Result

There were 82 patients enrolled in the study including 22 and 60 undergoing esophagectomy and ESD respectively. There is no difference of overall survival in 3 and 5 years with 89.1 % and 81.8 % for patients after ESD, 78.1 % and 78.1 % after esophagectomy (P=0.6)

Conclusion

For early esophageal cancer with T1aN0M0, ESD can provide an equivalent long-term survival outcome as compared to that with esophagectomy with three-field lymph node dissection.
326. SPONTANEOUS OESOPHAGEAL PERFORATION TREATED WITH OESOPHAGEAL STENT
Authors: Tang Linda , Lee Francis , Gaszynski Rafael , Kwon Sebastionus , Devadas Michael
Published: September 2024

We present the case of a 66-year-old male with spontaneous oesophageal perforation treated with oesophageal stenting. This patient reports sudden onset severe anterior chest pain after coughing and haematemesis with a background medical history of Type II DM, ESRF on Haemodialysis, Hypertension, OSA and takes prophylactic Aspirin. Endoscopy reveals multiple areas of oesophageal perforation in the proximal, middle, and distal oesophagus as well as a haematoma extending the entire length of the oesophagus to the COJ. This was treated with insertion of a WallFlex™ Fully Covered Oesophageal Stent as the patient was unsuitable for surgery. The result was re-epithelialisation of the entire oesophagus and complete resolution of the perforation at the mid-oesophagus.

Dutch physician Boerhaave first described spontaneous oesophageal perforation in 1724. Commonly, these were treated surgically with associated high morbidity and mortality. Advances in endoscopic and stent technology has given clinicians a greater armamentarium to treat patients especially in the frail end elderly population. These advances include choices such as stent covers, biodegradable and removable stents, and anti-reflux valves. Complications with oesophageal stents such as fistula formation, stent migration and retrosternal pain are often associated with the length of placement. The choice of a fully covered retrievable oesophageal stent in our case provided reconstitution of oesophageal lumen and minimisation of mediastinal sepsis.

With the progress in stent technology, we believe there will be greater use of endoscopic oesophageal stenting for oesophageal perforations bridges the gap between operative and non-operative management.
327. INCIDENCE OF GASTRIC BAND REMOVAL: A REVIEW OF THE LITERATURE
Authors: Tang Linda , Devadas Michael
Published: September 2024

Purpose

In the wake of the global obesity epidemic, bariatric surgery has become critical to prevent the complications of obesity and reduce the impact across health care systems. Laparoscopic Gastric Band insertion was at one point the most performed bariatric operation for obesity. In Australia, due to the limited publicly funded bariatric units, LAGB insertion is often performed in the private health sector. However, the post operative course for many of these patients who underwent LAGB has been fraught with complications often resulting in presentation to emergency, explantation of the LAGB and further surgical intervention. and is considered unfavourable in management of obesity.

Methodology

We performed a search of medical subject headings within PubMed, Medline and Embase for the terms ‘Gastric Band*’, ‘remov*’, ‘explant*. Following removal of duplicates, a total of 46 articles detailing the incidence of gastric band removals. Studies were included if they included discrete cohorts of patients who have undergone LAGB insertion, reported data on incidence of removal and median follow up >3 years.

Results

Results of the literature review will be discussed.

Conclusion

While it is considered unfavourable as a surgical option for management of obesity, public hospitals continue to absorb many patients who have undergone this procedure placing stress on an already stretched system. The incidence of LAGB varies in the literature. The authors would like to provide an updated review of the literature to determine the incidence of LAGB to better inform patients and health care providers.
332. OUTCOMES OF SALVAGE SURGERY FOR ESOPHAGEAL CARCINOMA: A NATIONWIDE COHORT STUDY
Authors: Visser Maurits , Voeten Daan , Gisbertz Suzanne , Ruurda Jelle , van Hillegersberg Richard , van Berge Henegouwen Mark
Published: September 2024

Background

Compared to a standard resection, salvage esophagectomy is a more complex procedure and associated with increased postoperative morbidity and mortality. This study aimed to investigate short-term outcomes of salvage surgery for esophageal carcinoma and the influence of hospital volume and baseline characteristics on outcomes.

Methods

All patients undergoing esophagectomy for esophageal cancer registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) between 2012-2022 in the Netherlands were included. Patients were classified as salvage or non-salvage by registering surgeons. The definition was: surgery after definitive chemoradiotherapy. Postoperative mortality (30-day/-in-hospital) and morbidity were compared between salvage and non-salvage patients using multilevel logistic regression analyses. Hospital variation in the use of salvage esophagectomy was investigated using funnel plots. The influence of annual hospital volume (<40->40) and annual salvage volume (<6->6) on outcomes of salvage patients were investigated. Using backward elimination, relevant baseline characteristics influencing outcomes after salvage surgery were identified.

Results

Between 2012-2022, 7,749 patients underwent esophagectomy, of whom 251 (3%) underwent salvage resection, varying from 0%-8% of esophagectomies between centers. Salvage surgery was associated with an increased risk of 30-day/in-hospital mortality (11% vs. 3%; OR:3.65; 95%CI:2.38-5.61) and severe complications (43% vs. 28%; OR:1.81; 95%CI:1.40-2.34). Salvage patients treated in high-volume esophagectomy centers (>40) had a decreased risk of 30-day/in-hospital mortality compared to low-volume centers (9% vs. 19%; OR:0.42; 95%CI:0.18-0.99), with no relation found between annual salvage volume and outcome. Certain baseline characteristics, foremost men, elderly (>75 years) and squamous cell carcinomas, were associated with worse short-term outcomes of salvage surgery.

Conclusion

Salvage surgery for esophageal carcinoma is infrequently but increasingly performed in the Netherlands, with wide hospital variation in its use. Salvage surgery is associated with worse short-term outcomes when compared with non-salvage esophagectomy. Outcomes after salvage surgery were favorable in high-volume esophagectomy centers, suggesting a volume-outcome relationship for salvage surgery.
335. IMPACT OF POSTOPERATIVE COMPLICATIONS ON LONG-TERM OUTCOMES AFTER ESOPHAGECTOMY
Authors: Saito Ryo , Maruyama Suguru , Kawaguchi Yoshihiko , Akaike Hidenori , Shoda Katsutoshi , Higuchi Yudai , Tanaka Hiroto , Ichikawa Daisuke
Published: September 2024

Background

Recently, it has been reported that postoperative complications after esophagectomy not only prolong hospital stay and reduce quality of life, but also have impact on the long-term outcomes. However, this still remains controversial. Here, we aimed to evaluate the prognostic impact of postoperative complications after esophagectomy, focusing on the type and severity of complications. In addition, we examined the impact of postoperative pneumonia on long-term prognosis stratified by the presence of COPD.

Methods

In total, 254 consecutive patients who underwent esophagectomy for esophageal cancer between 2009 and 2021 were eligible. We examined the association between postoperative complications and long-term outcomes. Severe postoperative complications can be defined as C-D III-V in this study.

Results

Postoperative complications occurred in 150 out of 254 cases (59.1%). Patients with postoperative pneumonia and anastomotic leakage had significantly lower OS, CSS and RFS rates compared to those without, whereas other complications were not associated with long-term outcomes. Regarding severity, non-severe complications did not affect long-term prognosis, whereas patients with severe complications significantly lower OS, CSS, and RFS rates (P < 0.01). In addition, patients without COPD who developed postoperative pneumonia had significantly lower long-term outcomes (P < 0.01). However, in patients with COPD, no survival difference between patients with and without postoperative pneumonia was observed.

Conclusion

Severe postoperative pneumonia and anastomotic leakage were found to strongly influence the long-term outcomes. Meanwhile, postoperative pneumonia may have a minimal impact on long-term outcomes in COPD patients.
340. THE IMPACT OF OBESITY ON SURGICAL OUTCOMES AFTER ESOPHAGECTOMY FOR CANCER IN SWEDEN
Authors: Skogar Martin , Lindblad Mats , Enblad Malin , Linder Gustav
Published: September 2024

Background

Global obesity rates continue to rise and are closely linked to an increase in esophageal adenocarcinoma. While obesity is associated with an increased risk of postoperative complications, its influence on long-term survival is less clear. Some studies suggest that obese patients have poorer outcomes due to higher comorbidity rates, while others indicate comparable or even better survival, possibly due to better nutritional reserves.

This study aims to investigate whether obesity affects the survival and risk of postoperative complications in a national cohort of esophageal cancer patients.

Methods

This retrospective population-based register study included all individuals who underwent esophageal resection between 2006 and 2018 in Sweden. Data were extracted from the national quality registry for esophageal and gastric cancer (NREV). The cohort was grouped based on body mass index (BMI) into underweight (BMI < 20), normal (BMI 20-25), overweight (BMI 25-30), and obese (BMI > 30). Kaplan-Meier was used for survival analysis, and logistic regression and Cox regression were used for adjusted analyses (adjusting for sex, age, marital status, education level, Charlson comorbidity index score, histopathology, disease stage, and year of diagnosis).

Results

In total, 1742 individuals (79.9% males, mean age 66) were included, of whom 242 (13.9%) were obese. Obese individuals had more comorbidities at surgery, more commonly had adenocarcinoma, and underwent surgery more frequently in the later time period. The risk of surgical complications (e.g., anastomotic leak, bleeding) for obese individuals was not increased compared to those with normal weight (OR: 0.83 [0.56-1.21]), but an increased risk of non-surgical complications (e.g., pneumonia, cardiopulmonary events) was observed (OR: 1.78 [1.22-2.60]). The risk of death of any cause was decreased in obese individuals compared to those with normal weight (HR: 0.74 [0.58-0.95]), resulting in superior overall survival.

Conclusion

Despite the presence of more comorbidities among obese individuals undergoing esophagectomy, their risk of surgical complications remained comparable to those with normal weight. However, obese individuals exhibited a heightened susceptibility to other postoperative complications. Surprisingly, obese individuals demonstrated an improved overall survival at 5 years compared to those with normal weight.
347. THE EFFICACY OF CONVERSION SURGERY IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA WITH INVASION OF OTHER ORGANS
Authors: Ho Keiso , Kawakubo Hirofumi , Takeuchi Masashi , Matsuda Satoru , Fukuda Kazumasa , Nakamura Rieko , Kitagawa Yuko
Published: September 2024

Background

There are cases of advanced unresectable esophageal squamous cell carcinoma (ESCC) with invasion of other organs that can be successfully treated with chemoradiotherapy and systemic chemotherapy, enabling surgical resection. We actively perform conversion surgery for ESCC with invasion of other organs after definitive chemoradiotherapy or systemic chemotherapy.

Methods

The patients who underwent conversion therapy in our hospital for ESCC between 2012 and 2022 at participating institutions were retrospectively reviewed. We evaluated patient backgrounds, treatment outcomes, and overall survival (OS) were evaluated. 31 patients were enrolled. 14 conversion cases were performed after chemoradiotherapy, 17 cases were after chemotherapy. All 17 patients received systemic chemotherapy with DCF (Docetaxel + Cisplatin + 5-FU), and all 14 definitive chemoradiotherapy was administered at least 50 Gy.

Results

There were 24 males and 7 females with a median age of 67 (47-75) years. Involved organs were trachea in 24 cases, aorta in 6 cases, and pulmonary vein in 1 case. 19 patients underwent open esophagectomy, 11 thoracoscopic, and 1 robot-assisted. 14 patients had complications of Clavien-Dindo grade 3, mainly pneumonia, leakage, and recurrent laryngeal nerve palsy. 22 (71%) were performed R0 resection. Recurrence was observed in 20 patients (65%). Overall, 3-year PFS was 22% and 3-year OS was 39%. 3-year OS in patients with R0 resection was 49% while 12.5% in patients with R1 and 2 resection.

Conclusion

This study showed that conversion therapy could be relatively safely for ESCC patients with organ invasion responded to initial chemotherapy and chemoradiotherapy. Especially in cases R0 resection was performed, good prognosis was obtained.
348. MANAGEMENT OF AORTO-ESOPHAGEAL FIFISTULA SECONDARY AFTER THORACIC ENDOVASCULAR AORTIC REPAIR
Authors: Zhou Haining , Tang Shoujun , Zhong Chuan
Published: September 2024

Background

Aorto-esophageal fifistula (AEF) is rare with highly fatal conditions and occurs most frequently secondary as a result of oesophageal malignancies, aortic aneurysms, thoracic trauma, and other thoracic surgerys. We evaluated the incidence of AEF after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results. Raising awareness and vigilance of AEF and developing individualized diagnosis and treatment measures are the key to improve the prognosis.

Methods

We conducted a voluntary survey in three centres with a thoracic endovascular programme.

Results

Of the patients who underwent TEVAR between 2010 and 2020,11/423 developed AEF. Aortic pseudoaneurysm was associated with the development of AEF among indications to TEVAR (P<0.05). Besides, emergent and complicated procedures resulted in increased risk of AEF (P<0.05). Five patients were treated conservatively, all of whom died within 30 days. Six patients underwent AEF surgical treatment, with a perioperative mortality of 33% (2/6). At a mean follow-up of 18.7+13.6 months, overall survival was 33% (2/6).

Conclusion

The incidence of AEF after TEVAR is not negligible and long-term follow-up is required especially for patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF are associated with high mortality. However, once AEF develops, conservative treatment does not appear to be an optimal management. Timely operation has positive correlation with increase of long-term survival rate of patients.