bluuebunny/crossref_metadata_2025 huggingface dataset:
374. RADIOGRAPHICALLY-DETERMINED FRAILTY IS ASSOCIATED WITH IMPAIRED GASTRIC CONDUIT PERFUSION DURING ESOPHAGECTOMY
Authors: Ishikawa Yoshitaka , Lin Jules , Brandser Andrew , Hider Ahmad , Askar Brandon , Lagisetty Kiran , Wakeam Elliot , Lynch William , Orringer Mark , Chang Andrew , Reddy Rishindra
Published: August 2023

Background

Frailty is considered a preoperative risk factor for complications after esophagectomy while impaired gastric conduit perfusion is associated with anastomotic leaks. Patients with impaired conduit perfusion may be candidates for gastric ischemic preconditioning, a surgical procedure performed prior to definitive esophagectomy to improve gastric conduit perfusion. The aim of this study was to investigate the association between radiographic determinants of frailty (morphomics) and gastric conduit perfusion assessed during esophagectomy.

Methods

Patients undergoing an esophagectomy with a cervical esophagogastric anastomosis (2015–2021) were included. Preoperative CT scans were processed using semiautomated algorithms (MATLAB; MathWorks, MA) to assess skeletal muscle (cross-sectional area, Martin’s criteria), subcutaneous fat (cross-sectional area, decreased when below the cut-off) and bone mineral density (decreased when below the cut-off). Indocyanine green perfusion was assessed intraoperatively (SPY Elite; Stryker, MI) and Ingress Index was calculated (standardized perfusion at the evaluated point). The morphomic index (MI), as an indicator of frailty, was determined using the number of decreased morphomic factors present (0–3). Multiple linear regression was used to analyze the data.

Results

One hundred and thirty-six patients were evaluated, with 25 patients developing anastomotic leaks (18.4%). Morphomic indices (MIs) of 2 or 3 were independently associated with reduced Ingress Index (p = 0.019 and 0.004, Table). In a sub-analysis for MI, MIs of 2 or 3 were associated with higher age (p = 0.029), lower BMI (p = 0.003), and cardiovascular disease (myocardial infarction, chronic heart failure, and vascular disease, p = 0.017). Other patient demographic factors including age, sex, and comorbidities did not affect Ingress Index.

Conclusion

Higher Morphomic Index (indicating lower than normal radiographic measures) were associated with impaired gastric conduit perfusion. More patients will be needed to investigate whether increased MI also is associated with development of anastomotic leaks. These findings may be useful in risk stratification and preoperative decision making in patients undergoing esophagectomy. Patients with MI of 2 or higher should be considered for gastric ischemic preconditioning.
391. PREHABILITATION DURING NACT IN ESOPHAGEAL CANCER CARE—A FEASIBILITY STUDY
Authors: St-Pierre Jade , Coca-Martinez Miquel , Drummond Kenneth , Minnella Enrico , Ferri Lorenzo , Scheede-Bergdahl Celena , Carli Franco
Published: August 2023

Background

Esophageal cancer bears a high disease burden with elevated morbidity and mortality. Treatment of esophageal adenocarcinoma (EAC) includes Neoadjuvant Chemotherapy (NACT) followed by surgical resection and subsequent adjuvant chemotherapy (ACT). This treatment triad effectively weakens already ill patients. Prehabilitation, a preoperative intervention designed to optimize patients through exercise, nutrition, and psychology, is understudied in this malignancy. Given limited prehabilitation resources at many hospitals, efficacy of home-based programs vs traditional supervised programs was investigated.

Methods

Patients diagnosed with EAC underwent a multimodal prehabilitation intervention and were blindly randomized to either supervised exercise or home-based exercise. The study was considered feasible if patients complied to 70% of the program. Compliance was measured by number of completed exercise sessions and adherence to nutritional advice and supplementation. Safety was measured by occurrence of adverse events. Cardiorespiratory fitness was measured by cardiopulmonary exercise testing (CPET). Functional capacity was measured by 6-minute walking test (6MWT), Sit-to-Stand and Hand Grip Strength. Quality of Life was measured by ESAS and FACT-E. All patients underwent assessment at baseline, preoperatively and 8 weeks postoperatively.

Results

44 patients were enrolled, supervised (n = 23) and home-based (n = 21). Average age was 64, BMI 27.9 kg/m2 and 68% underwent an Ivor Lewis esophagectomy. There were no significant differences between groups at baseline. Overall adherence to the program by the supervised group was 72% and 77% by the home-based group. Exercise allocation was not linked to adherence (p = 0.45). There were 2 non-serious adverse events recorded during this trial: one bout of syncope and one of light headedness during exercise. There is a relative maintenance or even improvement of cardiorespiratory fitness, functional capacity and QoL during NACT throughout the preoperative period.

Conclusion

Prehabilitation is an effective and safe intervention in esophageal cancer patients undergoing NACT. Home-based programs seem to provide similar benefits to supervised programs. This allows for wider implementation of prehabilitation in hospitals which do not have dedicated outpatient clinics for this purpose. Buffering functional decline during treatment is a triumph in a population that usually suffers. However, larger trials investigating prehab’s effect on post operative complications and QoL are needed.
401. THE ADJUVANT IMMUNOTHERAPY COMBINATIONS FOLLOWING ESOPHAGECTOMY FOR RESECTABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA WITH NEOADJUVANT THERAPY
Authors: Tian Dong , Hu Wen-Long , Jiang Kai-Yuan , Tang Hong-Tao , Chen Long-Qi
Published: August 2023

Background

The potential benefits of postoperative adjuvant therapy for resectable esophageal squamous cell carcinoma (ESCC) following neoadjuvant therapy remain controversial. This study aims to evaluate the value of immunotherapy combinations as a potential adjuvant treatment for ESCC patients.

Methods

This retrospective study reviewed patients with ESCC who underwent neoadjuvant therapy following radical esophagectomy at West China Hospital, Sichuan University, between 2018 and 2021. The primary outcomes were overall survival (OS) and disease-free survival (DFS). The survival curves and independent prognostic factors were analyzed using the Kaplan–Meier method and Cox proportional hazards model, respectively. In the patients who received postoperative adjuvant therapy, the survival curves of postoperative adjuvant therapy options, including immunotherapy combinations, chemotherapy (CT), and chemoradiotherapy (CRT), were compared.

Results

Of the total 482 patients, 141 (29.3%) received adjuvant therapy with 58, 58, and 25 cases receiving immunotherapy combinations, CT and CRT, respectively. Immunotherapy combinations demonstrated both a significantly better OS and DFS compared to CT or CRT, with a mean OS of 34 months vs. 29 months (95% confidence interval [CI] 27.633–34.503, P < 0.05) and a mean DFS of 32 months vs. 24 months (95% CI 24.994–32.853, P < 0.05), respectively. However, immunotherapy combinations were not identified as an independent prognostic factor for OS (hazard ratio [HR] 0.677, 95% CI 0.293–1.564, P = 0.361) and DFS (HR 0.470, 95% CI 0.208–1.064, P = 0.070).

Conclusion

Although adjuvant immunotherapy combinations prolong OS and DFS compared with CT and CRT in ESCC, they cannot independently predict prognosis. Therefore, the efficacy of immunotherapy combinations in adjuvant therapy still needs further exploration.
405. SHORT-TERM OUTCOMES OF ROBOT-ASSISTED ESOPHAGECTOMY
Authors: Kamei Takashi , Taniyama Yusuke , Okamoto Hiroshi , Sato Chiaki , Ozawa Yohei , Ishida Hirotaka
Published: August 2023

Background

Robot-assisted minimally invasive esophagectomy (RAMIE) has become widely performed in Japan, and the technique and short-term results have been accumulated. In our institute, we started with daVinci S in 2013, switched to Xi in 2018, and have experienced 110 cases so far.

Method; Technique and Devices: Semi-prone position with the left upper extremity placed under the body, 4 ports +1 assist port (Air Seal), double bipolar system—is the basic approach. The right upper extremity is placed so that it is attached to the head to provide axillary working space, and orthoglass to avoid direct compression of the right upper arm and robotic 4th arm. The range of motion of the 4th arm in the lower mediastinum is limited by the patient’s physique, so assistant forceps are used to assist as needed. Be willing to invert the camera to view the back of the operative field. Intraoperative recurrent nerve monitoring (NIM) was used in all cases.

Results

Five surgeons have performed RAMIE procedures. There have been no cases of conversion to thoracoscopic or open thoracotomy. The thoracic procedure time was significantly longer in RAMIE (299 min:274 min) than in thoracoscopic MIE. Blood loss tended to be less (17.1 mL: 44.0 mL). The incidence of recurrent nerve palsy (CD grade I or higher) was 44%:37%, that of pneumonia (CD grade II or higher) was 19%:18% and perioperative complications were similar between the two groups. Comparing the first half of the period when RAMIE was initiated with the second half, there was a significant decrease in the amount of bleeding, surgery time, and incidence of pneumonia, indicating an improvement in technique due to the number of experienced cases.

Conclusion

RAMIE can be performed safely, although no clear advantages can be demonstrated compared to thoracoscopic MIE at this time. RAMIE has clear advantages in terms of visual magnification of the dissected layer and stability of the surgical field, therefore, it is expected to reduce complications due to improved technique.
412. INTRAOPERATIVE APPLICATION OF ENDOFLIP FOR THE REPAIR OF HIATUS HERNIA AND FUNDOPLICATION
Authors: Tong Daniel
Published: August 2023

https://drive.google.com/file/d/1N3wVZ2UvO3eGBScjHMwtcJiCqfU0wUp1/view

Background

There is no objective measurement during repair of hiatus hernia and fundoplication intraoperatively. Whether the patient needs Nissen, Toupet or other fundoplication requires individual consideration. If the wrap repaired too tight, patient will develop dysphagia after surgery. If the wrap fold too loose, then the patient may experinced persistent reflux symptoms. This video demonstrate the application of EndoFlip intraoperatively to objectively measure the distensibility of the lower esophageal sphincter.

Method

Patient underwent laparoscopic hiatus hernia and fundoplication after symptoms assessment and confirmation of diagnosis. Intraoperatively, EndFlip probe was inserted and distensibility were measured as pre-dissection, post abdominal resection, post crural repair and after fundoplication. Tightness of fundoplication is adjusted aming at distenisbiliary index ranged 2–4.

Results

This study demonstrate the intraoperative aspproach for using EndoFlip as the tool to adjust the appropriate tightness on creating the wrap. Fpr this particular patient, before crus dissection, the distensibility index (DI) was 4.5, after crural dissection, DI was 5.5. After crural repair and Toupet fundoplication, the DI was 2.5. Post-operatively, patient had all the proton pump inhibitor stopped and enjoying good quality of life.

Conclusion

Objective intraoperative measurement during fundoplication is now available. Appropriate tightness of the wrap can be adjusted to avoidf post operative dysphagia or persistent reflus.
415. STEP-BY-STEP APPROACH TO CERVICAL LYMPHADENECTOMY IN ESOPHAGEAL CANCER
Authors: Fonseca Filipa , Cabral Francisco , Ramos Paulo , Monteiro Cecília , Abecasis Nuno , Casaca Rui
Published: August 2023

https://drive.google.com/file/d/1sByes2_wNgSmb8DW9BjNQknjN7HCXtf1/view

Background

Cervical lymphadenectomy is an essential component of the treatment of esophageal cancer. Over the last six years, our upper gastrointestinal unit has carried out 180 esophagectomies, with 20% of them involving 3-field lymph node dissection. According to our unit’s protocol, the procedure is indicated for the following conditions: supraclavicular lymph node metastases, upper thoracic esophageal cancer, and recurrent nerve lymph node metastasis. We aim to present a step-by-step approach to cervical lymphadenectomy.

Methods

Our upper gastrointestinal unit has implemented several learning protocols that aim to design the most efficient and effective training environment. The primary objective is to enhance the learning process and surgical performance while maintaining quality standards. One of the essential components of this learning environment is video coaching, which provides a powerful tool for demonstrating and deconstructing surgical procedures. In recognition of the importance of cervical lymphadenectomy, we have developed a video that is incorporated into our unit’s existing curriculum.

Results

As an essential component of our comprehensive teaching protocol, we have included a video demonstrating the systematic approach to cervical lymphadenectomy. It offers a clear and concise overview of the anatomical landmarks that must be identified during the procedure, as well as the steps involved and the main pitfalls that must be avoided.

Conclusion

Our unit is committed to a phased and systematized approach to learning based on steps through the deconstruction of complex procedures. The unit’s structured teaching protocol allows the acquisition of competencies that enable the performance of cervical lymphadenectomy in an effective and efficient way, without compromising patient safety. We believe that our step-by-step approach to cervical lymphadenectomy will be a valuable resource for healthcare professionals working in our upper gastrointestinal unit.
431. RARE CASE OF CONTAINED ESOPHAGEAL PERFORATION IN LONG STANDING ACHALASIA CARDIA AND ITS SUCCESSFUL MANAGEMENT
Authors: Sachanandani Kanchan , Salvi Prashant , Thapar Pinky
Published: August 2023

Background

Esophageal perforation is the most feared complication after any intervention in achalasia cardia, especially after pneumatic dilation. We present a case of contained perforation after manometry in a long-standing case of achalasia cardia and its successful management.

Methods

A 64-year-old lady, known case of long-standing Rheumatoid arthritis on steroids and methotrexate, presented to us with complains of dysphagia to solids and liquids and 15 kgs weight loss in the past 3 years. On evaluation, she was dehydrated and cachexic. Upper GI endoscopy showed lot of food residue with erosions in body of esophagus and tight LES. Barium swallow showed sigmoid esophagus with typical bird beak appearance. Patient was admitted for hydration and nutritional optimization was done with nasojejunal feeding. She was further subjected to manometry to characterize the achalasia, which couldn’t be completed despite multiple forceful attempts. After 5 days, she was admitted for elective surgery. A CT scan of chest was done to evaluate the anatomy thoroughly before surgery, which showed contained mucosal perforation in lower esophagus on right side with minimal right pleural effusion. We planned for surgery next day.

Results

Laparoscopic Heller’s cardiomyotomy with Dor’s fundoplication was done with thoracoscopic lavage. Intra-operatively, upper GI endoscopy with minimal insufflation was done to confirm adequate cardiomyotomy and to look for the site of perforation. The perforation was not found. Hence, right thoracoscopy was done, which showed reactive pleural effusion without any food contents. Lavage was given and ICD was placed. Feeding jejunostomy was done laparoscopically. Patient was kept NBM for 7 days and JT feeds were started on POD 1 and gradually increased. ICD removed on POD 7. Oral gastrograffin contrast study was done on POD 8, which showed delayed passage at 5 minutes and no extravasation. Oral liquids were started and escalated gradually. Supplemental high protein nutrition was given through JT feeding. Patient was discharged on POD 15. At 1 month follow up, patient had 2 kgs weight gain and tolerated semisoft diet adequately.

Conclusion

Successful management of contained perforation in long standing achalasia cardia was achieved by targeting the source pathology in an already immunocompromised patient.
432. SINGLE-CELL RNA SEQUENCING OF MORPHOLOGICALLY-PURE PATIENT-DERIVED ORGANOIDS FROM ESOPHAGEAL ADENOCARCINOMA PATIENTS
Authors: Shathasivam Premalatha , Naeem Mansur , Rispoli Thaiane , Aiyar Niharikaa , Akhter Akhi , Wilson Gavin , Darling Gail , Yeung Jonathan
Published: August 2023

Background

We have successfully cultured esophageal adenocarcinoma (EAC) patient-derived organoids (PDOs) from endoscopic biopsies. These PDOs recapitulate the histological and molecular features of the originating tumour and frequently exhibit morphological heterogeneity within the same patient sample. The underlying biology of these morphologies and their relation to treatment response remains unknown. This study will examine the gene expression profile of morphologically pure organoids.

Methods

EAC tissue samples collected from patients were processed and embedded into Matrigel to generate PDOs. Parental PDOs with heterogenous morphology were sorted to isolate clonal pure morphology organoids. Multiple clones were expanded and clones of different morphology were collected and dissociated to single cells for single-cell RNA sequencing.

Results

Multiple single morphology clones were grown from nine different mixed morphology parental PDOs, demonstrating that EAC organoids can be generated from single cells. Successful formation of organoids from single cells took between two to four weeks. The percentage of single cells successfully generating organoids was sample-dependent. Six clones of solid, cystic, budding or grape-like morphology from two PDOs have been expanded and dissociated to single cells for single-cell RNA sequencing.

Conclusion

PDOs have emerged as a powerful tool to study drug response and personalize therapy. This study will examine the correlation of EAC organoid morphology with gene expression. Future directions will include the identification of morphology-dependent drug targets, enabling the development of more precise targeted drug screening for each patient.
434. INCREASING TUMOUR INFILTRATING LYMPHOCYTES THROUGH EXERCISE ALONE—A PILOT RCT IN ESOPHAGEAL ADENOCARCINOMA
Authors: Rayner Charles , Allen Sophie , Seymour Tadd , Preston Shaun , Frampton Adam , Bartlett David , Annels Nicola , Abbassi-Ghadi Nima
Published: August 2023

Background

The immune system is highly responsive and positively adapts to exercise. A single bout of exercise results in the mobilisation of highly functional effector CD8+ T cells and NK-cells into the circulation. Murine cancer models have shown that exercise reduces tumour burden by increasing the frequency of tumour-infiltrating lymphocytes (TILs). There are no studies assessing the impact of an exercise programme on the levels of TILs in patients’ solid tumours in any cancer.

Methods

We recently completed a 16-week randomised prehabilitation exercise program (NCT02950324) in esophageal cancer patients before esophagogastric cancer resection. Exercise training was a low-to-moderate intensity twice supervised, thrice home-based weekly program. Tumour specimens obtained at the time of resection were formalin fixed paraffin embedded (FFPE) for multispectral immunohistochemical analysis. Tumour tissues were stained with primary antibodies for CD68, CD57, CD8, CD4, FoxP3, Granzyme B, PDL1 and pancytokeratin. Cell populations and spatial relationships were analysed using the Phenoimager HT (Akoya Biosciences) and QuPath.

Results

Although our exercise program was ~33% of the physical activity guidelines for cancer patients, physical fitness and well-being were maintained rather than significantly reduced in the intervention group compared to the control group. Multispectral analysis observed that 3.2% ± 1.1% of cells in the tumours were CD8+ T cells compared to 1.4% ± 0.5% in the control group (p < 0.001). Furthermore, we observed positive associations between increased frequencies of CD8 + TILs (Fig 1C: r = 0.562, p = 0.016), Granzyme B+/CD8 + TILs (r = 0.637, p = 0.003) and larger increases in exercise induced aerobic capacity. This data suggests that the more exercise can increase aerobic fitness, the greater the likelihood of increasing functional TILs.

Conclusion

New approaches to improve outcomes following surgery for esophageal adenocarcinoma are required. One such approach is immunotherapy. However, immunotherapy is relatively ineffective in esophageal adenocarcinoma due to the lack of CD8+ T cells and NK cells in the tumours. Increasing TILs through exercise programmes that are designed to focus on maintaining or improving aerobic capacity may improve patients’ response to immunotherapy and positively impact prognosis and survival.
436. USEFULNESS OF INTRAOPERATIVE CONTINUOUS NERVE MONITORING IN TRANSMEDIASTINAL MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: Nakamichi Naosuke , Fujiwara Hitoshi , Shiozaki Atsushi , Konishi Hirotaka , Inoue Hiroyuki , Nishibeppu Keiji , Ohashi Takuma , Shimizu Hiroki , Arita Tomohiro , Yamamoto Yusuke , Morimura Ryo , Kuriu Yoshiaki , Ikoma Hisashi , Kubota Takeshi , Otsuji Eigo
Published: August 2023

Introduction

We have previously reported that continuous intraoperative nerve monitoring (CIONM) is useful in reducing postoperative left recurrent laryngeal nerve paralysis (RLNP) in transmediastinal esophagectomy (TME). In this study, we investigated the relationship between the paralysis risk types on CIONM and postoperative RLNP.

Methods

A total of 161 patients who underwent TME for esophageal malignancies and esophagogastric junctional cancer with CIONM between October 2017 and July 2022. The relationship between clinical background factors, changes in amplitude during surgery, and left RLNP (endoscopic vocal cord findings on postoperative day 7) was retrospectively investigated. Furthermore, the relationship between LOS types (segmental or diffuse) and left RLNP was examined.

Results

The median age was 70 years, with 127 male and 34 female patients. At the end of transcervical procedure, 46 patients had amplitude less than 100 μV (LOS: loss of signal) and 78 patients had amplitude ≤50% of baseline. Postoperatively, 76.1% of LOS cases and 46.2% of cases with amplitudes ≤50% of baseline had left RLNP. The amplitude reduction types (LOS, baseline≤50%), primary tumor in the cervical/upper thoracic/middle thoracic esophagus, and males were significantly associated with left RLNP (p < 0.001). When examined by LOS type, RLNP was more common in segmental LOS than in diffuse LOS.

Conclusion

The pattern of amplitude reduction on CIONM is useful in predicting postoperative left RLNP. We will continue to increase the number of cases and verify the further effectiveness of CIONM for TME.
442. REFLUXSTOP PROCEDURE AS A NOVEL TECHNIQUE FOR MANAGEMENT OF GASTROESOPHAGEAL REFLUX DISEASE: TWO-YEAR FOLLOW-UP DATA AT A HOSPITAL IN SWITZERLAND
Authors: Borbély Yves , Kroell Dino , Martinelli Claudine Di Pietro , Haltmeier Tobias , Prevost Gian
Published: August 2023

Background

RefluxStop is a nonactive implantable medical device that aims to reduce gastroesophageal reflux disease (GERD) symptoms without compression of the food passageway. It restores the normal anatomy of the lower esophageal sphincter, gastroesophageal flap valve, and angle of His. This study presents data from two-year follow-up of patients managed with the RefluxStop procedure at a tertiary level hospital.

Methods

A total of 45 patients with GERD were treated with RefluxStop between January 2019 and December 2022 at a single institution in Switzerland. Two-year follow-up was recently completed for 20 of these patients. Reported outcome measures include GERD health-related quality of life (GERD-HRQL) score, proton pump inhibitor (PPI) usage, and intra- or postoperative adverse events (AEs).

Results

Patients were aged 49 ± 13.6 years with a body mass index of 27 ± 2.9 kg/m2. The mean size of hiatal hernia was 2.81 ± 1.97 cm. GERD-HRQL score at baseline was 21 ± 9.28 with two-year postoperative follow-up demonstrating a 85.7% reduction to 3 ± 3.66. All patients showed significant improvement in primary GERD symptoms such as heartburn and regurgitation, with one exception. This patient was converted to Toupet fundoplication but experienced recurrent symptoms. Of the 19 patients managed by RefluxStop, only one patient (5.2%) required use of PPIs for refractory symptoms. Serious AEs were experienced by 3 patients at one-year follow-up, none of which were device-related.

Conclusion

The effectiveness of RefluxStop as a novel technique to manage GERD was demonstrated by this study. Further investigation via ongoing prospective studies, such as head-to-head trials comparing RefluxStop to fundoplication techniques, are already in preparation.
455. SIGNIFICANCE OF NUTRITIONAL EVALUATION USING GLIM CRITERIA IN PATIENTS WITH ESOPHAGEAL CANCER
Authors: Ogata Takashi , Kanematsu Kyohei , Tanabe Emi , Onuma Shizune , Morita Junya , Nagasawa Shinsuke , Yamada Takanobu , Oshima Takashi
Published: August 2023

Background:
464. MINIMALLY INVASIVE IVOR LEWIS ESOPHAGECTOMY IN THE ELDERLY PATIENT: A MULTICENTER RETROSPECTIVE MATCHED-COHORT STUDY
Authors: Scarton Alessia , Capovilla Giovanni , Uzun Eren , Moletta Lucia , Hadzijusufovic Edin , Provenzano Luca , Salvador Renato , Pierobon Elisa Sefora , Zanchettin Gianpietro , Tagkalos Evangelos , Berlth Felix , Lang Hauke , Valmasoni Michele , Grimminger Peter P
Published: August 2023

Background

Several studies reported the advantages of minimally invasive esophagectomy over the conventional open approach, particularly in terms of postoperative morbidity and mortality. The literature regarding the elderly population is however scarce and it is still not clear whether elderly patients may benefit from a minimally invasive approach as the general population. We sought to evaluate whether thoracoscopic/laparoscopic (MIE) or fully robotic (RAMIE) Ivor-Lewis esophagectomy significantly reduces postoperative morbidity in the elderly population.

Methods

We analyzed data of patients who underwent open esophagectomy or MIE/RAMIE at Mainz University Hospital and at Padova University Hospital between 2016 and 2021. Elderly patients were defined as those ≥75 years old. Clinical characteristics and the postoperative outcomes were compared between elderly patients who underwent open esophagectomy or MIE/RAMIE. A 1-to-1 matched comparison was also performed. The difference in overall survival (OS) and disease free survival (DFS) between the two group was also evaluated. Patients <75 years old were evaluated as a control group.

Results

Among elderly patients MIE/RAMIE were associated with a lower morbidity (39.7% vs. 62.7%, p = 0.005), less pulmonary complications (32.8 vs. 56.9%, p = 0.003) and a shorter hospital stay (13 vs. 18 days, p = 0.03). Comparable findings were obtained after matching. Among <75 years-old patients, a reduced morbidity (31.2% vs. 43.5%, p = 0.01) and less pulmonary complications (22% vs. 36%, p = 0.001) were detected in the MI group. No difference was detected in the OS of the >75y MI group (26 months) and the >75y open group (19 months)(p = 0.84). The DFS was also similar (26 months vs. 13 months, p = 0.25).

Conclusion

Therefore, minimally invasive esophagectomy improves the postoperative course of elderly patients reducing the overall incidence of postoperative complications, particularly of pulmonary complications.
470. DO RADIOLOGISTS ALWAYS USE ORAL CONTRAST DURING CT SCANNING FOR POST-ESOPHAGECTOMY ANASTOMOTIC LEAK: SURVEY OF PROTOCOLS IN THE UK
Authors: Panackal Rohit , Sudlow Alexis , Kulasegaran Suheelan , Kumar Bhaskar
Published: August 2023

Background

Anastomotic leak (AL) is a life-threatening complication following esophagectomy. Early and accurate diagnosis is key. Although computerized tomography (CT) scan is a widely employed diagnostic modality, there is no consensus on whether oral contrast should be used in addition to IV contrast. We sought to survey protocols regarding the use of oral contrast amongst specialist radiologists when using CT scan to diagnose AL.

Methods

An online questionnaire was sent to 27 consultant gastrointestinal (GI) radiologists with a subspecialist esophageal interest from 11 tertiary centres. Participants were primarily asked for their preferred imaging modality to diagnose AL, choice of contrast if a CT scan was used (assuming no contraindications for IV contrast) and an explanation for their preferred choice of investigation.

Results

The response rate was 96.3% (n = 26). Most participants (16 [61.5%]) used CT scan as first choice modality, while six (23.1%) used fluoroscopy and two (15.3%) used CT scan and fluoroscopy. With CT scan, half the participants preferred using both oral and IV contrast to IV contrast alone. No participants chose oral contrast alone. Some participants who used oral contrast felt it helped differentiate between normal post-surgical changes and true leaks. Limitations of using oral contrast included concerns of missed leaks involving the anterior aspect of the esophagus and lowered enhancement of the esophageal mucosa.

Conclusion

The majority of radiologists favor using oral contrast in addition to IV contrast for CT scan for suspected AL. In spite of this, practice is variable even amongst radiologists from the same unit. The lack of consensus emphasizes the need for further research to establish best practice and formulation of guidelines.
484. ROBOTIC ASSISTED PRONE ESOPHAGECTOMY USING VERSIUS PLATFORM: A PROMISING APPROACH
Authors: Maurice Karim , Moussa Hatem , Hawary Ramy , Nabil Ahmed , Hamour Dina , Mikhail Sameh , Shazly Mostafa
Published: August 2023

Background

Esophagectomy for cancer is a complex procedure with high morbidity. Minimally invasive approach offers the benefits of minimal access across the different fields required during this operation. Robotic surgery is becoming an integral part of modern practice. It holds the potential of more precision especially in narrow thoracic space. Currently, Many Robotic platforms exist. This video aims to demonstrate the feasibility of Robotic Mc Keown esophagectomy in the prone position using Versius platform.

Methods

56 years old male patient presented with grade I dysphagia of 3 months duration. His complete assessment revealed an 11 cm long invasive non keratinizing squamous cell carcinoma located in the mid esophagus (cT3N1M0). Marked regressive course of the lesion occurred with neoadjuvant chemoradiation. Robotic assisted Mc Keown esophagectomy was performed in the prone position. Thoracic phase was performed with the robotic approach. Bed side units and Port placement is illustrated in the video. The abdominal phase was accomplished laparoscopically. Finally, the stomach was pulled up and the esophagogastric anastomosis was done in the neck.

Results

No intraoperative adverse events were encountered. The improved vision, dexterity and articulation of instruments facilitated the identification of the thoracic duct, ligation of azygos vein tributaries and dissection of the recurrent laryngeal lymph nodes. Instrument clash was insignificant due to patient’s wide chest cavity and optimal positioning of ports and bed side units improving ergonomics. The operative time of the thoracic phase was 310 min. Blood loss was 300 mL. The postoperative course was uneventful except for chest infection which improved on conservative measures. The length of stay was 18 days. Pathology revealed complete clinical response with 0/25 lymph node yield.

Conclusion

Robotic assisted esophagectomy is feasible and can be safely performed using Versius robotic platform. The enhanced visualization and articulation enabled meticulous dissection of the recurrent laryngeal lymph nodes. Patient positioning, optimal port and bed side units placement were keys to achieving minimal instrument clash. Further research is needed to confirm these findings and to compare the long-term oncological outcomes and cost effectiveness of this modality.

Video links:

https://we.tl/t-rpkTHvNlXI

or

https://drive.google.com/drive/folders/1tOsFPrEBUHBpVn8C9jF7BGoNxlYPuBjq?usp=sharing.
493. IRON DEFICIENCY AFTER ONCOLOGICAL ESOPHAGECTOMY AND GASTRECTOMY
Authors: Sallakhi Aria , Baumgartl Isabella Alexandra , Andresen Julian Ramin , Khater Hagar , Gibas Georg , Medibach Amadea , Marolt Cordula , Radlspöck Wolfgang , Zacherl Johannes
Published: August 2023

Removal of the entire stomach or parts of it may affect iron absorption and storage. These conditions mainly caused by altering the acid environment, bypassing the duodenal passage during reconstruction or by chronic inflammatory processes. In addition, patients with esophageal or gastric cancer often have an iron deficiency preoperatively due to malnutrition, gastrointestinal hemorrhage, or inflammatory processes. Sometimes these iron deficiencies lead to microcytic hypochromic deficiency anemia.

Between January 2015 and December 2019, 103 (=66%) esophagectomy patients and 54 (=34%) (sub)total gastrectomy patients were included. Fe, transferrin and ferritin were collected prospectively to be used for retrospective descriptive analysis: preoperatively and three, six, twelve, 18 and 24 months after the operations. The exclusion criteria were: Age below 18, primary bone marrow disease, hereditary forms of anemia, postoperative tumor recurrence, R1/R2 situation. Iron supplementation was not used in the first postoperative year, and thereafter only in cases of a severe iron deficiency. The severity of iron deficiency was classified by ferritin, according to iron deficiency stages I—III.

18% of patients with oncological esophagectomy and 45% of patients with oncological (sub)total gastrectomy have an iron deficiency two years after the operations. This is manifested mainly by pathologically decreased ferritin levels. There is only a significant difference between the groups, with respect to ferritin (p = 0.021) and transferrin levels (p = 0.028), after 2 postoperative years. 75% of esophagectomy patients with iron deficiency were in stage I, 12.5% in stage II and 12.5% in stage III of iron deficiency. 56% of iron deficiency patients with (sub)total gastrectomy were in stage I, 22% in stage II and 22% in stage III.

Patients with (sub)total gastrectomy are more likely to have iron deficiency than patients with esophagectomy during the 24-month postoperative follow-up period. Due to the duodenal bypassing in the (sub)total gastrectomy group a higher prevalence of iron deficiency could have been expected. Most patients have storage iron deficiency (= stage I). Only few patients with iron deficiency have the more severe and decompensated form of iron deficiency, iron deficiency anemia (= stage III).
Atypical presentation and percutaneous repair of ascending aortic pseudoaneurysm: a case report
Authors: Tobías-Castillo Pablo E , Oristrell Gerard , Reyes-Juárez José Luis , Martí-Aguasca Gerard
Published: August 2023

Background

Ascending aortic pseudoaneurysms (AAPs) are an unusual complication of cardiac or aortic surgery and are associated with a high risk of complications and mortality. Guidelines recommend surgical repair. There is few data concerning percutaneous occlusion of AAP. We present a case of syncope due to vascular and heart chamber compression by a large post-surgical AAP that was filled through a focal leak. Ascending aortic pseudoaneurysm was successfully occluded percutaneously.

Case summary

A 66-year-old man with a mechanical aortic prosthesis and a Dacron tube in the ascending aorta presented with syncope due to compression of the right atrium and superior vena cava by a large peritube collection. A computed tomography angiography (CTA) showed a large AAP that was filled through a small focal dehiscence of the tube proximal suture. Patient was dismissed for surgery due to high surgical risk. Then, AAP was successfully occluded percutaneously via a 6-French radial access and local anaesthesia.

Discussion

In patients with syncope and previous cardiac surgery, aortic complications should be ruled out. Although transthoracic echocardiography may be useful, CTA is the recommended diagnostic test for ruling out post-surgical AAP and allows the characterization of the number, localization, and size of the leaks. In selected patients with high surgical risk and favourable anatomic characteristics, a percutaneous closure could be indicated.
Case Report: emergent percutaneous directional thrombectomy in a patient with cardiogenic shock and large mobile thrombus in the right atrium
Authors: Blasco-Turrión Sara , Plaza-Martín María , Amat-Santos Ignacio J
Published: August 2023

Background

New percutaneous techniques for the management of acute pulmonary embolism (PE) are emerging, but there is lack of data regarding the approach of mobile thrombus in the right chambers, with the added risk of potential thrombus dislodgement that may prevent from mechanical circulatory support devices to be implanted in unstable patients.

Case summary

We present the case of a 65-year-old male with cardiogenic shock of unknown aetiology, severe biventricular dysfunction, and large mobile thrombus in the right atrium. Mechanical circulatory support devices could not be implanted, and current thromboaspiration systems were either too small or not available at that time. However, the patient’s condition deteriorated rapidly with thrombus in transit, hence, a novel approach was required: using a deflectable 14 Fr sheath, directional thrombectomy was performed, achieving complete extraction of the thrombi and allowing for circulatory support with extracorporeal membrane oxygenation (ECMO) to be implanted with outstanding results and progressive weaning of all intensive care measures.

Discussion

Despite the growing interest in the development of percutaneous strategies for acute PE, there is no evidence-based guidelines regarding the treatment of mobile right heart thrombus. Even though some cases of percutaneous right heart thrombectomy have been reported, it is still a challenging scenario, given the potential risk of thrombus dislodgement and atrial perforation. We describe a novel technique of percutaneous directional thrombectomy in a patient with cardiogenic shock of unknown aetiology and large mobile thrombi in the right atrium as a bridge to ECMO proving to be a feasible alternative to treat thrombus in transit.
Refining prediction of stroke in sinus node dysfunction patients without atrial fibrillation using a P-combined score: a multi-centre study
Authors: Dong Haoyu , Zhang Yan , Sun Dongxu , Wang Gaopin , Zhang Qinglong , Hidru Tesfaldet H , Yang Yiheng , Wang Shihao , Wei Yushan , Liu Fei , Zhang Jinpu , Xia Yunlong , Yang Xiaolei
Published: August 2023

Aims

Isolated sinus node dysfunction (ISND) is a sinus node dysfunction without atrial fibrillation. A high risk of ischaemic stroke (IS) has been reported in ISND populations. However, current guidelines do not recommend anticoagulation in ISND management. P-wave indicates ISND-related atrial remodelling. P-wave indices and the CHA2DS2-VASc score may contribute to risk stratification for ISND-related IS.

Methods and results

In this multi-centre longitudinal cohort, ISND patients were divided into development (n = 1185) and external validation (n = 988) cohorts. Ischaemic stroke prediction capacity of the P-combined score was assessed with regard to discrimination, calibration, and clinical effectiveness. The cut-off value of the score was confirmed by using a restricted cubic spline curve. One hundred and twenty-four (10.46%) ISND patients developed IS [1.63%/year; 95% confidence interval (CI): 1.49–1.78%/year] after a median 3.02-year follow-up in the development cohort. The P-wave terminal force in electrocardiogram-lead V1 (PTFV1) was the only significantly abnormal P-wave index (adjusted hazard ratio: 2.56; 95% CI: 1.72–3.80). Therefore, we incorporated the PTFV1 with the CHA2DS2-VASc score to generate a P-combined score. For a 5-year IS risk, the P-combined score improved Harrell’s C-statistic (95% CI) from 0.678 (0.618–0.738) to 0.716 (0.657–0.774) and 0.747 (0.677–0.816) to 0.808 (0.747–0.868) in the development and validation cohorts, respectively, along with calibration and decision curve analyses. The cut-off value of the score was 3 in the development cohort and well-discriminated in the validation cohort.

Conclusion

Chinese ISND patients have a higher IS risk than the general population. Compared with the CHA2DS2-VASc score, the PTFV1-combined CHA2DS2-VASc score shows a better risk-stratification capacity for ISND-related IS.
Down the rabbit hole: reviewing the evidence for primary prevention of cardiovascular disease in people with obesity
Authors: Stumpf Matheo A M , Cercato Cintia , de Melo Maria E , Santos Raul D , Mancini Marcio C
Published: August 2023

Obesity is a prevalent chronic disorder and a well-known risk factor for cardiovascular disease. However, the evidence of treating obesity for primary prevention of major cardiovascular events is still scarce and controversial. In this review, we provided a comprehensive description of the current evidence in treating obesity regarding cardiovascular protection. Bariatric surgery appears to be the most robust method to reduce events in people without established cardiovascular disease. High compliance to lifestyle interventions can further reduce cardiovascular risk. Concerning pharmacological therapies, a post hoc analysis from SUSTAIN-6 and a meta-analysis from STEP trials suggest that semaglutide, a GLP-1 receptor agonist, could reduce cardiovascular events in people without established cardiovascular disease. The first study addressed specifically a high-risk population with diabetes and, the second, low- or intermediary-risk individuals without diabetes. Tirzepatide, a novel dual GIP/GLP-1 agonist, although not yet tested in specific cardiovascular outcomes trials, could be an alternative since it induces loss in weight similar to the achieved by bariatric surgery. Therefore, extrapolated data in distinct baseline cardiovascular risk populations suggest that these two drugs could be used in primary prevention with the aim of preventing cardiovascular events, but the grade of this evidence is still low. Specifically designed studies are needed to address this specific topic.
Association of tobacco smoke exposure with metabolic profile from childhood to early adulthood: the Special Turku Coronary Risk Factor Intervention Project
Authors: Lehtovirta Miia , Pahkala Katja , Rovio Suvi P , Magnussen Costan G , Laitinen Tomi T , Niinikoski Harri , Lagström Hanna , Viikari Jorma S A , Rönnemaa Tapani , Jula Antti , Ala-Korpela Mika , Raitakari Olli T
Published: August 2023

Aims

To investigate the associations between passive tobacco smoke exposure and daily smoking with a comprehensive metabolic profile, measured repeatedly from childhood to adulthood.

Methods and results

Study cohort was derived from the Special Turku Coronary Risk Factor Intervention Project (STRIP). Smoking status was obtained by questionnaire, while serum cotinine concentrations were measured using gas chromatography. Metabolic measures were quantified by nuclear magnetic resonance metabolomics at 9 (n = 539), 11 (n = 536), 13 (n = 525), 15 (n = 488), 17 (n = 455), and 19 (n = 409) years. Association of passive tobacco smoke exposure with metabolic profile compared participants who reported less-than-weekly smoking and had serum cotinine concentration <1 ng/mL (no exposure) with those whose cotinine concentration was ≥10 ng/mL (passive tobacco smoke exposure). Associations of daily smoking with metabolic profile in adolescence were analysed by comparing participants reporting daily smoking with those reporting no tobacco use and having serum cotinine concentrations <1 ng/mL. Passive tobacco smoke exposure was directly associated with the serum ratio of monounsaturated fatty acids to total fatty acids [β = 0.34 standard deviation (SD), (0.17–0.51), P < 0.0001] and inversely associated with the serum ratios of polyunsaturated fatty acids. Exposure to passive tobacco smoke was directly associated with very-low-density lipoprotein particle size [β = 0.28 SD, (0.12–0.45), P = 0.001] and inversely associated with HDL particle size {β = −0.21 SD, [−0.34 to −0.07], P = 0.003}. Daily smokers exhibited a similar metabolic profile to those exposed to passive tobacco smoke. These results persisted after adjusting for body mass index, STRIP study group allocation, dietary target score, pubertal status, and parental socio-economic status.

Conclusion

Both passive and active tobacco smoke exposures during childhood and adolescence are detrimentally associated with circulating metabolic measures indicative of increased cardio-metabolic risk.
First Observations of a Potential Association Between Accumulation of Per- and Polyfluoroalkyl Substances in the Central Nervous System and Markers of Alzheimer’s Disease
Authors: Delcourt Nicolas , Pouget Alix-Marie , Grivaud Alicia , Nogueira Leonor , Larvor Frédéric , Marchand Philippe , Schmidt Eric , Le Bizec Bruno
Published: August 2023

The entire human population is exposed to persistent organic pollutants throughout their lives. Among them, per- and polyfluoroalkyl substances (PFAS) are synthetic chemicals widely used in industrial and consumer products that are known to exert adverse effects on human health. As they bioaccumulate in the human brain and are known to be neurotoxic in experimental models, they are assumed to be involved in neurodegenerative processes. In this proof-of-concept study, we measured the level of 18 PFAS in cerebrospinal fluid (CSF) from 8 patients hospitalized with suspected normal pressure hydrocephalus. We then analyzed whether PFAS levels could be related to both biological and clinical markers of Alzheimer’s disease. We showed that PFAS and perfluorooctanesulfonate were found in all CSF samples from a French region without fluorochemical industries. Moreover, we observed a significant difference between the levels of PFAS and perfluorooctanesulfonate in the CSF of patients with both Alzheimer’s disease markers and cognitive impairment compared with those with only 1 or neither. Two previous studies have shown that PFAS levels in human CSF increase with age and are linked to impaired blood–brain barrier integrity. Our results provide the first evidence of a link between PFAS accumulation in the central nervous system and clinical and biological markers of Alzheimer’s disease.
Perceived Age Discrimination in the Second Half of Life: An Examination of Age, Period, and Cohort Effects
Authors: Ayalon Liat , Bramajo Octavio
Published: August 2023

Background and Objectives

Ageism is defined as stereotypes, prejudice, and discrimination based on age. Perceived age discrimination (e.g., the behavioral component of ageism) is highly prevalent in society, as reported by 1 in 3 people in Europe. The present study examined variations in perceived age discrimination in the second half of life. We adopt a comprehensive approach that examines whether perceived age discrimination varies by age (chronological time from birth), period (the context when data were collected), or cohort (a group of people with shared life events experienced at a similar age) across gender and ethnic origin.

Research Design and Methods

We relied on psychosocial data from the Health and Retirement Survey between 2006 and 2018. We ran a set of age–period–cohort models to determine the separate effects of aging (age) factors, contextual (period) factors, and generational (cohort) factors on perceived age discrimination.

Results

Our findings show that perceived age discrimination increases with age but reaches a plateau around the age of 75. There also were some cohort effects, but they appeared minimal and inconsistent. No period effects were found.

Discussion and Implications

The findings attest to the consistent nature of perceived age discrimination, which is less likely to be affected by external contextual events. It also is less likely to be affected by gender or ethnicity. The findings also suggest that it is older persons who are more likely to report age discrimination, thus, interventions should address ageism in this age group.