bluuebunny/crossref_metadata_2025 huggingface dataset:
180. SINGLE-PORT MEDIASTINOSCOPIC LYMPHADENECTOMY IN THE UPPER AND MIDDLE MEDIASTINUM USING CONTINUOUS INTRAOPERATIVE NERVE MONITORING
Authors: Fujiwara Hitoshi , Shiozaki Atsushi , Konishi Hirotaka , Kubota Takeshi , Ohashi Takuma , Otsuji Eigo
Published: September 2022

The left cervical approach with single-port mediastinoscopy is essential for radical esophagectomy without thoracotomy for esophageal cancer, which provides excellent visibility and handling along the esophagus to achieve radical lymph nodes (LNs) dissection in the upper and middle mediastinum. However, the transcervical procedure dissecting along the recurrent laryngeal nerve (RLN) requires careful use of both energy device for dissection and forceps for surgical field expansion to minimize the risk of RLN palsy.

Using the left cervical approach, the LNs along the left RLN and tracheal bifurcation (subcarinal and bilateral main bronchial LNs) were dissected en bloc with the esophagus. The LNs along the right RLN were basically dissected through a right cervical incision under direct vision or dissected with the left cervical approach if visible. Intraoperative nerve monitoring (IONM) with NIM Response 3.0 was introduced to minimize the risk of RLN palsy. Continuous and intermittent IONMswere used for the left and right cervical procedures, respectively.

Until March 2019, 175 patients underwent transmediastinal esophagectomy. Squamous cell carcinoma was predominant (93.7%). The upper and middle thoracic tumors were the most frequent (65.7%). Since IONM introduction, RLN palsy (grade I or more, CD classification) was significantly reduced. Without IONM (n = 106), the left RLN palsy was observed in 35.9%, while was in 13.6% with IONM (n = 66). In addition, the bilateral RLNs palsy was 14.2% without IONM, while was reduced to 3.0% with IONM.

IONM is useful to reduce RLN palsy in transmediastinal esophagectomy. Especially, continuous IONM, which provides a real-time information on the risk procedure of RLN injury, is effective in preventing RLN palsy. The left cervical procedure with continuous IONM will be shown in movie.
196. RISK FACTORS OF CERVICAL LYMPH NODE METASTASIS IN ESCC AND ESTABILISHMENT OF PREDICTION MODEL
Authors: Gong Taiqian
Published: September 2022

Cervical lymph node metastasis of esophageal squamous cell carcinoma (ESCC) is an important basis for lymph node dissection of ESCC. Now, there are still disputes about whether to perform two field lymph node dissection or three field lymph node dissection. Establishing prediction model by analysis big data could promote the accuracy of prediction of cervical lymph node metastasis in patients with ESCC which can help clinicians to select individualized surgical scheme for patients.

The clinical data of 102 consecutive patients with ESCC who underwent radical esophagectomy and three-field lymph node dissection between December 2015 to December 2021 were retrospectively analyzed. They were divided into positive group and negative group according to cervical lymph node metastasis. The differences between the two groups were compared, and after the univariate analysis those who were statistically significant were included in multivariable logistic regression analysis to establish the risk prediction model and plot a nomogram by software R.

Among the 102 patients, univariate analysis(P<0.2)indicated that cervical lymph node metastasis of ESCC was related to the distance from upper edge of the tumor to the incisors (P = 0.101), vascular invasion (P = 0.144) and recurrent laryngeal nerve lymph nodes metastasis (P = 0.159). Multivariate logistic regression analysis showed that the distance from upper edge of the tumor to the incisors (P = 0.032) and the vascular invasion (P = 0.147) were independent risk factors. The AUC of ROC curve is 0.6817 (95% confidence interval: 0.5775–0.7859) and the Youden index is 0.294, 95% CI (0.620, 0.742).

The prediction model includes two variables: the distance from upper edge of the tumor to the incisors and the vascular invasion. It plays a certain role in predicting the risk of cervical lymph node metastasis of ESCC, and can assist doctors in individualized treatment for patients with ESCC.
199. FAVORABLE OUTCOMES OF JEJUNAL INTERPOSITION RECONSTRUCTION WITHOUT VASCULAR ANASTOMOSIS AFTER ESOPHAGECTOMY FOR CANCER: A SINGLE-CENTER EXPERIENCE OVER TWO DECADES
Authors: Zhao Lilan , Pan Xiaojie , Lin Zhaoxian , Chen Wenshu , Guo Tianxing , Zhu Lihuan , Ou Debin
Published: September 2022

The standard esophageal replacement after esophagectomy for cancer treatment is a gastric conduit. However, when the stomach is not available, a jejunal interposition can be performed under such circumstances. The purpose of this study was to review our experience with this technique especially without requiring microvascular anastomosis of artery or vein, and assess the surgical outcomes.

We retrospectively reviewed the medical records of patients with esophageal cancer who underwent jejunum interposition without vascular anastomosis at our institution from 2003 to 2020. Data pertaining to patient characteristics, operative technique, and postoperative outcomes were collected and analyzed. Factors affecting oncologic outcomes were assessed by Kaplan–Meier estimates and Cox proportional hazards regression analyses. Postoperative quality of life were evaluated by a standard questionnaire.

After 38 months of median follow-up time, 132 patients (122 males and 10 females; aged 40 to 86 years) were included. More than half of the patients (55.3%, 73/132) were above stage III. The operation time required was 294.5 ± 89.7 min, and the drainage time was 8.0 ± 5.3d. Fiveteen patients underwent cervical anastomosis. The anastomotic leakage rate was only 4.5% (6/132) among all the patients. The 90-days mortality rate was 5.3% and the overall survival at 1, 3 and 5 years were 91.7%, 76.8% and 61.8%, respectively. The prognosis was mainly correlated with tumor stage and most patients showed good quality of life.

This is the largest series of jejunal interposition in a single institution from China. The nearly 20-year follow-up data suggests that, even without vascular anastomosis, the procedure using jejunum as an alternative conduit is a feasible procedure for reconstruction after esophagectomy, resulting in low morbidity and favorable prognosis.
203. ESTABLISHING A MASS SPECTROMETRY BASED DIAGNOSTIC TEST FOR OESOPHAGEAL CANCER
Authors: Bringans Scott , Duong Marisa , Laming Connor , Di Prinzio Patsy , Hill Michelle , Lipscombe Richard
Published: September 2022

Diagnosis of oesophageal adenocarcinoma, or Barrett’s oesophagus, a pre-malignant condition associated with an increased risk of the adenocarcinoma, currently requires expensive and invasive endoscopy-biopsy procedures, which are often only performed when obvious symptoms have manifested (usually at a late stage of the disease). A targeted mass spectrometry-based method was developed to analyse serum samples for oesophageal adenocarcinoma.

Panels of lectin-pulled down serum protein biomarkers were identified that correlate with the presence of early stage oesophageal adenocarcinoma (high grade dysplasia). The method was automated and optimised the methodology to measure 33 target peptides in the lectin pulldown in a short 20 minute mass spectrometry run.

Analysis of an initial cohort (n = 50) shows the method to be robust and reproducible with an average intraday CV of 9.3% across the 33 peptides and an average interday CV of 11.5%. A larger cohort (n = 266) showed consistent results and was used to build statistical models which distinguished between disease status, using protein biomarker measurements and simple clinical parameters. Several models achieved good discrimination with AUROC values ranging from 0.89–0.97. Model validation was undertaken in the smaller cohort, with the two best performing models achieving AUROC values of 0.82 and 0.87.

The assay has the potential to produce a clinically viable diagnostic test to support screening and early detection in populations at high risk of oesophageal adenocarcinoma and Barrett’s oesophagus.
206. SINGLE-CELL RNA-SEQ ANALYSIS REVEALS ACCELERATED PROLIFERATION OF ESOPHAGEAL EPITHELIAL CELLS TO ELIMINATE NRF2-ACTIVATED CELLS
Authors: Hirose Wataru , Horiuchi Makoto , Taniyama Yusuke , Kamei Takashi , Taguchi Keiko , Yamamoto Masayuki
Published: September 2022

Nrf2 is a transcription factor that regulates cytoprotective genes in response to oxidative and electrophilic stresses. The activity of Nrf2 is mainly controlled by the protein degradation by Keap1, a ubiquitin E3 ligase adaptor. Most of esophageal squamous cell carcinomas (ESCC) exhibit constitutive Nrf2 activation by Keap1 dysfunction, resulting in the poor prognosis. However, it has not been clarified whether Nrf2 activation serves as the initiation in tumorigenesis of ESCC.

We generated tamoxifen-inducible and squamous epithelium-specific Keap1 conditional knockout (Keap1-cKO) mice in which Nrf2 is activated segmentally in esophageal epithelium at the adult stage. Using Nqo1 that is a representative Nrf2 target gene as the marker of Nrf2-acitivated cells, we distinguished Keap1-deleted/Nrf2-activated cells and Nrf2-normal cells in immunohistochemical analysis and gene expression analysis. Single-cell RNA-seq (scRNA-seq) analysis was conducted to compare the gene expression of Nrf2-activated cells and Nrf2-normal cells from Keap1-cKO mice, and control cells from control mice.

In Keap1-cKO mice, Nrf2-activated cells accounted for 35% at 1 week and 20% at 4 weeks after induction of Keap1 deletion. This decrease was based on observations that Nrf2-activated cells were eliminated from the epithelium due to the weakened attachment to the basement membrane. In contrast, DNA damage accumulated in Nrf2-normal cells neighboring Nrf2-activated cells. To clarify the cell fate in the esophagus, we compared Nrf2-normal cells to Nrf2-activated cells or control cells in scRNA-seq analysis. Gene sets of G2/M checkpoint and E2F targets, which regulate cell proliferation, were enriched in Nrf2-normal cells.

Constitutive Nrf2 activation renders esophageal epithelial cells able to be selectively eliminated via cell competition. Nrf2-normal cells suffered from DNA damage, but not Nrf2-activated cells, have a potency to be an origin of ESCC. These results suggest that Nrf2 activation serves as a tumor promoter of ESCC, but not the initiator. We speculate that the other gene mutations such as Tp53 are needed for the initiation to form ESCC prior to Nrf2 activation.
220. DOES LYMPH NODE YIELD IMPROVE WITH ADVANCING TECHNOLOGIES IN OESOPHAGECTOMIES: 12 YEARS ON
Authors: Chaudhury Madhu , Singh Mohan , Shetty Vinutha Daya , Ward Jeremy , Ball Chris , Turner Paul , Pursnani Kishore
Published: September 2022

Oesophagectomy involves resection of tumour along with surrounding lymph nodes (LN). One of the quality indicators suggesting successful oesophagectomy is the number of LNs retrieved in dissection. Current available data remains controversial on benefits of high lymph node yield for patient receiving neoadjuvant and on disease-free survival. In our cancer centre, we have evolved in performing Oesophagectomies from open to laparoscopic to more recently robotically (Da Vinci Xi, Intuitive Surgical) over the last 3 years.

This was a retrospective study using the electronic database containing information on patients who underwent elective cardio-oesophagectomy from April 2009 to December 2021 in a Tertiary Upper GI cancer centre. SPSS V22 was used to calculate any statistical difference (p < 0.05).

A total of 560 patients underwent cardio-oesophagectomy. The median length of stay was 13 (Range 3 to 148) days and the median age was 62 (49–79) years. M/F 2:1. The median lymph node yield between open, MIO and robot 17 (12–45) nodes, 15 (11–40) and 17 (0–31) respectively. Non parametric comparisons were made between each group, the p-value found in each group (details on table, attached separately).

Our robotic data is still at its infancy. Based on our current findings, it suggests the trend that with advancement in technology resulting in better visualization of anatomy as well as improved economy of movement during robotic surgery, there is the advantage of increased lymph node yield which can contribute to improving patient prognosis.
230. ENDOSCOPIC REFERENCE SCORE REMODELING SUBSCORE AND ESOPHAGEAL EOSINOPHIL COUNT DO NOT CORRELATE IN PLACEBO-TREATED EOSINOPHILIC ESOPHAGITIS PATIENTS FROM DUPILUMAB STUDIES
Authors: Hirano Ikuo , Rothenberg Marc E , Spergel Johnathan M , Aceves Seema , Greenhawt Matthew , Schoepfer Alain M , Philpott Hamish , Chen Zhen , Radwan Amr , Khodzhayev Angela , Deniz Yamo , Rowe Paul J , Pela Tiffany , Jacob-Nara Juby A
Published: September 2022

Although eosinophils are the hallmark of eosinophilic esophagitis (EoE) with threshold levels required for diagnosis, their exact role in EoE is unclear. The EoE-Endoscopic Reference Score (EREFS) assesses endoscopic inflammatory (edema/exudate/furrows) and remodeling (rings/strictures) features. We assessed the correlations between peak esophageal intraepithelial eosinophil count (eos/high-power field [hpf]) and EREFS in placebo-treated EoE patients from two clinical trials: phase 2 proof-of-concept (POC; NCT02379052; n = 24) and part A of phase 3 TREET (Phase3-PartA; NCT03633617; n = 39).

POC was a 12-week trial in adults and Phase3-PartA was a 24-week trial in adults and adolescents. Endoscopic examination of the esophagus was performed at baseline (BL) and end of treatment (EOT) and scored for inflammatory and remodeling subscores and total score using EREFS (higher scores indicate greater severity). Peak eos/hpf was measured from pinch biopsies of proximal, mid, and distal esophagus at BL and EOT. Pearson correlations were performed between total/proximal/mid/distal eos/hpf and EREFS total, subscores, and components at BL, EOT, and for change from BL at EOT.

Some strong correlations (r > 0.5) were observed between total peak eos/hpf and EREFS at BL in both studies and at EOT in Phase3-Part A (Table). Moderate-to-strong correlations (r > 0.3) were observed between total peak eos/hpf and EREFS inflammation subscore and edema/exudates/furrows individual components (some P > 0.5) in both studies. Correlations of total peak eos/hpf with EREFS remodeling subscore and rings/stricture components were not significant (P = 0.07–0.94). Peak eos/hpf in the proximal, mid, or distal esophagus were more strongly associated with EREFS inflammation subscore (majority moderate-to-strong correlations; P = 0.001–0.66) than EREFS remodeling subscore (weak correlations, P = 0.22–0.99) at BL/EOT for both studies.

In these EoE patients, moderate-to-strong correlations were observed between eos/hpf and endoscopic markers of inflammation. No strong correlations were observed between total, proximal, mid, or distal peak eos/hpf and endoscopic parameters of remodeling. These data support a role for intact eosinophils in inflammatory changes in the esophagus in EoE and demonstrate the need for both histology and endoscopic evaluation. Further study, with larger sample sizes, is required to verify these findings in other contexts.
232. EVALUATING THE CORRELATION BETWEEN CLINICAL AND PATHOLOGICAL TUMOUR AND NODAL STAGING IN OESOPHAGEAL CANCER –A 12 YEAR ANALYSIS
Authors: Chaudhury Madhu , Ball Chris , Shetty Vinutha Daya , Ward Jeremy , Pursnani Kish , Turner Paul , Singh Mohan
Published: September 2022

Oesophageal cancer is clinically staged using the TNM classification by modalities such as CT, PET-CT and endoscopic ultrasound. This is used to assess and guide oncological treatment in the form of neoadjuvant chemotherapy, radiotherapy and surgery. Following neoadjuvant therapy and/or surgery the resected specimen is analysed and given a final histological stage. The purpose of this study was to evaluate the accuracy and variation in pre-operative (radiological) stage from the final histopathological stage.

This retrospective study was conducted using an electronic database containing pre- and post-operative TNM staging information on all patients undergoing elective oesophagectomies from April 2009 to December 2021 at a single tertiary upper gastrointestinal cancer centre.

568 patients underwent Ivor Lewis oesophagectomies. The median age was 63 years old (45–82) with M:F 1.78:1. The median length of stay (LOS) was 13 (3–148) days. Results on table attached.

Based on our data, there is an observed significant down-staging amongst tumours with higher T and N stages from their predicted pre-operative stage to the final TNM stage allocated after histopathology review. This reflects the continued value of neoadjuvant chemo(radio)therapy. Early T1N0 tumours still appear challenging to accurately stage pre-operatively, hence adjuncts such as endoscopic ultrasound remain crucial in guiding management.
235. NEAR-INFRARED FLUORESCENCE IMAGING OF THORACIC DUCT IN MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: Cheng Sida , Yang Feng , Li Hao , Zhou Jian , Zhao Xiaoyi , Zhou Zuli , Li Jianfeng , Li Yun
Published: September 2022

Chylothorax is a serious complication after esophagectomy and an important reason for reoperation and prolonged hospital stay. A clear localization of thoracic ducts (TDs) and the potential leakage site is an ideal strategy to prevent postoperative chylothorax. In order to explore the feasibility and safety of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify TDs and potential chyle leakage during video-assisted thoracoscopic esophagectomy, a prospective clinical trial was conducted.

We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy for esophageal cancer in this prospective, single-arm clinical study between December 2020 and December 2021. The primary endpoint was the performance of NIR-FI in identifying TDs and chyle leakage. The ICG was injected subcutaneously into the right inguinal region 30 minutes before the thoracic operation, and it becomes fluorescent when excited by the light with a special wavelength in the NIR system. According to the intraoperative demands, surgeons can observe the position of the TDs under the real-time guidance of NIR-FI.

In 38 of 41 patients (92.7%) using NIR-FI, TDs were clearly visible in high contrast. The mean signal-to-background ratio (SBR) of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligation were performed intraoperatively. No patient had postoperative chylothorax.

NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs, as well as determine the source of chyle leakage, to prevent TD injury and direct selective TD ligation. It’s an effective navigation tool to minimize the incidence of chylothorax after minimally invasive esophagectomy.
242. ENDOSCOPIC MUCOSAL CONGESTIVE CHANGE ON POSTOPERATIVE DAY 1 AS A PREDICTIVE FACTOR OF POSTOPERATIVE ANASTOMOTIC STRICTURE
Authors: Fujiwara Naoto , Ito Sono , Shigeno Takashi , Kakuta Ryota , Shinohara Hajime , Shiobara Hiroyuki , Saito Katsumasa , Hoshino Akihiro , Okada Takuya , Kawada Kenro , Tokunaga Masanori , Kinugasa Yusuke
Published: September 2022

Anastomotic stricture is one of the crucial complications after the esophageal cancer surgery. Although anastomotic leakage is said to be a risk factor, anastomotic stricture can also occur without anastomotic leakage. From 2008, we have routinely conducted endoscopy on postoperative day 1, and evaluated the anastomotic site or mucosal condition of reconstructed organ. Among these data, we focused on the mucosal congestive change and examined the association with postoperative anastomotic stricture.

From 2010 to 2015, 203 esophageal cancer patients were conducted esophagectomy with retrosternal gastric tube reconstruction in Tokyo Medical and Dental University. Among them, 197 patients for which endoscopic data on postoperative day 1 were obtained were included in this study. Mucosal congestion was defined as blue or black color on endoscopic findings, and classified into four groups as absent, mild, moderate, and severe. Univariate and multivariate analysis were performed to clarify the relationship between the mucosal congestive change on endoscopic findings and occurrence of postoperative anastomotic stricture.

Among 197 patients, 60 patients (30.4%) experienced postoperative anastomotic stricture. Univariate and multivariate analysis revealed that the mucosal congestive change as moderate or severe was the independent risk factor for postoperative anastomotic stricture along with lower pathological Stage. Circular stapler size used for esophago-gastric anastomosis or postoperative anastomotic leakage were not independent risk factors for postoperative anastomotic stricture in this study.

It is said that congestive change induces secondary ischemia because of the high internal tissue pressure, and sometimes causes more severe damage than arterial ischemia. Our postoperative endoscopic evaluation method is useful to detect the risk of developing anastomotic stricture in early postoperative state. In such cases, management of postoperative fluid balance might be important to prevent postoperative anastomotic stricture, but it requires further investigation.
262. A STUDY OF METASTATIC LOCATION AND PROGNOSIS FOR ESOPHAGEAL CANCER WITH ONE OR TWO METASTATIC LYMPH NODES
Authors: Natsuki Seiji , Lee Shigeru , Tanaka Hiroaki , Mori Takuya , Deguchi Sota , Miki Yuichiro , Yoshii Mami , Tamura Tatsuro , Toyokawa Takahiro , Maeda Kiyoshi
Published: September 2022

Esophageal cancer has high frequency of lymph node (LN) metastasis and poor prognosis, and often relapse early even after radical esophagectomy. Extensive LN dissection has made it possible to grasp the detailed metastatic status and the relationship between LN metastasis and prognosis. It is necessary to study more about metastatic style and prognostic factors for minimalization of surgical invasion and individualization of treatment.

We analyzed about metastatic location, prognosis and recurrence for esophageal cancer cases with a few LN metastasis. We study 168 stageII, III esophageal cancer cases that underwent radical esophageal resection with regional LN dissection (D2 or more) from January 2015 to December 2017. Those cases included 37 or 29 cases with one or two LN metastasis.

The number of cases on each tumor location (Ce/Ut/Mt/Lt/Ae) were 4/19/80/55/10 cases. On LN dissection, D2 were 68 cases and D3 were 100 cases. In a comparison of survival rate, age (<65/≧65), lymphatic invasion, the number of metastatic lymph node have significant difference. The 5-years overall survival rate of esophageal cancer with one or two metastatic LNs was each 82.9% or 65%. Most of a few LN metastasis cases have first group LN metastasis (11th Japanese Classification of Esophageal Cancer), for example No.106rec or abdominal LNs, but we didn’t sometimes detect them prior to surgery.

Esophageal cancer with a few metastatic lymph nodes had relatively good prognosis, and metastasis was likely to stay nearby the primary lesion. However, it is difficult to detect metastasis precisely prior to surgery, so developing the further technique of diagnosis and individualized treatment are expected in the future.
284. VALUE OF EXTENDED AND TOTAL MEDIASTINAL LYMPHADENECTOMY IN ESOPHAGEAL TUMORS
Authors: Pardo Luis Hurtado , Navarro Fernando Mingol , Esteban Marcos Bruna , Audí David Abelló , Jiménez Míriam Menéndez , Alonso Carla Pérez , Sánchez Marta Nieto , Urbaneja Javier Vaqué
Published: September 2022

The extent of lymphadenectomy in esophageal cancer surgery is a point of controversy at present, although the most recent evidence shows that survival is directly related to the number of nodes removed during surgery.

Descriptive study of patients with esophageal neoplasia who underwent esophagectomy with extended and total mediastinal lymphadenectomy by minimally invasive approach (right prone thoracoscopy, laparoscopy and left cervicotomy) in our center from January 2019 to December 2021. The data of patients included were retrospectively examined. Extended lymphadenectomy was indicated in patients with distal third adenocarcinoma type tumors while total lymphadenectomy was indicated in patient with squamous tumors and middle third adenocarcinoma. The primary endpoint was the incidence of affected lymph nodes in the upper mediastinum based on pathological examination. The secondary endpoint was to analyze the short-term outcomes.

A total of 45 patients were included (26.7% extended and 73.3% total mediastinal lymphadenectomy). The median number of removed nodes was 2 (IQR 4–1) and 2 (IQR 3–1) in the right and left recurrent area, respectively. Overall, the median incidence of recurrent lymph node metastases was 11.1%. Twenty percent of the patients with adenocarcinoma (100% distal third) and 0% of the patients with squamous cell carcinoma had positive recurrent nodes. Ninety-day mortality was 15.6%. With respect to postoperative complications such as recurrent laryngeal nerve paralysis was present in 24.4%. Anastomotic leakage was present in 20% (4.4% thoracic and 15.6% cervical).

Based on our results, extended and total lymphadenectomy increases both the overall number of lymph nodes removed and the number of affected nodes. This prevalence of positive recurrent nodes is not negligible. This greater radicality is associated with significant morbidity. The results of this study support the performance of extended lymphadenectomies also in distal third adenocarcinomas.
285. HOW TO DO IT? SUPRACARINAL APPROACH OF THE LEFT RECURRENT LARYNGEAL NERVE AREA FOR LYMPHADENECTOMY DURING THORACOSCOPIC ESOPHAGECTOMY
Authors: Pardo Luis Hurtado , Navarro Fernando Mingol , Esteban Marcos Bruna , Jiménez Míriam Menéndez , Alonso Carla Pérez , Sánchez Marta Nieto , Chicote Cristina Martínez , Urbaneja Javier Vaqué
Published: September 2022

It is important to know the anatomical relationships of the left recurrent laryngeal nerve during the total mediastinal lymphadenectomy. The objective of this procedure is to resect the lymph nodes located in this area without damaging the nerve. In order to approach the left recurrent laryngeal nerve (LRLN) area it is important to know different strategies to achieve this objective.

This video illustrates different ways of approaching the LRLN area during thoracoscopic esophagectomy.

The first approach illustrated, the esophagus is completely retracted to the right side. With this strategy it is possible to visualize the left paratracheal groove, and tissues and lymph nodes around LRLN are tented. The next approach consists of leaving the esophagus attached on its right and anterior side, creating an ample window, through which the LRLN area can be approached. Another approach involves section of the proximal esophagus. Once that the esophagus is dissected to the thoracic apex, it is divided proximal of the tumor with a stapler. Retraction of this stump creates an optimal view of the area.

Standardization of the supracarinal approach is necessary to improve dissection of the LRLN area and achieve a more adequate surgical resection with a low rates of complications.
293. STRATEGY FOR RECONSTRUCTION AFTER ESOPHAGECTOMY—AIMING FOR ESOPHAGO-GASTRIC ANASTOMOSIS WITHOUT LEAKAGE, NECROSIS, STENOSIS
Authors: Kurahashi Yasunori , Nakamura Tatsuro , Kono Shugo , Hojo Yudai , Nakao Eiichiro , Ishida Yoshinori , Shinohara Hisashi
Published: September 2022

The important points in esophagogastric anastomosis after esophagectomy are ensuring blood flow at the tip of the gastric tube and releasing tension at the anastomotic site. The biggest drawback of the retrosternal route is the narrow space behind the sternoclavicular joint at the thoracic inlet, which increases the risk of anastomotic leakage and stenosis.

We note the following three points during anastomosis. (1) Confirm the blood flow of the gastric tube using ICG fluorescence method, (2) Insert circular stapler from the side wall of the gastric tube and be careful not to put tension on the wall of the gastric tube. (3) Adjust the length of the residual esophagus so that the anastomotic site is not located behind the sternoclavicular joint that can cause anastomotic leakage and stenosis.

Of the 132 cases of subtotal esophagectomy for esophageal cancer performed in our department from January 2017 to March 2022, 94 cases underwent retrosternal reconstruction. There are 66 and 28 cases, respectively, before and after the procedure revision in November 2020. Improvement was observed in the incidence of anastomotic leakage which decreased from 43.9% to 10.7%, and the incidence of anastomotic stenosis which decreased from 34.8% to 17.9%.

It is suggested that securing blood flow at the tip of the gastric tube, releasing the tension at the anastomotic site, and adjusting the anastomotic site not to be located behind the sternoclavicular joint may reduce anastomotic leakage and stenosis in the retrosternal esophagogastric anastomosis after esophagectomy.
296. A BEGINNER’S THREE-YEAR LEARNING CURVE WITH ESOPHAGECTOMIES: A STUDY FROM A PERIPHERAL CANCER CENTRE IN NORTH-EAST INDIA
Authors: Das Gaurav
Published: September 2022

North-East India has a high incidence of esophageal cancer but lacks good infrastructure for cancer care delivery. I aim to present my experience with esophagectomies done in a cancer center of the region, as a beginner immediately after completion of broad specialty surgical oncology training. The objectives include estimation of 30-day morbidity and mortality rates and the short-term oncological outcomes including nodal yield and completeness of resection.

Retrospective observational study of a prospectively maintained database, during the study period from 1st November 2018 to 31st March 2022 (29 months). All patients had confirmed diagnosis of esophageal cancer and underwent esophagectomy by the same surgeon. They received neoadjuvant treatment as per institutional protocol. The results were presented with median values, range and percentages.

46 patients underwent esophagectomy; one had inoperable disease. Clinicopathological factors are in Table 1. 74.5% had neoadjuvant chemoradiation (NACRT). Minimally invasive trans-thoracic esophagectomy (67.4%) was favoured approach (conversion rate of 6%). 41.3% had ‘extended 2-field’ lymphadenectomy. 30-day mortality was 4.2% and morbidity included hoarseness of voice (17.4%), anastomotic leak (10.9%) and pneumonia (8.7%). Median nodal yield was 12 (range 4 to 48). Pathological complete response was noted in 44.1% of post-NACRT patients. Margin-negative resection was achieved in 91.3% patients. After median follow up of 20 months, 5 locoregional and 3 distant recurrences were noted. 76.6% patients are alive without disease.

Surgical audit is key at the beginning of a surgical career to gain insights into learning curve and areas of improvement include nodal yield and morbidity rates. The high margin negative resection rates are partly attributable to selection bias of a beginner.
300. RETROSPECTIVE STUDY FOR EVALUATING IMPACT OF NEOADJUVANT THERAPY USING CDDP +5-FU TOWARD ELDERLY ESOPHAGEAL CANCER PATIENTS
Authors: Ozawa Yohei , Taniyama Yusuke , Sato Chiaki , Okamoto Hiroshi , Fukutomi Toshiaki , Koseki Ken , Akaishi Ryujiro , Horie Yuta , Yamauchi Takuro , Kamei Takashi
Published: September 2022

A number of elderly esophageal cancer patients who have eligibility for radical esophagectomy are increasing. However, we have no clearly evidence of treating strategy for these population because mostly high evidential clinical studies doesn’t include over 75-year-old patients. In this study, we retrospectively assessed efficacy of neoadjuvant chemotherapy using CDDP +5-FU in over 75-year-old patient in our hospital.

We extracted total 105 over 75-year-old esophageal cancer patients who underwent radical esophagectomy from 2007 to 2020 in our hospital. We classified them Group A (surgery alone) and Group B (neo-FP(±RT) + surgery) and analyzed perioperative surgical risk, surgical outcomes, and adverse events or effectiveness for neoadjuvant therapy. Furthermore, long-term survival was assessed by using matched cohort from propensity score matching.

Preoperative risk score calculated by E-pass scoring system was significantly higher in group A while surgical score was similar between two groups. Among group B, 86% of patients were underwent neoadjuvant chemotherapy (NAC) and its completion rate was 78.9%. Number of the patients occurred adverse events during NAC were 8/7/12/3 in the G1/2/3/4 respectively. Postoperative complications decided by Clavien-Dindo classification weren’t seen significant difference between two groups. Postoperative in hospital days were significantly shorter in group A.

Survival analysis showed significantly worse overall survival and disease-free survival in group A in both all cohort and matched cohort.

The level of preoperative risk score was different between two different treatment strategies. Although this study has several limitations including low number population, difference of preoperative risk, and short follow up period, neoadjuvant therapy using FP may safety and effective treatment for elderly esophageal cancer patients.
302. PATIENT SPECIFIC AUGMENTED REALITY IN EXTENDED ROBOTIC ESOPHAGUS RESECTION FOR TYPE II GASTRO- ESOPHAGEAL JUNCTION ADENOCARCINOMA
Authors: Faiz Kaneshka , Faiz Zohra
Published: September 2022

For several procedures augmented reality (AR) allowed surgeons to work by the realtime visual feedback of the surgery field during lockdown by the COVID-19 pandemic. Integrating AR into medical practice could play a key role for the improvement of the learning curve and lower the costs. Also renovate the educational model with one consensus regarding the financing of medical specialist degree.

A global surgical model has not yet been achieved for type II adenocarcinoma of the gastro-esophageal junction (GEJ), while its incidence increases worldwide. Controversies exist about the type of resection. Minimally invasive surgery provides magnified anatomy that enables to perform dissection at the appropriate planes. This technique has made possible the standardization of surgery by ‘concentric-structured model’ for cancers arising in the middle part of esophagus. A patient specific model for GEJ will be conducted using the data of surgeries applied to the real anatomy with AR. The validity will be investigated, conforming the images.

Dutch single-center cohort study have demonstrated that after gastrectomy a positive margin was more common. While, esophagus resection provided a more complete lymph node dissection. The CARDIA trial has shown that one of the strongest independent prognostic factors is the presence of metastatic lymph nodes. Importantly, patients with positive upper mediastinal lymph nodes had a poorer prognosis. Related to this, German group have shown feasibility and superiority of a fully robotic surgery allowing a highly controlled lymph node dissection. Also, Korean study reported favorable outcomes of full four-arm robotic compared to robotic surgery combined with open abdominal surgery.

The increasing incidence of GEJ cancers, the different approaches and emerging new minimal invasive and robotic approach need a comprehensive anatomy concept of the type II GEJ. By having a global concept of surgical anatomy, surgery procedures can be performed consistently and standardized worldwide.
315. PATIENT-DERIVED ESOPHAGEAL ADENOCARCINOMA ORGANOIDS TREATED WITH CHEMOTHERAPEUTIC AGENTS MAY PREDICT TUMOR RESPONSE IN VIVO
Authors: Bolger Jarlath , Allen Jonathan , Radulovich Nikolina , Ng Christine , Allison Frances , Bach Yvonne , Akhter Akhi , Shathasivam Premalatha , Elimova Elena , Tsao Ming , Darling Gail , Yeung Jonathan
Published: September 2022

The current management of locally-advanced esophageal adenocarcinoma (EAC) includes neoadjuvant therapy; however, there are no robust markers that predict treatment response. While 25% of patients will have a complete pathological response, up to 40% will have little or no response. Identification of this non-responsive subgroup prior to treatment could allow personalization of induction regimens. This study aims to determine the feasibility of using patient-derived organoids (PDOs) generated from EAC to predict induction treatment response.

PDOs were generated from endoscopic biopsies taken pre-treatment in patients with locally advanced (LA) or metastatic (M) esophageal cancer. For those with LA disease, samples were also taken post-resection. PDOs were established, passaged, then treated with a drug panel of platinum-based drugs, taxane-based drugs, topoisomerase inhibitors and 5-flurouracil. Treatment response curves and growth metrics were mapped back to treatment response, based on pathological tumor regression grade in the LA group and clinical response based on cross-sectional imaging in the M group.

19 organoids from 7 LA tumors and 10 organoids from 8 M tumors were treated. For LA PDOs, there were significant correlations between cisplatin IC50 (p = 0.007), EC50 (p = 0.002) and TRG. There was a correlation between paclitaxel AUC and TRG (p = 0.02). There were no correlations with irinotecan or 5-FU drug metrics and TRG. For M PDOs, there was a correlation between cisplatin and clinical response for AUC (p = 0.04), and a trend for IC50 (p = 0.07). There were also correlations between paclitaxel and clinical response for IC50 (p = 0.04) and AUC (p = 0.01). There were no correlations with irinotecan or 5-FU.

Treatment responses of EAC PDOs treated in vitro with standard chemotherapeutic agents may predict clinical response in the corresponding patient’s tumor. A PDO model may form the basis for screening therapeutic agents in the neoadjuvant window, allowing the development of truly personalized neoadjuvant strategies.
330. RANDOMIZED PHASE II STUDY OF DOCETAXEL VERSUS PACLITAXEL IN PATIENTS WITH ESOPHAGEAL SCC REFRACTORY TO FLUOROPYRIMIDINE- AND PLATINUM-BASED CHEMOTHERAPY: OGSG1201
Authors: Matsuyama Jin , Yamamoto Sachiko , Kii Takayuki , Hara Hiroki , Kawabata Ryohei , Kawada Junji , Takeno Atsushi , Ueda Shugo , Kawakami Hisato , Okita Yoshihiro , Endo Shunji , Kimura Yutaka , Yanagihara Kazuhiro , Okuno Tatsuya , Kurokawa Yukinori , Shimokawa Toshio , Satoh Taroh
Published: September 2022

There is no standard chemotherapy for esophageal squamous cell carcinoma (ESCC) refractory to first-line fluoropyrimidine- and platinum-based chemotherapy. We therefore performed a randomized, selection-design phase II trial to compare docetaxel (DTX) and paclitaxel (PTX) in this setting.

Eligible patients were randomly assigned to receive either DTX (70 mg/m2 on day 1 of each 21-day cycle) or PTX (100 mg/m2 on days 1, 8, 15, 22, 29, and 36 of each 49-day cycle). The primary end point was overall survival (OS), and secondary end points included progression-free survival (PFS), time to treatment failure (TTF), response rate (RR), and safety. Seventy-eight eligible patients (N = 39 in each group) were included for efficacy analysis.

The median OS was significantly longer in the PTX group (8.8 vs. 7.3 months; hazard ratio [HR], 0.62; P = 0.047). A significant benefit of PTX over DTX was also apparent in the median PFS (4.4 vs. 2.1 months; HR, 0.49; P = 0.002) and median TTF (3.8 vs. 2.1 months; HR, 0.45; P < 0.001). RR (25.6% vs. 7.7%, P = 0.065) were higher in the PTX group. Neutropenia (80% vs. 28%) and leukopenia (76% vs. 28%) of grade 3 as well as febrile neutropenia (46% vs. 0%, P < 0.0001) occurred more frequently in the DTX group.

PTX showed a significantly better efficacy as well as a more manageable toxicity compared with DTX.
339. RESULTS OF LEFT COLON RECONSTRUCTION FOR ESOPHAGECTOMY IN A LOW VOLUME HOSPITAL IN JAPAN
Authors: Suenaga Takahiro , Nakanishi Yasutaka , Hata Hiroaki , Degawa Kanako , Moriyama Masaaki , Kanbe Hiroyuki , Miki Akimori , Yamaguchi Takashi
Published: September 2022

Our hospital is a low volume hospital that performs about 5–10 esophageal cancer surgeries per year in Japan. We aimed to evaluate the results of colon reconstruction in our hospital and the appropriateness of performing this procedure in a low volume hospital.

We retrospectively examined complications such as suture failure, conduit necrosis, and anastomotic stenosis in colon reconstruction cases performed at our hospital from 2012 to 2022.

Five cases were performed. In all cases, we have confirmed arterial supply of colon by dynamic CT before surgery, and have chosen to posterior mediastinal reconstruction using the left-sided colon. Esophageal-colon anastomosis was performed, with hand-sewn in 2 cases and triangulating stapling in 3 cases. Although a plastic surgeon was always waiting in case of poor blood supply of conduit, none of the cases needed microvascular anastomosis. Recurrent nerve palsy in 1 patient, ileus in 1 patient, and pneumonia in 2 patients were detected. The median operative time was 654 minutes, and the median blood loss was 260 mL.

We believe that our cautious preparations make it acceptable to perform esophageal cancer surgery with colon reconstruction even in low volume hospitals.
356. A CASE REPORT: A CASE OF HIATAL HERNIA WITH UPSIDE-DOWN STOMACH TREATED WITH LAPAROSCOPIC SURGERY
Authors: Uemura Takuji , Morishima Rento , Kanai Norifumi , Yoshida Satoru , Yonaiyama Shinnosuke , Maruyama Shota , Nakayama Yoshihito , Nishimura Ryuichi , Sato Tomoyuki , Aoki Kazunori , Mizuno Yutaka
Published: September 2022

Upside-down stomach (UDS) is a rare type (<5%) of hiatal hernia, often accompanied by organoaxial gastric volvulus. Although surgery is required for most patients, approach method is still controversial. It has been reported that open approach is a standard method in the case of UDS, but recently laparoscopic approach is reported to be useful for the patient without stomach ischemic sign. Here we report the case of UDS successfully treated by laparoscopic surgery.

Case presentation: A 57 year-old male patient with hiatal hernia for several years was referred to our institution because of frequent vomiting and UDS. He had no pain and vital signs were stable. Hematological investigations revealed neutrophil dominant elevation of white blood cell count, but CRP was normal in blood biochemistry. An enhanced computed tomography revealed a giant hiatal hernia (Type IV) and whole stomach migrated into posterior mediastinum with organoaxial gastric volvulus, but obviously ischemic signs were not detected. An esophagogastoroduodenoscopy (EGD) showed erosion of gastric mucosa, but no necrotic sign of stomach.

From these findings, surgery was thought to be necessary to improve the obstruction of stomach and prevent from necrosis of the incarcerated stomach. However, because of stable general conditions and no ischemic findings, we performed laparoscopic repair of hiatal hernia and Toupet fundopulication. Ischemic change of the stomach was not observed. After stomach withdrawal into the abdominal cavity from the mediastinum, hiatal defect was repaired and fundoplication was performed by Toupet method. After surgery, the symptom and stomach passage obstruction improved and the patient was discharged without no complications.

We successfully performed hiatal hernia repair and fundopulication with laparoscopic approach in the case of UDS. If there are no findings obviously indicating gastric ischemia and necrosis on an enhanced computed tomography and an EGD, laparoscopic hiatal hernia repair and fundoplication are considered as a useful method because of its less invasiveness and magnifying effect.
357. POSTOPERATIVE OUTCOMES OF SALVAGE ESOPHAGECTOMY AFTER DEFINITIVE CHEMORADIOTHERAPY AND PLANNED ESOPHAGECTOMY AFTER NEOADJUVANT CHEMORADIOTHERAPY
Authors: Pan Jie , Liu Zhichao , Li Chunguang , Yang Yang , Zhang Long , Jiang Chao , Liu Zhonghe , Yu Boyao , Li Zhigang
Published: September 2022

Salvage esophagectomy is indicated for esophageal cancer patients for recurrent/persistent disease after definitive CRT (dCRT). Salvage esophagectomy reportedly has higher postoperative complications and poor survival. This study aimed to compare the perioperative outcomes and survival of patients with dCRT followed by salvage esophagectomy (DCRE) and neoadjuvant chemoradiotherapy (nCRT) followed by planned esophagectomy (NCRE) in esophageal squamous cell carcinoma (ESCC).

Patients were identified from a prospectively maintained database at single institution from 2018 to 2021. All locally advanced ESCC patients receiving neoadjuvant/definitive chemoradiotherapy and following esophagectomy were reviewed. A total of 41 DCRE (24 persistent-disease, 17 recurrence) and 261 NCRE patients were included. Propensity score matching (PSM) was used to compensate for differences in some baseline characteristics.

No significant between-group differences were identified in in-hospital mortality, postoperative complications (Figure A), overall-survival and progression-free survival (all p > 0.05) (Figure B-C). The median CRT-to-surgery interval was 47d in NCRE group, 43d and 440d in DCRE group of persistent-disease and recurrence, respectively. DCRE group was observed with more advanced ypT stage (63% vs 38%, p = 0.001), poorer differentiation (32% vs 15%, p = 0.005) and more lymphovascular invasion (29% vs 11%, p = 0.001) compared with NCRE. Similar results were obtained after PSM. Analyses comparing DCRE (due to persistent-disease), DCRE (due to recurrence) and NCRE groups showed no differences in postoperative complications, in-hospital mortality and survival.

Postoperative complications and prognosis were equivalent between DCRE and NCRE. DCRE has acceptable outcomes and is appropriate for selected patients.
363. THE MODALITY OF NEOADJUVANT VERSUS ADJUVANT CHEMORADIOTHERAPY FOR LOCALLY ADVANCED ESOPHAGEAL. CARCINOMA: A SINGLE CENTER, RANDOMIZED, CLINICAL TRIAL
Authors: Kun Liu
Published: September 2022

Neoadjuvant chemoradiotherapy (nCRT) plus surgery is recommended as standard treatment for locally advanced esophageal squamous cell carcinoma (ESCC). However, studies have shown that surgery combined with adjuvant chemoradiotherapy (aCRT) can also provide survival benefits. The optimal modality of surgery combined chemoradiotherapy for esophageal cancer have not been determined yet.

From March 2018 to January 2021, 203 patients with resectable middle and lower thoracic ESCC, were enrolled in this prospective study. Patients were randomized into two groups: nCRT plus minimally invasive esophagectomy (MIE), MIE plus aCRT. In nCRT group, the patients were treated with paclitaxel plus carboplatin for two cycles, with a total concurrent radiation dose of 40.0Gy. In aCRT group, the patients with pN (+) were treated with paclitaxel plus carboplatin for four cycles, with a total sequential radiation dose of 54.0Gy, The primary end points were 3-year OS and DFS on the analysis of an intention-to-treat basis.

74 patients received surgery in the nCRT group，99 patients received surgery in aCRT group. Among 74 patients in nCRT group, 62 patients (83.8%) underwent MIE, compared with 88 of 99 (88.9%) in aCRT group (P = 0.65). With median follow-up of 28.4 months for all the enrolled patients, no significant differences were found in the 3-year OS (77.2% vs 75.8% P = 0.82) and DFS (60.9% vs 60.6% P = 0.86) among nCRT and aCRT groups. Postoperative complications did not differ significantly between groups, except for arrhythmia, which occurred more frequently in nCRT group (31.1%) than in aCRT group (14.1%) (P = 0.07).

Initial results of the trial showed that the treatment modality of nCRT followed by MIE has similar safety and survival benefit to that of MIE combined aCRT for locally advanced ESCC.