bluuebunny/crossref_metadata_2025 huggingface dataset:
P199 IS ROUTINE ICU ADMISSION NECESSARY AFTER TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL AND ESOPHAGOGASTRIC JUNCTION CANCER?
Authors: Pansa Andrea , Da Roit Anna , Basato Silvia , Gentile Damiano , Riva Pietro , Marano Salvatore , Castoro Carlo
Published: November 2019

Aim

We evaluated short-term outcomes of esophagectomy for esophageal and esophagogastric carcinoma without routine postoperative admission to Intensive Care Unit (ICU).

Background & Methods

esophagectomy is subject to high rates of complications and mortality even when performed in high-volume centers and conventional postoperative management often involves routine ICU admission according to recent guidelines and recommendations1 .

From January 2018 to June 2019 a total of 112 esophagectomies were performed in the Upper GI Surgery division of Humanitas Research Hospital. We included the 83 patients that underwent transthoracic esophagectomy with a hybrid technique (laparoscopy + right thoracotomy) and high intrathoracic anastomosis for esophageal and esophagogastric junction cancer. Preoperative assessment included a prehabilitation program (nutritional evaluation, respiratory physiotherapy and adjustment of cardiologic therapy). Postoperatively, patients were managed by surgical team members. We retrospectively recorded data on necessity of ICU, operative times, complication rate (according to ECCG)2,3, length of hospital stay, in-hospital, 30-day and 90-day mortality.

Results

68 patients were males and 15 females. Mean age was 65 years old (range 29-82). 67 patients underwent neoadjuvant therapy (49 chemo-radiotherapy, 18 chemotherapy alone). Postoperative ICU admission was necessary in 6 patients (9,5%), reasons for admission were necessity of ventilatory weaning in 2 patients, high lactate levels in one patient, glottic oedema following oro-tracheal intubation in one patient, while in the other cases ICU admission was planned for severe comorbidities. Mean duration of prehabilitation was 20.3 days (1-107). Mean surgery duration was 452.4 minutes (337-549). Overall complication rate was 33.8%, with the most common complications being atrial fibrillation (50% of all complications) and urinary retention (20%). There were two type I anastomotic leaks. Median length of hospital stay was 11 days (range 8-29). All patients were alive at 30 and 90 days after surgery.

Conclusion

routine ICU admission is not necessary after transthoracic esophagectomy for cancer in over 90% of patients. Careful patients’ evaluation, stratification of the surgical risk and systematic use of a prehabilitation program, along with adequate peri-operative management, can narrow the need for postoperative ICU admission in the setting of a high-volume centre without any impact on short-term outcomes.
P203 PHARYNGOESOPHAGEAL RECONSTRUCTION AFTER LARYNGECTOMY AND RADIOTHERAPY
Authors: Maltzaris Nikolaos , Kotrotsiou Maria , Stavrianos Spyridon
Published: November 2019

Aim

The purpose of this presentation is to review our experience and evaluate our results in the treatment of patients with pharyngoesophageal fistula after laryngectomy and radiotherapy.

Background & Methods

10 patients were examined at the head and neck combined oncology clinic after previous laryngectomy and radiotherapy and pharyngocutaneous fistula with weakness to feed food as well frequent aspiration pneumonia. The interval between the effect of the laryngectomy varies between 3-5 years depending on the severity of the symptomatology and after the complete failure of the conservative methods of reconstruction.

Reconstruction was performed with musculocutaneous major pectoral flap in 8 patients, radial forearm flap and anterolateral thigh flap.

Results

The postoperative period was uncomplicated, and in all patients the feeding was held after barium swallow test, after 7-15 days with soft food. The gold standard treatment of pharyngoesophageal fistula after laryngectomy and radiotherapy is the musculocutaneous major pectoral flap and in severe radionecrosis of the neck with free tissue flap reconstruction.

Conclusion

Reconstruction with microsurgical techniques offer improved prognosis and quality of life of our patients.
P206 EVALUATION OF PREEMPTIVE MULTIMODAL ANALGESIA IN IVOR LEWIS ESOPHAGECTOMY
Authors: Papaioannou E , Doka P , Mavrommatis E , Danassi D , Kalogiannis E , Lampadariou A
Published: November 2019

Aim

of the study is the evaluation of preemptive multimodal analgesia vs established technique of single epidural, in Ivor Lewis esophagectomy, perioperatively.

Background & Methods

In a randomized prospective trial, 25 patients were randomly assigned to two groups (A=12: preemptive multimodal analgesia, and B=13: epidural analgesia) after informed consent. Patients with coagulative disorders, and renal or hepatic impairment were excluded from study. In all patients a thoracic epidural (T5 – T7) was placed before anesthesia induction. Anesthetic protocol was the same, according body weight, in both groups, apart from analgesic drugs. Group A patients received morphine 1.5-3mg and ropivacaine 0.25% 10-12 ml epidurally (ed), and paracetamol 1gr, parecoxib 40mg, clonidine 150mcg, dexamethasone 8mg, lidocaine 1mg/kg, and magnesium sulfate 25% 10 ml iv, at least 20 min before surgical incision, while in group B same doses of ed morphine and ropivacaine were administered post-incision and iv paracetamol and parecoxib were administered 1hr before end of surgery. Surgical incision infiltration in both wounds with ropivacaine 0.375% 20ml was performed jn both groups’ patients. Intraoperative opioid doses were titrated accordingly. Analgesic needs intra- and postoperatively, as well as vital signs stability and side effects such as postoperative nausea or vomiting (PONV), dizziness, sleepiness, and respiratory suppression were recorded.

Results

Group A patients received significantly lower opioid doses intraoperatively (p<0.001), 2 (17%) of them did not need extra opioids at all, and in 8 (67%), operation was completed with only one low dose of fentanyl (2-3mcg/kg) before abdominal surgical incision. Group A patients had stable heart rate (HR) and blood pressure (BP) during whole operation, while 11 (84.6%) from group B (p<0.001) demonstrated HR and BP raising in certain surgical times. All both groups’ patients were transferred to ICU awake. 5 (38.46%) group B patients (p>0.005) required rescue amalgesic post-awakening. None of both groups’patients demonstrated any drugs’ side effects.

Conclusion

Preemptive multimodal analgesia seems to be more efficient, reducing needs for opioids intraoperatively, rescue analgesics postoperatively and providing better hemodynamic stability, than single epidural. Further studies are needed to support this conclusion.
P208 PARAVERTEBRAL CATHETER ANALGESIA FOR MINIMALLY INVASIVE IVOR LEWIS OESOPHAGECTOMY
Authors: van den Berg J , Tabrett K , Cheong E
Published: November 2019

Background

Oesophagectomy is a major complex operation associated with significant morbidity and mortality. Epidural analgesia has long been the gold standard postoperative analgesia but is associated with side-effects like hypotension, epidural haematoma and infection. In an attempt to lower morbidity and enhance recovery postoperatively, we have adopted the use of paravertebral catheter analgesia (PVCA) for patients undergoing totally minimal invasive oesophagectomy (TMIO) .

Methods

Our objective was to review the current literature about the use of both PVCA and epidural analgesia. In addition, we evaluated the effect of PVCA in a large group of patients undergoing TMIO for cancer. We reviewed the records of 100 consecutive patients who had a TMIO with PVCA, spinal morphine, and PCA. Prospective independent scoring of postoperative pain, length of stay, HDU stay, PVCA failure, the use of patient-controlled analgesia (PCA), and the use of vasoconstrictor medication postoperatively was analysed.

Results

One hundred consecutive patients received PVCA with PCA after the TMIO. Catheter related failures occurred in 4 cases. The median pain score over each of the 5 days were 0. The average pain score was highest in the first 24 hours and decreased over the next 4 days postoperatively. The use of PCA was highest in the first 2 days and reduced daily over the subsequent 3 days. Seven patients required rescue analgesia in the form of intercostal nerve block. Spinal morphine was successful in 94% of cases. Vasoconstrictors were required in 19% on day 1 and 3% on day 2, postoperatively.

Conclusions

Intraoperative placement of PVCA results in good postoperative pain control after a TMIO. This technique is simple, safe, reproducible and with very low failure rates. Therefore, it should be used instead of epidural catheter analgesia.
P210 HYBRID LAPAROSCOPIC ROBOT-ASSISTED MINIMALLY-INVASIVE ESOPHAGECTOMY: A PROSPECTIVE EXPERIENCE IN A REFERRAL CENTER
Authors: Santi S , Belluomini M , D'Imporzano S , Pallabazzer G , Solito B , Bellomini M , Zenzaro M
Published: November 2019

Aim

To report the prospective experience in Hybrid Laparoscopic Robot-assisted Minimally-invasive Esophagectomy (HLRAMIE) in a referral Center.

Background & Methods

The minimally-invasive esophagectomy (MIE) is an attractive and established technique to improve the reduction of post-operative morbility with sound oncological results. The hybrid combination of laparoscopy and full robotic thoracic phase (HLRAMIE) is an approach aimed to be as effective as MIE to treat esophageal neoplasms.

Inclusion criteria: patients undergone to multimodal medical advice panel, affected from non-cT4, from mid thoracic to cardia, esophageal neoplasms, with and without neoadjuvant treatment, fit for minimally-invasive surgery. HLRAMIE: laparoscopic stage plus full robotic thoracic stage by Da Vinci Xi® (Intuitive Surgical, US), with gastric-pull first-choice conduit. Prospective, dedicated database.

Results

From October 2015 to April 2019, 33 patients underwent to HLRAMIE (site of neoplasm: 1 mid thoracic; 9 inferior; 23 cardia). 5 out 33 were converted to open. 27/28 underwent to a Ivor Lewis esophagectomy, 1/28 to McKeown procedure. The mean total surgical time was 517 minutes, mean robotic docking time 12 min with mean thoracic time 269 min (positive trend). Gastric pull-up was performed in 28/28. In 23/28 patients the esophago-gastric anastomosis was performed full robotic after the fashion of hand, in 5/28 was performed by circular stapler. The mean extubation time was 12 hours. The mean number of lymph node removed was: overall fields 32.4 (range 15-58), thorax 9.8 (3-27). The mean number of metastatic lymph node was 3.8 (0-18). 100% were R0 resections. The mean hospital-stay was 15 days. The perioperative mortality and 30-day mortality were both 0%. The overall post-operative morbility was 32.1%. 4/28 (14.2%) patients developed an anastomotic leakage, 75% were managed by endoscopy. 11/28 (39.2%) patients developed a late anastomotic stenosis (all in the hand made group).

Conclusion

In our experience, HLRAMIE is surgically reproducible with the principle of learning curve; oncologically adequate in relation to radical dissection; safe and effective in relation to post-operative early morbility and mortality. Long-term follow up and more powerful, randomized series are needed to establish the definitive clinical and oncological results of HLRAMIE.
P213 PROGNOSTIC SIGNIFICANCE OF CHANGES IN LYMPH NODE MORPHOLOGY ON SURVIVAL IN ESOPHAGEAL CANCER AFTER NEOADJUVANT THERAPY: A SYSTEMATIC REVIEW AND META-ANALYSES
Authors: Eliza Hagens , Karina Tukanova , Sara Jamel , Mark van Berge Henegouwen , George B Hanna , Suzanne Gisbertz , Sheraz R Markar
Published: November 2019

Aim

To assess the prognostic significance of lymph node regression or downstaging following neoadjuvant therapy for esophageal cancer.

Background and methods

The prognostic value of histomorphologic regression in the primary esophageal cancer has been established, whilst the impact of lymph node response on survival still remains unclear.

An electronic search was performed to identify articles evaluating lymph node regression or downstaging after neoadjuvant chemo- or chemoradiotherapy. Random effects meta-analyses were performed for regression and downstaging and primary outcome was the hazard ratio (HR) for overall mortality. Survival data were compared between patients with complete regression and those with partial or no response. Histopathological tumor regression in lymph nodes was defined by the absence of viable cells or degree of fibrosis. Furthermore, survival of patients with downstaged lymph nodes to N0 were compared to those with positive nodes following treatment.

Results

Eight articles were included, 4 of which assessed tumor regression (number of patients=789) and 4 assessing downstaging (number of patients=1937). Complete tumor regression (average rate of 30.0%) in the lymph nodes was associated with higher survival [HR= 0.63, 95% CI (confidence interval) = 0.43 – 0.92; p=0.017] (figure 1). Lymph nodes downstaging (average rate of 47.6%) had improved survival compared to node positivity (HR = 0.38, 95% CI = 0.29 – 0.50; p<0.0001) (figure 2).

Conclusion

A prognostic benefit was seen in patients with good lymph node response to neoadjuvant therapy, suggesting this should be used as an important additional prognostic marker in staging and in comparative evaluation of different neoadjuvant regimes.
P214 ESOPHAGECTOMY FOR ESOPHAGEAL CANCER IN AN UPPER GI UNIT OF THE NATIONAL AND KAPODISTRIAN UNIVERSITY OF ATHENS DURING THE PERIOD 2004-2019
Authors: Mylonas K , Schizas D , Hashemaki N , Mpaili E , Ntomi V , Michalinos A , Theochari N , Theochari C , Mpoura M , Liakakos T
Published: November 2019

Aim

To describe the clinicopathological features and outcomes of patients registered in the esophageal cancer database of an academic upper GI unit in Greece.

Methods

We performed a retrospective analysis of patients that underwent esophagectomy for esophageal or gastroesophageal junction (GEJ) cancer at an upper GI unit of the National and Kapodistrian University of Athens, during the period January 2004-June 2019. Time-to-event analyses were performed to explore trends in survival and recurrence.

Results

A total of 146 patients were identified. Mean patient age was 62.3 xxx 10.3 years. Male to female ratio was 6.3:1. Overall, Ivor-Lewis, McKeown, and left thoracoabdominal esophagectomy was performed in 98 (67.1%), 34 (23.3%), 12 (8.2%), patients, respectively. Pharyngolaryngoesophagectomy was performed in 2 (1.4%) cases. R0 resection was achieved in 142 (97.7%) patients. Postoperative complications developed in 62 (45.3%) patients. Neoadjuvant chemotherapy and radiation were administered to 35 (26.9%) and 11 (8.5%) patients, respectively. Postoperative chemotherapy and radiation were administered to 68 (54.8%) and 17 (13.7%) patients, respectively. In total, 4 (2.7%), 23 (15.8%), 30 (20.6%), 55 (37.7%) 34 (23.3%) patients were Stage 0, I, II, III, IV respectively. Among patients with available follow-up information, overall recurrence and all-cause mortality rates were 41.2% and 46.2%, respectively. Median recurrence time and median time of death were 11.3 months and 2.5 years, respectively. On multivariate Cox regression, presence of positive lymph nodes (HR: 1.1, p=0.03) was predictive of higher recurrence rates, while neoadjuvant chemotherapy had a protective effect on disease relapse (HR=0.4, p=0.04). On multivariate Cox regression, need for neoadjuvant radiotherapy (HR: 6.9, p=0.001) and recurrence (HR: 3.4, p=0.002) were independently associated with higher risk of all-cause mortality.

Conclusions

In this study, we explored outcomes of patients undergoing esophagectomy for esophageal and GEJ cancer in an upper GI unit in Greece over a 15-year period. Outcomes were comparable to those reported from major referral centers across the globe.
P215 THE COMPLEX BENIGN UPPER GI MDT - A QUALITY IMPROVEMENT INITIATIVE FROM A TERTIARY CENTRE
Authors: Syed Soulat Raza , Ikenna Anderson Aneke , Alistair Sharples , C Bradbury , Stephanie Evans , Nagammapudur Balaji
Published: November 2019

Introduction

The Upper GI cancer Multidisciplinary team (MDT) has become an essential and integral part of the cancer treatment pathway in the management of Oesophagogastric (OG) cancer. There exists an need for the MDT management of complex benign diseases of the oesophagus which can be equally rewarding if proper decision making for treatment is achieved in this potentially challenging group of patients.

Methods

We explore the utility of a Benign Complex MDT model consisting of Surgeons, Gastroenterologists, radiologists and GI Physiologists in a tertiary teaching hospital setting.

A retrospective review of 72 patients who were discussed in the Complex Benign UGI MDT over a 2 year was undertaken. The referral pattern, decisions and outcomes have been analysed. All results were analysed using SPSS version 23. Results are reported in median +/- ranges or percentages where applicable.

Results

Patients had median age of 57 years with 62.5% being women.

30/72 (41.7%) patients had previous surgery. Majority of the referrals were made by surgeons 61/72 (84.7%) followed by gastroenterologist 10/72 (13.9%).

Dysphagia was the predominant symptom in 34/72 (47.2%) patients followed by reflux in 31/72 (43%) patients and 19.4% patients had a combination.

The purpose of an MDT referral was expert advice in 45/72 (62.5%) and consideration of surgery in 23/72 (31.9%) patients. The recommendations of the MDT was further clinic review (30%), further investigation (30.5%), surgery (18%), discharge (11%). MDT changed patient’s management in 30/72 (41.7%) cases.

Conclusion

Our results show that surgery was recommended less frequently after initial MDT discussions in patients who were initially referred for potential surgical advice. The management of complex benign conditions of the oesophagus can be challenging particularly after initial interventions. A MDT approach to the management of these patients can be recommended as equally vital to their management on recommending/avoiding further surgical or endoscopic interventions.
P217 SAFETY OF ESOPHAGEAL DILATION IN PATIENTS WITH EOSINOPHILIC ESOPHAGITIS IN A SINGLE CENTER COHORT
Authors: Weidan Zhao , Asad Ali , Craig Rosenstengle , Kuangda Shan , Yehudith Assouline-Dayan
Published: November 2019

Aim

This study is aimed to assess the safety of esophageal dilation (ED) in a large cohort of eosinophilic esophagitis (EoE) cases in a single center.

Background & Method

EoE, the leading cause of food impaction, is a chronic immune-mediated disorder characterized by esophageal dysfunction and mucosal eosinophilic infiltration (≥ 15 eos/hpf). ED is considered a second-line therapy for EoE after failure of medication, due to concern of perforation.

We performed a retrospective review of EoE patients who received ED at University of Iowa Hospitals and Clinics from 2006 to 2018. ED types, complications, and symptomatic improvement were extracted via chart review. Descriptive statistic with univariate analysis was performed.

Results

Of 1050 EoE patients, 160 received 295 EDs, ranging from 1-12 dilations per patient, with 67 patients requiring >1 dilations. Procedures were generally well-tolerated, without major bleeds or perforations. The overall complication rate was 6.1%, mostly post-procedural chest pain (4.8%). Three patients had sedation-related complications: one aspiration pneumonia and two ICU admissions for respiratory distress. Symptomatic improvement was documented in 87% of dilations on follow up.

Conclusion

EoE prevalence is increasing with rates of 1 cases per 1000 individuals, with up to one-third requiring ED for symptomatic relief. Previous reports suggested an increased procedure-related risk, mainly esophageal perforation. However, recent systematic reviews have shown low perforation rate of <0.3%, approximating that of other benign conditions. Our findings are consistent with current data, suggesting that ED should be considered a safe treatment for EoE along with dietary and pharmacological interventions.
P220 DEVELOPMENT OF A NEW PSYCHOLOGICAL TOOL TO IMPROVE PATIENT ABILITIES TO DEAL WITH ESOPHAGECTOMY: PRELIMINARY RESULTS
Authors: Pinto E , Fabbian A , Alfieri R , Da Roit A , Marano S , Mattara G , Pilati P , Castoro C , Turchi G P
Published: November 2019

Aim

This study aims to create a tool for evaluation of patient ability to deal with postoperative course after esophagectomy for cancer.

Background & Methods

Esophagectomy requires patient to be active and compliant to face up to postoperative impairments. Health related quality of life (HRQoL) data in short and medium-term after surgery show that competences used by patients are not appropriate. Lack of patient abilities to manage postoperative course influences patient recovery and reduces HRQoL.

Psychological analysis of patient clinical needs was conducted to identify peculiar patient competences involved after esophagectomy. Four competences (future forethought; context evaluation; consequences of own actions forethought; use of available resources), each relevant to four areas (clinical; familiar; working; daily-activities) were identified and converted in open-ended questions to assess patient level of skills: a 16 questions structured interview was composed.

From April to June 2019 we performed a feasibility study on 18 consecutive patients between 3rd and 15th postoperative day. They underwent esophagectomy for esophageal or esophagogastric junction cancer in two high volume centers. Patients with metastasis, with language problems due to neurological impairment or age <18 were excluded. M.A.D.I.T.-Methodology of Computerized Textual Data Analysis (University of Padua) was used.

Results

Each interview was administered orally to all patients and took 15 minutes. 5 questions were asked to be repeated. No complaints or negative comments were received.

Non-responding percentage was 0,4% (one question in one interview). Textual corpus was composed of 3210 words, passable of analysis. No differences between postoperative days administration were found.

M.A.D.I.T. analysis showed that answers were adequate and pertinent and allowed us to stratify patients in three different levels of competences (low, median, high). No need of additional competences or areas was observed.

Conclusion

This new psychological tool shows content validity, adequacy and pertinence to the study aim. It is understandable, easy, quick to be answered during any postoperative day and useful to identify patients with low abilities to deal with esophagectomy.

Therefore a multicentric study will be conducted to use this tool further in multiple-choice format with a larger number of patients, in order to identify which patients will benefit of psychological intervention for HRQoL improvement.
P221 THE ROLE OF SUBCARINAL LYMPH NODE DISSECTION IN ESOPHAGECTOMY - A 5-YEAR SINGLE CENTER EXPERIENCE
Authors: Mpaili Eustratia , Schizas Dimitrios , Mpoura Maria , Vagios Ilias , Zografos Constantinos , Michalinos Adamantios , Davakis Spyridon , Kyros Eleandros , Charalabopoulos Alexandros , Liakakos Theodore
Published: November 2019

Aim

To evaluate the involvement of subcarinal lymph node dissection (SLND) in the surgical treatment of esophageal cancer, as well as its impact on surgical outcomes following esophagectomy.

Background & Methods

Data on patients that underwent esophagectomy from 01/03/2014 to 01/03/2019 were prospectively collected and retrospectively reviewed. Based on the medical records, the following parameters were collected and analyzed: patient demographics, histopathological parameters, surgical- oncological outcomes. All patients were staged according to the AJCC 8th edition.

Results

A total of 79 patients underwent Ivor Lewis or McKeown esophagectomy for either squamous cell carcinoma (n= 7 patients) or adenocarcinoma of the esophagus or gastroesophageal junction (n= 72 patients). In 26 cases, esophagectomy was performed without SLND, while 53 cases underwent SLND. Among the 53 patients, 50 (94.3%) were men, and 3 (5.7 %) were women. Mean age was 61.4 years, (range 34-78). Mean nodal harvest was 34.7 lymph nodes per patient. Lymph node invasion was noted in 33 patients (62.2%), with a mean of 9 positive lymph nodes per patient. Subcarinal lymph nodes were involved in 5 out of 53 patients (9.4%). The ratio of positive subcarinal lymph nodes to resected ones was 1/2 (50%), 3/3 (100%), 1/2 (50%), 1/2 (50%) and 1/1 (100%) for each patient. Final histopathological report showed adenocarcinoma of moderate or poor differentiation (G2 2/5, G3 3/5) in all five patients (100%). Four out of 5 patients had not received neoadjuvant treatment and their pathological staging was T3N3M0. One patient had received neoadjuvant chemotherapy and his final staging was ypT3N2M0. Noteworthy, the seven patients diagnosed with squamous carcinoma, were subjected to SLND and were 100% negative for invasion histologically.

Conclusion

Subcarinal lymph nodes were infiltrated in 9.4% of patients operated for esophageal cancer. In the squamous cell cancer group, the relative infiltration rate was notably 0%. It seems that omission of subcarinal lymph node dissection during transthoracic esophagectomy cannot be justified.
P223 BILATERAL RECURRENT LARYNGEAL NERVE LYMPHADENECTOMY DURING THORACOSCOPIC ESOPHAGECTOMY IN PRONE POSITION
Authors: Jiménez-Rosellón R , Mingol F , Navío A , Bruna M , Álvarez E , Vaqué J
Published: November 2019

Aim

To present a video of a complete bilateral recurrent laryngeal nerve lymphadenectomy performed during minimally invasive esophagectomy using thoracoscopic video-assisted surgery in the prone position.

Background and Methods

Surgical treatment for esophageal cancer needs detailed lymphadenectomy. Indeed, the number of surgically dissected lymph nodes is important for staging accuracy and also determines patient’s prognosis, including those along the recurrent laryngeal nerve. However, recurrent laryngeal nerve dissection remains difficult and increases the appearance of postoperative complications.

This is a video of a bilateral recurrent laryngeal nerve lymphadenectomy during thoracoscopic esophagectomy performed in the prone position in a female patient with esophageal cancer.

Results

A 75 year-old female was diagnosed with recurrent squamous cell middle third esophageal carcinoma. The patient had first been diagnosed eleven years ago, receiving chemoradiotherapy as a radical treatment. The patient achieved a complete response after treatment, which remained for eleven years. Eleven years later, during routine follow-up, tumor recurrence was identified in the middle third of the esophagus. After presentation in a Multidisciplinary Group the patient underwent minimally invasive McKeown esophagectomy.

First, a video-assisted thoracoscopic surgery was performed in the prone position to mobilize the thoracic esophagus and complete a detailed mediastinal lymph node dissection, including infra-carinal lymph nodes, bilateral bronchial lymph nodes and also bilateral recurrent laryngeal nerve lymph nodes.

Afterwards, the abdominal esophagus and lymph node dissection is performed using a laparoscopic approach, and also a left cervicotomy in the supine position. An assistance laparotomy was made to externalize the specimen and make the gastric conduit. A manual end-to end esophago-gastric anastomosis was executed and finally, a feeding jejunostomy tube was placed.

The patient presented a benign postoperative course, introducing enteral nutrition and oral intake developing no complications, such as dysphonia, nor dysphagia and was discharged on the 8th postoperative day. The postoperative barium swallow radiography showed no leaks nor other complications and pathology report confirmed tumor free resection margins.

Conclusion

Detailed mediastinal lymph node dissection and exhaustive bilateral recurrent laryngeal nerve lymphadenectomy can be safely performed by minimally invasive surgery, as is shown in the video. The technique shown is feasible, achieves a complete lymph-node dissection and avoids postoperative complications such as dysphonia and recurrent laryngeal nerve palsy.
P24 TREATMENT FOR RECURRENT ESOPHAGEAL SQUAMOUS CELL CARCINOMA AFTER CURATIVE ESOPHAGECTOMY
Authors: Hiroshi Okamoto , Yusuke Taniyama , Chiaki Sato , Kai Takaya , Toshiaki Fukutomi , Takahiro Oikawa , Takuro Konno-Kumagai , Naoto Ujiie , Takashi Kamei
Published: November 2019

Aim

The aim is to find out what treatment should be chosen at the time of recurrence of the esophageal squamous cell carcinoma (ESCC) after curative esophagectomy.

Background & Methods

ESCC patients with recurrence after curative resection have extremely poor survival rates. However, long-term survival cases and complete cure cases have also been reported. We retrospectively evaluated 184 patients with recurrent ESCC after curative esophagectomy between 2001 and 2015.

Results

M/F: 148/36, Median age: 64(36-84), Location: Upper third/Middle/Lower: 18/105/61, Pretreatment: None/Neoadjuvant chemotherapy/Neoadjuvant chemoradiotherapy (CRT)/Definitive CRT: 79/42/30/33, pT0/1/2/3/4: 3/39/18/119/5, pN0/1/2/3: 51/59/51/22, pStage1/2/3/4: 24/51/95/14 (UICC 7th), Recurrence site: Lymph node 124 (67%) [cervical 35 (19%), mediastinum 82 (45%), abdomen 35 (19%)], lung 36 (20%), liver 32 (17%), pleura 18 (10%), bone 13 (7%), brain 3 (1.6%), peritoneum 3, skin 2 (1.1%) adrenal 2, residual esophagus 1 (0.5%), gastric tube 1, colon 1, kidney 1, testis 1.

First treatment after recurrence: Surgery/CRT/chemotherapy/Best Supportive Care (BSC): 8/89/64/23. Regarding to overall survival after recurrence by the treatment groups, there was a significant difference between all groups; surgery (median 61 months) > CRT (17) > chemotherapy (9) > BSC (1). Surgery was performed to the patients with solitary lesion (lung 3, cervical lymph node 3, descending colon 1, brain 1). Prognosis of the patients with single-organ recurrence was better than that of those with multi-organ recurrence only in CRT group, and prognosis of the patients without pretreatment was better than that of those with pretreatment only in chemotherapy group. Regarding to the time from esophagectomy to recurrence, the patients with the duration of 6 months or more had a good prognosis compared with those with less than 6 months only in CRT group.

Conclusion

As treatment for recurrent ESCC after curative esophagectomy, some treatment may be recommended as much as possible. Priority is given in the order of Surgery > CRT > Chemotherapy. Surgery may be recommended for the patients with solitary recurrence of lung or cervical Lymph nodes. CRT may be recommended for the patients with single-organ recurrence, at least six months after esophagectomy. Chemotherapy may be recommended for the patients without preoperative treatment.
P27 PERORAL ENDOSCOPIC MYOTOMY (POEM) FOR TREATMENT OF ACHALASIA. CLINICAL OUTCOMES OF A SINGLE-CENTER INSTITUTE IN UK
Authors: Vrakopoulou Gavriella Zoi , Barbieri Lavinia , Ilczyszyn Andrei , Hamaoui Karim , Memos Nikolaos , Smyth Edel , Jafari Jafar , Zeki Sebastian , Wong Terence , Dunn Jason M , Botha Abraham
Published: November 2019

Aim

Assessment of the clinical outcomes, resolution of dysphagia, incidence of postoperative gastro-oesophageal reflux disease (GORD), and quality of life (QoL) of patients after POEM.

Background&Methods

POEM is increasingly performed worldwide for treatment of achalasia proving itself effective and safe. From a prospective database of all POEM’s performed in our institution from 2015 to 2018, we extracted data for patients with a minimum follow up period of 6 months. All patients underwent a standardized diagnostic work-up including gastroscopy, barium study and high-resolution manometry (HRM). Postoperatively, they had a surveillance gastroscopy in the 1st postoperative year. Standardized questionnaires evaluating Eckardt, GERD and achalasia QoL (Urbach) scores were completed before and after POEM. HRM and pH studies were offered to all patients after 6 months.

Results

Demographic data and procedure details can be seen in Table1. The preoperative Eckardt, GERD and Urbach scores changed significantly: the median Eckardt score of 7(4-11) decreased to a median of 1(1-9, p<0.001), the GERD score showed a reduction from 26(8-52) to 5(0-40, p<0.001) and Urbach score from 25(17-30) to 14(10-28, p<0.001). Furthermore, preoperative dysphagia score was significantly reduced from a median of 3(1-3) to a median of 0(0-3). Long-term clinical success (Eckardt score ≤ 3) was 87.2%. Postoperatively, 11 patients (29%) were taking PPI’s for chest symptoms. Nine of these agreed to undergo pH studies of whom only 1 had a DeMeester score > 14.5.

Conclusion

POEM is an effective and safe treatment option for achalasia with good relief of dysphagia and improvement in patients’ QoL.
P28 AN OPEN TRANSTHORACIC ESOPHAGECTOMY RESULTS IN HIGHER POSTOPERATIVE C-REACTIVE PROTEIN LEVELS COMPARED TO MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: Babic B , van der Sluis P , Gockel I , Corvinus F , Tagkalos E , Lotichius M , Ventzki L , Lang H , Grimminger P
Published: November 2019

Aim

With the introduction of minimally invasive access in centers for esophageal surgery, complications as well as mortality rates decreased. Laboratory tests are used routinely to screen patients for postoperative complications as early as possible. Still, the course of several laboratory parameters after esophagectomy following different surgical approaches has not been described yet and thus, reference values do not exist. Nowadays, the interpretation of inflammatory markers depends on the expertise of the medical staff. The aim of this study is to evaluate the development of CRP and leukocytes after thoracoabdominal esophagectomy following four different surgical approaches.

Background & Methods

217 consecutive patients receiving a thoracoabdominal esophagectomy with either open, hybrid, totally minimally invasive or robot-assisted minimally invasive technique between 2008 and 2018 have been evaluated. Daily blood tests regarding C-reactive protein (CRP) and leukocytes have been performed daily in all patients. Data was collected prospectively and analyzed depending on the postoperative course and the surgical approach.

Results

There is a natural increase of leukocytes and CRP with peak values on the 2nd postoperative day (POD) after thoracoabdominal esophagectomy following all surgical approaches. The increase of inflammatory parameters is significantly higher after open esophagectomy on the first three postoperative days compared to the three minimally invasive procedures. Furthermore, postoperative CRP values > 200 mg/l on the 2nd postoperative day as well as an open esohagectomy are independently associated with postoperative complications.

Conclusion

The development of postoperative inflammatory laboratory parameters after esophagectomy is significantly depending on the surgical approach. Open esophagectomy results in significantly higher CRP and leukocyte values compared to the hybrid esophagectomy, minimally invasive esophagectomy and robot assisted minimally invasive esophagectomy. Open esophagectomy and an increase of CRP on the 2nd postoperative day above 200 mg/l are an independent positive predictor for postoperative complications in multivariate analysis.
P29 COMPARISON BETWEEN MINIMALLY INVASIVE AND OPEN ESOPHAGECTOMY IN PATIENTS AGED ≥75 YEARS: A NATIONWIDE PROPENSITY-SCORE MATCHED COHORT STUDY
Authors: Nikolaj Baranov , Linda Claassen , Frans van Workum , Camiel Rosman
Published: November 2019

Aim

To compare postoperative outcome in elderly undergoing either open or minimally invasive esophagectomy.

Background & Methods

Randomized controlled trials have shown improved short term outcome in patients undergoing minimally invasive compared with open esophagectomy. However, all of them have excluded patients aged 75 years or older. Evidence regarding this patient group, therefore, remains scarce.

A propensity score matched retrospective cohort study was performed in a Dutch nationwide cohort from the period of april 2011 to april 2016 of patients aged ≥75 years diagnosed with local and locally advanced esophageal cancer who underwent either minimally invasive or open esophagectomy. Primary outcomes consisted of anastomotic leakage and perioperative mortality. Secondary outcomes were the rate of other complications, reintervention and hospital/ICU readmission.

Results

After matching, 322 patients were included, 161 in the open esophagectomy and 161 in the minimally invasive esophagectomy group. In the minimally invasive group, a significantly higher incidence occurend of Clavien-Dindo ≥3 complications (RR 1.63, CI-95% 1.24—2.13), anastomotic leaks (RR 1.60, CI-95% 1.12—2.29) and reinterventions (RR 1.70, CI-95% 1.19—2.42). There were no significant differences regarding perioperative mortality, other complications and readmission rate.

Conclusion

Elderly patients diagnosed with locally advanced esophageal cancer should undergo minimally invasive esophagectomy in favor of open esophagectomy.

Keywords

Elderly, minimally invasive esophagectomy, open esophagectomy, esophageal cancer, clinical outcome, perioperative mortality.
O30 NON-RADICAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER; A NATIONWIDE STUDY ON INCIDENCE, RISK FACTORS AND OUTCOMES IN SWEDEN
Authors: Edholm David , Hollertz Petter , Sandström Per , Björnsson Bergthor , Björk Dennis , Halldestam Ingvar , Dzhendov Todor , Lindblad Mats
Published: November 2019

Aim

To identify potential risk factors for a microscopically non-radical esophageal cancer resection (R1) and investigate how such a resection affects long-term survival.

Background & Methods

Esophageal cancer resections that are considered R1 have been associated with worse survival. The Swedish National Register for Esophageal and Gastric Cancer includes information on all esophageal cancer resections in Sweden. All patients having undergone esophageal resection with curative intent 2006-2017 were included. Risk factors for R1 resection were assessed through logistic regression. Factors predicting five-year survival were assessed through Cox-regression, adjusted for T-stage, N-stage, age and R-status.

Results

The study included 1,504 patients. The margins were microscopically involved in 146 patients (10%). Of these the circumferential margin was involved in 115 (8%). The proximal margin was involved in 55 patients (4%) and the distal in 30 (2%). In 54 (4%) specimens two margins were involved. Independent risk factors for R1-resection were absence of neoadjuvant treatment and clinical T3 stage or higher. The 5-year survival for the entire cohort was 41%, but only 19% for those with an R1 resection. Independent risk factors for death within 5-year from resection were regional lymph node metastasis (Hazard Ratio (HR) 2.6 (95% CI 2.2-3.1), histopathological stage T3 or higher (HR 1.2 95% CI 1.1-1.5), age above 60 years and R1-resection (HR 1.6 95% CI 1.4-2.0)

Conclusion

Involved margin in the resected specimen is an independent risk factor predicting worse 5-year survival. Besides striving for adequate surgical margins, the rate of R1-resections could be decreased through neoadjuvant treatment in fit patients.
P31 SURGICAL MANAGEMENT OF ACQUIRED TRACHEOESOPHAGEAL FISTULA CAUSED BY ESOPHAGEAL DIVERTICULUM
Authors: Yifeng Sun , Shuguang Hao , Xufeng Guo , Yu Yang , Bo Ye , Xiaobin Zhang , Haoyao Jiang , Zhigang Li
Published: November 2019

Aim

To assess the safety and feasibility of surgical treatment for acquired tracheoesophageal fistula caused by esophageal diverticulum.

Background & Methods

There are rare studies of the treatment for acquired tracheoesophageal fistulas (TEFs) or bronchoesophageal fistulas (BEFs) caused by traction esophageal diverticula. Between Jan. 2014 and Apr. 2019, twelve patients were admitted to our department for TEF/BEF combined with esophageal diverticula. Clinical characteristics of the twelve patients were retrospectively reviewed.

Results

Among the 12 orifices in the airway side, there were two at the carina, three at the right main bronchus and seven at the right intermediate bronchus. All orifices in the esophagus side opened at the diverticula wall. All TEF/BEFs received surgical treatment. Firstly, the fistula tunnels were dissected easily. Then, interrupted sutures repaired the fistula orifices in the airway membrane. A limited diverticulectomy with the fistula resection was done in the esophagus. Separate layers of repair were performed for the defect in the esophagus. The serratus anterior muscle flap interposition was performed in all 12 cases. There were no postoperative morbidity and mortality. No recurrence fistula and symptomatic diverticula occurred. The airway and esophagus were unobstructed during the follow-up period.

Conclusion

Acquired TEF/BEFs caused by esophageal diverticula can be treated successfully by surgery. A limitated diverticulectomy is sufficient to ensure esophagus remodeling.
O32 LYON CONSENSUS CRITERIA SIGNIFICANTLY CHANGES THE PH IMPEDANCE DIAGNOSIS OF GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Authors: Alexandros Ioannou , Daniele Mandolesi , Stavroula Chaita , Francesco Torresan , Franco Bazzoli
Published: November 2019

Aim

To investigate the Lyon Consensus Criteria impact on Ph-Impedance diagnosis of GERD and their relation to high resolution manometric tracing results.

Background & Methods

GERD is a complex disease with a heterogeneous symptom profile and a multifaceted pathogenic basis that defies a simple diagnostic algorithm or categorical classification. The Lyon Consensus defines parameters on esophageal testing that conclusively establish the presence of GERD and characteristics that rule out GERD. We retrospectively evaluated according the new criteria our patients underwent pH-Impedance one year before the publication of Lyon Consensus Criteria and analyzed the differences in relation to the older diagnostic criteria.

Results

130 patients (56 M, median age 52,03 R18-77) Ph-impedance exams for suspected typical and atypical GERD were re-evaluated. According to Lyon criteria for conclusive evidence of GERD 15,38% of them were over-diagnosticated and 1,53% had inconclusive evidence of the disease using the past criteria. In the evaluation of 94 patients with typical symptoms 23,4% were over-diagnosticated in according to the past diagnostic criteria. Statistical analysis of manometric values of the patients highlight that LES basal pressure (median 108.95, R38.7-283.4) (p=0,049) and UES residual pressure (median 7.8 R0.6-63.5) (p=0,003) significantly predict the Lyon criteria pH-impedance outcome. Analysis of manometric values of the patients with typical symptoms revealed that LES residual pressure (median 5,21 R0,1-20,7) (p=0,007) and Total Number of refluxes (median 28,03 R1-122) (p=0,013) significantly predict the Lyon criteria pH-impedance outcome.

Conclusion

Lyon Consensus Criteria significantly changes the pH-impedance diagnosis in patients undergoing testing for suspected GERD. In patients with typical symptoms new criteria allow not to overdiagnose 25% of GERD patient. Manometric values analysis significantly correlates and predict the Lyon criteria pH-impedance outcome.
P33 UPPER ESOPHAGEAL SPHINCTER (UES) ABNORMALITIES ARE SIGNIFICANT DIAGNOSTIC FINDINGS IN PATIENTS WITH ATYPICAL GERD UNDERWENT PH-IMPEDANCE AND HIGH RESOLUTION MANOMETRY (HRM)
Authors: Ioannou Alexandros , Mandolesi Daniele , Chaita Stavroula , Torresan Francesco , Bazzoli Franco
Published: November 2019

Aim

To investigate UES function in patients underwent esophageal testing with pH-impedance and HRM for suspected GERD

Background & Methods

GERD is a complex condition with a typical: heartburn, regurgitation or epigastric pain and an atypical presentation with symptoms such as chronic cough, hoarseness, globus, dysphagia or throat clearing caused by the retrograde movement of gastric contents above the UES into the laryngopharynx. The association between GERD and abnormalities of UES and esophageal motility is not clearly known. HRM has allowed accurate measurement and evaluation of UES and esophageal function. We evaluate the UES function of the HRM exams in patients underwent pH-impedance for suspected GERD with typical or atypical symptoms.

Results

HRM tracings of 60 patients (35F, median age 53,08 R23-74), 35 with typical (20F, m.a 51,42 R24-74) and 25 with atypical (15F, m.a 51,73 R29-74) symptoms who underwent Ph-impedance for suspected typical and atypical GERD were evaluated. 40% of those with typical presentation had a positive pH-impedance for GERD versus 8% of those with atypical symptoms. Patients with typical symptoms presented in 42,85% UES abnormalities versus 60% of the patients with atypical presentation. From those patients with typical GERD symptoms that had a positive pH-impedance the 40% had a concomitant UES abnormality versus 100% of the patients with atypical presentation and a confirmed GERD diagnosis. Statistical analysis revealed a significant association between positive pH-impedance result and LES residual pressure in patients with typical (p=0,045) and atypical (p=0,038) symptoms.

Conclusion

UES abnormalities is the prevalent diagnostic finding in patients with atypical GERD underwent pH-impedance. UES dysfunction characterize all patients diagnosticated with atypical GERD by Ph-impedance.
P35 GASTROESOPHAGEAL REFLUX DISEASE (GERD) AFTER BARIATRIC SURGERY – EXPLORING THE PATHOPHYSIOLOGICAL MECHANISMS AROUND THE OESOPHAGOGASTRIC JUNCTION
Authors: Hatem Al Saadi , Alistair Sharples , Carl Bradbury , Vittal Rao , Balaji Nagammapudur
Published: November 2019

Background

It is not uncommon to get de novo GERD after certain types of bariatric surgery. Sleeve gastrectomy (SG), Adjustable Gastric Band ( AGB) and the One anastomosis gastric bypass (OAGB) have been frequently implicated to cause GERD. Roux Y gastric bypass (RYGB) is usually proposed as a curative procedure in patients who develop GERD after a LSG or LAGB.

Hypothesis

The alteration in mechanics around the Oesophagogastric junction (OGJ) after all types of bariatric surgery predispose to the development of GERD in varying proportions including the RYGB.

Aims

To theoretically explore the changes around the OGJ in the 4 most common types of bariatric procedures: AGB, SG, OAGB and RYGB

Methods and results

The following 6 variables that are frequently implicated in causing reflux are equated with each procedure and a score produced to quantify the potential effect on the OGJ. Elimination of the angle of HisInterruption of the Sling fibresInterruption of the Phreno-oesophageal membranePredisposition to the herniation through the hiatus.Effect on the Lower Oesophageal Sphincter residual pressure.Creation of a high-pressure zone below the LES promoting reflux.

Based in a standardised technique of performing the 4 common operations, the following scores were obtained.

AGB affected 5/6 variables, SG affected 6/6 variables, RYGB affected 5/6 variables and OAGB affected 5/6 variables that influence the antireflux barrier mechanism around the OG junction.

Conclusion

All bariatric surgeries technically affect the dynamics around the OGJ and indirectly reduce the efficacy of the antireflux barrier mechanisms. The varying contribution of certain individual factors may affect the relative incidence of GERD after surgery after different types of bariatric surgeries. The common recommendation that RYGB serves as a magic bullet against GERD is to be taken in context of the above mechanisms in action.