bluuebunny/crossref_metadata_2025 huggingface dataset:
624. LONG-TERM OUTCOME OF NEOADJUVANT CHEMOTHERAPY FOLLOWED BY ESOPHAGECTOMY VERSUS DEFINITIVE PROTON BEAM THERAPY FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Honda Michitaka , Toshiyama Satoshi , Takagawa Yoshiaki , Murakami Masao , Yamamoto Ryuya , Teranishi Yasushi
Published: September 2024

Background

Proton beam therapy (PBT) for esophageal squamous cell carcinoma (ESCC) is a promising curable treatment to avoid surgery, however the long-term outcomes have not enough been reported. Herein, we compared the survival outcomes of PBT with those of esophagectomy after neoadjuvant chemotherapy, which is the standard of care in Japan.

Methods

Patients with thoracic ESCC, clinical stage II or III, who underwent neoadjuvant chemotherapy plus radical resection and proton beam therapy between 2011 and 2020 were identified from database of our institute. The chemotherapy regimen was 5FU, CDDP (CF) with/without docetaxel. PBT was defined as irradiation of 50 GyE or more to the primary tumor, prophylactic irradiation, and concurrent chemotherapy (CF). Patients with other severe diseases and patients who could not be followed up were excluded. To adjust confounding factors, propensity score matching was performed; covariates included T and N-factor, age, gender, time of treatment and site of tumor. We retrospectively evaluated overall survival time of the surgery and PBT groups as primary outcome in this study.

Results

244 patients were selected from the database. Median age was 71 years, 209 were male, 102 had esophagectomy after chemotherapy, and 142 had PBT. After propensity score matching, 46 patients in each group were selected by propensity score matching. Median survival was 42.8:44.6 months in the surgery and PBT groups, respectively (p=0.784). There were no treatment-related deaths, and Grade 3 or higher adverse events occurred in 8 and 8 patients (p=1.00), respectively.

Conclusion

PBT for stages II and III ESCC was comparable to neoadjuvant chemotherapy followed by surgery in long-term outcomes and adverse events.
627. LEFT THORACOSCOPIC PRIMARY REPAIR OF ESOPHAGEAL PERFORATION SECONDARY TO BOERHAAVE SYNDROME
Authors: Oo Aung Myint , Yeo Charleen , Tan Ryan Jun-Yi
Published: September 2024

Background

With the advancement of the minimally invasive surgical techniques, more and more acute surgical conditions including esophageal perforations can be performed safely using minimally invasive surgical approach.

Methods

A middle aged male patient presented to our department with 3 days history of epigastric pain and vomiting. He was febrile on admission and investigation revealed the left sided esophageal perforation due to Boerhaave Syndrome with left sided pleural effusion. He underwent left thoracoscopic primary repair of esophageal perforation and wash out successfully. This is the video of the thoracoscopic primary repair of the perforation. Patient was put in the right lateral semi prone position, the area of perforation was identified by careful dissection of the pleura and repaired was performed in 2 layers. The pleura cavity was washed out with warm saline and underwater sealed chest tube drain was inserted.

Results

Post operatively patient was transferred to surgical intensive care unit for 1 day. Patient was kept nil by mouth with parenteral nutrition for 7 days. Contrast study was performed on post operative day 7 and started oral feeding when there was no evidence of leakage. Patient recovered and discharged well.

Conclusion

Thoracoscopic primary repair with wash out of spontaneous esophageal perforation secondary to Boerrhave Syndrome is challenging however it is safe and can be performed successfully.

https://drive.google.com/file/d/1JTfJLV-ngUBwzMybGV4FL8EEQB-ysj9O/view
630. ENDOSCOPIC MANAGEMENT OF DELAYED-GASTRIC-EMPTYING AFTER ESOPHAGECTOMY IN A TERTIARY REFERRAL CENTER: COMPARISON BETWEEN DIFFERENT ENDOSCOPIC PROCEDURES
Authors: Battaglia Silvia , Giuseppe Dell'Anna , Mandarino Francesco Vito , Puccetti Francesco , Cossu Andrea , Barbieri Lavinia , Barchi Alberto , Azzolini Francesco , Fanti Lorella , Fanizza Jacopo , Elmore Ugo , Fuccio Lorenzo , Annese Vito , Rosati Riccardo , Danese Silvio
Published: September 2024

Background

Delayed Gastric Emptying (DGE) after Esophagectomy with a gastric conduit is a complication that occurs in 15-39% of patients. It is associated with short and long-term complications and with a poor quality of life. Intra-Pyloric Injection of Botulinum Toxin (BT), Pyloric Pneumatic Dilation (PD), and combination of these two techniques (BTPD) in the same session, represent the main endoscopic procedures, but comparative data are currently unavailable.

Methods

We retrospectively analyzed prospectively collected data on all consecutive patients with DGE after esophagectomy endoscopically treated from December 2018 to November 2023. DGE was classified based on the onset time (early/late), and the Gastric Outlet Obstruction Score (GOOS) was used for clinical staging. All BT patients received 200UI of toxin, while those PD patients have been dilated up to 20mm. Technical success (TS) was defined as the completion of the procedure, clinical success (CS) as achieving a GOOS of ≥2, and recurrence as the need for endoscopic/surgical treatment in patients who achieved CS. Adverse events (AEs) were classified using the AGREE classification.

Results

34 patients (82.4% male, 94.1% Ivor-Lewis, divided as follow: 13 (38.2%)BTPD-group, 12 (35.3%)BT-group and 9(26.5%)PD-group. Median follow-up was of 170 days (IQR 67-604), with no differences between the three groups. No statistically significant differences were found in the baseline characteristics among the three groups (e.g.surgical pyloromyotomy, neoadjuvant treatments). Despite identical TS (100%), BT-group exhibited a higher rate of clinical failure (25%) compared to the other groups (p=0.03). No difference in the recurrence rate was observed between the three groups (p=0.47). Dysfunction analysis showed that BTPD-group was characterized by a significatively shorter median time to refeeding of 1 day (IQR 1) compared to the other two groups (log-rank test p=0.0051). No AEs procedures related were recorded.

Conclusions

Our study reveals that BT is associated with a considerable rate of clinical failure, and that the combined BTPD treatment may offer a more rapid clinical success, maintaining an equivalent safety profile. Further prospective studies are needed to validate these findings.
637. UPFRONT SURGERY IN ESOPHAGEAL CANCER: ACCURACY OF PREOPERATIVE CLINICAL STAGING
Authors: Wallner Eva , Rudisch Björn , Farmaki Filitsa , Avramovska Irina , Kemeter Melissa , Giulini Luca , Diener Markus , Erhardt-Kreutzer Christina , Weitzendorfer Michael , Emmanuel Klaus , Koch Oliver
Published: September 2024

Background

Treatment of locally limited esophageal cancer is still a frequently discussed topic. Especially, the inaccuracy of clinical staging in lymph node-negative T2-carcinomas has to be considered further in the treatment pathway. Aim of this study was to evaluate the accuracy of clinical staging in patients treated with esophagectomy without neoadjuvant treatment.

Methods

We conducted a retrospective multicenter analysis at the departments of surgery from two university clinics. All patients between January 2016 and December 2023, who underwent an esophagectomy because of an esophageal adenocarcinoma or squamous cell carcinoma without neoadjuvant treatment were included. Advanced tumor stage, T staging greater than T2, was defined as exclusion criteria.

Results

Fifty-three patients after upfront esophagectomy were included in the analysis.

In 40 (75%) patients a gastroesophageal junction adenocarcinoma was diagnosed, and 13 (25%) patients were treated because of a squamous cell carcinoma of the esophagus.

Clinical T staging was T1 or T2 and all lymph node stages were included.

The endosonographic preoperative staging of invasion depth was accurate in 32 (60%) patients in comparison to the histopathological staging. In 7 (13%) cases the T-values were upstaged one level and in 5 (9%) cases one level downstaged after resection.

The endosonographic preoperative staging of nodal spread was accurate in 32 (60%) patients. Furthermore, in 7 (13%) cases node status was upstaged and in 5 (9%) patients downstaged.

Nine (17%) patients did not undergo a sufficient endosonographic staging, mainly due to prior endoscopic submucosal dissection or stenosis. In these patients, clinical lymph node staging was accurate in 4 patients.

Conclusion

Preoperative staging using endoscopic ultrasound and computed tomography is not accurate enough in a high number of patients, therefore we are seeking to identify other predictive factors underlying advanced stage esophageal cancer.
644. CUSTOMIZING A LARGE LANGUAGE MODEL TO PROVIDE CLINICALLY TAILORED ADVICE FOR EMERGENCY ESOPHAGEAL IMPACTIONS
Authors: Huo Bright , Hanna Nader
Published: September 2024

Background

There is interest in applying Large Language Models (LLMsclinically, but they are not trained for medical purposes. Equally, the development of LLMsrequires significant time and financial resources. Customizing an existing LLM for clinical purposes may overcome these limitations and would be of interest to clinicians, patients, hospital managers, and government/policy makers.

Methods

Thirty patient cases with nonbony esophageal impactions were developed using guidance from UpToDate. Standardized prompts were engineered for physicians as the end user. The customization tool was applied to ChatGPT-4.0 to create the Esophageal Impaction Tool (GPT-EIT), which provides advice for managing patients with esophageal impactions. Both GPT-EIT and the generic ChatGPT-4.0 models were queried February 28th, 2024. Their performance was evaluated based on guidelines for the removal of foreign bodies from the European Society of Gastrointestinal Endoscopy. Outcome data was presented using descriptive statistics in the form of counts and percentages.

Results

The GPT-EIT provided accurate recommendations for 30/30 (100.0%) cases. Each case was managed appropriately, recommending that stable patients received endoscopy within 24 hours, while patients with drooling were recognized as a surgical emergency and advice was given to provide endoscopy within 2 hours, but no more than 6 hours. GPT-EIT also advised to consider the appropriateness of treatment for patients presenting at 97 years of age based on their comorbidities and health status. The generic ChatGPT-4.0 model produced accurate guidance for 14/30 (46.7%) of cases. Patients with signs of significant obstruction would not have received timely endoscopy (Table 1).

Conclusions

ChatGPT can be customized to overcome limitations with its training dataset to develop clinically relevant, accurate advice for esophageal impactions. Clinicians, patients, hospital managers, and policymakers should take note that this methodology may be applied for other clinical purposes to avoid limitations related to resource constraints with developing LLMsfrom scratch.
645. CLINICAL SIGNIFICANCE OF LOCAL TREATMENT FOR RECURRENCE WITHIN THE SURGICAL FIELD AFTER RADICAL ESOPHAGECTOMY
Authors: Kanamori Jun
Published: September 2024

Background

In recent years, more aggressive multidisciplinary treatment and minimally invasive approaches with meticulous lymph node dissection have become the standard in esophageal cancer surgery, but recurrence cases within the surgical field after radical resection are unfortunately frequently observed. We will compare the clinicopathological characteristics of the cases of intra-sugical field recurrence with those of extra-surgical and both intra- and extra-surgical field recurrence and discuss their significance in light of the results of local treatment for intra-surgical field recurrence.

Subjects

The study included 130 cases of intra-surgical field recurrence among 490 esophageal cancer patients who underwent radical subtotal esophagectomy and cervical anastomosis (Mckeown-esophagectomy) with right thoracic approach between January 2013 and April 2019.

Results

The 130 cases of recurrence were categorized as intra-surgical field recurrence (Group I)/extra-surgical field (Group O)/intra- and extra-surgical field (Group I+O): 19/86/25. Preoperative factors: Tumor localization tended to be more common in Ut in group I (p=0.078), but there were no other differences such as cStage or preoperative treatment. Intraoperative/postoperative factors: I+O group had significantly more blood loss (p=0.045), but there were no other differences in the range of lymph node dissected field, number of dissected lymph nodes, combined resection of the thoracic duct, postoperative complications, hospital stay, or histological therapeutic effect. 19 patients in group I had 17 patients (89.5%) who received initial local treatment (surgery/CRT/RT: 4/7/6). The response rate (R0 resection or CR+PR) was 58.8%. Compared to cervical and upper mediastinal lymph node recurrence, the response rate to initial local treatment tended to be lower in patients with middle and lower mediastinal lymph node and anastomotic recurrence (80%/43%, p=0.145).

Discussion

Intra-surgical field recurrence after radical resection tended to be more common in the primary site of Ut. Recurrence in the upper mediastinal lymph nodes in the cervical region shows a relatively high response rate to local treatment, and long-term recurrence-free ("cure") is achieved. On the other hand, mid and lower mediastinal lymph node and anastomotic recurrences have a low response rate to local treatment and should be complemented with more systemic treatment, such as sequential ICI to initial treatment.
740. RABEPRAZOLE PROTECTS REFLUX ESOPHAGITIS DUE TO BILE IN RAT MODEL
Authors: Hashimoto Naoki
Published: September 2024

Aims

we studied the effect of proton pump inhibitor(PPI)(Rabeprazole) therapy on esophageal bile reflux in esophagitis after total gastrectomy. (Methodology) Sixteen 8-week old male Wistar rats were underwent total gastrectomy and esophagoduodenostomy to induce esophageal reflux of biliary and pancreatic juice. In 5 rats the sham operation induced a midline laparatomy alone (Sham). One week following surgery, they were treated with saline (Control) (n=8) PPI (Rabeprazole)(n=8)(30mg/kg/day) ip for 2 weeks. 3 weeks after operation, all rats were killed and the esophagus was evaluated histologically. Esophageal injury was evaluated by macroscopic, microscopic findings and expression of COX2 and PGE2. We performed the measurement of bile acid in the esophageal lumen and common bile duct.

Results

At 3 weeks after surgery, duodenal reflux induced esophageal erosions and ulcer formation. The macroscopic ulcer score and microscopic ulcer length were significantly reduced by PPI. The enhanced expression of COX2 and PGE2 in the control group was also markedly inhibited in the PPI group. Really, there is no difference between control group and PPI group in bile acid concentration from the common bile duct. PPI does not inhibit the secretion of bile acid from the common bile duct. But, the bile acid activity in the esophageal lumen was significantly increased in the control group, and this increase was significantly inhibited in the PPI group.

Conclusion

These results indicate that bile acid, which is inhibited by Rabeprazole, plays an important role in the mucosal damage induced by duodenal reflux.
741. EXPRESSION OF COX2 AND P53 IN RAT ESOPHAGEAL CANCER INDUCED BY REFLUX OF DUODENAL CONTENTS
Authors: Hashimoto Naoki
Published: September 2024

Aim. Reflux of duodenal contents can induce mucosal injury, stimulate cell proliferation, and promote tumorigenesis. We examined the expression of COX2 and p53 in rat esophageal lesions induced by duodenal content reflux. Methods. Thirty 8-week-old male Wistar rats were exposed to duodenal content esophageal reflux. All animals underwent an esophagoduodenal anastomosis (EDA) with total gastrectomy in order to produce chronic esophagitis. Ten rats were the sham. Control. They were sacrificed at the 40th week. Their esophagi were examined for HE, COX2, p53, and proliferating cell nuclear antigen (PCNA). Results. After 40 weeks of reflux, dysplasia, squamous cell carcinoma (SCC), and adenocarcinoma (ADC) were found. PCNA labeling index was higher in dysplastic and cancer tissue than that in normal. Overexpression of COX2 was shown in ADC and SCC. Wild-type p53 accumulation was found in ADC, and not in SCC. Conclusion. Reflux of duodenal contents into the esophagus led to ADC and SCC in rats. COX2 may play an important role in esophageal cancer by duodenal content reflux. Our present results suggest an association between wild-type p53 accumulation and COX2 expression in ADC, with no such relation seen in SCC.
745. A CASE OF ESOPHAGEAL METASTATIC STRICTURE 9 YEARS AFTER BREAST CANCER SURGERY
Authors: Nakazato Hidetsugu , Nagamine Shinji , Tokizawa Hiromi , Tomiyama Takeshi , Tomori Takehiko , Nagayoshi Seiji , Miyagi Jun
Published: September 2024

Background

Oesophageal metastasis of breast cancer is relatively rare. In this report, we describe our experience of a case in which dysphagia was the main complaint, leading to the diagnosis of esophageal metastasis.

Method

A 63-year-old woman who had undergone partial mastectomy and sentinel lymph node removal in 20xx with a diagnosis of breast cancer presented 9 years after surgery with dysphagia. The postoperative pathological diagnosis of breast cancer was invasive ductal carcinoma, T2, N0, M0, ly1. She had previously received chemotherapy for recurrent bone metastases and mediastinal lymph node metastases 7 years post-operatively, and RT and chemotherapy for a diagnosis of SVC syndrome due to mediastinal lymph nodes 8 years post-operatively. In the present case, upper gastrointestinal endoscopy showed oesophageal stricture and biopsy showed ER+ and PgR- from oesophageal mucosa. Radiotherapy and chemotherapy were administered for the diagnosis of oesophageal metastasis of breast cancer, and the patient's symptoms improved.

Conclusion

In the case of oesophageal stricture with dysphagia after breast cancer surgery, it is essential to consider oesophageal metastases of breast cancer as a differential, although rare, in addition to benign and primary disease.
746. ESOPHAGECTOMY, WITH CHOLECYSTECTOMY HAS A HIGH INCIDENCE OF REFLUX ESOPHAGITIS AND GASTRIC TUBE ULCER
Authors: Hashimoto Naoki
Published: September 2024

The surgical methods for thoracic esophageal cancer was subtotal esophagectomy, with gastric pull up via retrosternal route, and cervical anastomosis. However, some cases were complicated by acute cholecystitis in the early postoperative period, and cholecystectomy was performed intraoperatively to prevent postoperative cholecystitis in some cases. The disruption of normal anti-reflux mechanisms including the lower esophageal sphincter, angle of His, and diaphragmatic muscle and the denervation of the vagus nerve are generally thought to be the main factors that interfere with gastric motor function. Furthermore, the pressure difference between thoracic (negative) and abdominal cavity (positive) is another factor that promotes reflux across the anastomosis.

Due to these factors, postoperative reflux esophagitis is frequently experienced. Furthermore, after cholecystectomy, due to loss of gallbladder reservoir function after cholecystectomy and decrease in antroduodenal motility, bile is not excreted by food intermittently but continuously, resulting in duodenogastric reflux. We investigated postoperative reflux esophagitis and gastric tube ulcers in cases with and without intraoperative cholecystectomy for the past three years. We investigated cholecystectomy with esophagectomy (n=65) and non-cholecystectomy with esophagectomy (n=101) in 166 cases of radical surgery for esophageal cancer in which 2-3 regions had been dissected in the past 3 years. As shown in Fig. 1, there are no differences in location, TNM, gender, and PPI administration .reflux esophagitis of the cervical esophagus is A:0 B:2 (3%), C:5 (8%), D:3 (5%) for chole(+), A:2 (2%), B:2 (2%), C:2 (2%), and D:2 (2%) for chole(-). Gastritis was Chole(+) superficial gastritis 14 (21%), metaplasia 4 (6%), chole(-) superficial gastritis 25 (25%), metaplasia 3 (2%). However, gastric tube ulcers occurred in 5 cases (7%) of Chole(+) and 1 case of perforation, while only 1 case (1%) of gastric tube ulcers occurred in Chole(-)..

(Conclusion) Esophagectomy, gastric pull up with cholecystectomy has a high incidence of reflux esophagitis in the neck and can also cause ulcers in the gastric tube. Therefore, care should be taken in postoperative follow-up.
754. PATHOLOGICAL RESPONSE PREDICTS EFFICACY OF ADJUVANT FLOT CHEMOTHERAPY IN GASTROESOPHAGEAL CANCER: AN INTERNATIONAL COHORT STUDY
Authors: Liu David , Hall Ms Katheryn , Wong Darren , Lee Margaret , Duong Cuong , Bright Tim , Aly Ahmad , Watson David ,   on behalf of all SPACE-FLOT investigators
Published: September 2024

Background

Perioperative FLOT-based chemotherapy is the current standard of care for all patients with locally-advanced gastroesophageal cancer. However, many patients are unable to complete all planned adjuvant FLOT cycles due to treatment related toxicity and diminished performance status after radical surgery. Within this context, it is unclear whether adjuvant FLOT will improve oncological outcomes for patients with cancers that either don’t respond or respond exceptionally well to neoadjuvant FLOT. To facilitate clinical decision-making, we examined whether pathological response to neoadjuvant FLOT can guide its adjuvant use.

Methods

Prospectively collected data from 43 centres across 12 countries was analysed. Patients with non-metastatic gastroesophageal adenocarcinoma who received neoadjuvant FLOT followed by radical surgery between 2017-2022 were included. Pathological response was assessed using validated tumour regression grading (TRG) systems. All TRG were trichotomized into minimal responders (MR=worse TRG category), complete responders (CR=pathological complete response), and partial responders (PR=all TRG categories between MR and CR). Survival outcomes of patients who did and did not receive adjuvant FLOT within these cohorts were compared using Kaplan Meier and Cox regression analysis. These findings were validated using propensity score matched analysis.

Results

1887 patients (MR n=459, CR n=221, PR n=1207) were evaluated. The median follow-up was 25.5 months. In the MR group, there was no DFS (HR=1.03, 95%CI 0.78-1.36) or adjusted-OS (HR=0.96, 95%CI 0.70-1.30) difference between those who did (n=272) and did not (n=187) receive adjuvant FLOT. In the CR group, there was no DFS (HR=0.88, 95%CI 0.41-1.85) or OS (HR=0.69, 95%CI 0.31-1.54) difference between those who did (n=136) and did not (n=85) receive adjuvant FLOT. In the PR group (adjuvant FLOT n=847, no adjuvant FLOT n=360), adjuvant FLOT conferred a significant DFS (HR=0.68, 95%CI 0.55-0.86) and OS (HR=0.55, 95%CI 0.44-0.69) benefit.

Conclusions

Pathological response to neoadjuvant FLOT predicts therapeutic efficacy to adjuvant FLOT. Only partial responders benefit from adjuvant treatment. Our findings challenge the current doctrine that perioperative FLOT should be applied to all patients regardless of pathological tumour response.
762. A PROPOSAL FOR CERVICAL ANASTOMOTIC LEAKAGE CLASSIFICATION AFTER ESOPHAGECTOMY
Authors: Gonçalves Beatriz Pereira , Chumbinho Beatriz , Cabral Francisco , Ramos Paulo , Monteiro Cecília , Casaca Rui
Published: September 2024

Background

Anastomotic leak (AL), a potently life-threatening complication after esophagectomy, has a wide spectrum of presentation. There are also several treatment modalities but uncertainty about its clinical applicability remains, being mostly guided by personal experience and available resources.

Regarding cervical anastomosis, literature is especially scarce. Although classically it was managed conservatively with cervical wound drainage, 60-70% have an intrathoracic manifestation, which is not only associated with worst clinical severity, as it appears more difficult to manage.

In this study, we propose a new classification system for cervical esophago-gastric leak, based on its imaging presentation, with a standardized therapeutic approach.

Methods

Cervical AL classification and therapeutic protocol were developed through retrospective evaluation of a prospective database, including all patients submitted to esophagectomy with gastric conduit reconstruction and cervical anastomosis since the 1st January 2018 to the 31st March 2024, in an upper gastro-intestinal surgery unit, at a tertiary cancer center.

AL manifestation was classified according to imaging appearance on CT scan, reviewed by a dedicated radiologist.

Protocol was developed considering treatment patterns according to each manifestation and respective success rate.

Results

During this period, 253 esophagectomies were performed, 171 with cervical anastomosis and thus included to analysis. AL rate was 21.6%.

Four types of AL manifestation were identified: A – exclusive cervical manifestation (32.4%); B – mediastinal drainage without pleural involvement (8.1%); C – apical pleural collection (8.1%); D – pleural involvement (51.2%).

Based on these patterns, a standardized therapeutic algorithm was developed (figure 1): conservative treatment with cervical wound drainage for A, endoscopic therapy for B and C (first-line endoluminal esosponge®, stent as option) and for type D, in addition to endoscopic therapy, pleural drainage and empyema decortication in refractory cases.

Conclusion

Although well stablished and easy to apply, the Esophagectomy Complications Consensus Group (ECCG) classification for esophagectomy AL differentiates its severity, but does not guide its treatment. In this study, we identified four types of cervical AL manifestation, which we consider relevant to select the appropriate treatment modality. This protocol was recently adopted in our center and we pretend to evaluate its results in a short-term.
767. INFLUENCE OF NEOADJUVANT IMMUNOTHERAPY-CHEMOTHERAPY ON PERIOPERATIVE OUTCOMES IN LOCALLY ADVANCED ESOPHAGEAL ADENOCARCINOMA
Authors: Nevo Yehonatan , Tankel James , Zao Henry , Ramirez Jaime , Cools-Lartigue Jonathan , Muller Carmen , Alcindor Thierry , Ferri Lorenzo
Published: September 2024

Background

This study evaluates the perioperative outcomes of patients with locally advanced esophageal adenocarcinoma (EAC) who were treated with neoadjuvant immunotherapy (IO) and chemotherapy versus a matched cohort of patients that received neoadjuvant chemotherapy (NAC) alone.

Methods

A single center non-randomized phase II trial was undertaken in locally advanced (cT3-4 and/or N+) EAC and 49 patients completed neoadjuvant Avelumab + DCF (Docetaxel, Cisplatin, 5FU) and esophagectomy between 2/2018 and 2/2020. These patients were matched to contemporary patients (1/2018-6/2020) who met inclusion criteria but received neoadjuvant chemotherapy alone (NAC) with a comparable Docetaxel based. The postoperative outcomes were then compared between the two groups.

Results

Ninety-nine patients with locally advanced EAC underwent esophagectomy and meet enrolment criteria for this study. Of these patients, 50 received NAC alone 49 received IO+NAC. Baseline characteristics such as age, gender and clinical stage were comparable between groups.

Operative approach and rate of MIE (~60%) was similar in both groups. Overall and major complication rate were similar between groups (50 vs. 51%, p=0.91; 20 vs. 26%, p=0.44 respectively) with concordant rates of anastomotic leak (6 [12%] vs. 6 [12%], p=0.86) and respiratory complications (13 [26%] vs. 11 [22%], p=0.68) in NAC alone and IO+NAC group respectively. There were no significant differences in the LOS and 30- and 90-days mortality rates between the two groups.

Conclusion

The addition of immunotherapy to neoadjuvant chemotherapy for locally advanced esophageal adenocarcinoma does not appear to significantly alter perioperative short-term outcomes after esophagectomy
779. IMMUNE CHECKPOINT INHIBITOR WITH CHEMOTHERAPY (CISPLATIN+5FU) FOR ADVANCED ESOPHAGEAL CANCER
Authors: Narumiya Kosuke , Suda Hiroshi , Shimamoto Naoaki , Suzuki Tatunori , Muraishi Ryu , Okumura Yasuhiro , Okamura Yukiyasu
Published: September 2024

Background

First-line chemotherapy for advanced esophageal carcinoma results in poor outcomes. Compared with placebo plus chemotherapy, pembrolizumab plus chemotherapy improved overall survival in patients with previously untreated, advanced oesophageal squamous cell carcinoma according to the KEYNOTE-590. We studied 17patients for the unresectable esophageal cancer and gastroesophageal junction adenocarcinoma cases treated with pembrolizumab and chemotherapy at our hospital between November 2023 and May 2024.

Methods

17 patients with advanced carcinoma of the thoracic esophagus having either T4 tumor or distant lymph node metastasis were enrolled in this study. pembrolizumab 200mg/m2 and CDDP 80 mg/m2 was administered on days 1 and 5-FU 800 mg/m2 was administered on days 1-5 intravenously 3corse in 3-week cycles.

Results

Back ground: Averaged Age 76 (55-86), male: female =16:1, location (Ce: Ut: mt: Lt: Jz =1:1:6:6:3), strength 71mm (30-120), Stage (IVA: IVB= 7:10), Pathology (SCC: AD= 16:1), Times (3 courses completed: uncompleted: ongoing=9:3:5), Response PR:SD:PD: unknown=6:1:2:8, Toxicity: iRAE: liver dysfunction: Febrile neutropenia=4:2:6, The incidence of Grade 3 or higher adverse events was 3/15. One toxicity-related death occurred. We performed conversive esophagectomy for 2 patients. After chemotherapy: operation: radiation: observation: death:=2:2:10:3

Conclusion and discussion

Due to the small number of cases, it is unclear whether the treatment was safe in a single center. I would like to consider increasing the number of cases. We will show one toxicity-related death and two conversive operation.
787. THE CHALLENGE OF GASTRO-ESOPHAGEAL ONCOLOGICAL SURGERY AFTER BARIATRIC PROCEDURES: EXPERIENCE OF A REFERRAL HIGH-VOLUME UPPER GI SURGICAL CENTER
Authors: Cuce Federica , Belluomini Mario Antonio , Pallabazzer Giovanni , Gennai Andrea , Marini Paola , Solito Biagio , Santi Stefano
Published: September 2024

Background

The effectiveness of bariatric surgery for weight loss in morbidly obese patients has been well established and it's becoming more common as many surgeons are trained to perform them safely, even in older patients. Obesity is associated with reflux and hormonal imbalances that increase the risk of Barrett's esophagus, esophageal adenocarcinoma and gastric cancer.

Bariatric procedures alter gastric anatomy, vascularization and lymphatic drainage and render subsequent upper gastrointestinal surgery for malignancies a technical challenge, that will present more and more in the future.

We present laparoscopic sleeve gastrectomy, gastric bypass and gastric banding conversion to oncological respective surgeries.

Methods

We retrospectively reviewed the medical records of our referral high-volume center for upper gastrointestinal surgery and identified patients who underwent upper gastrointestinal oncologic surgery from January 1998 to May 2024. We selected all patients who had previously undergone bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic gastric bypass, gastric banding, or other less common procedures). Three patients met our criteria, and we recorded: demographic characteristics, surgical technique, oncologic surgical outcome, postoperative complications, long-term complications, and oncologic follow-up.

Results

A hybrid IvorLewis esophagectomy was performed years after a sleeve gastrectomy for distal esophageal adenocarcinoma. The sleeve was used for gastric pull-up, adequately vascularized by the right gastroepiploic artery as demonstrated by intraoperative indocyanine green.

A patient developed adenocarcinoma of the cardia after Roux-en-Y gastric bypass, infiltrating the gastric pouch, the gastric remnant and liver S2. After neoadjuvant chemotherapy, an open Ivor-Lewis esophagectomy was performed using the gastric remnant for a pull-up.

In a third patient, a locally advanced adenocarcinoma of the stomach developed after gastric banding. After neoadjuvant chemotherapy, an open total gastrectomy with Roux-en-Y esophagojejunostomy was performed.

Conclusion

We report three cases of successful esophago-gastric oncological surgery in patients with altered anatomy and vascularization due to previous bariatric surgery, without major postoperative complications or mortality. Oncologic benchmarks for both esophageal and gastric surgery were met as a high lymph node yield and oncologic margins were maintained.

Our heterogeneous series suggests that sleeve gastrectomy, gastric bypass, and gastric banding surgery can be successfully converted to resective surgeries after a metachronous neoplasia diagnosis in high-volume upper gastrointestinal centers.

These and similar modified reconstructive techniques are likely to be used in the future as metabolic surgery and esophago-gastric cancer are increasing.
790. RISK FACTORS FOR ESOPHAGEAL CANCER IN NORTHEAST INDIA: A MULTI-CENTRIC CASE-CONTROL STUDY
Authors: Harris Caleb , Mawlong Anisha , Tapkire Ritesh , Albert Sandra , Jagtap Vikas
Published: September 2024

Background

Northeast India has a high incidence of esophageal cancer(EC), with age-adjusted incidences ranging from 19 to 50 per 100,000 (in females and males respectively). This is over ten times the average incidence of EC in India. The local preparation of raw betel nut,‘kwai’, is integral to the culture, but its role has not been established. This study aimed to assess the role of betel nut, with or without tobacco as a causative agent for EC. The role of alcohol was also studied.

Methods

A multi-centric, matched case-control study was performed from October 2022 to March 2024 in three centres situated in the Northeast region of India. All cases of biopsy proven squamous EC, arising from the cricopharynx to the gastroesophageal junction were included, with matched controls (1:3 ratio) being patients visiting the hospital for minor ailments and healthy volunteers from the community. A validated questionnaire was administered by trained trial coordinators. The data was analysed using a conditional multivariate logistic regression which incorporated the individual matching of cases with 3 controls. A p-value of < 0.05 was considered statistically significant.

Results

A total of 185 cases and 556 controls were matched for age (± 5 years), ethnicity, and gender. There was an increased risk of EC for those consuming betelnut with slaked lime [Calcium hydroxide Ca(OH)2] (Odds Ratio(OR) of 3.77 (Confidence Interval(CI) 1.30-10.92)); alcohol (OR 2.00 CI: 1.80-6.67) and tobacco (OR 3.47 CI:1.80-6.67). The risk was higher for those who swallowed the betel quid and juice as compared with those who spit it out (OR 4.01 CI: 2.24-6.73). The risk was increased in those consuming betelnut while hungry, instead of a meal (OR 10.40 CI 3.66-29.57). The risk was increased in those with no formal education (OR of 4.13 CI: 2.01-8.49). On adjusting with other risk factors (tobacco and alcohol), the risk was highest for betelnut with tobacco (OR 7.84 CI 2.12-29.90) and betelnut with alcohol (OR 2.84 CI 1.11-7.29). All these OR were statistically significant.

Conclusion

Consumption of betelnut with slaked lime increases the risk of EC. This risk is increased by the concomitant use of tobacco and alcohol.
794. RETROSPECTIVE ANALYSIS OF CLINICAL CHARACTERISTICS AND PROGNOSIS OF SYNCHRONOUS MULTIPLE PRIMARY ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Wenyi Liu , Yu Zhentao
Published: September 2024

Background

Multiple primary esophageal squamous cell carcinoma (MPESCC) is a rare and complex type of esophageal cancer, categorized into synchronous multiple primary esophageal squamous cell carcinoma (S-MPESCC) and metachronous multiple primary esophageal squamous cell carcinoma (M-MPESCC). Compared to solitary esophageal squamous cell carcinoma (SESCC), multiple primary esophageal squamous cell carcinoma (MPESCC) generally has a poorer prognosis, with significant differences in treatment strategies and survival outcomes. This study aims to explore the clinical characteristics and prognosis of S-MPESCC through a retrospective analysis of a large patient cohort.

Methods

This study retrospectively analyzed clinical data from 758 patients with esophageal squamous cell carcinoma (ESCC) who underwent surgical resection at two medical centers in China from January 2012 to December 2021. The S-MPESCC group included 68 patients, and the SESCC group included 690 patients. All patients underwent radical esophagectomy with systematic lymph node dissection. Preoperative and postoperative data were collected, including gender, age, family history, tumor staging, and lymph node metastasis.

Results

There were no significant differences in baseline characteristics, such as gender, age, and family history, between the S-MPESCC and SESCC groups. The lymph node metastasis rate was significantly higher in the S-MPESCC group compared to the SESCC group, especially in the upper mediastinal and abdominal regions (P<0.05). Survival status was monitored through outpatient visits and telephone calls until December 2022. The results showed that the 3-year and 5-year survival rates of the S-MPESCC group were significantly lower than those of the SESCC group (P< 0.05). Patients with a greater depth of primary tumor infiltration had poorer survival outcomes in the S-MPESCC group.

Conclusion

This study clarified the clinical characteristics and prognosis of S-MPESCC through a retrospective analysis of 758 ESCC patients. S-MPESCC patients had a significantly higher rate of lymph node metastasis and a poorer prognosis compared to SESCC patients. Future efforts should focus on optimizing treatment strategies to improve the prognosis and survival rates of patients with S-MPESCC.
799. OPTIMUM NUMBERS OF DISSECTED LYMPH NODES FOR ACCURATE NODAL STAGING IN CT1-2N0 ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Park Seong Yong , Park Boram , Yun Jae Kwang , Kim Hyeong Ryul , Kim Yong-Hee , Jeon Yeong Jeong , Lee Junghee , Cho Jong Ho , Kim Hong Kwan , Choi Yong Soo , Zo Jae Il , Shim Young Mog
Published: September 2024

Background

Patients with esophageal squamous cell carcinoma (ESCC) with lymph node metastasis may be misclassified as pN0 due to an inadequate lymph node dissection. The purpose of this study was to confirm that patients with cT1-2N0 ESCC are indeed pN0 and to propose an adequate number of lymph nodes for correct nodal staging.

Methods

A total of 1,855 patients who underwent upfront surgery for cT1-2N0 ESCC at two tertiary academic hospital in Korea between 1995 and 2019 were included in the study. The probability of false-negative lymphadenectomy and NSS (nodal staging score) was calculated to assess the probability of pN0 status.

Results

The mean age was 63.36 ± 8.01 years, with 1,726 (93.05%) male patients. The mean number of dissected lymph nodes was 34.69 ± 13.98. The clinical T stages were as follows: cTis & cT1a 354 (19.08%), cT1b 1,053 (56.77%), and cT2 448 (24.15%). Pathologic nodal upstaging occurred in 443 (23.91%); pN1 352 (19.0%), pN2 78 (4.21%), and pN3 13 (0.7%). By calculating the probability of false-negative lymphadenectomy, removing fewer than 33 lymph nodes was associated with a 20% risk of missing a positive lymph node, whereas removing 53 lymph nodes was associated with a 10% risk of missing a positive lymph node. The NSS, which reflects the probability that a patient with ypN0 status is actually free of occult nodal disease after surgery, increased as the number of dissected lymph nodes increased.

Conclusions

Extensive lymph node dissection is mandatory for accurate staging and reducing the risk of missing positive lymph nodes in early-stage ESCC. The survival benefits of extensive lymph node dissection need to be evaluated in further analysis.
804. NUTRITIONAL OUTCOMES AND IMPACT OF MALNUTRITION IN A RANDOMIZED COMPARISON BETWEEN STANDARD AND PROLONGED TIME TO SURGERY AFTER NEOADJUVANT CHEMORADIOTHERAPY FOR ESOPHAGEAL CANCER
Authors: Ericson Jessica , Klevebro Fredrik , Sunde Berit , Szabo Eva , Halldestam Ingvar , Smedh Ulrika , Wallner Bengt , Johansson Jan , Johnsen Gjermund , Ahlin Eirik , Johannessen Hans-Olav , Hjortland Geir-Olav , Bartella Isabel , Schröder Wolfgang , Bruns Christiane , Rouvelas Ioannis , Nilsson Magnus
Published: September 2024

Background

Prolonged time to surgery (TTS) after neoadjuvant chemoradiotherapy (nCRT) may enable malnourished oesophageal cancer patients´ nutritional status to recover better, possibly improving outcomes after esophagectomy.

Methods

This is a substudy within a randomised multicenter controlled trial comparing outcomes in esophageal cancer patients after standard TTS of 4-6 weeks to prolonged TTS of 10-12 weeks after nCRT. Patients were categorized as malnourished or non-malnourished at baseline and compared regarding nutritional endpoints.

Results

The mean weight decreased significantly from baseline to the standard TTS (p<0.001) while at the prolonged TTS it had recovered to baseline level (p=0.131), Figure 1. There was no significant difference in postoperative complications between patients malnourished at baseline when allocated to standard compared to delayed surgery (OR: 0.90, 95% confidence interval, CI: 0.29-2.77 and OR 1.13, 95% CI: 0.32-4.00, respectively). Patients malnourished at baseline had a strong trend to worse survival after delayed compared to standard TTS, Hazard ratio (HR) 1.72 (95%, CI: 0.82-3.59, p=0.147). which was less pronounced for non-malnourished patients, HR 1.26 (95% CI:0.82-1.94, p=0.291).

Conclusions

Prolonged TTS led to better weight recovery at time of surgery. Patients malnourished at baseline did not benefit in terms of less postoperative morbidity after delayed surgery and had a stronger trend to detriment in survival from delayed surgery than non-malnourished patients.
807. A REVISED APPROACH TO THE ESOPHAGOGASTRIC JUNCTION: A MODIFIED SIEWERT CLASSIFICATION
Authors: Fonseca Filipa , Cabral Francisco , Ramos Paulo , Monteiro Cecília , Abecasis Nuno , Casaca Rui
Published: September 2024

Background

Esophagogastric junction (EGJ) adenocarcinomas are challenging due to their anatomical and histopathological features and treated either as part of the esophagus or stomach cancers. Siewert (S) and Nishi classifications rely on the tumor’s epicenter to guide treatment decisions, which can lead to diagnostic and therapeutic inconsistencies. Moreover, recent studies helped define the optimal extent of lymphadenectomy for EGJ cancers. Here we present our standardized approach to EGJ cancers that integrates these insights, providing a framework to guide clinical decision-making.

Methods

Our modified classification relies on tumor extent rather than the epicentre, based on endoscopic measurement of the proximal and the distal limits, and the exact location of the EGJ. This approach classifies tumors based on their extent which results into six categories: SI, SI/II, SII, SII/III, SIII, and SI/II/III. Lower esophageal tumors whose distal limit lies between + 1cm and -2cm are classified as I/II. Cardia tumors whose proximal limit falls between those boundaries are II/III. Tumors that span more cephalad than + 1cm and more distally than – 2cm, are I/II/III. For Siewert I, I/II and II tumors, surgical management depends on the extent of esophageal involvement, mainly dictated by the probability of mediastinal basement nodal involvement, as defined by Kurokawa et al (2019). Additionally, a 3-field lymphadenectomy is performed when there is involvement of the cervical or recurrent laryngeal nerve lymph node stations.

Results

In SI, SI/II, and SI/II/III, with esophageal involvement exceeding 4 cm we favor a transthoracic esophagectomy (TTE) with total thoracic lymphadenectomy. If the involvement is between 1-4 cm, a transhiatal esophagectomy (THE) with lower mediastinal lymphadenectomy is performed. In SII, THE is done for 0-1 cm of involvement; absence of esophageal involvement permits a transhiatal extended total gastrectomy (eTG) with abdominal D2 lymphadenectomy and intra-operative margin status assessment via frozen sections.

In SI/II/III and esophageal involvement of more than 4 cm, TTE is required; for esophageal involvement of 1-4 cm, we perform a THE and total gastrectomy with abdominal D2 lymphadenectomy based on distal margin findings.

Conclusion

This proposed modification to the classification of EGJ adenocarcinomas introduces a comprehensive framework that is tailored to the extent of tumor involvement. By addressing the limitations of existing systems and incorporating current insights, this updated classification aims to improve patient categorization and standardize treatment protocols, potentially leading to enhanced clinical outcomes.
“It’s What Would Work for Her”: An Analysis of Adaptations to the Individualized Positive Psychosocial Interaction Program in U.S. Nursing Homes
Authors: Kunkel Miranda C , Talmage Alexis , Noble Molly , Van Haitsma Kimberly , Abbott Katherine M
Published: September 2024

Background and Objectives

The Individualized Positive Psychosocial Interaction (IPPI) program is an adaptable, evidence-based intervention. IPPI trains nursing home care partners to engage residents living with moderate to severe dementia in preference-based, one-to-one interactions using emotion-focused communication. We sought to understand provider-driven adaptations made to the IPPI program and whether the adaptations made were fidelity-consistent.

Research Design and Methods

Data were collected from n = 78 interviews with n = 23 nursing home provider champions who led a quality improvement project to implement the IPPI program with 3–5 residents per care community. Using content analysis, we report quantitative data on the adaptation characteristics according to the Framework for Reporting Adaptations and Modifications-Expanded core modules and participant quotes to illustrate adaptations.

Results

Champions reported 34 adaptations, with an average of 2.6 adaptations per nursing home. The majority of IPPI adaptations pertained to implementation (65%; n = 22), whereas 17% (n = 6) were content and 17% (n = 6) were context. Some adaptations were motivated by the organization (e.g., time constraints), while others were motivated by the recipient (e.g., cognitive capacity). Most adaptations made to the IPPI protocol by care partners were fidelity-consistent (92%; n = 33).

Discussion and Implications

Care partners’ adaptations to the IPPI made the intervention more resident-centric. Future healthcare intervention providers must consider the user perspective and encourage adaptations that further tailor to the user, as long as the adaptations are fidelity-consistent.
Achieving normal pulmonary function following tracheoplasty in infancy
Authors: Harrison Ciara , Harrison Jo , Fricke Tyson A , Konstantinov Igor E
Published: September 2024

Infant long-segment congenital tracheal stenosis (LTS) is rare and presents a challenging clinical scenario. We describe the management of a child who required extracorporeal membrane oxygenation following a respiratory arrest and underwent slide tracheoplasty in infancy for severe LTS and required repeated bronchoscopic reinterventions for recurrent tracheal granulations. At 9 years of age, the child has normal pulmonary function testing and a normal exercise tolerance.