bluuebunny/crossref_metadata_2025 huggingface dataset:
529. ANALYSES OF CLINICAL FACTORS AFFECTING POSTOPERATIVE SYMPTOMS INCLUDING BODY WEIGHT LOSS, ORAL INTAKE, AND REFLUX AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Mine Shinji , Hashimoto Takashi
Published: September 2022

Some patients complain of serious postoperative digestive symptoms after esophagectomy. However, it has not been clear what clinical factors are related to these symptoms. In this study, we investigate the relationships between postoperative digestive symptoms (body weight loss, subjective oral intake, and reflux) and clinical factors.

Of 155 patients who underwent esophagectomy at our department from April 2019 to July 2021, 75 patients were eligible because they could be followed up at our outpatient clinic without relapse. Postoperative symptoms including body weight loss, oral intake ≥70%, and reflux were asked. Regarding clinical factors, age, sex, route of reconstruction, the width and the location of the gastric tube in CT images, and the location of pylorus ring in CT images were investigated retrospectively.

The median body weight loss was 10.5%. Oral intake ≥70% was found in 37/61. 24/50 patients complained of reflux. The mean body weight loss was 6.2% in the intrathoracic anastomosis, 10.5% in the posterior mediastinal route, and 12.6% in the retrosternal route (p=0.04). Oral intake ≥70% was found in 20/29 of the wide gastric tube group and 16/31 of the narrow gastric tube group (p=0.197). The group with oral intake ≥70% was likely to be younger (p<0.01), and male is likely to have oral intake ≥70% (p=0.193). Regarding reflux, there were no difference in clinical factors.

Although this is a retrospective study and biases in each group are found, body weight loss is less found in the intrathorax anastomosis and in the duodenostomy group via a retrosternal route. Oral intake is likely to be more in younger patients, in male, and in patients with wider gastric tube. On the other hand, no clinical factors were found related to reflux.
535. ENDOSCOPIC AND THORACOSCOPIC MANAGEMENT OF OESOPHAGEAL PERFORATION
Authors: Kumar Bhaskar , Khanzada Zubair
Published: September 2022

This is a rare case of boerhaave’s syndrome associated with ischaemic small bowel in a young patient. A 45-year-old man, background of schizophrenia, alcohol excess and previous TIAs, presented to resus room in a peri-arrest condition secondary to sepsis. A CT scan confirmed gross mediastinitis with extensive right pleural contamination and an ischaemic segment of small bowel. An intercostal chest drain in resus was placed and drained enteric content from the oesophagus confirming the diagnosis.

The patient was immediately taken to operating theatre and a large distal oesophageal perforation was localized on OGD under GA. Using a novel technique, a guide wire was placed into the mediastinal cavity via the perforation. Over the guide wire, an exudrain was placed to act as an endovac (200mmHg wall suction) and a large bore NG tube placed into the stomach. A right sided VATs decortication and wash out and insertion of further chest drains was carried out, followed by laparotomy and resection of a 10cm segment of ischaemic small bowel.

Following a short critical care unit stay, the patient made a steady recovery free of any complications. In total, 3 endoscopies were performed post operatively to assess mediastinal healing. Psychotropic medications were delivered through an NJ tube. At 3 weeks, the patient showed complete healing of the oesophageal defect and had a stricture which needed dilatation.

Endoscopic negative pressure treatment can be combined with a minimally invasive thoracoscopic approach to the mediastinum to achieve success even in an unstable patient. Vigilance needs to be applied for concomitant pathology such as small bowel ischaemia, although rare, contributes to the risk associated with this serious condition.
538. A DECADE OF ESOPHAGEAL AND ESOPHAGO-GASTRIC JUNCTION CANCER EPIDEMIOLOGY IN NATIONAL CANCER INSTITUTE MEXICO
Authors: Takahashi Alberto Mitsuo Leon , Basave Horacio Noe Lopez , Silva Leonardo Saul Lino , Ruiz German Calderillo , Garcia Erika Betzabe Ruiz , del Consuelo Diaz Romero Maria , Martinez Marytere Herrera , Torres Cesar Alejandro Paleta , Castañeda Karla Fabiola Hernandez , Gomez Angel Herrera
Published: September 2022

In 2020, the incidence of esophageal cancer was 8th and mortality was 6th in the world. However, it´s not the top 10 in Mexico. Mexico is a developing country and has no national cancer registration. Moreover, Mexico is the 2nd largest obese country in the world, and obesity is one of the leading factors for adenocarcinoma. Therefore, we believe that the actual incidence of esophageal cancer in Mexico is likely to be higher.

Retrospective study of patients diagnosed as esophageal and esophago-gastric junction (EGJ) cancer from January 2011 to September 2021. We used the 8th edition (AJCC) to separate esophageal and esophago-gastric junction from gastric cancer and determine the clinical stage. Descriptive statistics were used and Mean Overall Survival (MOS) and Overall Survival (OS) were figured from the date of diagnosis to the date of death or the last follow-up. Kaplan-Meier was used to assess the patients' survival and the differences in subgroups were analyzed by the log-rank with SPSS ver.26.

617 patients were admitted during the period (496 were esophageal and 121 true EGJ). The ratio was men 500 (81%) to women 117 (19%) and the mean age was 60.7±12.3 y.o. (18-90). Main symptoms were solid dysphagia 466 (75.5%) and weight loss 508 (82.3%). The mean BMI was 23.8± 4.6(14.6-42.6). The main histology was intestinal adenocarcinoma 288 (46.7%) and then squamous cell carcinoma 214 (34.7%). Clinical stage IVB 325 (52.7%) and III 213 (34.5%) were the most frequent and 158 (25.6%) cases could not start treatment. The mean following was 11 (0-98) months, MOS was 19.1 (95%CI,16.4-21.9) months and OS was 30.8%. The 5-year SV by stage were I-100%, IIA-37%, IIB-16%, III-15%, IVA-B 6%.

This study shows epidemiology from National Cancer Institute in Mexico. Most patients were men in their 60s. The main histology was adenocarcinoma, yet we had many squamous cell carcinoma cases. Although Mexico is the second largest obese country in the world, our patients in the average were not obese. Unfortunately, most patients are diagnosed in advanced stage (IVB) and it might cause the poor prognosis of survival.
539. SURGICAL TECHNIQUES AND OUTCOMES OF GASTRIC CONDUIT RECONSTRUCTION FOLLOWING ESOPHAGECTOMY BY HAND-ASSISTED LAPAROSCOPIC SURGERY (HALS) FOR ESOPHAGEAL CANCER
Authors: Suzuoki Masato , Hiraoka Kei , Takahashi Ryo , Niwa Hiroki , Mizunuma Kenichi , Wada Hideyuki , Iwashiro Nozomu , Ohara Masanori
Published: September 2022

After esophagectomy with reconstruction using a gastric conduit for esophageal cancer, anastomotic leak can cause serious complications and has a significant impact on the postoperative course.

At our institution, gastric conduit reconstruction by hand-assisted laparoscopic surgery (HALS) is the first-line technique for reconstruction following esophagectomy due to its reliability and shortened operative time. In this study, we performed a retrospective review of the surgical outcomes.

We reviewed characteristics and perioperative outcomes of 124 patients who underwent esophagectomy with gastric conduit reconstruction for esophageal cancer by HALS from February 2011 to December 2021.

Surgical procedure: We created a gastric tube via the HALS incision. A 3-cm wide gastric tube was fashioned using the linear staplers. We mobilized and manually stretched the stomach to ensure the length of the gastric tube. Then the blood flow in the gastric tube was evaluated by ICG fluorescence method followed by esophagogastric anastomosis using a 25-mm circular stapler on the greater curvature side.

Among the 124 patients, there were 99 males and 25 females with a median age of 70 years (range, 46 – 85 years). Neoadjuvant therapy was performed in 50 patients. The median operative time was 259 minutes (135-454 minutes). Complications related to the gastric conduit reconstruction included anastomotic leak in two patients (1.6%) and anastomotic stricture requiring dilatation in 39 patients (31.5%), of whom 15 (12.1%) underwent repeat dilatation. Gastric tube stenosis, gastric tube hemorrhage, and gastric tube-to-pulmonary fistula were also observed in one case each.

In the present study, while the incidence of anastomotic leak was low (1.6%) in patients received HALS esophagectomy with gastric conduit reconstruction, almost one-third (31.5%) of the patients had anastomotic stricture and required dilatation.
543. THORACO-LAPAROSCOPIC EXCISION OF A FOREGUT DUPLICATION CYST WITH A PYLORO-DUODENAL COMMUNICATION
Authors: Surendran Suraj , Paul Negine , Yacob Myla , Chandran Sudhakar , Samarasam Inian
Published: September 2022

Foregut duplication cysts presents rarely in adults. Rarely, they can have an intraluminal communication. Traditionally, these cysts are excised via open surgical approaches.

This video case describes the Thoraco-laparoscopic management of a 34-year old female patient who was diagnosed with foregut duplication cyst with a pyloro-duodenal communication.

Successful excision of the foregut duplication cyst was achieved, through minimally invasive technique. Postoperatively, a right-sided pleural collection resulted, which was successfully managed with image-guided drainage. She is currently alive and asymptomatic at 1-year follow-up.

Minimally invasive surgery is feasible and safe in the management of foregut duplication cysts with luminal communication.
544. NON-EPSTEIN-BARR VIRUS ASSOCIATED LYMPHOEPITHELIOMA-LIKE CARCINOMA OF THE ESOPHAGUS WITH SURGICAL TREATMENT: A REPORT OF TWO CASES
Authors: Nakano Toru , Sawada Kentaro , Mitamura Atsushi , Suzuki Hideyuki , Sakurai Hiroto , Miura Tomoya , Takami Kazuhiro , Kondo Noriko , Yamamoto Kuniharu , Katayose Yu , Shibata Chikashi
Published: September 2022

Lymphoepithelioma-like carcinoma (LELC) can occur in many organs such as lung, stomach, skin, breast, bile ducts, esophagus, and other many organs. Esopahageal lymphoepithelioma-like carcinoma is an extremely rare disease. LELC has been reported to be associated with Epstein-Barr virus (EBV) in some organs, although there are many controversies. Here, we report a surgically treated two cases of non-Epstein-Barr virus associated LELC of the esophagus.

Case 1was a 46-year-old woman who was presented epigastralgia while eating. Upper gastrointestinal endoscopy showed a submucosal tumor in the lower esophagus. Biopsies were taken, and they identified atypical cells proliferating follicular manner and heavy infiltration of lymphocytes.

Case 2 was a 71-year-old man who was pointed out to have a tumor in the esophagus by barium examination and was referred to our hospital. Upper gastrointestinal endoscopy showed submucosal tumor was found 23-26 cm from the cut tooth. Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-FNA) was performed and diagnosed with LELC.

These patients underwent subtotal esophagectomy with lymphadenectomy and reconstruction with gastric tube.

Case1 was pathologically diagnosed with LELC, SM3, INFa, ly0, V0, pIM0, pPM0 (100mm), pDM0 (120mm), pRM0, pN0, cM0, pStageI, and case2 was diagnosed with LELC, ly1, V1, pIM0, pPM0, pDM0, pRM0, pN0, cM0, pStageI, according to the 10th edition of Japanese classification of Esophageal cancer. Immunohistochemical staining of the specimen from case 1 was positive for AE1/AE3, P40, p63, and negative for CD56 and chromogranin A. Immunohistochemical staining of the specimen from case 2 was positive for CK, EMA, P40, and negative forαSMA and desmin. EBV was not detected by EBER in situ hybridization in the specimen from both patients.

LELC is relatively common in salivary glands, thymus, lungs, stomach, skin, and cervix, and EBV that directly infects epithelial cells or infects lymphocytes infects epithelial cells and infects them. EBV infects epithelial cells and is thought to be associated with carcinogenesis of these organs. However, esophageal LELC is rare and it has been argued that EBV may not be involved. In these two cases, EBV was not detected in situ hybridization.
552. LAPAROSCOPIC RE DO FUNDOPLICATION
Authors: Ramakrishnan Parthasarathi , Balasubramanian Shankar , Natarajan Ramesh , Bharath Cumar M , Chinnusamy Palanivelu
Published: September 2022

Laparoscopic fundoplication though an effective form of therapy for patients with refractory gastroesophageal reflux disease, can fail due to poor patient selection or compromised surgical technique. Redo laparoscopic fundoplication is a challenging task prone to further failures.

Retrospective analysis of consecutive patients who underwent laparoscopic redo fundoplication in a tertiary care center between July 2015 and March 2022.

There were a total of 24 patients that underwent redo fundoplication during the study period. Wrap migration was noted in 8 (33.3%) patients while the wrap was too tight which led to dysphagia in 5 (20.8%) patients. Two patients had previously undergone laparoscopic redo fundoplication while one patient initially underwent open Nissen’s fundoplication. All the patients were managed successfully laparoscopically without any conversion. The median time interval between the first surgery and the redo operation was 8 months (3 months to 12 years). Symptomatic improvement was observed in 20 (83.3%) while 4 (16.7%) patients continued to have symptoms.

Laparoscopic redo fundoplication can yield satisfactory results in patients after initially failed anti reflux surgery when performed in experienced centers. Proper case selection and meticulous surgical technique to address the primary cause of failure is paramount.
561. VIDEO ASSISTED THORACOSCOPIC ESOPHAGECTOMY WITH ABERRANT VASCULAR ANATOMY
Authors: So Choi Kwan , Lam Chin Tou , Cheung Siu Hong , Chow Tam Lin
Published: September 2022

Aberrant right subclavian artery is an important vascular anomaly for upper mediastinal dissection in esophagectomy.

We encountered a patient with this aberrant vascular anatomy, which was identified in preoperative CT scan. Operative video was taken in the consent of patient and saved for further educational purpose.

This was a 67 years old male with advanced middle thoracic esophageal tumour. Biopsy confirmed squamous cell carcinoma. He underwent trimodality treatment after multidisciplinary team discussion. Neoadjuvant chemoradiotherapy was completed 6 weeks before the surgery.

The patient underwent minimally invasive McKwown esophagectomy with complete mediastinal dissection. The patient was put in semiprone position with bronchial block for one lung ventilation. The aberrant anatomy was successfully identified intraoperatively, and the operation was uneventful. The total operative time was 6 hours 39 mins and the total blood loss was 120ml. The patient ran an uneventful recovery and was discharged on postoperative D10.

To be able to acknowledge this unusual anatomy in preoperative imaging and clearly identify it intraoperatively are the keys to prevent inadvertent injury and massive bleeding.
562. PROGNOSTIC IMPACT OF CLINICOPATHOLOGICAL FEATURES FOLLOWING METASTECTOMY FOR METACHRONOUS PULMONARY METASTASIS FROM ESOPHAGEAL CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Prasad Pooja , Nevins Edward , Brown Joshua , Phillips Alexander W
Published: September 2022

Disease recurrence following treatment for esophageal cancer (EC) remains common despite incremental gains from receipt of neoadjuvant chemotherapy. The lung is a common site of distant metastasis following definitive EC treatment. Clinicopathological features of the primary EC tumour have implications on the development of metastatic disease and overall survival. This systematic review sought to identify the prognostic impact of clinicopathological features of the primary esophageal tumour following treatment of metachronous pulmonary metastasis from EC.

A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to March 2022. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting on the clinical and pathological features of the primary EC tumour among patients undergoing treatment for metachronous pulmonary metastasis were included. A random effects meta-analysis model was used to compare the impact of gender (male vs female), primary EC pathological T-stage (pT1/2 vs pT3/4) and pathological N-stage (N0 vs N1+), on 5-year survival following pulmonary metastectomy.

Seven non-randomised studies comprising 110 patients undergoing pulmonary metastectomy for metastatic EC were included. Gender did not have an impact upon 5-year survival (Risk Ratio (RR) =0.65; 95% confidence interval (CI):0.37-1.15; p=0.14). A lower primary EC T-stage (T1/2) was associated with improved 5-year survival following pulmonary metastectomy compared to advanced T-stages (T3/4), though this did not reach statistical significance (RR= 1.76; 95% CI:0.96-3.20; p=0.07). The absence of nodal disease (N0) in the primary EC tumour did not confer a survival benefit over those patients with nodal involvement disease (N1+) proceeding to pulmonary metastectomy (RR= 1.45; 95% CI:0.86-2.46; p=0.18).

Patient gender and pathological T- and n-stages of the primary tumour do not impact upon prognosis following metastectomy for metachronous pulmonary metastasis from EC. However, current evidence from smaller non-randomised studies remains weak owing to variation in the treatment of the primary EC, limiting outcome assessment.
566. PROGNOSTIC SIGNIFICANCE OF TUMOUR BURDEN AND OPERATIVE TECHNIQUE FOR METACHRONOUS PULMONARY METASTASIS FROM ESOPHAGEAL CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Prasad Pooja , Nevins Edward , Brown Joshua , Chmelo Jakub , Phillips Alexander
Published: September 2022

Disease recurrence following treatment for esophageal cancer (EC) remains common despite incremental gains from neoadjuvant chemotherapy. The lung is a common site of distant metastasis following definitive EC treatment. Tumour burden influences the surgical approach utilised in the treatment of pulmonary metastasis from EC. In turn, this impacts patient prognosis. This systematic review sought to identify the impact of tumour burden and surgical approach on 5-year survival following metastectomy of metachronous pulmonary metastasis from EC.

A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to March 2022. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting on the number of metastatic pulmonary tumours and operative techniques utilised were included. A random effects meta-analysis model was used to compare the impact of number of metastatic pulmonary deposits (single vs multiple), and operative approach (wedge vs anatomical resection) on the 5 year survival of patients following metastectomy for metachronous pulmonary metastasis from EC.

Seven non-randomised studies comprising 142 patients undergoing pulmonary metastectomy for metastatic EC were included. The number of metastatic deposits (single vs multiple) did not affect 5-year survival (Risk Ratio = 1.08; 95% confidence interval 0.58-2.02; p = 0.81). With respect to surgical technique, anatomical resection did not confer a survival benefit compared to wedge resection of pulmonary metastases from EC (Risk Ratio = 1.33; 95% Confidence Interval: 0.81 – 2.19; p = 0.26).

Tumour burden and surgical technique utilised does not impact upon the prognosis of patients undergoing pulmonary metastectomy for metastatic EC. However, current evidence from smaller non-randomised studies remains weak owing to variation in the clinicopathological features of the primary EC and pulmonary metastasis, limiting outcome assessment.
570. INCIDENCE AND ONCOLOGICAL IMPLICATION OF ADRENAL INCIDENTALOMAS IN ESOPHAGEAL CANCER PATIENTS
Authors: Van Doesburg Jasmijn , Voeten Daan , Kalff Marianne , Jol Saskia , van der Bergh Janneke , Engelsman Anton , Gisbertz Suzanne , Daams Freek
Published: September 2022

Adrenal incidentalomas are regularly encountered during imaging for esophageal cancer patients, but their oncological significance remains unknown. This study aimed to describe the incidence and etiology of adrenal incidentalomas observed during the diagnostic workup for esophageal cancer.

This retrospective cohort study included all esophageal cancer patients referred to or diagnosed in the Amsterdam UMC between January 2012 and December 2016. Radiology and multidisciplinary team meeting reports were reviewed for adrenal incidentalomas. In case of adrenal incidentaloma, the 18FDG-PET/CT was reassessed by a radiologist blinded for the original report. In case of a metachronous incidentaloma during follow-up, visibility on previous imaging was reassessed. Primary outcome was the incidence, etiology and oncological consequence of synchronous adrenal incidentalomas.

This study included 1,164 esophageal cancer patients, with a median age of 66 years. Patients were predominantly male (76.1%) and most had an adenocarcinoma (69.0%). Adrenal incidentalomas were documented in 138 patients (11.9%) during the diagnostic workup. At primary esophageal cancer workup, 22 incidentalomas proved malignant. However, follow-up showed seven malignant incidentalomas missed or inaccurately diagnosed as benign. In total, stage migration occurred in 15 of 22 (68.2%), but this number would have been higher if no incidentalomas were missed or inaccurately diagnosed.

The oncological impact of adrenal incidentalomas in patients with esophageal cancer is significant as a considerable part of incidentalomas changed treatment intent from curative to palliative. As stage migration is likely, pathological examination of a synchronous adrenal incidentaloma should be considered.
573. DOES CHEST PAIN AFFECT THE LONG TERM OTCOME OF SURGERY FOR ESOPHAGEAL ACHALASIA?
Authors: Tassi Valentina , Baldi Fabio , Lugaresi Marialuisa , Daddi Niccolò , Bassi Francesco , Pilotti Vladimiro , Mattioli Sandro
Published: September 2022

Literature supporting the adoption of POEM in place of the standard Heller myotomy in the presence of significant chest pain associated with typical symptoms like in case of Achalasia Type III according to the Chicago classification, generally reports on outcome data collected after short follow up periods. We aimed to assess behaviors of chest pain in the long term in a case series of patients submitted to the Heller-Dor operation.

Between 1978 and 2021,394 achalasia patients underwent the Heller-Dor operation. Chest pain was evaluated according to its frequency (0: absent; 1: occasional; 2: weekly; 3: daily): 81 preoperatively complained of chest pain (score 2-3) (CP group), 313 did not (score 0-1) (NCP group). Patients were followed up according to a timed protocol based on clinical assessment of dysphagia (D0 absent – D3 each meal), GERD symptoms (RS0 absent-RS3 each meal). Barium swallow and endoscopy (E0: normal, E1: mild esophagitis, E2-3: erosive/ulcerative esophagitis) were performed at each planned control. CP and NCP were compared.

CP group had shorter duration of dysphagia (p=0.03), smaller esophageal diameter and lower barium column (p<0.05). At a median follow-up of 10 years for CP and 11 years for NCP (p=0.166), the frequency of dysphagia (p=0.05), GERD symptoms (p=0.3) and esophagitis (p=0.27) was similar in the two groups. Chest pain progressively attenuated in intensity and frequency.; median chest pain score preoperatively was 3, at follow-up it was 0 (p<0.01). Clinical results obtained in CP patients (satisfactory D0–2, RS0–2, and E1 in 95%) were not inferior to those obtained in NCP patients (satisfactory in 93%) (p=0.05).

According to our single center case series, in the long term chest pain does not influence negatively HD outcome which is absolutely competitive with that generally reported for POEM and pneumatic dilation. Results presented in this study must be verified: as new randomized prospective studies would require a too long lag time, valid retrospective multi center studies should be performed.
574. MINIMALLY INVASIVE ESOPHAGECTOMY IN ESOPHAGEAL CANCER: IMPROVING OUTCOMES WITH A SYSTEMATIC PROTOCOL
Authors: Cheng Shi Yu , Lim Jolene , Voon Kelvin
Published: September 2022

Minimally invasive esophagectomy (MIE) has the advantages of reduced post-op cardiopulmonary complications, faster recovery and better quality of life. MIE has been the standard approach for esophageal cancer in our center since year 2020. A systematic approach with prehabilitation and enhanced recovery after surgery is key in improving outcomes after MIE.

We herein report our protocol for MIE in esophageal cancer. A stepwise diagnostic, staging and multidisciplinary management pathway was adopted. All patients with histologically confirmed esophageal cancer were staged according to the 8th edition AJCC cancer staging with PET-CT scan. Patient assessment, comorbidity optimization and 3-axis prehabilitation were initiated on the first consultation. All cases were discussed in the multidisciplinary tumour board meeting and multimodality treatment approach was advocated. MIE was the standard surgical approach with selective ERAS pathway especially on goal directed fluid therapy, multimodality analgesia, timely extubation, early ambulation and enteral feeding.

A total of 10 patients underwent MIE between June 2020 to June 2021 with the MIE protocol. The mean age was 56.7. Adenocarcinoma was the commonest histology. All patients had neoadjuvant therapy due to locally advanced disease. 6 patients had McKeown MIE with either 3-field or total 2-field lymphadenectomy. The mean length of stay post-op was 8.3 days. The average post-op pain score was 2.3 and the mean time to ambulation post-op was 1.6 days. Post-operative complications were noted in 4 patients with only one being Clavien Dindo grade 3. There was no 90-day mortality post-op.

The early result of this systematic protocol with multidisciplinary approach, prehabilitation, MIE and selective ERAS pathway was promising. Evidence based practice with regular clinical audit are important in improving the quality of care and clinical outcomes.
577. FDG PT-CT METABOLIC TUMOUR AND NODAL RESPONSE AS A PREDICTOR OF PATHOLOGICAL RESPONSE AND SURVIVAL IN PATIENTS WITH OESOPHAGEAL ADENOCARCINOMA
Authors: Moore Jonathan , Subesinghe Manil , Santaolalla Aida , Green Michael , Deere Harriet , Van Hemelrijck Mieke , Lagergren Jesper , Chicklore Sugama , Maisey Nick , Kelly Mark , Gossage James A , Baker Cara R , Davies Andrew R
Published: September 2022

2-deoxy-2[18F]fluoro-D-glucose positron emission tomography-computed tomography (FDG-PET-CT) is routinely used for staging of oesophageal cancer and has an emerging role in assessing response to neoadjuvant therapy. The primary aim of this study was to evaluate the ability of FDG-PET-CT to predict pathological response in the primary tumour (pTR) and lymph nodes (pNR) in patients with oesophageal adenocarcinoma undergoing neoadjuvant chemotherapy before surgery. The secondary aim was to assess the prognostic effect of metabolic and pathological response.

Cohort study of 75 patients with locally advanced oesophageal or oesophago-gastric junctional adenocarcinoma who underwent FDG-PET-CT before and after neo-adjuvant chemotherapy, prior to surgical resection at a tertiary referral centre in the United Kingdom, between 2017-2020. Standardised uptake value (SUV) metrics related to the primary tumour and loco-regional lymph nodes were derived. pTR and pNR were evaluated using the Mandard classification. Receiver operator characteristic (ROC) analysis was performed and area under the curve (AUC) calculated to determine optimum SUVmax thresholds for metabolic response in the primary tumour (mTR) and lymph nodes (mNR). Survival was assessed using multivariable Cox regression.

ROC analysis demonstrated an optimum tumour SUVmax decrease of 51.2% for predicting pTR. A pragmatic 50% cut-off provided better prediction of pTR (AUC 0.714, sensitivity 73.5%, specificity 69.2%, p<0.001) than PERCIST (30% reduction) and MUNICON (35% reduction) criteria. Using a 30% SUVmax threshold and excluding metabolically negative nodes, mNR demonstrated high sensitivity but low specificity (sensitivity 92.6%, specificity 57.1%, p=0.010) for predicting pNR. pTR, mTR, pNR and mNR were independent prognostic factors (pTR responder HR 0.10 95% CI 0.03-0.34; mTR responder HR 0.17 95% CI 0.06-0.48; pNR responder HR 0.17 95% CI 0.06-0.54; mNR responder HR 0.13 95% CI 0.02-0.66).

Metabolic response predicted pathological response in both the primary tumour and lymph nodes in this cohort of patients with locally advanced oesophageal adenocarcinoma treated with neo-adjuvant chemotherapy. Metabolic tumour response, pathological tumour response, metabolic nodal response and pathological nodal response were all independent prognostic factors for survival. Currently utilised metabolic response criteria may not be optimal for this tumour group.
578. ENHANCED RECOVERY AFTER SURGERY (ERAS) IN PATIENTS UNDERGOING OESOPHAGECTOMY: A PROSPECTIVE OBSERVATIONAL STUDY
Authors: Jethani Manish , Mistry Rajesh
Published: September 2022

Esophagectomy remains the main stay of treatment in localized esophageal carcinoma. Radical Esophagectomy is associated with high morbidity and mortality. To minimise peri and post-operative complications and accelerate recovery, concept of ERAS has been introduced. Standardized ERAS guidelines were lacking in esophagectomy patients until the ERAS society published their guidelines in late 2018.

This is a prospective observational study were ERAS protocol was followed for all patients undergoing esophagectomy during the study period (July 2020 to November 2021). Aim of the study was to compare the post-operative morbidity and mortality associated with ERAS protocol to published historical data from same institute. All patients undergoing esophagectomy for carcinoma of esophagus and GEJ were included and all the components of ERAS protocol as specified in the published guidelines were followed during the study.

Out of 52 patients, 36 underwent minimal invasive procedure and 15 had open surgery. Median age was 59.5 years. Average blood loss for thoracic part was 150 ml and 100ml for the abdominal. 37/52 (71.15%) were extubated and rest were electively ventilated till next morning. Median post-operative ICU stay was one day (1-2) and over all hospital stay was 10 days (9-12). Overall morbidity was 11/52 (21.15%) with major morbidity in 4/52 (7.69%); there was no mortality. 2/52 (3.84%) had anastomotic leak.

It was possible to follow the ERAS protocol for patients undergoing esophagectomy. The incidence of post-operative morbidity and mortality was no different from that seen in patients undergoing similar surgery before the implementation of ERAS protocol. The probable reason is many of the components of ERAS protocol were followed in our practice routinely. Notwithstanding our results, ERAS program is a collective responsibility and should be recommended in all patients undergoing esophagectomy to improve post-operative outcomes.
586. CIRCUMFERENTIAL HIATAL DISSECTION DURING MINIMALLY INVASIVE ESOPHAGECTOMY CLINICAL AND ONCOLOGICAL OUTCOMES
Authors: Davakis Spyridon , Sdralis Ilias , Sakellariou Stratigoula , Ziogas Dimitrios , Theochari Maria , Stratigopoulou Panagiota , Ntoka Polyxeni , Liakakos Theodoros , Charalabopoulos Alexandros
Published: September 2022

Circumferential resection margin involvement is an independent prognostic factor in patients with adenocarcinoma of the distal esophagus and esophago-gastric junction. However, there is currently no consensus on the extent and the technique of hiatal dissection. Herein, we aim to present our technique of circumferential hiatal dissection during 2-stage totally minimally invasive esophagectomy for adenocarcinoma of the distal esophagus and esophago-gastric junction with its related histopathological results.

A prospective study of 200 consecutive patients undergoing 2-stage totally minimally invasive esophagectomy over a period of 60 months was conducted. Dissection of the hiatus included peri-esophageal surrounding tissues in a cylindrical fashion maximizing the distance from the esophageal wall. Crural muscle fibers and pleura bilaterally, pericardial fat anteriorly and pre-aortic tissue posteriorly were excised en bloc. Histopathological results particularly focused on involvement of the circumferential resection margin.

Complete histological clearance (R0) was achieved in 96% (n=192) according to the criteria of the College of American Pathologists and in 95% (n=190) according to those of the Royal College of Pathologists. In pT3 tumors (n=102), the circumferential resection margin was negative in 97 patients (95%) according to the College of American Pathologists, and in 95 (93%) according to the Royal College of Pathologists.

Adoption of this safe and reproducible technique might reduce the incidence of circumferential resection margin involvement and improve pathological outcomes. In addition, there may be positive implications for training and quality control.
587. ROLE OF THORACOSCOPIC HAND-SEWN ESOPHAGO-GASTRIC ANASTOMOSIS IN 2-STAGE TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY. REPORT OF 200 CONSECUTIVE CASES
Authors: Davakis Spyridon , Liakakos Theodoros , Sakellariou Stratigoula , Ziogas Dimitrios , Theochari Maria , Ntoka Polyxeni , Stratigopoulou Panagiota , Mpaili Efstatia , Charalabopoulos Alexandros
Published: September 2022

Esophagectomy is the mainstay of treatment of esophageal and gastro-esophageal junction cancer. Minimally invasive esophagectomy has been introduced in the 2000s in an effort to reduce post-operative pulmonary and cardiac complications. 2-stage totally minimally invasive esophagectomy combines laparoscopic abdominal phase followed by thoracoscopic thoracic phase. The rate limiting step of the procedure is the construction of esophago-gastric anastomosis. We aim to present our technique and results on hand-sewn thoracoscopic esophago-gastric anastomosis in prone position.

This is prospective analysis of consecutive patients that underwent 2-stage totally minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. All operations were identical in terms of patient positioning, lymphadenectomy and type of anastomosis formed. Study included adult patients with no upper age limit (>18 years); all hybrid esophagectomies, esophagectomies for malignancy and emergency operations were excluded from the study. The anastomosis was manually facilitated thoracoscopic in prone position, in 2-layers, using barbed sutures. Primary endpoints were anastomotic leakage and anastomotic stricture rate. Secondary endpoints were 30- and 90-day mortality rates.

During a 5-years-period, n=200 consecutive patients underwent 2-stage totally minimally invasive esophagectomy for cancer. Most patients were males. Median age was 65.5 years. Median operative time was 280 minutes while median suturing time for the anastomosis was 50 minutes. Anastomosis was thoracoscopic, hand-sewn constructed in prone position in all cases. There was no conversion to open. Anastomotic leak complicated n=5 patients (2.5%); n=4 were type I anastomotic leaks and n=1 was type I, which was treated with chest drainage. Anastomotic stricture was presented in n=13 patients (6.5%). 30-day mortality rate was 1% and 90-day mortality rate was 2.5%.

Formation of the esophago-gastric anastomosis is one of the most challenging aspects during 2-stage totally minimally invasive esophagectomy. Most surgeons prefer the construction using circular or linear staplers. Our anastomotic technique, present a safe and effective anastomosis, with favorable clinical outcomes. It can be reproduced and established in the hand of experts, offering all the advantages of manual anastomosis and reduction of devastating post-operative anastomotic leakage, which still complicates stapled constructed anastomosis with significant incidence.
589. HOW COULD PATIENTS SUPPORT SURGEONS? ANALYSIS OF PATIENT'S SKILLS BEFORE AND AFTER OESOPHAGOGASTRIC SURGERY AND IMPACT ON QUALITY OF LIFE
Authors: Alfieri Rita , Turchi Gian Piero , Pinto Eleonora , Fabbian Alessandro , Marano Salvatore , Cavarzan Marco , Riva Marta Silvia Dalla , Da Roit Anna , Orru Luisa , Pilati Pierluigi , Castoro Carlo
Published: September 2022

The role of hospital case volume and surgeon expertise in improving results after esophagectomy is well known. However, health-professionals expertise and hospital volume are not enough. Prehabilitation trials outlined that patient involvement is mandatory to improve adherence to therapeutic programs.

This study aims to identify what are patient’s modalities of dealing with postoperative course, supporting surgical outcomes with a psychological intervention and to evaluate his effect in the medium-term postoperative period.

Literature analysis was conducted to identify specific patient’s skills supporting the postoperative course. Sixteen peculiar dimensions were identified, considering four patients skills applied to clinical, daily activities, family and work areas. Patients textual data were collected by a sixteen-questions interview. Methodology for the Analysis of Computerized Text Data was used to identify discursive repertoires used by esophageal cancer patients. These textual data let construct a closed-ended questionnaire used to assess patient’s skills in the early postoperative course.

A psychological intervention aimed at enhancing competencies was conducted. Skills were re-assessed and quality of life (QOL) data were collected 9-months after intervention.

In this study 28 consecutive gastroesophageal cancer patients were enrolled within a larger group of patients undergone major surgery for gastrointestinal tumours. Low/medium/high levels were detected for each of the four skills. Wilcoxon signed-rank test showed that three of the four skills levels increased after the supportive intervention.

Analysis revealed no differences in relation to diagnosis, oncological treatment and demographic variables. Compared to other patients, skills levels showed no differences in gastroesophageal patients. Furthermore, quality of life at 9-months after esophagectomy was comparable to date reported in current literature in the medium-long term period after surgery for digestive tract cancer.

In these preliminary data, even with poorer prognosis, gastroesophageal patients deal with major surgery side effects using the same skills levels used by other gastrointestinal cancer patients.

Results show that skills evaluation during hospital stay can reveal the lacking modalities of dealing with the postoperative problems due to patients’ wrong beliefs about surgical results and physical recovery. When aimed at improving surgical outcomes and based on surgeon’s indications, even patients can support surgical outcomes.
590. GERD AND BARRETT`S ESOPHAGUS IN BARIATRIC SURGERY
Authors: Moulla Yusef , Feisthammel Jürgen , Blüher Matthias , Gockel Ines , Dietrich Arne
Published: September 2022

The role of preoperative Gastroscopy in obesity surgery in detecting a lot of abnormalities of Upper-GI such as GERD and BE`s has been already proved in our pervious study. The Development of GERD and BE`s after bariatric surgery still controversy in the bariatric surgery. The Aim of this study is to evaluate the development of GERD and BE`s in patients underwent bariatric surgery including LGB and LSG

In our single center prospectively-established database of obese patients, who u nderwent bariatric surgery from 01/2012 to 12/2019, we retrospectively compare the preoperative endoscopic finding of patients with BE`s to these findings after 1-2 years and 3-5 years after the bariatric surgery. The regression of BE’s was defined based on the endoscopic findings as a 1 cm down grade of Prague classification circumferential (C) as well as maximum extent (M) or complete regression of BE’s, histologically as a conversion of intestinal metaplasia to squamous epithelium or conversion of dysplastic dysplasia to intestinal metaplasia

Among 914 bariatric patients, we found 119 patients (13%) with BE`s. A control gastroscopy could be performed in 74 BE`s Patients. 37 patients received a control gastroscopy after 1-2 years and 47 patient after 3-5 years. The surgical procedure was the only significant factor for the development of GERD and BE`s after bariatric surgery (P< 0.05). Progression of GERD after LGB was detected only in one patient (4.2%, n=54) and in 10 patients (50%, n=10) after LSG in patients. Furthermore, the progression of BE`s after LGB in 4 patient (7.4%, n=54) and in 6 patients (30%, n=20) after LSG

Laparoscopic gastric bypass should be considered in obese patients with GERD or BE`s. Therefore, detecting of GERD and BE`s prior to bariatric surgery may has an obvious impact on decision making regarding the suitable surgical bariatric procedure
594. TOTALLY MINIMALLY INVASIVE 2-STAGE ESOPHAGECTOMY VERSUS HYBRID 2-STAGE ESOPHAGECTOMY. A SINGLE CENTER EXPERIENCE
Authors: Davakis Spyridon , Liakakos Theodoros , Mpaili Efstratia , Ziogas Dimitrios , Theochari Maria , Ntoka Polyxeni , Stratigopoulou Panagiota , Giagkos Christos , Charalabopoulos Alexandros
Published: September 2022

Totally minimally invasive 2-stage esophagectomy (TMIE) eliminates the thoracotomy associated with hybrid 2-stage minimally invasive esophagectomy (hybrid-MIE). This has an important role in minimizing post-operative respiratory complications. There is ongoing growing evidence in published literature of improved clinical and oncological outcomes in totally MIE comparing to hybrid MIE, due to enhanced optics and extend of lymphadenectomy as well as to shorter length of hospital stay and surgical trauma associated to thoracoscopy.

This is a retrospective analysis of consecutive patients that underwent 2-stage minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. TMIE combines a laparoscopic and thoracoscopic approach while hybrid-MIE includes laparoscopic open thoracotomic phase. Study included adult patients with no upper age limit (>18 years). All esophagectomies for benign disease, as well as emergency operations were excluded from the study. Primary endpoints were 30- and 90-day mortality rate, anastomotic leak, anastomotic stricture, pulmonary complications, and length of hospital stay. Secondary endpoints were overall survival and progression-free survival rates respectively.

During an 8-year-period, 150 patients underwent hybrid-MIE, while 200 underwent TMIE. Operative-time was shorter in the hybrid-MIE group (320 vs 280 min). Anastomotic leak was significantly reduced in the TMIE group comparing to the hybrid-MIE group (2.5% vs 9.5%). Respiratory complications were reduced in the TMIE group (10 vs 25%). Median LOS was similar (7 vs 7.5 days). Median number of resected-lymph nodes was increased in the TMIE group (28 vs 35 lymph nodes). OS survival rate was 60 versus 51 months and PFS was 52 vs 43 months in the TMIE and hybrid-MIE groups respectively.

In general, TMIE was associated with moderately lower morbidity compared to hybrid-MIE, but randomized controlled evidence is lacking. The higher anastomotic leakage rate, higher rate of pulmonary complications and lower lymph node count that was found after hybrid-MIE in comparative analysis, indicate that TMIE can significantly improve clinical outcomes of patients undergoing esophagectomy. The findings of this study should be considered carefully by surgeons when moving from hybrid-MIE to TMIE.
607. COMPARISON OF RECURRENCE PATTERNS AND SURVIVAL AFTER NEOADJUVANT CHEMORADIOTHERAPY VS. CHEMOTHERAPY FOR ESOPHAGEAL CANCER, A MULTI-CENTER EUROPEAN COHORT STUDY
Authors: Klevebro Fredrik , Elliott Jessie , Montziari Styliani , Markar Sheraz R , Goense Lucas , Johar Asif , Lagergren Pernilla , Zanninotto Giovanni , van Hillegersberg Richard , van Berge Henegouwen Mark , Nilsson Magnus , Hanna George , Schäfer Marcus , Reynolds John
Published: September 2022

Curative treatment for esophageal cancer requires local and systemic disease control. Neoadjuvant treatment increases long-term survival, but the evidence to date is insufficient to determine if neoadjuvant chemoradiotherapy (nCRT) with focus on local control or neoadjuvant chemotherapy (nCT) with focus on systemic control, is more beneficial. In this analysis of the ENSURE study we aimed to compare recurrence patterns and survival between nCRT and nCT in a large multicenter European cohort study.

All patients treated with neoadjuvant therapy and esophagectomy for cancer from 2009-2015 in the ENSURE study (NCT03461341) were included. Univariable and multivariable logistic regression and Cox proportional hazard models were used to compare recurrence pattern, diseases-free, and overall survival. Results are shown as odds ratios (OR), hazard ratios (HR) and 95% confidence intervals (CI). The multivariable model was pre-specified and included age, sex, clinical tumor stage, and tumor histology. In total 3267/4682 (69.8%) patients were treated with neoadjuvant therapy and were included in the study. nCRT was given to 1798 (55.0%) patients, and nCT was given to 1496 (45.0%) patients.

Median age for nCRT was 63 vs. 64 for nCRT, 65.5% in the nCRT group had adenocarcinoma vs. 81.4% in the nCT group. In the nCRT group 38.7% of patients had tumor stage III-IV compared to 61.3% in the nCT group. Multivariable adjusted OR for local recurrence comparing nCRT to nCT was 1.31 (95% CI: 1.08-1.59), distant recurrence OR 1.87 (95% CI: 1.57-2.22), and combined recurrence 1.49 (95% CI: 1.26-1.76). Adjusted HR for disease specific survival comparing nCRT to nCT was 1.38 (95% CI: 1.24-1.55), disease free survival: 1.39 (95% CI: 1.25-1.54), and for overall survival: 1.44 (95% CI: 1.30-1.60).

The results of the study show significantly increased risk for recurrent disease and decreased survival after nCRT compared to nCT for esophageal cancer. nCRT is administered with a lower total dose of chemotherapy compared to nCT. Radiotherapy is given for local control, which is also achieved with adequate lymphadenectomy. The results indicate that effective systemic treatment with nCT might be beneficial compared to nCRT in curative intended treatment of esophageal cancer.
608. INCIDENCE AND IMPACT OF PREOPERATIVE HIATAL HERNIA IN PATIENTS WITH ESOPHAGEAL CARCINOMA UNDERGOING CURATIVE SURGICAL RESECTION
Authors: Solomon Daniel , Zaslavsky Adi , Varon Danielle , Israeli Tal , Amlinsky Yelena , Tamir Shlomit , Kashtan Hanoch
Published: September 2022

Hiatal hernia (HH) and gastroesophageal reflux disease (GERD) are risk factors for esophageal adenocarcinoma. High positive margin rates and poor survival were previously described among HH patients undergoing esophagectomy. We sought to describe incidence and impact of HH on outcomes following esophagectomy in a population of patients undergoing predominantly cervical anastomosis.

Patients who underwent esophagectomy 2012-2019 for esophago-junctional carcinoma were included. CT studies were blindly reviewed by two radiologists. A third radiologist reviewed cases of disagreement. Hernias >3 cm were included in the HH group.

Overall, 66 patients (33%) had HH >3 cm. The control group included 12 patients (6%) with <3 cm HH and 106 (53%) without HH. Patients with HH had higher Charlson Comorbidity Index (CCI) (p=0.017). Location of anastomosis was similar among cohorts (cervical anastomosis 82.2% vs 92.4%, p=0.113). HH patients had higher incidence of atrial dysrhythmia (16.7% vs 5.1% p=0.015). Rates of R0 resections were similar (95.8% vs 93.9%, p=0.724). Subgroup analysis on adenocarcinoma patients confirmed higher rates of signet ring cell features among HH patients (28.6% vs 12.3%, p=0.034). HH was not associated with poor disease free survival (p=0.274).

Patients with preoperative HH had higher CCI, higher rates of postoperative atrial dysrhythmias and signet ring cell features on pathology. In a population with predominant cervical anastomosis, positive margin rates were low and survival comparable among cohorts.