bluuebunny/crossref_metadata_2025 huggingface dataset:
295 PREDICTION OF MORBIDITY AND MORTALITY AFTER THORACOABDOMINAL ESOPHAGEAL SURGERY
Authors: Nilsson Erik , Olsén Monika Fagervik , Trölle Ulrika , Eriksson Frances , Hermansson Michael
Published: September 2021

Complications after esophageal cancer surgery has been shown to decrease long-term quality-of-life and to increase the risk of postoperative mortality, making patient selection important. The physical strength of the individual patient is likely to affect the patient’s chance of withstanding a major surgical intervention. The aim of this study was to evaluate if validated physical tests can predict the risk of postoperative complications after a thoraco-abdominal esophagectomy.

Methods

All patients who had a thoraco-abdominal esophagectomy at three Swedish university hospitals from 2014–2017 were eligible for inclusion in this prospective study. In addition to a bicycle test, patients were evaluated preoperatively by a physiotherapist using eight validated physical tests. Data on postoperative complications were extracted from the Swedish National Registry for Esophageal and Gastric Cancer. Patients were divided into two groups according to Clavien Dindo (CD) classification of the most severe complication (CD 1–2 and CD 3–5). Tests results were compared between the groups. We also compared performance in each validated test to the risk of specific complications.

Results

A total of 114 patients were enrolled. 26 patients were excluded because of missing data leaving 88 patients for statistical analyses. Total 90-days mortality was 2.3%. Patients who suffered from an anastomotic leak after surgery had a significantly lower performance in the bicycle test. Performance in the preoperative shoulder abduction- and 6-minute-walk tests were significantly lower in patients who suffered from pneumonia or cardiovascular complications. Patients scoring in the lowest quartile in the hand grip-strength test had a higher frequency of complications rated as CD 3–5. No other significant differences could be shown between the CD groups.

Conclusion

In this prospective multicentre study, we found a connection between patient performance on four different preoperative physical tests (bicycle test, shoulder abduction test, 6-minute walk test and hand grip-strength test) and the risk of postoperative complications. We believe that these relatively simple tests can help the surgeon when evaluating the surgical risk for the individual patient.
305 RISK OF GENERALIZATON IN PATIENTS WITH HIGH-RISK EARLY ESOPHAGEAL CANCER: RETROSPECTIVE ANALYSIS OF PROSPECTIVELY COLLECTED DATA INCLUDING LYMPH-NODE MICROMETASTASES ASSESSMENT
Authors: Hugova Kristina , Kollar Marek , Maluskova Jana , Krajciova Jana , Pazdro Alexandr , Harustiak Tomas , Snajdauf Martin , Vackova Zuzana , Spicak Julius , Martinek Jan
Published: September 2021

Esophagectomy is a standard of care for patients with "high-risk" early esophageal cancer (HRC) despite a growing evidence that endoscopic treatment may be a safe alternative. Our aims were 1. to prospectively evaluate the long-term results of endoscopic and surgical treatments in consecutive patients with HRC and 2. to determine the risk of lymph node (LN) metastases and micrometastases in patients with HRC.

Methods

HRC was defined as any cancer with submucosal (sm) invasion or mucosal cancer with at least one of the following: poor differentiation, invasion to blood or lymphatic vessels and high tumor cell dissociation (TCD3). All patients (n = 69) underwent endoscopic resection (ER or ESD) and after the histopathological diagnosis of HRC, patients without contraindications were referred to surgery (n = 30). The remaining patients (n = 39) continued in endoscopic treatment, if necessary. All resected LNs were stained for hematoxylin–eosin to evaluate metastases and immunohistochemistry was used for the detection of micrometastases or isolated tumor cells.

Results

Eighteen patients (26%) had T1a and 51 (74%) had T1b cancer; 51 had adenocarcinoma (AC) and 18 had squamous cell carcinoma (SCC). The median follow-up was 32 months (3–120). No patient with mucosal invasion (15 AC, 3 SCC) experienced LN involvement. Among 17 patients with sm1 invasion, only 2 (12%, both AC)experienced generalization or LN involvement. The further rates of LN involvement were 0% (0/5) in sm2 AC, 50% (3/6) in sm2 SCC, 25% (4/16) in sm3 AC and 29% (2/7) in sm3 SCC. 60% (18/30) of surgically treated patients would have been completely cured by endoscopy (Table 1).

Conclusion

The risk of LN metastases/micrometastases was lower than expected. No patients with high-risk mucosal cancer or low-risk sm1 cancer experienced lymph node involvement. Endoscopic treatment provided long-term remission (or cure) in considerable number of patients and it may represent a valid alternative to surgery in patients with high-risk early esophageal cancer.
311 PATHOLOGIC COMPLETE LYMPH NODE REGRESSION AFTER NEOADJUVANT CHEMORADIOTHERAPY FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Hsu Po-Kuei
Published: September 2021

Pathologic complete lymph node regression, which is defined as lymph nodes with evidence of neoadjuvant treatment effect but without viable residual cancer cells, are sometimes observed following neoadjuvant treatments and has been shown to be prognostic, yet with conflicting results. We aim to study its clinicopathological correlation and prognostic impact.

Methods

Patients who received neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for esophageal squamous cell carcinoma (ESCC) in a single institute are retrospectively reviewed. Lymph nodes retrieved at post-nCRT esophagectomy are re-examined by a dedicated pathologist. Patients are classified as (1) lymph node-negative with no evidence of tumor involvement or regression (true negative; plausible cN0, ypN0; group 1); (2) lymph node-negative with evidence of complete regression (e.g. fibrosis; plausible cN+ ypN0; group 2); and (3) lymph node-positive (ypN+; group 3). Kaplan–Meier curve and log-rank test, and cumulative incidence of recurrence (CIR) are used for outcome analysis.

Results

A total of 136 patients, including 73, 25, and 38 in group 1, 2, and 3, respectively, are included. Group 2 is significantly associated with lower risk for lymphovascular invasion (0%, p < 0.001) and perineural invasion (4%, p = 0.038), and higher rate of pathologic complete response in primary tumor (76%, p < 0.001). The 5-year overall survival rates in group 1, 2, and 3 are 42.1%, 52.8%, and 8.0%, respectively. There is no survival difference between group 1 and 2 (p = 0.454). The CIR at 24 months are 46% and 41% in group 1 and 2 (HR: 0.84, 95% CI: 0.432–1.623, p = 0.601, figure 1).

Conclusion

Pathologic complete lymph node regression correlates with treatment response in primary tumor. The outcome of patients with pathologic complete lymph node regression is comparable to that of those with true negative lymph node involvement. Pathologic complete lymph node regression could be a surrogate for chemoradiotherapy sensitivity and regarded as a good prognostic factor in patients with ESCC.
321 RANDOM SURVIVAL FOREST FOR PERSONALISED PROGNOSTICATION AFTER ESOPHAGECTOMY
Authors: Rahman Saqib , Walker Robert , Crosby Tom , Maynard Nicholas , Trudgill Nigel , Cromwell David , Underwood Timothy
Published: September 2021

For patients with esophageal cancer, producing accurate prediction models for long-term survival after esophagectomy has proved challenging. We investigated whether Random Survival Forests (RSF), a machine learning method, could produce an accurate prognostic model for overall survival after esophagectomy.

Methods

The study used data from the 'National Oesophago-Gastric Cancer Audit' (NOGCA) and included patients diagnosed with esophageal adenocarcinoma or squamous cell carcinoma between 2012 and 2018 in England and Wales and who underwent a curative esophagectomy with adequate lymphadenectomy (15 lymph nodes) and survived to discharge (n = 6838). Missing data was handled using multiple imputation. 15 variables were selected for inclusion using Random Forest variable importance and used to train the final model. The same variables with non-linearity transformations were used to develop a traditional Cox regression model for comparison.

Results

Median survival was 50 months. The final RSF model had good discrimination on internal validation with a C-index of 0.7627 (0.7625–0.7629), exceeding the cox model 0.7539 (0.7541–0.7537). At 3 years post-surgery, overall survival was 56.2%. The RSF yielded a mean predicted survival of 59.3% (IQR 33.3–87.1%) with good calibration (Figure 1) compared to 57.4% (38.4%–79.8%) for the cox model. The most influential variables were lymph node involvement and pT/ypT stage, however other variables including neoadjuvant treatment completion and surgical complications were also important. Decision curve analysis was undertaken which also showed an increased net benefit with the RSF model.

Conclusion

A Random Forest survival model provided better performance in predicting survival after curative esophagectomy. This will allow more personalised predictions to be delivered clinicians and patients. An online web app is provided at https://uoscancer.shinyapps.io/NOGCA/
335 DIFFERENTIALLY EXPRESSED MICRORNAS AND PREDICTIVE TARGET GENES IN BASALOID SQUAMOUS CELL CARCINOMA OF THE ESOPHAGUS
Authors: Nakamura Jiro , Furuya Shinji , Hagio Kotaro , Maruyama Suguru , Shiraishi Kensuke , Shimizu Hiroki , Akaike Hidenori , Hosomura Naohiro , Kawaguchi Yoshihiko , Amemiya Hidetake , Kawaida Hiromichi , Sudo Makoto , Kono Hiroshi , Ichikawa Daisuke
Published: September 2021

Background/Aim: Esophageal cancer is the sixth leading cause of cancer-related deaths worldwide. Esophageal squamous cell carcinoma (ESCC) is considered as one of the most aggressive carcinomas of the gastrointestinal tract. Basaloid squamous cell carcinoma of the esophagus (BSCCE) is reported to have a poorer prognosis compared to conventional ESCC. The current study aimed to elucidate molecular differences between BSCCE and ESCC, using miRNA profiling and predictive target gene searching.

Methods

Materials and Methods: Four BSCCE and 94 ESCC patients who underwent esophagectomy were selected for this study. Cell lines were used for target gene validation. Total RNA samples, extracted from formalin-fixed paraffin-embedded blocks, were used for microarray profiling and validation of the miRNAs, selecting the candidate target genes, and elucidating their clinicopathological features. Furthermore, total RNA samples, extracted from miRNA mimic- and inhibitor-transfected cells in cell line experiments, were used for target gene validation. Both miRNA and mRNA quantifications were performed by quantitative reverse transcription-polymerase chain reaction.

Results

The microarray analysis revealed seven highly expressed miRNAs (miR-205-5p, −4732-5p, −1246, −3687, −3175, −6087, and − 1587) in the BSCCE patients when compared with control. We selected miR-4732-5p and − 3687 for the validation study, and target gene investigations were conducted for miR-3687 ultimately. Several candidates were selected after searching for the target genes via TargetScan and in the literature. Through a pilot and a validation study, progesterone receptor membrane component 2 (PGRMC2) was identified as a target gene. Further investigations revealed that PGRMC2 was associated with tumor size clinicopathologically.

Conclusion

miR-3687 may constitute a candidate marker of aggressiveness in BSCCE, and PGRMC2 is one of its target genes. Moreover, the gene may play a role in cell proliferation and local progression. Although the current study included only a small number of samples, this is the first report regarding differentially expressed miRNAs and predictive target genes in BSCCE patients.
337 MESH REINFORCEMENT OF THE HIATOPLASTY. PROTECTING THE ACHILLES' HEEL
Authors: Brandalise Andre , Lorenzetti Claudia , Aranha Nilton , Brandalise Nelson
Published: September 2021

Disruption of hiatoplasty is one of the main causes of anti reflux surgeries failure. There are some conditions that are associated with higher risks of disruption, leading to hernia recurrence.

Bioabsorbable meshes have a safer profile compared to the permanent ones and we show in this video its use aiming to prevent early and possibly, late recurrence.

Methods

We present a video about different indications for reinforcement of hiatal closure with bioabsorbable mesh.

With the security of bioabsorbable materials and previous experiences with these kind of meshes used in an U configuration, we are suggesting that it can be used as an inverted C over the posterior and anterior sutures placed to close the hiatal defect.

The mesh is cut during the surgery to better accommodate as an onlay protection. It can be fixed to the diaphragm in different ways, but we used fibrin glue in this series.

Results

Sixteen patients were operated with this technique. The long term results are not available at this point, but short term results are very encouraging. We have noticed a slightly higher complaint of dysphagia among these patient compared to what we use to observe in our non-mesh patients, but dilatation was not necessary in any patient.

Conclusion

The use of bioabsorbable mesh in the hiatus is safe and can be used with more frequently to prevent hiatal recurrences in specific groups of patients.

Video

https://www.dropbox.com/s/jsblif0pfjcuicu/BIOMESH.mov?dl=0.
344 THE ROLE OF TRPV2 IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Kato Shunji , Shiozaki Atsushi , Fujiwara Hitoshi , Konishi Hirotaka , Kudou Michihiro , Yamazato Yuzo , Katsurahara Keita , Shoda Katsutoshi , Arita Tomohiro , Kosuga Toshiyuki , Komatsu Shuhei , Kubota Takeshi , Okamoto Kazuma , Kishimoto Mitsuo , Konishi Eiichi , Marunaka Yoshinori , Otsuji Eigo
Published: September 2021

Transient receptor potential vanilloid 2 (TRPV2) was recently shown to be involved in migrant potentials. Previous studies reported that TRPV2 was involved in cancer progression, migration, and invasion. The present study aimed to investigate its role in esophageal squamous cell carcinoma (ESCC).

Methods

In human ESCC cell lines, we investigated the role of TPRV2 in ESCC using a cancer function assay with the knockdown of TRPV2 by siRNA, microarray, pathway, and gene ontology analyses. The significance of TRPV2 expression in 62 ESCC samples was then evaluated by immunohistochemical staining.

Results

TRPV2 was overexpressed in TE15 and KYSE170 cells. TRPV2 depletion suppressed cell proliferation, cell cycle progression, and invasion/migration, and induced apoptosis. A pathway analysis of microarray data revealed that TRPV2 depletion down-regulated WNT/β-catenin signaling-related genes and basal cell carcinoma signaling-related genes. The suppression of cancer functions, such as proliferation, invasion, and angiogenesis, by TRPV2 depletion was predicted in the ontology analysis. Immunohistochemical staining revealed a relationship between strong TRPV2 expression and a poor prognosis in ESCC patients.

Conclusion

The present results suggest that TRPV2 regulates tumor progression by affecting WNT/β-catenin or basal cell carcinoma signaling, and that its strong expression is associated with a worse prognosis in ESCC patients. These results provide an insight into the role of TRPV2 as a therapeutic target or biomarker for ESCC.
382 INTRATHORACIC VERSUS CERVICAL ANASTOMOSIS AFTER MINIMALLY INVASIVE ESOPHAGECTOMY FOR OESOPHAGEAL CANCER: A RANDOMIZED CONTROLLED TRIAL (ICAN TRIAL)
Authors: Verstegen Moniek , Workum Frans , Klarenbeek Bastiaan , Bouwense Stefan , Gisbertz Suzanne , Haveman Jan Willem , Heisterkamp Joos , Kouwenhoven Ewout , Lanschot Jan , Nieuwenhuijzen Grard , Peet Donald , Polat Fatih , Ubels Sander , Hannink Gerjon , Rovers Maroeska , Rosman Camiel
Published: September 2021

Robust evidence is lacking whether Ivor Lewis minimally invasive esophagectomy (MIE) or McKeown MIE should be preferred for patients with mid to distal esophageal or gastro-esophageal junction Siewert I-II (GEJ) cancer.

Methods

In this multicenter randomized controlled trial, patients with esophageal (below the level of the carina) or GEJ cancer planned for curative resection were recruited. Eligible patients were randomly assigned (1:1) to either Ivor Lewis MIE or McKeown MIE. The primary endpoint was anastomotic leakage (AL) requiring endoscopic, radiologic or surgical intervention. Secondary outcome parameters were overall AL rate, postoperative complications, length of stay and mortality.

Results

A total of 262 patients were randomly assigned to Ivor Lewis MIE (n = 130) or McKeown MIE (n = 132). Seventeen patients were excluded due to not meeting inclusion criteria (n = 2), physical unfitness for surgery (n = 3), patients’ choice (n = 3), interval metastases (n = 5) or peroperative metastases (n = 4). AL necessitating reintervention occurred in 15 (12.3%) of 122 patients after Ivor Lewis MIE and in 39 (31.7%) of 123 patients after McKeown MIE (RR 0.39, 95%CI 0.22–0.65). Severe complications (Clavien-Dindo ≥3b) were observed in 10.7% after Ivor Lewis MIE and in 22.0% after McKeown MIE (RR 0.49, 95%CI 0.25–0.88).

Conclusion

This study provides evidence for a lower rate of AL requiring reintervention after Ivor Lewis MIE compared to McKeown MIE for patients with mid to distal esophageal or GEJ cancer.
388 TREATMENT OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY (TENTACLE—ESOPHAGUS) STUDY: FACTORS ASSOCIATED WITH ANASTOMOTIC LEAKAGE SEVERITY
Authors: Ubels Sander , Verstegen Moniek , Bouwense Stefan , Hannink Gerjon , Siersema Peter , Klarenbeek Bastiaan , Workum Frans , Rosman Camiel
Published: September 2021

Anastomotic leakage is a common and severe complication after esophagectomy. It is largely unknown which characteristics contribute to leakage severity. We aimed to investigate which factors are associated with leakage severity and to create an anastomotic leakage severity classification.

Methods

The TENTACLE—Esophagus is a multinational retrospective cohort study in which patients with anastomotic leakage after esophagectomy in the period 2011-2019 were included. Detailed data regarding casemix (e.g. age, sex, physical condition, comorbidity, tumor characteristics), surgical procedure (e.g. McKeown, Ivor Lewis, Orringer, anastomotic technique, omental wrap, pleural flap), leakage characteristics (e.g. contamination, drainage at leakage diagnosis, leak circumference) and treatment were collected. The primary outcome is 90-day mortality. Regression analysis will be used to analyze which leakage characteristics are associated with 90-day mortality and to compose an evidence-based anastomotic leakage severity score. The study protocol is accessible at www.tentaclestudy.com.

Results

Detailed data of 1407 patients with anastomotic leakage from 70 centers in 20 countries were collected. Anastomotic leakage occurred 0-43 days after surgery and 90-day mortality rate was 11.1%. The TENTACLE—Esophagus study data is currently being validated and it is awaiting full analysis. The results and the evidence based anastomotic leakage severity classification system will be ready for presentation at the ISDE meeting.

Conclusion

This is the largest study that investigates which factors contribute to anastomotic leakage severity after esophagectomy. The evidence-based anastomotic leakage severity classification system can be used by clinicians to grade severity of a given leak and might aid clinicians in choosing the most appropriate treatment.
400 OUTCOME OF PATIENTS THAT DO NOT UNDERGO RESECTION AFTER NEOADJUVANT TREATMENT FOR CANCER OF THE ESOPHAGUS.
Authors: Cutforth Iona , Brown Joshua , Chmelo Jakub , Navidi Maziar , Wahed Shajahan , Immanuel Arul , Phillips Alex W
Published: September 2021

Patients with locally advanced esophageal cancer usually receive neoadjuvant treatment prior to surgery. A proportion of patients will not receive their surgery due to disease progression. Little is known about what happens to these patients and their prognosis. The aim of this study was to evaluate outcomes in patients that have received neoadjuvant treatment but not undergone esophagectomy.

Methods

A review of a contemporaneously maintained database of all patients that underwent neoadjuvant treatment for esophageal adenocarcinoma, or squamous cell carcinoma (SCC) but did not have a subsequent esophagectomy was carried out. Patients that were diagnosed with cancer between January 2009 and December 2018 were included. All patients underwent a standardised staging protocol, and were restaged on completion of their neoadjuvant treatment. Overall survival from the date of their initial staging CT and any subsequent treatments were recorded.

Results

Over the time period 927 patients received neoadjuvant treatment, and 107 did not progress to surgery. Of the 107, 106 received neoadjuvant chemotherapy and one chemoradiotherapy. 83 of the 107 were adenocarcinoma and 24 SCC. The median age of patients who had surgery was 66 compared to 67 for those that did not.

Overall median survival for patients not having surgery was 328.5 days. 40 patients had subsequent oncological treatments. Median survival for patients who received no further treatment was 264 days, palliative chemotherapy 412 days palliative radiotherapy 418.5 days and any combination of the two was 390.5 days.

Conclusion

These results show median survival after disease progression during neoadjuvant treatment was over 10 months and this was extended with further oncological treatment with radiotherapy prolonging survival times the most to over 13 months. This information can help when counselling patients to potential treatment options.
469 ASSESSMENT OF PERFUSION OF GASTRIC CONDUIT AND PROXIMAL ESOPHAGEAL STUMP BY INDOCYANINE GREEN FLUORESCENCE IMAGING IN PATIENTS UNDERGOING ESOPHAGECTOMY
Authors: Thammineedi Subramanyeshwar Rao
Published: September 2021

Post esophagectomy anastomotic leakage and stricture are crucial factors in determining morbidity and mortality. Good vascularity of the gastric conduit is essential to avoid this complications. This prospective study assesses the utility of intraoperative indocyanine green (ICG) fluorescence imaging to determine gastric conduit vascularity in patients undergoing esophagectomy.

Methods

Thirteen consecutive patients who were undergoing esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from August 2019 to September 2019, were included. Three patients underwent laparoscopic-assisted transhiatal esophagectomy, ten thoraco-laparoscopic assisted esophagectomy. Reconstruction was done by gastric pull up via posterior mediastinal route. Vascularity of gastric conduit was assessed by the near-infrared camera using ICG.

Results

On visual assessment of perfusion at the tip of gastric conduit, it was dusky in 11 patients, pink in two. Fuorescence imaging showed inadequate perfusion at the tip of conduit in 12 patients, needing revision. In one patient visual inspection showed adequate perfusion, but ICG disclosed poor vascularity requiring revision of the conduit’s tip. Resection of the devitalized portion of the proximal esophageal stump was needed in 5 patients both by visual and ICG assessment. The median time to appearance of blush from the time of injection of dye was 15 seconds (10 to 23 seconds).

Conclusion

Visual inspection of the gastric conduit vascularity can underestimate perfusion and hence can compromise resection of the devitalized part. ICG fluorescence imaging is more objective and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. It could complement the visual inspection to decide the site of anastomosis.
513 WHAT FACTORS INFLUENCE THE ACCURACY OF CLINICAL STAGING OF ESOPHAGEAL- AND GASTRIC CANCER IN SWEDEN? A NATIONAL REGISTER STUDY
Authors: Kollatos Christos , Johansson Jan , Hermansson Michael
Published: September 2021

Cancer treatment is increasingly tailored to the individual patient. Treatment decisions are based on the evaluation of clinical stage which in turn is based on the result of the diagnostic pre-treatment work-up. The aim of this study was to investigate the accuracy of clinical staging of esophageal and gastric cancer in Sweden and what factors influence the quality of the staging procedure.

Methods

All patients operated for esophageal or gastric cancer, without neoadjuvant treatment, in Sweden from 2006 to 2018 was extracted from the Swedish national registry for esophageal and gastric cancer. Clinical TNM (cTNM) and pathological TNM (pTNM) was compared. The most common preoperative modalities for staging were endoscopy and CT-scan. Data on sex, age, smoking habits, multidisciplinary cancer conferences (yes/no), time of surgery (categorized in 5-year periods), number of resected lymph nodes and region of surgery were extracted from the registry. Uni- and multivariate logistic regression analyses were made comparing patients with correct cTNM to patients with incorrect cTNM.

Results

A total of 2500 patients met the inclusion criteria. 1173 patients were excluded because of missing data leaving 1327 patients for analyses. cTNM stage and pTNM stage was identical in 38% of patients. In 35% of patients there was a +/−1 stage difference comparing cTNM to pTNM. For esophageal cancer T-stage was on target in 32% and N-stage in 50% of cases. For gastric cancer the corresponding figures were 35% and 48% respectively. Multivariate regression analyzes showed that operation in the later time periods, a higher number of resected lymph nodes and discussion at multidisciplinary cancer conference improved staging accuracy.

Conclusion

In this study we found that 73% of patients were staged on target or +/− one stage-level. Operation in the later time periods, a higher number of resected lymph nodes and discussion at multidisciplinary cancer conference improved staging accuracy. This data indicate that treatment decisions should be made in a multidisciplinary setting. We believe that the gradual centralization of surgery and treatment decisions in Sweden during this time-period partly explains the improved accuracy over time.
518 DIVERTICULECTOMY WITH EXTENDED MIOTOMY FOR TREATMENT OF ESOPHAGEAL INTRATHORACIC DIVERTICULUM
Authors: Bianchi Edno Tales , Lopes Leticia , Fernandes Felipe , Seiti Caio , Szachnowicz Sergio , Sallum Rubens , Cecconello Ivan
Published: September 2021

The treatment of thoracic esophageal diverticulum is based on removing the diverticulum and treating the possible cause that gave rise to it. We associate a myotomy below the area of the diverticulum to treat any difficulty in emptying and decrease the esophageal pressure that may have led to the diverticulum.

Methods

We show a video how to manage the esophagel diverticulum.

Results

We show a video how to manage the esophagel diverticulum.

Conclusion

The diverticulectomy should be associated with an extended miotomy.

Video

https://www.dropbox.com/s/c1m2r0ic4mw4cb5/Bianchi%20ET%20-%20diverticulectomy.mp4?dl=0.
521 PREOPERATIVE BOTULINUM TOXIN TYPE A: PROPOSAL OF A NEW STRATEGY FOR GIANT HERNIA MANAGEMENT
Authors: Bianchi Edno Tales , Cedro Rider , Vilanova Camila , Tustumi Francisco , Abdalla Ricardo , Szachnowicz Sergio , Sallum Rubens , Cecconello Ivan
Published: September 2021

Botulinum toxin is already in use to treat abdominal wall giant hernia. The concept is to reduce pressure e create new space in the abdominal compartiment after the surgey. We show a case that a similar aproach was used to treat giant hiatal hernia.

Methods

We used botulinum toxin 4 weeks prior the surgery to increase de abdominal compartment. it was checked in a ct scan.

Results

The surgey was performed with a hiatoplasty, fundoplication and a gastropexy.

Conclusion

The use of botulinum seens to be a new stragy for selected cases.

Video

https://www.dropbox.com/s/td7fr3a6buejqnd/Bianchi%20ET%20botox.wmv?dl=0.
535 EVALUATION OF THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER FROM 650 CASES IN A SINGLE INSTITUTE
Authors: Kamei Takashi , Taniyama Yusuke , Okamto Hiroshi
Published: September 2021

Minimally invasive surgery (MIS) for esophageal cancer has been wide-spreading in worldwide since the first report in 1992. In Japan, we firstly introduced thoracoscopic esophagectomy as a MIS for esophageal cancer in 1994 and performed more than 650 cases over the last two decades. The aim of the present study is to evaluate an oncological feasibility and less invasiveness of this operation from short and long term results.

Methods

Thoracoscopic esophagectomy was performed in almost all resectable thoracic esophageal cancer patient, briefly indication for this operation is cT1-T3 tumors and lymph node involvement within the regional lesion.

We performed thoracoscopic esophagectomy with one lung ventilation in left lateral decubitus position (Group L) up to 2011. From 2012, prone thoracoscopic esophagectomy with bilateral ventilation and artificial pneumothorax (Group P) has been undergone.

We analyzed the long-term outcome in all patients who received thoracoscopic esophagectomy with or without neoadjuvant treatment. Furthermore, we evaluated the less invasiveness from the results of short-term outcome and operation-related morbidity between Group L and Group P.

Results

The 5-year survival rates in no treatment before surgery cases were 61.9% overall, and 86.9%, 71.5%, 68.1%, 40.9%, 37.4% for pathological stages I, IIA, IIB, III and IVa, respectively (TNM classification 6th edition). 30 days mortality in this series was 0.6%. 5-year survival in cStage II and III with neoadjuvant chemotherapy was 65.7%. 3-year survival in salvage esophagectomy after failure of definitive chemoradiotherapy with R0 resection was 43.0%. Total amount of blood loss, rate of postoperative pulmonary complications and the postoperative inflammatory response were significantly lower in Group P than in Group L.

Conclusion

Thoracoscopic esophagectomy is safety and oncologically feasible. From the view point of less invasiveness benefits, prone esophagectomy has advantages than lateral decubitus procedure and this operation is recommended in almost all patients with a resectable esophageal cancer.
536 QUALITY OF LIFE AND FOLLOW-UP AFTER ESOPHAGEAL AND GASTRIC CANCER SURGERY. PROTOCOL FOR DEVELOPING AND TESTING A NEW FOLLOW-UP MODEL
Authors: Hovdenak Jakobsen I , Kjaer D
Published: September 2021

Esophageal and gastric cancers are aggressive diseases. Due to extensive treatment, many patients experience adverse effects such as dysphagia, dumping, pain, fatigue, fear of recurrence and depression—all negatively impacting quality of life (QoL).

The purpose of this study is to develop and test a follow-up model for patients after surgery for esophageal and gastric cancer. The model targets handling of adverse effects and psychosocial distress, aiming at improving patients’ QoL and functional level.

Methods

Development of the model follows recognized principles for complex interventions by the Medical Research Counsil. Extensive patient involvement is included in the development process, by means of a national patient advisory board.

The assumed effect of the new model will be tested in a national two-part prospective study, executed before and after national implementation of the model, in both parts including approximately200 patients. Participants will be recruited prior to surgery, and follow-up is one year. Patient-reported data will be collected pre-operatively, at 3, 6, 9 and 12 months postoperatively, along with clinical and sociodemographic data.

Results

Development of the follow-up model after surgery will be completed in august 2020 and inclusion of patients for the prospective study part one, before implementation of the model, will commence summer 2020.

Conclusion

The perspectives of this study may be crucial for future follow-up of esophageal and gastric cancer patients. First, the extensive patient involvement in developing the model will ensure a patient-centred approach to follow-up. And second, the follow-up studies will provide important and up-to-date knowledge about clinical and patient-reported outcomes in a population-based, national cohort.
544 MANAGEMENT OF ACUTE ANASTOMOTIC COMPLICATIONS AFTER IVOR-LEWIS ESOPHAGECTOMY
Authors: Harustiak Tomas , Tvrdon Jiri , Pazdro Alexandr , Snajdauf Martin , Faltova Hana , Lischke Robert
Published: September 2021

Anastomotic leak (AL) and conduit necrosis (CN) are among the most serious surgical complications after esophageal resection. Endoscopic, radiological and surgical methods are used in their treatment. The aim of this paper is to evaluate the results of the treatment of acute anastomotic complications after Ivor-Lewis esophagectomy in a single high-volume center.

Methods

We performed a retrospective audit of a consecutive cohort of 815 patients undergoing transthoracic esophagectomy with intrathoracic esophago-gastric anastomosis from 2005 to 2019. AL was graded according to Esophagectomy Complications Consensus Group recommendation.

Results

There were 79 patients with AL and 6 patients with CN (10%). AL type I, II and III was diagnosed in 33 (39%), 25 (29%) and 27 (32%) patients, respectively. Esophageal stent was used in 40 patients. Primary surgical revision (with/without stent insertion) was performed in 14 patients. Reoperation was necessary overall in 25 patients (29%). Seventeen patients (20%) ended-up with esophageal diversion. Treatment with esophageal stent was successful in 28/40 patients (70%). Endoscopic vacuum-therapy was successfully used in three patients for peristent leak after stent extraction. Mortality of severe AL (type II and III) was 10/52 patients (19%).

Conclusion

Successful management of acute anastomotic complications requires early diagnosis and an individual treatment approach with the use of endoscopic, radiological and surgical methods. The primary attempt for anastomosis preservation using esophageal stent is desirable. Considering the clinical condition and CT finding, we recommend not to hesitate with surgical revision with debridement and drainage of pleural cavity and mediastinum. If primary therapy fails, life-saving procedure is the esophageal diversion.
545 INCIDENCE OF INVOLVEMENT OF PARATRACHEAL LYMPHNODES IN SIEWERT AEG-I TUMORS
Authors: Zacherl Johannes , Radlspöck Wolfgang , Albinni Said , Höfle Cordula , Kertesz Viktoria , Öhler Leopold , Schima Wolfgang , Sitzwohl Christian , Braun Otto
Published: September 2021

Transthoracic esophagectomy with 2-field-lymphadenectomy (LAD) is the state of the art treatment of resectable adenocarcinoma of the distal esophagus (Siewert-Stein AEG type I) and may be performed in AEG II cardia cancers. However, it remains unclear whether paratracheal LAD contributes to a survival benefit. In this study we collected data regarding lymph node involvement of paratracheal nodes.

Methods

From 2014 to 2019 consecutive patients were included in the prospective analysis. Patients underwent hybrid or open Ivor Lewis esophagectomy and 2-field LAD. Paratracheal tissue was removed from the right side of the trachea along the superior vena cava above the azygos vein up to the the upper thoracic aperture. Paratracheal lymph nodes were histologically evaluated separately from the nodes of other stations.

Results

Ninety-five consecutive patients (12 were female, mean age 67, sd 10, AEG I 84, AEG II 11) were included in the prospective observation study. Seventy-two and 5 patients preoperatively received chemotherapy or radiochemotherapy, respectively. All of them underwent transthoracic esophagectomy (Ivor Lewis 93, McKeown 2—because of coexisting ultralong segment Barrett esophagus).

Overall the mean (sd) lymph node count was 37 (12). In the right paratracheal region we found a median of 6 lymph nodes (range;1–22). In 42 (44%) patients positive lymph nodes were recorded, but there was no case with right paratracheal node involvement.

Conclusion

In the present study paratracheal lymph node involvement was evaluated after transthoracic esophagecotmy with 2-field lymphadenectomy. Remarkably, despite a high proportion of overall lymphatic involvement we did not observe any paratracheal nodal metastasis. Larger studies may show whether paratracheal lyphmadenectomy is necessary during radical esophagectomy for AEG I and AEG II cancers.
552 NON-ALCOHOLIC FATTY LIVER DISEASE AND THE HEPATIC RESPONSE TO SURGERY AMONG PATIENTS WITH ESOPHAGEAL ADENOCARCINOMA
Authors: Donlon Noel , Elliott Jessie A , Doyle Suzanne L , King Sinead , Beddy Peter , Moran Brendan , Donohoe Claire , Ravi Narayanasamy , Reynolds John V
Published: September 2021

Visceral obesity, metabolic syndrome and non-alcoholic fatty liver disease (NAFLD) represent risk factors for esophageal adenocarcinoma (EAC). The prevalence of NAFLD, and its impact on the hepatic response to esophageal cancer surgery, has never been systematically evaluated, and was the focus of this study.

Methods

Consecutive patients (n = 547) treated with curative intent for esophageal cancer from 2007–2017 were studied. In an unselected subgroup (n = 138), liver biopsies were collected intraoperatively and assessed for NAFLD, defined as ≥5% macrovesicular steatosis. Postoperative complications were recorded prospectively, including Clavien-Dindo grade (CD) and comprehensive complications index (CCI). Liver function tests were monitored in the first postoperative week, with hepatocellular dysfunction defined as a transaminase rise ≥3-times the upper limit of normal. Multivariable logistic and Cox proportional hazards regression were utilised to determine independent predictors of operative and oncologic outcome. The study was registered on clinicaltrials.gov (NCT04152044).

Results

NAFLD was evident in 62 patients (47.7%) who had biopsies, with a mean (SD) score of 10.1(9.3)%. NAFLD was associated with metabolic syndrome (41.9 vs 25%, P = 0.04), obesity (44.1 vs 11.9%, P < 0.001) and visceral adiposity (172.8 vs 136.5 cm2, P = 0.008), but not clinical or pathologic disease stage. Postoperative hepatocellular dysfunction was observed in 287 (54.8%) patients, associated with NAFLD (P = 0.006), but not visceral obesity (P = 0.396), and normalized in a median (range) of 9 (1–76) days. NAFLD did not impact oncologic outcome, but postoperative hepatocellular dysfunction was independently associated with reduced overall survival (HR 1.87 (1.16–2.29), P = 0.002) on multivariable analysis.

Conclusion

A marker of metabolic dysregulation in obesity-associated carcinogenesis, NAFLD is prevalent among patients with esophageal cancer. Liver dysfunction post esophagectomy is common, and although temporary, is associated with worse oncologic outcomes. Baseline NAFLD did not incur an adverse long-term oncologic outcome.
555 VISCERAL OBESITY: PREVALENCE, AND IMPACT ON OPERATIVE AND ONCOLOGIC OUTCOMES IN THE CURATIVE MANAGEMENT OF ESOPHAGEAL CANCER
Authors: Elliott Jessie A , Donlon Noel E , Doyle Suzanne L , King Sinead , Beddy Peter , Donohoe Claire L , Ravi Narayanasamy , Reynolds John V
Published: September 2021

Obesity, in particular visceral obesity, is a risk factor for esophageal cancer, but its prevalence and impact on operative and oncologic outcomes is unclear. The aim of this study was to study adipose distribution in esophageal cancer (EC), and to assess its independent impact.

Methods

11 consecutive patients undergoing treatment with curative intent for esophageal cancer were studied. Total (TFA), subcutaneous (SFA) and visceral fat areas (VFA), and fat mass (FM), were determined pre-treatment, preoperatively, and 1 year postoperatively. Visceral obesity was defined by CT at L3 as VFA greater than 163.8 cm2 for men and 80.1 cm2 for women. All complications were recorded prospectively, including comprehensive complications index, Clavien-Dindo, and pulmonary complications (PPC). Multivariable logistic and Cox proportional hazards regression were utilized to determine independent predictors of operative and oncologic outcome.

Results

Visceral obesity (VO) was evident in 290 patients (47.5%), and was associated with BMI-defined obesity, diabetes, metabolic syndrome, Barrett’s esophagus (P = 0.001), well-differentiated tumors (P = 0.027), and lower cN stage (P = 0.012). VO did not impact tumor regression grade (TRG) after neoadjuvant therapy. Postoperatively, VO independently predicted anastomotic leak (P = 0.033, OR2.42 [1.07-5.45]) and pneumonia (P = 0.046, OR1.53 [1.01–2.32]), but not in-hospital mortality (P = 0.466), which was 1% overall. VO was associated with significantly improved overall and disease-specific survival on univariable (P = 0.005, Figure), and multivariable analysis (P = 0.026, 0.74 [0.57–0.97]). In survivorship, VO significantly declined, and was evident in just 15.3% at one year postoperatively.

Conclusion

VO is linked with Barrett’s associated EC, and less aggressive tumour biology. Although it negatively impacted operative outcomes, VO was associated with improved oncologic outcomes, independent of BMI or fat mass, indicating a distinct biologic phenotype, and highlighting the importance of research elucidating the interaction between the visceral fat microenvironment, metabolic dysfunction, and the tumor microenvironment.
587 PATIENT-REPORTED SYMPTOMS FOR ESOPHAGEAL CANCER PATIENTS UNDERGOING CURATIVE INTENT TREATMENT
Authors: Gupta Vaibhav , Allen-Ayodabo Catherine , Davis Laura , Zhao Haoyu , Hallet Julie , Mahar Alyson , Ringash Jolie , Kidane Biniam , Darling Gail , Coburn Natalie
Published: September 2021

Esophageal cancer (EC) patients experience considerable symptom burden from treatment. This study utilized population-level patient-reported Edmonton Symptom Assessment System (ESAS) scores collected as part of standard clinical care to describe symptom trajectories and characteristics associated with severe symptoms for patients undergoing curative intent EC treatment.

Methods

EC patients treated with curative intent at regional cancer centers and affiliates between 2009–2016 and assessed for symptoms in the 12 months following diagnosis were included. ESAS measures nine common patient-reported cancer symptoms. The outcome was reporting of severe (≥7/10) symptom scores. Multivariable analyses were used to identify characteristics associated with severe symptom scores.

Results

1,751 patients reported a median of 7 (IQR 4–12) ESAS assessments in the year following diagnosis, for a total of 14,953 unique ESAS assessments included in the analysis. The most frequently reported severe symptoms were lack of appetite (n = 918, 52%), tiredness (n = 787, 45%) and poor wellbeing (713, 40.7%). The highest symptom burden is within the first five months following diagnosis, with moderate improvement in symptom burden in the second half of the first year. Characteristics associated with severe scores for all symptoms included female sex, high comorbidity, lower socioeconomic status, urban residence, and symptom assessment temporally close to diagnosis.

Conclusion

This study demonstrates a high symptom burden for EC patients undergoing curative intent therapy. Targeted treatment of common severe symptoms, and increased support for patients at risk for severe symptoms, may enhance patient quality of life.
594 HAND-SEWN CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS AFTER ESOPHAGECTOMY
Authors: Nozaki Isao , Hato Shinji , Mikuriya Yoshihiro , Ochiai Ryoji , Kobayashi Naruyuki , Kobatake Takaya , Ohta Koji
Published: September 2021

Successful anastomosis is essential in esophagogastrectomy. Staplers are more popularly applied for the anastomosis. However, a hand-sewn anastomosis is a basic and cost-effective method. Herein, we introduce our technical tips of all hand-sewn cervical esophagogastric anastomosis.

Methods

Step 1: A 6 cm gastric tube is created and pulled up through the posterior mediastinal route. Step 2: A single layer Gambee sutures are used to approximate the cervical esophagus and the posterior wall of the gastric tube in end-to-side fashion. Step 3: The redundant part in the gastric tube apex is removed.

Results

We analyzed 199 consecutive patients who underwent this anastomosis in our institute from 2004 to 2019. There was no postoperative mortality. Anastomotic leak (Clavien-Dindo classification; Grade ≥ II) rate was 2.5%. Anastomotic stricture which required balloon dilation was 3.5%.

Conclusion

The anastomotic complication rates in the hand-sewn anastomosis were comparable to those of the mechanical stapled anastomosis in the previous reports.

Video

https://www.dropbox.com/s/sxnxs4962aj5n5k/anastomosis.mp4?dl=0.
608 RADIOMICS MODEL FACILITATES ORGAN-SAVING STRATEGY IN PATIENTS WITH ESOPHAGEAL SQUAMOUS CELL CANCER RECEIVING NEOADJUVANT CHEMORADIOTHERAPY
Authors: Li Yue
Published: September 2021

After neoadjuvant chemoradiotherapy(NCRT) in locally advanced esophageal squamous cell cancer(ESCC), roughly 40% of the patients may achieve pathologic complete response (pCR) of the primary tumor. Those patients may benefit from organ-saving strategy if the probability of pCR could be correctly identified before esophagectomy. A reliable approach to predict pathological response allows future studies to investigate individualized treatment plans. We aim to establish a CT-based radiomics model to predict tumor response to NCRT.

Methods

121 patients with ESCC who underwent NCRT followed by esophagectomy were retrospectively collected. Radiomics features extracted from pre−/post-NCRT CT images were selected by univariate logistic (p < 0.157) and LASSO regression. A radiomics signature(RS) developed with selected features was combined with 4 clinical variables, including percentage of tumor thickness reduction, tumor adventitia type, tumor minimum diameter on post-NCRT esophagogram and age, to construct RS + clinical model with multivariate logistic regression which was internally validated by bootstrapping. Performance and clinical usefulness of RS + clinical model were assessed by receiver operating characteristic(ROC) curves and decision curve analysis, respectively, comparing with the model of clinical variables alone.

Results

Among the 121 patients, 51 achieved pCR(42%) after NCRT. 16 radiomics features were selected and incorporated into RS. The RS + clinical model has improved prediction performance for pCR compared with the clinical model(corrected area under the ROC curve,0.843 vs. 0.700). At the 60% probability threshold cutoff(i.e., the patient would opt for observation if his probability of pCR was >60%), net 12% surgeries could be avoided by RS + clinical model without an increase in the number of missed residual diseases, equivalent to implementing organ-saving strategy in 29.4% of the 51 true-pCR cases.

Conclusion

The model built with CT radiomics features and clinical variables shows the potential of predicting pCR after NCRT; it provides significant clinical benefit in identifying qualified patients to receive individualized organ-saving treatment plans.