bluuebunny/crossref_metadata_2025 huggingface dataset:
P12 LONG-TERM QUALITY OF LIFE AFTER TOTAL GASTRECTOMY VERSUS IVOR LEWIS ESOPHAGECTOMY
Authors: Jezerskyte E , Saadeh L M , Hagens E R C , Sprangers M A G , Noteboom L , van Laarhoven H W M , Eshuis W J , van Berge Henegouwen M I , Gisbertz S S
Published: November 2019

Aim

The aim of this study was to investigate the difference in long-term health-related quality of life in patients undergoing total gastrectomy versus Ivor Lewis esophagectomy in a tertiary referral center.

Background & Methods

Surgical treatment for gastroesophageal junction (GEJ) cancers is challenging. Both a total gastrectomy and an esophagectomy can be performed. Which of the two should be preferred is unknown given the scarce evidence regarding effects on surgical morbidity, pathology, long-term survival and health-related quality of life (HR-QoL).

From 2014 to 2018, patients with a follow-up of > 1 year after either a total gastrectomy or an Ivor Lewis esophagectomy for GEJ or cardia carcinoma completed the EORTC QLQ-C30 and EORTC QLQ-OG25 questionnaires. Problems with eating, reflux and nausea and vomiting were chosen as the primary HR-QoL endpoints. The secondary endpoints were the remaining HR-QoL domains, postoperative complications and pathology results. Multivariable linear regression was applied taking confounders age, gender, ASA classification and neoadjuvant therapy into account.

Results

30 patients after gastrectomy and 71 after Ivor Lewis esophagectomy with a mean age of 63 years were included. Median follow-up was two years (range 12-84 months). Patients after total gastrectomy reported significantly less choking when swallowing and coughing (β=-5.952, 95% CI -9.437 – -2.466; β=-13.084, 95% CI -18.525 – -7.643). Problems with eating, reflux and nausea and vomiting were not significantly different between the two groups. No significant difference was found in postoperative complications or Clavien-Dindo grade. Significantly more lymph nodes were resected in esophagectomy group (p=0.008). No difference in number of positive lymph nodes or R0 resection was found.

Conclusion

After a follow-up of > 1 year choking when swallowing and coughing were less common after total gastrectomy. No significant difference was found in problems with eating, reflux or nausea and vomiting nor in postoperative complications or radicality of surgery. Based on this study no general preference can be given to either of the procedures for GEJ cancer. Patients may be informed about the HR-QoL domains that are likely to be affected by the different surgical procedures, which in turn may support shared decision making when a choice between the two treatment options is possible.
P120 MULTIMODAL THERAPY IN ESOPHAGEAL CANCER BEYOND CLINICAL TRIAL: SINGLE CENTRE EXPERIENCE
Authors: Giacopuzzi S , Alberti L , Weindelmayer J , De Pasqual C A , Torroni L , Verlato G , De Manzoni G
Published: November 2019

Aim

investigate factors influencing the choice of neoadjuvant treatment type in the real world, analyzing our single high-volume center experience.

Background & Methods

The neoadjuvant chemoradiotherapy is the standard of care for esophageal cancer [1-2]. This consensus stems from the results of CCT performed on highly selected patients. However, the best treatment for non-selected patients remains unclear. In our clinical practice the treatment considered the goal standard is a TCF with 50GyRT [3-4-5], which showed an R0 resection rate of 88% and 5 y OS of 43%, better than CROSS trial.

Despite these results, since 2012 not all patients underwent the same ideal treatment. We analyzed a real life patients group, that from the oncological point of view, they would be treated with our protocol in an intention to treat setting.

Results

From 2012 to 2017, 244 patients were treated. Analyzing retrospectively our data, it emerges that we have chosen the therapeutic strategy based on patient's characteristics: those aged over 75 yrs or with severe comorbidities were addressed to a “weakened” treatment: 37 with chemotherapy, 24 with radiotherapy and 55 with concomitant chemoradiotherapy different from our protocol. 125 with our protocol. Further selection involved lymph node status and patients with lymph node involvement (>N2 were referred to chemotherapy. The results confirmed that the protocol achieves better results in pathological response (pT0N0 in protocol 40,8% vs 18.2% in standard chemoradiotherapy – p value <0.001) and overall survival, especially for squamous hystotype. Regarding adenocarcinoma, chemotherapy and our protocol obtain good results for OS, although they differ on pathological response (pCR: 40.8% vs 5.4%). Most of the patients referred to chemotherapy had nodes involvement at the diagnosis (88.9%) and pathological response on nodes was significantly worse than protocol (pN0: 26.7% in chemotherapy vs 77.5%), however survival was similar between the two treatments.

Conclusion

Chemoradiotherapy is currently the gold standard of treatment but it cannot be consider the only treatment, especially for real life patients, less ideal but still requiring treatment. Clinical trials are certainly useful in providing information on highly selected patients, but clinical practice must consider patients whose conditions require tailored treatment.
P121 ESOPHAGECTOMY-SPECIFIC OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILL (E-OSATS): VALIDATION PROTOCOL
Authors: Eddahchouri Yassin , van Workum Frans , Rosman Camiel
Published: November 2019

Aim

The objective of this study is to develop the ‘Esophagectomy-specific Objective Structured Assessment of Technical Skills’ tool (E-OSATS) and determine its validity, reliability and feasibility of use.

Background & Methods

Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure. Increased morbidity and mortality are associated with the long learning curve of the procedure. Specific and structured feedback may shorten the learning curve and decrease the associated morbidity and mortality. Consensus regarding the essential procedural steps has recently been achieved and allows for development and validation of a procedure specific assessment tool for MIE (E-OSATS).

The E-OSATS was created by anchoring previously defined essential steps for both Ivor-Lewis (IL) and McKeown (McK) approach. Ten video recordings of novice surgeons (<15 MIE performed) and 10 recordings of expert surgeons (>100 MIE performed) should be rated by two independent, blinded and trained raters. Records of time needed for the assessment are created. Inter-rater and test-retest reliability will be determined. Validity will be determined by analyzing differences between novice and expert surgeons.

Results

All IL video recordings are collected, McK collection is still pending. First assessments of video recordings are expected to take place in August 2019. We aim to collect all assessments before December 2019.

Conclusion

We hypothesize that we will demonstrate the feasibility, reliability and validity of the E-OSATS in MIE specific assessment of technical skill. This tool will allow for specific and structured feedback and will potentially shorten the learning curve and decrease learning associated morbidity.
P123 ROBOT ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE4) WITH INTRATHORACIC ANASTOMOSIS: PROMISING RESULTS AND LESSONS LEARNED IN 100 PATIENTS
Authors: Tagkalos E , van der Sluis P C , Hadzijusufovic E , Babic B , Uzun E , van Hillegersberg R , Lang H , Grimminger P P
Published: November 2019

Aim

The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 with intrathoracic anastomosis for esophageal cancer within our case series of 100 consecutive patients.

Background & Methods

Robot assisted minimally-invasive esophagectomy (RAMIE) with intrathoracic anastomosis is gaining popularity as a treatment for esophageal cancer. In this study, we present the results of 100 RAMIE procedures using the da Vinci Xi robotic system (RAMIE4). The aim of this study was to describe postoperative complications and short-term oncologic outcomes for RAMIE4 within our case series of 100 consecutive patients. Between January 2017 and February 2019, data of 100 consecutive patients with esophageal carcinoma undergoing modified Ivor-Lewis esophagectomy were prospectively collected. All operations were performed by the same surgeon using an identical intrathoracic anastomotic reconstruction technique with the same perioperative management and pain control regimen. Intra-operatively and post operatively complications were graded according to definitions stated by the Esophagectomy Complications Consensus Group (ECCG).

Results

Mean duration of the surgical procedure was 416 min (± 80). In total, 70 patients (70%) had an uncomplicated operative procedure and postoperative recovery. Pulmonary complications were most common and were observed in 17 patients (17 %). Anastomotic leakage was observed in 8 patients (8%). Median ICU stay was 1 day and median overall postoperative hospital stay was 11 days. 30 day mortality was 1%. A R0 resection was reached in 92% of patients with a median number of 29 dissected lymph nodes.

Conclusion

RAMIE4 with intrathoracic anastomosis for esophageal cancer or cancer located in the esophagus was technically feasible and safe. Postoperative complications and short term oncologic results were comparable to the highest international standards nowadays. These results could only be obtained due to a structured RAMIE training pathway. The superiority of RAMIE compared to conventional minimally invasive esophagus is currently investigated in multiple randomized controlled trials. Results of these trials will define the role for RAMIE for patients with esophageal cancer in the future.
P125 HEALTH-RELATED QUALITY OF LIFE ONE YEAR AFTER THE DIAGNOSIS OF OESOPHAGEAL AND JUNCTIONAL CANCER: A POPULATION-BASED STUDY FROM THE SWEDISH NATIONAL REGISTRY FOR ESOPHAGEAL AND GASTRIC CANCER
Authors: Berit Sunde , Mats Lindblad , Marlene Malmström , Jakob Hedberg , Pernilla Lagergren , Magnus Nilsson
Published: November 2019

Aim

The aim of this study is to describe and analyse patient reported HRQoL one year after the diagnosis of oesophageal and junctional carcinoma in an unselected cohort comprising both palliative and curative intent patients.

Background & Methods

Short and long-term health-related quality of life (HRQoL) has been extensively described in operated oesophageal cancer patients in several population-based studies. However, the knowledge of HRQoL in patients with palliative intent management is not well described, and further, documentation of HRQoL in curative intent patients treated with definitive chemoradiotherapy is also quite scarce. A nation-wide population-based cohort, of patients diagnosed between 2009 and 2016 collected in the Swedish National Registry for Esophageal and Gastric Cancer (NREV) with prospectively registered exposure data and Health-related quality of life (HRQoL) outcome data. Validated instruments from the European Organisation for Research and Treatment of Cancer QLQ-C30 and QLQ-OG25 were used, and data was analysed with means and adjusted mean differences.

Results

In patients alive one year after diagnosis, 1,156 responded to the HRQOL questionnaires and were included in the analyses. Both curative and palliative intent patients reported severe symptoms of problems in oesophageal specific domains. In the comparison between the curative and palliative intent groups, more prominent symptoms among palliative patients were detected regarding dysphagia (MD 11; 95% ci: 7-15) and anxiety (MD 10; 95% ci: 6 -15). Levels of anxiety were reported with high levels in all groups analysed and problems with dysphagia was also more common in patients treated with definitive chemoradiotherapy compared with surgically treated patients (MD 11; 95% ci: 4 -18) diagnosed in locally advanced disease stages.

Conclusion

One year after diagnosis high levels of anxiety were reported in all subgroups of oesophageal and junctional cancer patients, and problems with dysphagia are a major problem in the palliative intent subcohort and in patients treated with definitive chemoradiotherapy.
P126 HIGH ESOPHAGOTRACHEAL FISTULA DURING STENT TREATMENT OF AN ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY
Authors: Tagkalos Evangelos , Andrae Hannah K , Musholt Thomas J , Lang Hauke , Grimminger Peter P
Published: November 2019

Aim

We present a case of a 71 year old female with a combined anastomotic leakage after ivor-lewis resection and esophagotracheal perforation.

Background & Methods

Anastomotic leakage after esophageal resection is still associated with high morbidity and mortality throughout hospitalization. Nowadays there are several methods to accomplish sufficient closure of the anastomotic leakage such as clipping and using fibrin sealant in smaller leakages. Severe insufficiencies are commonly treated using esophageal stents. In our case the use of such a stent (10cm covered) placed to an anastomotic leak following esophagectomy with high intrathoracic anastomosis lead to an esophagotracheal fistula that was treated in a two-step approach. Firstly a tracheotomy was performed and the cuff of the tracheal cannula was blocked below the esophagotracheal fistula to prevent respiratory insufficiency. The stent was removed and an endosponge therapy was induced in order to manage the anastomotic leak. Finally, the semicircular wound could be covered by a fibrin sealant for final closure. In a second step, via open cervical surgery, the esophagotracheal fistula was resected, followed by overstitching of the pars membranacea and the esophagus and interposition of a muscle flap of the left pectoralis major muscle between trachea and esophagus.

Results

Postoperatively the patient was extubated with spontaneous breathing and the tracheal tube could be removed five days after surgery. After four days, the patient started drinking and enteral nutrition could be increased with a constant sufficiency of the gastric interponate. A postoperative contrast swallow at day 11 showed no leak and a good emptying of the gastric conduit. The control of the recurrent laryngeal nerves showed no abnormalities.

Conclusion

Our experience with endosponge treatment suggests that this is the first choice for successful healing of anastomotic leakage after ivor-lewis resection, especially in patients with a low BMI, to prevent esophageal stent perforations. Furthermore, the combination of an esophagotracheal fistula and an anastomotic leak does not have to result in a cervical outlet and removal of the gastric conduit. Patients should be delivered to specialized upper GI surgical centers, which have a high standard of complex esophageal surgery and endoscopic intervention possibilities.
P13 DIFFERENCE IN LONG-TERM QUALITY OF LIFE BETWEEN MCKEOWN AND IVOR LEWIS ESOPHAGECTOMY
Authors: Jezerskyte E , Saadeh L M , Hagens E R C , Sprangers M A G , Noteboom L , van Laarhoven H W M , Eshuis W J , van Berge Henegouwen M I , Gisbertz S S
Published: November 2019

Aim

The purpose of this study was to investigate the difference in long-term health-related quality of life (HR-QoL) between McKeown and Ivor Lewis esophagectomy in a tertiary referral center.

Background & Methods

The therapy of esophageal cancers consist of (neo)adjuvant chemo(radio)therapy and surgery. Often different surgical approaches are possible such as transthoracic esophagectomy with a cervical anastomosis (McKeown) or an intrathoracic anastomosis (Ivor Lewis). Evidence is scarce on whether either of these approaches is better in terms of survival, perioperative morbidity, pathology results and quality of life.

Patients with mid-, distal esophageal, gastroesophageal (GEJ) or cardia carcinoma who have undergone a McKeown or an Ivor lewis esophagectomy in the period of 2003 – 2018 were included in this study. EORTC QLQ-C30 and EORTC QLQ-OG25 questionnaires were handed out during the outpatient clinic visits and a follow-up of at least one year was ensured. Problems with eating, reflux and nausea and vomiting were chosen as primary HR-QoL domain endpoints while the remaining HR-QoL domains, postoperative complications and pathology results were observed as secondary endpoints. Correction for confounders age and gender was performed.

Results

147 patients were included in the McKeown group and 120 in the Ivor Lewis group. Mean age was 63.5 years and median follow-up was three years (range 12-137 months). No significant difference was found in problems with eating, reflux and nausea and vomiting. Significantly more problems with eating with others were found in McKeown group (β=10.435, 95% CI 4.474 – 16.395) and anastomotic leakage was significantly more common after McKeown esophagectomy (p=0.004). No significant difference was found in Clavien Dindo classification. During Ivor Lewis esophagectomy significantly more lymph nodes were resected (p<0.001). Number of lymph node metastases and R0 resection rate did not differ between groups.

Conclusion

No major differences in long-term HR-QoL were found in patients with mid-, distal esophageal, GEJ or cardia carcinoma following McKeown or Ivor Lewis esophagectomy. Problems with eating with others and anastomotic leakages were more common after McKeown esophagectomy, however, Clavien Dindo classification and radicality of surgery were similar between the two groups. Results of this study could assist the patient during the decision-making process prior to the surgery.
P131 REVEALING THE ERGONOMIC CRISIS OF AN UPPER GASTROINTESTINAL ROBOTIC SURGEON – STILL A LOT TO IMPROVE IN MINIMALLY INVASIVE SURGERY
Authors: Fuchs H , Ahn F , Leers J , Schröder W , Höfler C , Bruns C
Published: November 2019

Introduction/Aim

Minimally invasive technologies have improved outcomes after esophagectomy and the use of robotic technology in Europe is rapidly increasing. Even though robotic technology was primarily developed to improve perioperative outcomes, many robotic surgeons complain about ergonomics when using existing devices. Aim of this study is to evaluate the ergonomics of the newest robotic technology in a center of excellence for upper gastrointestinal surgery.

Background and Methods

Starting 02/2017 the latest available robotic system (davinci xi) was introduced at our academic center (certified center of excellence for surgery of the upper gastrointestinal tract, n>300 esophageal cases/year). Surgeons ergonomics were studied using a standardized video capture and touch sensor protocol (Fig 1 & 2). Data recorded were analyzed to study whether the new robotic system was used in an ergonomic fashion throughout robotic esophageal surgery.

Results

From 02/2017 – 05/2019, a total of 90 mainly upper gastrointestinal robotic cases including 45 Esophagectomies for cancer and 25 Heller Myotomies were performed. All cases were performed safely without operation-associated intraoperative complications.

Even though experienced robotic console surgeons used the robotic device, the davinci xi arm rest was used in less than 25% of surgery time (Fig. 3), resulting in loss of efficacy when using the robotic range of motion. Video documentation using the new technology is provided to showcase the dilemma.

Conclusion

Robotic technology allows for safe minimally invasive upper gastrointestinal surgery. Further development in robotics should focus on improvement of surgeons ergonomics.
P134 NASOGASTRIC TUBE UTILIZATION IN PATIENTS UNDERGOING ESOFAGUECTOMY: AN UNNECESSARY PROCEDURE
Authors: Menéndez M , Mingol F , Bruna M , Vaqué F J , Alvarez E , Hurtado L , Pérez C , García-Granero E
Published: November 2019

Aim

To evaluate the rate of complications and hospital stay length in patients undergoing esophagectomy in whom a descompressive tube was not utilized during the postoperative period.

Background & Methods

A descriptive and retrospective study was performed at our Health Care Center. All patients undergoing esophagectomy from March 2015 to April 2018, in which no decompressive tube was placed in the plasty during the postoperative period were included. We evaluated epidemiological variables, postsurgical morbidity -including nausea, vomiting or plasty emptying problems- postsurgical mortality, decompressive tube placement necessity and hospital stay lenght.

Results

A total of 41 patients were included, with an average age of 61.1 years. 82.9% were males. 43.9% were hypertensive, 63.4% were smokers and 13.1% were diabetics. 78% of patients had received neoadjuvant chemotherapy and / or radiotherapy prior to surgery. The surgical technique used was Mc Keown's esophagectomy in 23 patients (56.1%) and Ivor-Lewis tecnique in 18 (43.9%). In 85.4% of the cases, a thoracoscopic approach was used; and in 48.8% laparoscopy was utilized for abdominal approach. For the reconstruction, a gastroplasty was performed in 36 patients (87.8%) and a coloplasty was performed in 5 of them (12.2%). The anastomosis was performed manually in 53% of cases, and mechanically in 47%, by utilizing a circular stapler. The rate of complications was : 1 necrosis of the coloplasty (2,4%) who died because of a multiorganic failure; 2 stenosis of the anastomosis (4,8%) treated by endoscopic dilatations and 4 anastomosis leaks (9,8%). The mortality rate was 4,8%. 1 patient died due to coloplasty necrosis and the other one because of an acute respiratory distress syndrome (ARDS).

Conclusion

The non-use of a descompressive probe during the postoperative period of an esophagectomy does not entail a higher rate of complications compared to the available literature.This fact can improve the comfort of the patient and reduce hospital stay length.
P136 COMPARISON OF TOTALLY MINIMALLY AND HYBRID IVOR LEWIS ESOPHAGECTOMY FOR CANCER OF DISTAL ESOPHAGUS AND ESOPHAGOGASTRIC JUNCTION
Authors: Stefano de Pascale , Uberto Fumagalli Romario
Published: November 2019

Aim

Aim of this retrospective study is the comparison of the short-terms outcomes and QoL of Hybrid Ivor Lewis (HIL) and Totally Minimally Invasive Ivor Lewis (TMIIL).

Background & Methods

Minimally invasive techniques for esophagectomy represents a challenging procedure with aiming to decrease cardiopulmonary complications and guarantee better quality of life (QoL) compared to open techniques, without compromising oncological radicality. Patients with cancer of distal esophagus and EGJ were included into (HIL) and (TMIIL) groups in the period January 2017 – March 2019. General features, intraoperative and postoperative results were analyzed. For all the patients a feeding jejunostomy was performed. The surgical radicality and number of resected nodes were also evaluated. QoL was determined preoperatively, at 7 and 90 days postoperatively with EORTC QLQ-C30 questionnaire.

Results

Eighteen and 24 patients were submitted to TMIIL and HIL respectively. General features were similar in the two groups. Median intervention duration was 360 minutes [range: 240-420] in TMIIL group and 335 minutes [range: 150-400] for HIL group (p=0.0647). Median blood losses were similar for TMIIL and HIL group, 100 ml [range:50-400] and 175 ml [50-350] respectively (p=0.0831). No differences were observed in terms of postoperative complications CD≥2. One exitus occurred in HIL group (CD=5), none in TMIIL group (p=n.s). No differences were evidenced for median number of lymphnodes harvested in the two group as well for rate of R0 and R1 resections. Results obtained from the QoL questionnaires evidenced a reduction of postoperative pain during the first 7 postoperative day for patients in the TMIIL group compared to HIL; these data were confirmed by the analysis conducted on postoperative day 90, as well for the global health status, physical functioning and role functioning.

Conclusion

Our experience evidenced TMIIL esophagectomy seems to give the similar results, of HIL influencing positively the QoL within 90-day after surgery. Duration of surgery and anastomotic leaks are the key elements influencing the learning curve. Randomized controlled trials are necessary to confirm the good results obtained and to give recommendations to avoid a high rate of complications
P137 OUTCOME OF PATIENTS UNDERGOING ENDOSCOPIC MUCOSAL RESECTION FOR CANCER OF THE OESOPHAGUS FROM A SINGLE CENTRE
Authors: Chmelo J , Milito P , Madhavan A , Griffin S M , Wahed S , Hayes N , Immanuel A , Phillips A W
Published: November 2019

Aim

To evaluate the outcomes patients undergoing endoscopic mucosal resection (EMR) as a therapeutic and or diagnostic treatment for oesophageal cancer.

Background

Management of early oesophageal cancer usually involves major surgery (oesophagostomy) which has a reported morbidity of 50% and mortality of 3%. EMR is increasingly used as a treatment for patients with early (T1 N0) oesophageal cancer. It may also be employed as a diagnostic tool in those where previous biopsies have been insufficient in proving a cancer.

Methods

A retrospective review of patients who underwent EMR with a curative intent for cancer of the oesophagus or oesophago-gastric junction (OGJ) at a single centre between October 2006 and February 2019 was conducted. Patients were included in the study if the EMR sample was positive for T1a or T1b cancer.

Results

Overall 144 patients were identified who underwent 276 therapeutic or diagnostic procedures. 141 patients were diagnosed with adenocarcinoma and 3 patients with squamous cell cancer (SCC). T1a stage was confirmed for 120 patients with adenocarcinoma and one with SCC. 21 patients with adenocarcinoma and 2 with SCC were staged as T1b. 78 patients underwent EMR as their sole treatment for cancer- three year cancer related survival was 89% and 5 year 69%. A further 49 patients progressed to having surgery (gastrectomy (2), trans-thoracic oesophagectomy (47). Six (12%) were node positive.

There was no mortality associated with EMR, however bleeding requiring intervention or readmission was observed after 29 procedures (11%) and perforation was seen after 3 procedures (1.1%).

Conclusion

EMR is a safe procedure in the treatment of early oesophageal or OG junctional cancer. However survival may not be as high as expected in patients similarly staged but undergoing more radical treatment.
P138 IMPACT OF NEOADJUVANT FLOT CHEMOTHERAPY ON CARDIORESPIRATORY RESERVE OF PATIENTS WITH OESOPHAGOGASTRIC ADENOCARCINOMA
Authors: Chmelo J , Sinclair R C F , Navidi M , Phillips A W
Published: November 2019

Introduction

Neoadjuvant chemotherapy is known to have a deleterious effect on the cardiorespiratory reserve of patients with oesophagogastric cancer[1,2]. A low anaerobic threshold is associated with increased morbidity after major surgery[3] The effect that FLOT (5FU, leucovorin, oxaliplatin, docetakel) chemotherapy has upon cardiopulmonary reserve has not been reported. This work aims to quantify this effect.

Methods

Cardiopulmonary exercise testing (CPET) was completed in 18 consecutive patients with oesophagogastric cancer who received FLOT chemotherapy. CPET pre-chemotherapy and 4-5weeks post-chemotherapy measured the ventilatory anaerobic threshold (AT) and peak oxygen uptake (Vo2p). Ventilatory equivalents for CO2 (Ve/VCO2) and total ventilation (Ve) were reported. The group mean change in these objective measurements of cardiopulmonary reserve was compared before and after FLOT.

Results

Between October 2018 and January 2019 eighteen patients (median age 58.1 years, 16/18 male) were tested before and after FLOT. In 14 patients (78%) a decline in AT and VO2p was demonstrated. A mean decrease in AT of 2.1 mlkg-1min-1 (14.9 Vs 12.8 mlkg-1min-1, p=0.02) and VO2p of 2.3 mlkg-1min-1 (20.6 vs 18.3 mlkg-1min-1, p=0.01) was seen after FLOT. Ve/VCO2 and Ve were unchanged.

Conclusion

Patients receiving FLOT chemotherapy demonstrate a clinically significant decrease in cardiorespiratory reserve. This appears to be similar to that observed in patients who have previously received neoadjuvant ECX (MAGIC regimen) [1,2,4]. Further investigation into the clinical impact of this observation is required.
P139 CHYLE LEAK FOLLOWING RADICAL EN-BLOC OESOPHAGECTOMY WITH 2 FIELD NODAL DISSECTION: PREDISPOSING FACTORS, MANAGEMENT AND OUTCOMES
Authors: Milito P , Chmelo J , Kamarajah S K , Madhavan A , Wahed S , Hayes N , Immanuel A , Griffin S M , Phillips A W
Published: November 2019

Background

Chyle leaks may result from damage of the main thoracic duct or its tributaries during radical en-bloc sub-total oesophagectomy (STO). Treatment strategies and outcomes vary and management of this problem remains controversial. This study assessed the incidence, management and outcomes of chyle leaks in a dedicated oesophago-gastric cancer unit.

Methods

A retrospective study was conducted among patients who underwent elective STO with 2-field nodal dissection for oesophageal cancer between January 1997 and March 2019. The thoracic duct was routinely ligated during surgery. The diagnosis of post-operative chyle leak was performed clinically by a consultant and it was based on high output (> 500 ml/24h) from chest and/or abdominal drains and on visual characteristics of the fluid.

Results

1320 patients underwent surgery over the time reviewed. The study group consisted of 347 (26.3%) women and 974 (73.7%) men, with a median age of 65 (IQR 13) years. Oesophageal adenocarcinoma was diagnosed in a total of 937 (70.9%) patients, while squamous cell carcinoma in 274 (20.7%) patients. 93 (7%) patients developed a chylothorax. Univariable analysis showed that lower body weight, lower BMI, female sex and histology of a squamous cell carcinoma were significant independent predictive factors for chyle leak (p<0.005).

Chyle leak was associated with a higher risk of return to ITU (45.1% vs 10.1%, p<0.001) and longer hospital stays (median 21.5 vs 15 days, p=0.002). Overall in-hospital mortality was 3.7% and was significantly higher in the chyle leak group (10.75% vs 3.2%, p<0.001), although the causes of death were not directly related to it. Chyle leak was not associated with anastomotic leak, or wound and respiratory infection.

Chylothorax was treated surgically in 39 (41.9%) patients and conservatively in 54 (58.1%). Between these two groups, a significant difference in terms of post-operative hospital stay and in 30-day mortality rate was seen (p< 0.002 and p=0.031, respectively). Survival rate was similar in both groups.

Conclusions

Chyle Leak post oesophagectomy is associated with an increased risk of return to ITU, and longer hospital stay and increased in hospital mortality. However, surgical treatment is safe and early re-operation is recommended in order to diminish hospital stay and to decrease the 30-day mortality rate.
P141 IVOR LEWIS MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER : IMPACT OF THORACOSCOPY ON POST-OPERATIVE MORBIDITY
Authors: Louis Martin , Thibault Voron , Vincent Drubay , Marguerite Messier , Clarisse Eveno , Guillaume Piessen
Published: November 2019

The aim

of this study is to assess the impact of thoracoscopy versus conventional thoracotomy on postoperative and oncological outcomes in patients undergoing Ivor Lewis esophagectomy with laparoscopic gastric mobilisation for esophageal resectable cancer.

Background & Methods

Esophagectomy for cancer is a complexe procedure associated with a high rate of mortality and morbidity1,2, especially respiratory, despite recent improvements in perioperative cares and advances in surgical techniques. Recently, minimally invasive esophagectomy has shown a benefit in decreasing postoperative respiratory complications in 2 randomized trials comparing firstly the hybrid approach (Ivor Lewis with laparoscopy and right thoracotomy) to the open approach (MIRO trial3) and secondly the totally minimally invasive approach with cervical anastomosis (McKeown with laparoscopy and thoracospy) to the open approach (TIME trial4).

Few studies have focused on comparing specifically thoracosopic(TMIE) versus conventional thoracotomy approach(HYBRID) for intra-thoracic anastomosis. We performed a single-center retrospective study, including all patients undergoing either Ivor Lewis HYBRID or TMIE in our high-volume center between 2010 and 2019. The primary endpoint was major postoperative complications within 30 days (Dindo-Clavien grade≥III). Secondary endpoints included operative parameters, postoperative morbidity and mortality within 90 days and quality of oncological resection.

Results

498 patients were included, 440 underwent HYBRID and 58 TMIE. Ninety-six patients(19.3%) had major postoperative complication, 11 patients(19%) in TMIE and 85 patients(19.3%) in HYBRID. Anastomotic leak (AL) rate was significantly higher in TMIE (36.2% versus 10.8%,p<0.001). However AL in TMIE group were frequently less severe than in the HYBRID group (rate of AL type 2/3 respectively 23.8% and 50%;p=0.044). Respiratory complications were observed in 202 patients (45.9%) in the HYBRID group and in 14 patients (24.1%;p=0.002) in TMIE group, without significant difference in severe respiratory complications rate. The complete resection rate (R0 resection) (5.3% vs 3.7%) and the number of lymph nodes retrieved (25.26 vs 25.92) were comparable in both groups.

Conclusion

The TMIE approach is burdened with a significant AL rate, probably related to an unreached learning curve, which mitigates the benefit of this approach to respiratory complications. The technical difficulty caused by intrathoracic anastomosis, whose modalities are not well-established, remains a major concern.
P142 IMPACT OF NEO-ADJUVANT CHEMOTHERAPY ON CARDIORESPIRATORY RESERVE, SARCOPENIA AND QUALITY OF LIFE IN OESOPHAGO-GASTRIC CARCINOMA
Authors: Navidi M , Phillips A , Griffin M , Petrides G , Perthen J , Ali T , Greystoke A , Sinclair R
Published: November 2019

Background

The management of locally advanced oesophago-gastric (OG) adenocarcinoma in the UK includes three cycles of MAGIC protocol neoadjuvant chemotherapy (NAC). NAC may have a detrimental impact on fitness, quality of life and sarcopenia. Determination of the oxygen uptake at the anaerobic threshold (AT) by cardiopulmonary exercise testing (CPET) objectively measures cardiorespiratory reserve (fitness). AT can be used to predict perioperative risk. Sarcopenia is defined by decreased skeletal muscle mass and is a poor prognostic factor. Patients view their health by means of quality of life (QOL) rather than traditional clinical outcomes. This study was conducted to determine the impact of neoadjuvant chemotherapy on fitness, sarcopenia and quality of life following neoadjuvant chemotherapy.

Methods

Patients with locally advanced OG adenocarcinoma were recruited. CPET, sarcopenia and QOL were measured before and following NAC. AT and peak oxygen uptake (VO2 Peak) were used to assess fitness. CT images at staging and upon completion of NAC were used to measure sarcopenia (muscle mass and function). EORTC QOL-Core 30 and QLQ-Oesophagogastric 25 questionnaires assessed QOL.

Results

31 patients with a median age of 65 (41-81) were recruited, 27 patients completed all three cycles of NAC. The results of pre and post NAC measured parameters are outlined in the table below.

Conclusion

NAC significantly impacts fitness, sarcopenia levels and QOL. Preventing this reduction through development of ‘prehabilitation’ strategies, or optimising timing of surgery after recovery of the observed decline, may decrease perioperative risk, reduce postoperative complications and improve quality life. This should be the focus of future studies.
P143 RNA-BASED LIQUID BIOPSIES FOR BETTER CLINICAL MANAGEMENT OF BARRETT’S ESOPHAGUS AND ESOPHAGEAL ADENOCARCINOMA
Authors: Annouck Philippron , Kathleen Schoofs , Philippe Nafteux , Lieven Depypere , Jo Vandesompele , Katleen De Preter , Piet Pattyn
Published: November 2019

Aim

In this study we will explore several RNA types in blood, including microRNA, messenger RNA, long non-coding RNA and circular RNA as a potential liquid biomarker to facilitate early diagnosis, prognosis and monitoring of esophageal adenocarcinoma

Background & Methods

In the past decades the incidence of esophageal adenocarcinoma (EAC) has increased dramatically in most Western populations. Due to the lack of symptoms EAC is often detected in a late stage, contributing to a poor 5-year survival rate. The potential of RNA (coding and miRNA) as circulating biomarker in blood has already been shown for many cancer entities but requires further investigation for EAC.

Blood and tissue samples from patients with non-dysplastic Barrett’s esophagus (NDBE), high-grade dysplasia (HGD) and EAC have been collected. Currently, our biobank includes >5000 samples from 120 patients. A proof-of-concept study was conducted including 17 patients from three groups (EAC, HGD and NDBE). For each patient, biopsies from diseased tissue and healthy tissue as well as blood were collected and analyzed using small RNA and total RNA sequencing.

Results

Gene expression analysis was performed to identify differentially expressed genes across the three groups. The highest number of significantly differentially expressed m(i)RNAs were present in the tissues of EAC versus NDBE patients, while these differences were much lower or even absent in the plasma samples. Moreover, we have identified between 1500 and 7500 unique circular RNAs in individual EAC cancer patients’ plasma, indicating promising opportunities for a blood-based liquid biomarker for BE and EAC.

Conclusion

An exploration of several RNA types in blood and tissue biopsies has been done in patients with Barrett’s Esophagus and esophageal adenocarcinoma. Additional samples are needed to significantly increase the power of the differential expression study as well as to verify the results of our proof-of-concept study.
O144 CALCIFICATION IN THE DESCENDING AORTA PREDICTS POSTOPERATIVE LEAKAGE OF INTRA-THORACIC ANASTOMOSIS AFTER OPEN ESOPHAGECTOMY FOR CANCER
Authors: Ukkonen M , Wirta E , Khan J , Tyrväinen T , Kechagias A
Published: November 2019

Aim

Postoperative anastomotic leakage is a major complication in the surgery of the esophagus. In this study, we aim to examine whether calcifications of the aortic segments can predict anastomotic leakage after open esophagectomy for cancer with intra-thoracic anastomosis of a gastric conduit.

Background and methods

All patients with esophageal cancer who underwent elective esophagectomy with an intra-thoracic anastomosis at Tampere University Hospital between 2007-2018 were evaluated. Preoperative data were associated to outcome. These included demographic, anamnestic, clinical, laboratory, and radiologic data. Preoperative staging thoraco-abdominal CT-scans were re-evaluated to document the presence of calcifications in the various aortic segments.

Results

A total of 97 patients (median age 64 (43-78) years, 20% female) were analysed, with anastomotic leakage occurring in 22 patients (23%). Median time from surgery to leakage was 10 (1-32) days, and follow-up time 28 (1-143) months. From all the factors that were evaluated in the univariate analysis, only the presence of calcification in the descending thoracic aorta was associated with a higher risk of anastomotic leakage (11% vs. 33%, HR 4.571; 95% CI 1.40-15.0; p=0.011). There was a trend for anastomotic leakage in the presence of calcification in the suprarenal abdominal aorta (13% vs. 29%, p=0.057). A higher leakage rate was documented when a calcification was present in the infrarenal abdominal aorta (8.3% vs. 25%, p=0.205), and in the ascending thoracic aorta (22% vs. 30%, p=0.559), without reaching statistical significance.

Conclusion

The presence of a calcification in the descending thoracic aorta is associated with higher risk of anastomotic leakage after open esophagectomy for cancer.
P145 OPTIMAL PERIOPERATIVE PAIN MANAGEMENT IN ESOPHAGEAL SURGERY
Authors: Feenstra ten Hoope M L , Hermanides W , Gisbertz J , Hollmann S S , van Berge Henegouwen M W , Eshuis M I ,   WJ
Published: November 2019

Aim

To compare paravertebral analgesia with epidural analgesia in thoracolaparoscopic Ivor Lewis esophagectomy.

Background

In esophagectomy, thoracic epidural analgesia (TEA) is standard of care for perioperative pain management. Although TEA is effective, it has unwanted side-effects, such as hypotension, urinary retention and epidural haematoma. Thoracoscopic guided paravertebral analgesia (PVA) is an alternative that is being applied more in thoracic surgery and supposedly has less side-effects.

Methods

In this feasibility study, TEA was compared with PVA for efficacy in two consecutive series of 25 thoracolaparoscopic Ivor Lewis esophagectomies. In PVA the catheter was placed by the surgeon under direct thoracoscopic vision. TEA consisted of continuous bupivacaine and sufentanil with a patient-controlled bolus function. PVA consisted of continuous bupivacaine and intravenous morphine patient-controlled analgesia. Primary outcome was the highest recorded Numeric pain Rating Scale (NRS) every 8 hours. Secondary outcomes included opioid consumption, vasopressor consumption, fluid administration and length of hospital stay.

Results

In both groups, the NRS was acceptable (below 5) during the first three postoperative days with no difference in overall pain. Patients with PVA had a higher NRS the first postoperative night (median 4 vs 0, p<0.001). Opioid consumption was significantly lower in patients with PVA. In TEA three catheters failed after successful insertion, in PVA only two. There was no difference in vasopressor consumption, fluid administration and length of hospital stay.

Conclusion

PVA seems to be a safe and effective alternative for TEA in thoracolaparoscopic Ivor Lewis esophagectomy. This hypothesis should be confirmed in a randomized trial.
P149 MINIMAL INVASIVE TEMPORARY GASTRIC ELECTRO STIMULATION - 1 YEAR FOLLOW
Authors: Corvinus F , Babic B , Tagkalos E , Hadzijusufovic E , Heinrich S , Lang H , Grimminger P
Published: November 2019

Aim

To predict the outcome of the implantation of an electronic gastric stimulation device (Enterra®, Medtronic) we established a minimal invasive procedure to perform a temporary gastric test stimulation prior to a definite implantation (1). We achieved promising short time results. This study will demonstrate the long-term results after more than 1 year.

Background & Methods

Gastroparesis (GP) is a complex disorder of gastric motility. It is defined as a delayed gastric emptying without pyloric obstruction. Due to its etiology GP is divided into three groups: diabetic (GP), postoperative (PG) and idiopathic (IP). Although electronic stimulation of the stomach is a well-established and approved procedure since over 18 years for the therapy of symptomatic GP, the response to gastric stimulation remains unpredictable.

13 patients (11 female, 2 male) with a history of symptomatic gastroparesis (4 idiopathic, 7 postoperative, 2 diabetic) were included. Patients underwent laparoscopy and received 2 temporary electrodes (Medtronic Streamline 6492®) 10 cm proximal to the pylorus into the gastric wall. Threads were passed through the abdominal wall and connected to an external gastric stimulator (Enterra, Fa. Medtronic). The device was taped to the abdominal wall by a dressing. Symptom intensity was measured by a standardized questionnaire, Gastoparesis Cardinal Symptom Index (GCSI)(2). Therapeutic response was defined as a GCSI reduction of at least 50% under the preoperative score. Half time gastric emptying was also measure pre and postoperatively using a half-solid test meal.

Results

10 of 13 patients reported a response to temporary gastric stimulation with an increase of the pre-therapeutic GCSI over 50 %. 10 patients received a permanent stimulation device. 7 patients reached the 1-year follow up. They all remained responders with a reduction of GCSI over more than 50 %. In comparison to results after 6 months gastric half time emptying continued to decrease.

Conclusion

Temporary gastric electronic stimulation can predict the long-term outcome of patients receiving a definite implantation of an electronic gastric stimulation device.
P153 DEVELOPMENT OF A NOMOGRAM FOR THE PREDICTION OF INTERVAL METASTASES AFTER CHEMORADIOTHERAPY IN PATIENTS WITH ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Yin-Kai Chao
Published: November 2019

Aim

To develop a nomogram for predicting interval metastases during chemoradiotherapy(CRT) in esophageal squamous cell carcinoma(ESCC) patients.

Background&Methods

During CRT for esophageal cancer, some patients develop systemic metastasis. Nomograms incorporating multiple prognostic factors are useful for individualized estimation of survival in cancer patients. However, nomograms for the prediction of interval metastases after CRT in patients with esophageal cancer are scarce.

We retrospectively reviewed the records of 358 ESCC patients who underwent CRT as first line treatment. Data were subjected to multivariate logistic regression analyses for selecting variables to be included in the nomogram. The performance of the resulting nomogram was internally and externally validated by calculating the bias-corrected concordance statistic (c-statistic) and the area under the receiver operating characteristics curve (AUROC).

Results

After CRT, 21 patients (5.9%) were found with new distant metastatic lesions. The following variables were included in the nomogram: 1) age, 2) Tumor SUXmax on pretreatment18F-FDG PET, 3) pretreatment tumor length, 4)chemotherapy regimen (Paclitaxel+Carboplatin v.s. Fluorouracil+Cisplatin). The bias-corrected c-statistic and AUROC was 0.7094.

Conclusions

At least 5.9% of ESCC patients developed interval metastasis after CRT. Our nomogram showed an adequate performance for predicting interval metastases in ESCC patients.
P154 SAFETY AND ONCOLOGICAL EFFICACY OF BILATERAL RECURRENT LARYNGEAL NERVE LYMPH NODE DISSECTION AFTER NEOADJUVANT CHEMORADIOTHERAPY IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Yin-Kai Chao,
Published: November 2019

Aim

We sought to evaluate the safety and oncological efficacy of bilateral recurrent laryngeal nerve (RLN) lymph node dissection (LND) in patients with esophageal squamous cell carcinoma (ESCC) who had undergone neoadjuvant chemoradiotherapy (nCRT).

Methods

The need to dissect RLN lymph nodes in patients who had undergone nCRT is controversial. No data are currently available on the clinical utility and implications of RLN nodal dissection in nCRT-treated patients with esophageal cancer.

We retrospectively examined the records of ESCC patients who were judged to be ycN-RLN(-) following nCRT. Patients were divided into two groups according to the extent of LND (standard two-field LND [STL group] versus total two-field LND [TTL group]). Only lower mediastinal and upper abdominal lymph nodes were removed in the STL group. In addition to the standard procedure, patients in the TTL group underwent resection of upper mediastinal lymph nodes located along the bilateral RLN. Using propensity score matching, 29 pairs were identified and compared with regard to perioperative complications, lymph node metastases rates, overall survival (OS), and disease-specific survival (DSS).

Results

No significant intergroup differences were identified in terms of in-hospital mortality and morbidity. Metastases to the RLN lymph nodes were identified in 20.7% (6/29) of TTL patients, being the only site of lymph node metastases in three of them. TTL was associated with lower upper mediastinal lymph node recurrence rate(6.5%) compared with STL (21.5%, p=0.134), although the overall recurrence rate was similar (STL, 44.8% versus TTL, 46.4%). No significant intergroup differences were also evident with regard to 3-year DSS and OS rates.

Conclusions

RLN LND can be safely performed in ESCC patients who had undergone nCRT, ultimately resulting in an improved local control and should be practiced as part of the surgical routine.