bluuebunny/crossref_metadata_2025 huggingface dataset:
PS02.209: PROGNOSTIC VALUE OF CHEST-TUBE AMYLASE IN DETECTING EARLY ANASTOMOTIC LEAKAGE AFTER IVOR-LEWIS ESOPHAGECTOMY
Authors: Giulini Luca , Dubecz Attila , Solymosi Norbert , Stein Hubert
Published: September 2018

Background

Intrathoracic anastomotic leaks after esophagectomy are a significant cause of postoperative morbidity and death. Early detection and timely management is crucial but existing diagnostic methods are either invasive or have a low sensitivity. The aim of this study was to evaluate the effectiveness of daily drain amylase levels in detecting early anastomotic leaks after Ivor-Lewis esophagectomy compared with C-Reactive Protein (CRP) levels.

Methods

Between June 2015 and September 2017, 126 Ivor-Lewis esophagectomies for cancer were performed in our surgical department. In 80 of these patients, drain amylase levels were collected as long a right-sided chest-tube was in place. Chest-tubes were removed at a secretion volume < 300 ml/24 h. CRP levels were measured daily. If bile was detected in the chest-tube and/or after re-exploration of the chest, no further data were collected. Early anastomotic leaks were defined as occurring as long as the chest tubes were in site, in the mean the 5th postoperative day (POD). According to the collected data, drain amylase levels > 350 U/l, and CRP > 30 mg/dl were considered positive. Sensitivity and specificity in detecting anastomotic insufficiency for both drain amylase and CRP were calculated.

Results

A clinically significant anastomotic leak occurred in 7,1% (9/126) of all esophagectomy patients with 0,8% (1/126) postoperative 30-days mortality. An early anastomotic disruption occurred in 4 of the 80 analysed patients. Three of them had a positive chest-drain amylase level and none a positive CRP level on POD1. The same three patients had on POD 2 a positive CRP level or presented bile in the chest-tube. The fourth patient presented at POD 2 bile in the chest tubes. On POD 1 he presented neither positive amylase nor CRP. The sensitivity and specificity for drain amylase and CRP within the first 3 POD was 0,75 and 0,98 vs 0,75 and 0,85 respectively. The accuracy for both amylase and CRP were calculated at 0,97 vs 0,85.

Conclusion

Chest-tube amylase levels after Ivor-Lewis esophagectomy are more accurate for the detection of early esophageal anastomotic leaks than CRP. This could facilitate early detection of anastomotic leaks up to 24 hours earlier than elevated blood CRP levels.

Disclosure

All authors have declared no conflicts of interest.
PS02.220: ATTENUATION OF SATIETY GUT HORMONES INCREASES APPETITE AFTER CURATIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Elliott Jessie , Docherty Neil , Murphy Conor , Eckhardt Hans , Ravi Narayanasamy , Le Roux Carel , Reynolds John
Published: September 2018

Background

Reduced appetite and weight loss after esophagectomy (ES) occur in the context of an exaggerated postprandial satiety gut hormone response. Satiety gut hormones modulate central processing of food reward, resulting in reduced energy intake. The aim of this study was to investigate the effect of satiety gut hormone attenuation using the somatostatin analogue octreotide on appetitive behavior among patients after curative ES.

Methods

In this randomized, double-blind, placebo-controlled crossover study, disease-free patients at least one year after ES with gastric conduit reconstruction and matched controls received either 1mL 0.9% saline or 1mL (100μg) octreotide subcutaneously, before completing a progressive ratio task (PRT). A measure of appetitive behavior, the PRT requires subjects to undertake progressively increasing amounts of work to obtain a reinforcer—the final completed increment (breakpoint) representing reinforcer reward value in different states. Separate cohorts were studied in the fasted or 1-hour postprandial states. The institutional Research Ethics Committee approved the study (REC 2015/21/02), which was registered on ClinicalTrials.gov prior to recruitment of the first participant (NCT02381249).

Results

36 subjects (ES, n = 18, matched controls, n = 18) were studied. 2.5 ± 0.3 years postoperatively, ES patients demonstrated 14.6 ± 2.6% weight loss and an elevated postprandial GLP-1 (49.2 ± 13.4 versus controls with 20.2 ± 2.3 pM, P = 0.038). Octreotide did not alter appetite among ES or control subjects when tested fasting (breakpoint, ES: 980 ± 371 versus 1700 ± 583, P = 0.16; control: 1056 ± 274 versus 1124 ± 273, P = 0.80). When tested one hour postprandially, octreotide was associated with increased appetitive behavior versus placebo among ES subjects (breakpoint, 322 ± 143 versus 246 ± 149, P = 0.037), but not controls (248 ± 119 versus 247 ± 120, P = 0.98).

Conclusion

Attenuation of the exaggerated postprandial satiety gut hormone response is associated with increased appetitive behavior towards a sweet-fat stimulus among patients post ES. Suppression of satiety gut hormones may represent a novel target to increase appetite, food intake and body weight in patients after esophagectomy.

Disclosure

All authors have declared no conflicts of interest.
PS02.222: CLINICAL CHARACTERISTICS AND MANAGEMENT OF GASTRIC TUBE CANCER AFTER ESOPHAGECTOMY
Authors: Shirakawa Yasuhiro , Noma Kazuhiro , Maeda Naoaki , Ninomiya Takayuki , Ogawa Toshihiro , Sakurama Kazufumi , Tanabe Shunsuke , Fujiwara Toshiyoshi
Published: September 2018

Background

Gastric cancer is the second most common malignancy, overlapping with thoracic esophageal cancer (TEC). Among them, metachronous gastric tube cancers after TEC surgery have been increasing. The aims of this study were to examine the clinicopathological factors and treatment outcomes of gastric tube cancer (GTC) after TEC surgery.

Methods

Thirty-three GTCs in 30 cases after TEC treated between 1997 and 2016 were investigated retrospectively.

Results

Most cases were males. The median interval from TEC surgery to GTC occurrence was 68.1 months (6–190 months). Almost 2/3 lesions occurred in the lower third of the gastric tube (21/33); 29 lesions (in 26 cases) were superficial cancers, and 4 lesions were advanced cancers. Twenty-two lesions of superficial cancer were differentiated type, and the remaining seven lesions were undifferentiated type. Treatment for superficial cancer had previously been performed with partial gastric tube resection (10 lesions), and the number of cases undergoing endoscopic submucosal dissection (ESD) had increased recently (19 lesions). Most cases with superficial cancer survived without relapse. Four lesions of advanced cancer were found after a relatively long interval following TEC surgery. Most lesions of advanced cancer were scirrhous, undifferentiated type, and they died due to GTC.

Conclusion

GTCs may occur late in the postoperative course following TEC surgery. If they are discovered at an early stage, these lesions can be cured with ESD. Long-term periodic endoscopic examinations after TEC surgery are important.

Disclosure

All authors have declared no conflicts of interest.
PS02.229: ASSESSMENT OF VARYING QUALITY OF LIFE OUTCOMES BASED ON A STRATEGY OF ORGAN PRESERVATION VERSUS SURGERY FOR UPPER GASTROINTESTINAL MALIGNANCIES
Authors: O Connell Lauren , Coleman Mary , Kharyntiuk Natalia , Walsh Thomas
Published: September 2018

Background: Background

Neoadjuvant chemoradiotherapy (naCRT) for upper gastrointestinal malignancies induces a pathological complete response (pCR) in 25–85% of patients, depending on disease stage and regimen chosen. All patients with a pCR will have a clinical complete response (cCR). Avoidance of surgery is desirable where feasible, as operative intervention entails morbidity and mortality risks and a reduction in lifelong health related quality of life (HRQoL). Pursuant on a policy of permitting selected patients with a cCR to opt for surveillance, this study aims to compare the QoL of patients who chose surveillance over adjuvant surgery following a cCR to naCRT.

Methods: Methods

One hundred and fourteen patients participated in the study. These comprised 4 groups; Group 1 (n = 31) were healthy controls; Group 2 (n = 26) had chemoradiotherapy only; Group 3 (n = 31) had oesophagectomy post naCRT and Group 4(n = 26) had gastrectomy alone. A novel 33 point questionnaire assessing 5 functional domains was completed focusing on symptoms of antro-pyloric function, respiratory reflux and post-vagotomy symptoms, as well as a previously validated questionnaire instrument for purposes of comparison and external validation. The data was aggregated to produce a total score ranging from 20–93 with 20 representing the least symptomatic.

Results: Results

Mean(± sd) overall QoL scores were significantly better in patients avoiding resection (28.9 ± 4.5) vs oesophagectomy (32.3 ± 58. P = 0.042) and vs gastrectomy(33.19 ± 5.9, P = 0.004. Scores did not differ between patients undergoing oesophagectomy or gastrectomy (P = 0.889). Oesophagectomy was associated with a trend towards increased reflux-related respiratory symptoms (7.3 ± 2.2 vs 6.5 ± 1.9; P = 0.396) while gastrectomy patients reported more symptoms related to vagotomy (1.82 ± 0.9 vs 1.4 ± 0.6; P = 0.438) and early dumping (8.2 ± 1.4 vs 7.1 ± 1.7; P = 0.239). The mean score for the control group administered the novel questionnaire was 20.74, approaching the lowest possible score of 20. This was significantly lower than any of the scores recorded for the treatment groups (P = < 0.001).

Conclusion: Discussion

A strategy of active surveillance in complete responders to neoadjuvant chemoradiotherapy is rewarded with a superior quality of life than in those undergoing surgery.

Disclosure

All authors have declared no conflicts of interest.
PS02.231: RELATIONSHIP BETWEEN CHANGE IN TONGUE PRESSURE AND PNEUMONIA AFTER ESOPHAGECTOMY
Authors: Yokoi Aya , Ekuni Daisuke , Yamanaka Reiko , Morita Manabu
Published: September 2018

Background

Esophagectomy for esophageal cancer is a highly invasive procedure with several serious postoperative complications, including pneumonia. It is commonly accepted that deteriorated swallowing function causes postoperative pneumonia. However, measurement to evaluate swallowing function related to postoperative pneumonia has not been developed. Recently, it became possible to measure tongue pressure using a non-invasive, easy and portable device. We hypothesized that tongue pressure relates to postoperative pneumonia. The aim of this study was to investigate the relationship between change in tongue pressure and pneumonia after esophagectomy among inpatients with esophageal cancer.

Methods

Fifty-eight inpatients (39 males and 19 females; 33–77 years old) who underwent esophagectomy participated in this study. Measurement of tongue pressure was performed using a portable device before esophagectomy (baseline) and at postoperative 1 and 2 weeks. Repetitive saliva swallowing test (RSST) was also performed to evaluate swallowing function at the same time. Pneumonia was postoperatively diagnosed by the chest X-ray, white blood count, body temperature and purulent sputum. The data of general and oral conditions were collected from medical and dental records. Data also included sex, age, type of cancer, cancer stage (International Classification of Diseases for Oncology ICD-10 version 2015), type of operation (thoracotomy or thoracoscopy), type of preoperative chemotherapy, surgical duration, amount of bleeding during surgery, type of reconstruction, incidences of postoperative complications, intubation period, body temperature, blood chemical analysis, health behaviors and oral condition. Differences in parameters between the pneumonia (+ ) group (n = 10) and pneumonia (-) group (n = 48) were analyzed by Mann-Whitney U or Chi-square test. Level of significance was set at P < 0.05.

Results

Tongue pressure significantly decreased after esophagectomy (P < 0.05). The decrease in tongue pressure, age, amount of bleeding during surgery, length of fasting days, the ratio of thoracotomy and aspiration in the pneumonia (+ ) group were significantly greater than those in the pneumonia (-) group (P < 0.05).

Conclusion

The decrease in tongue pressure was related to the incidence of pneumonia after esophagectomy among inpatients with esophageal cancer.

Disclosure

All authors have declared no conflicts of interest.
PS02.232: BASALOID CARCINOMA OF THE ESOPHAGUS: MULTIMODAL APPROACH
Authors: De Vega Marta , Miliani Carlos , Rodriguez Vitoria Juan , Antonio Martinez-Piñeiro Juan , Pereira Fernando
Published: September 2018

Background

Basaloid cell carcinoma of the esophagus (BSCCE) is a rare (0.07–4%) poorly-differentiated variety of squamous cell carcinoma (SCC), more aggressive and with a worse prognosis than typical SCC. There are no published studies on the best therapeutic option for these tumors or on of the effectiveness of Neoadjuvant chemoradiotherapie; so there is no standard treatment. We describe the characteristics and the therapeutic strategy applied to a patient with an avanced basaloid squamous cell carcinoma of the distal esophagus.

Methods

A 70-year-old woman with dysphagia and severe malnutrition was diagnosed with locally advanced esophageal cáncer of lower esophagus The biopsy indicated moderately differentiated basaloid cell carcinoma. The clinical diagnosis was cT4NxM0, We decided multimodal treatment with curative intent: Neoadjuvant chemoradiotherapie at a dose of 41.4 Gy and concomitant carboplatin and pacliotaxel 5 cycles (CROSS scheme) plus surgery.

Results

PET-TAC post-neoadjuvant re-evaluation showed partial morphological response (reduction of tumor metabolism in 34.7%). 6 weeks after radiochemotherapy we performed a three fields total esophagectomy. Postoperative course without incidents. The pathological diagnosis was BASALOID cell CARCINOMA located in distal esophagus of 10 cm long with 30% tumor residual; it affects gastro-oesophageal junction. Stage TNM 7th ed: ypT3 N0 (0/17) L0V1R0 Our patient is fine and without evidence of recurrence after 15 meses.

Conclusion

Basal squamous cell carcinoma is more common in men around 60 years old, being rare in older women. They are located more frequently in the middle than in lower esophagus. They are tumors of poor prognosis (poorly differentiated, locally advanced and with an aggressive biological behavior that predisposes to early metastasis) although the latest publications relate the prognosis especially with the stage of the tumor. There are no published data about the use of Neoadjuvant treatment for these tumors. We have carried out a multimodal treatment (Cross scheme) followed by surgery with clinical, radiological (PET-TAC) and pathological response (30% of residual tumor in the piece) CONCLUSION The multimodal treatment with Cross scheme and surgery was useful in patients with Basaloid tumor of the esophagus can be considered for patients with this type of tumor.

Disclosure

All authors have declared no conflicts of interest.
PS02.235: POOR ORAL HEALTH INCREASES RISK OF ESOPHAGEAL SQUAMOUS CELL CARCINOMA: THE FOLLOW-UP STUDY OF THE LINXIAN NUTRITION INTERVENTION TRIAL
Authors: Yu Pei , Zhang Su , Wang Ming , Liang He , Fan Hu , Qiao Lin , Taylor Philip
Published: September 2018

Background

Several studies have suggested an association between poor oral health and esophageal squamous cell carcinoma (ESCC). We conduct this study to further examine the association between oral hygiene and ESCC risk in Linxian, the high risk area of China.

Methods

We recruit 29,553 healthy and 3318 esophageal squamous dysplasia participants aged between 40 and 69 in 1985 and then followed up until April, 2015. Basic characteristics were collected and oral related diseases were examined by trained doctors. Cox regression models were used to calculate hazard rations (HRs) and 95% confidence intervals (CIs).

Results

In general group, 2577 participants’ dead for ESCC and the cumulative rate of ESCC death was 12.9%. Teeth loss more than 20, before age of 40, bleeding of teeth, chapped lips, oral leukoplakia were significantly associated with risk of death from ESCC, and with 1.28 (95% CI: 1.18–1.38), 1.12 (95% CI: 1.03–1.23), 1.28 (95% CI: 1.13–1.45), 1.14 (95% CI: 1.04–1.25), 1.23 (95% CI: 1.12–1.35) fold increased risk of death from ESCC respectively in models adjusted for potential confounders. In dysplasia group, 540 participants’ dead for ESCC and the cumulative rate was 24.7%. Those who loss teeth more than 20, before age of 40, bleeding of teeth, have 1.24 (95% CI: 1.02–1.51), 1.25 (95%CI: 1.02–1.52), 1.35(95%CI: 1.06–1.70) fold increased risk after adjustment. Association between chapped lips and ESCC death was not found.

Conclusion

Severe teeth loss, early age teeth loss and teeth bleeding were associated with ESCC death and excess risk increased as dysplasia occurred. Chapped lips loss association with ESCC death in dysplasia group, it may reveals that it react before dysplasia change. Further studies are warranted to find the mechanism association and improvements of protecting oral health should be done.

Disclosure

All authors have declared no conflicts of interest.
PS02.241: SINGLE CELL RNA SEQUENCING REVEALS THE HETEROGENEITY OF NON-CANCER CELL POPULATIONS WITHIN THE ECOSYSTEM OF ESOPHAGEAL ADENOCARCINOMA
Authors: Walker Robert , Secrier Maria , Harrington Jack , Parker Rachel , Kelly Jamie , Byrne James , West Jonathan , Rose-Zerilli Mat , Underwood Tim
Published: September 2018

Background

Esophageal adenocarcinoma (EAC) develops in a complex ecosystem that defines tumour evolution, response to treatment and patient outcomes. We have shown that high levels of cancer associated fibroblast (CAF) in the tumour microenvironment (TME) predicts poor outcome and is inversely related to tumour infiltrating lymphocyte (TILs) abundance. Bulk sequencing studies lack the resolution to dissect the phenotypic and functional heterogeneity and cell-cell interactions of the TME. We have applied single cell RNA sequencing to 12 EAC patients to address this challenge.

Methods

A total of 24 single-cell suspensions were prepared from resected specimens and paired normal tissue. Single cells and barcoded mRNA-binding micro-particles were combined in droplets containing cell lysis buffer using a custom-built microfluidic platform. Captured mRNA with a cell barcode and unique molecular identifier was reverse transcribed, amplified and sequenced. SEURAT (v2.1, R-package) was used to identify highly-variable genes and perform cell clustering.

Results

Analysis of 6859 of the highest quality cells using the 4167 most variable genes revealed 46 clusters which were divided into 12 broad populations. Antigen Presenting Cells (n = 189), B Cells (n = 265), Cancer Cells (n = 1449), Endothelial Cells (321), Fibroblasts (1690), Mast Cells (n = 184), Monocytes/Macrophages (n = 254), Plasma Cells (n = 208), Smooth Muscle, (n = 115), Squamous Epithelium (n = 751), T Cells (n = 1433). Analysis of publicly available bulk RNAseq datasets (TCGA) of EAC showed that tumours that were ‘hot’ for a CAF gene signature were ‘cold’ for a T-Cell signature. Subset analysis of the fibroblasts from tumour samples that were enriched for the same CAF signature revealed 3 subtly different clusters. One of these sub-populations differentially expressed genes associated with the Gene Ontology terms GO:00,40011 (locomotion) GO:0,006928 (movement of cell or subcellular component) and GO:00,48870 (cell motility). The two tumours with the highest ratio of this type of CAF to T-Cells were both found to have distant metastasis at resection.

Conclusion

EAC CAFs are a heterogeneous population with distinct biological functions which may have different implications for prognosis. These early results suggest that we are able to identify candidate biological processes that may describe the mechanisms through which CAFs and TILs influence outcome.

Disclosure

All authors have declared no conflicts of interest.
PS02.243: THE EFFECT OF PREHABILITATION ON SARCOPENIA DEVELOPMENT DURING NEOADJUVANT CHEMOTHERAPY FOR OESOPHAGOGASTRIC CANCER: A RANDOMISED CONTROLLED TRIAL
Authors: Allen Sophie , White Daniel , Rockall Timothy , Preston Shaun , Sultan Javed
Published: September 2018

Background

Neoadjuvant chemotherapy (NAC) and surgery improves 5-year survival in patients with oesophagogastric (OG) cancer. NAC induces loss of skeletal muscle mass and function, leading to the development of sarcopenia (defined as > 5% skeletal muscle (SM) loss in patients with a BMI of > 20kg/m2). This is a poor prognostic indicator of outcome. We assess whether a prehabilitation programme (during NAC) results in a reduced rate of SM loss compared with ‘standard care’.

Methods

A single-centre, randomised controlled trial was conducted in patients undergoing NAC for OG cancer. Patients were assigned to a 15-week prehabilitation programme comprising twice weekly supervised aerobic and resistance training and a thrice weekly home exercise plan (Prehab), or standard care (Control). Patients underwent CT imaging at baseline (week 0) and following NAC (week 10). Analysis was performed using Tomovision SliceOmatic software, with a single slice at the third lumbar vertebra. Height provided the skeletal muscle index (SMI, cm2/m2). Hand grip strength (HGS) using an analogue dynamometer at weeks 0 and 10 supplied functional outcome.

Results

Since December 2016, 46 patients have been recruited, with a 15% drop-out rate (7/46). All patients received NAC. To date, complete dataset is available for 29 subjects (Prehab n = 16; Control n = 13). Groups were matched for baseline demographics, SMI and HGS (P = ns): Mean SMI 53.71 ± 10.15cm2/m2 and HGS 46 ± 11.13kg at baseline. There was a weak correlation between baseline HGS and SMI (0.58). No difference was observed in the rate of sarcopenia development during NAC (Prehab 68.75% (11/16) vs. Control 69.23% (9/13); P = 0.98), however there was a non-significant trend towards a smaller amount of skeletal muscle loss in Prehab subjects compared with Controls (-3.02 ± 3.22 cm2/m2 vs. -5.28 ± 3.00cm2/m2; P = 0.38). Similarly, NAC induced a trend towards lesser decline in mean HGS in the Prehab group versus Controls (-1.07 ± 1.28 kg vs. -2.08 ± 3.84kg; P = 0.25). A greater mean visceral fat loss was seen in the Prehab subjects compared with Controls (-16.04 vs -7.95; P = 0.02).

Conclusion

Interim analysis demonstrates a trend towards preservation of muscle mass and HGS, and significantly more visceral fat loss in patients receiving prehabilitation during NAC. Trial completion is warranted. The full dataset will be available by June 2018.

Disclosure

All authors have declared no conflicts of interest.
PS02.244: PEDICLED FLAPS IN ESOPHAGEAL SURGERY: WHERE THORACIC-, PLASTIC- AND ENT- SURGEONS MEET
Authors: Gschwandtner Elisabeth , Lindenmann Jörg , Fink-Neuböck Nicole , Fediuk Melanie , Porubsky Christian , Swatek Paul , Maier Alfred , Spendel Stephan , Schintler Michael , Thurnher Dietmar , Smolle-Jüttner Freyja-Maria
Published: September 2018

Background

Esophageal, esophago-hypopharyngeal and esophago-tracheobronchial fistulae or strictures arising either de novo or following therapeutic interventions constitute serious therapeutic challenges. If conservative measures fail, pedicled muscular or myocutaneous flaps are life-saving assets.

Methods

During the last 10 years we treated 13 patients (11 males, 2 females; mean age: 59; range: 44–82y) with complex esophageal/hypopharyngeal problems by using pedicled muscle flaps.

Results

All had but one case of lye ingestion had underlying malignant disease, all but two of the latter had had chemo- and or radiotherapy. At the time of the intervention eight patients were in a critical, septic condition. There were 5 esophago-tracheal, 2 esophago-bifurcational, one esophago-colo-bronchial, and one hypopharyngo-tracheal fistula, as well as one pharyngo-cutaneous fistula all following resection/reconstruction and/or attempts of surgical closure. One patient had stricture following external irradiation, another one anastomotic stricture. We applied a total of 17 pedicled flaps: 10 pectoralis major flaps (7 of them myocutaneous, three split flaps), 5 deltoideo-pectoral myocutaneous flaps and 2 sternocleidomastoideus flaps. In 11 patients additional intermittent stenting was used. In 6 patients the respective condition healed, 4 patients could be discharged but had minor recurrent fistulae that could be handled conservatively, in three cases persisting sepsis and multiorgan failure could not be overcome.

Conclusion

Muscle flaps can be life-saving in large fistulae of the esophagus and the hypopharynx and are useful for refractory cervical stenosis. In presence of multiorgan dysfunction, however, healing of flaps however initially vital, is often impaired.

Disclosure

All authors have declared no conflicts of interest.
RA01.02: THORACIC DUCT LIGATION DURING THORACOSCOPIC RADICAL ESOPHAGECTOMY
Authors: Perwaiz Azhar , Singh Amanjeet , Chaudhary Adarsh
Published: September 2018

Description

What is this video? This video is about ligation of thoracic duct during thoracoscopic radical esophagectomy for carcinoma esophagus with focus on where to search for thoracic duct during medistinal dissection. Why this video is unique? Routine ligation of thoracic duct during radical esophagectomy does not assure against post operative chyle leak but is can reduce incidence of clinically signifiant chyle leaks and need of invasive procedure to manage it. The video aims for post graduates teaching and for beginners and can be a usefull guide to search for thoracic duct while planning thoracic duct ligation for chyle leak. Note- the video uploaded is not in high definition as the permissible limit donot allow > 120mb

Disclosure

All authors have declared no conflicts of interest.
RA01.04: A METHOD FOR TOTALLY MEDIASTINOSCOPIC TRANSHIATAL MIDDLE AND LOWER MEDIASTINAL LYMPH NODE DISSECTION FOR ESOPHAGEAL CANCER
Authors: Hoshino Akihiro , Nakajima Yasuaki , Kawada Kenro , Tokairin Yutaka , Okada Takuya , Ryotokuji Tairo , Kume Yuichiro , Yamaguchi Kazuya , Kinugasa Yusuke
Published: September 2018

Description

Thoracoscopic esophagectomy for esophageal cancer is performed via different approaches at each hospital. In order to reduce the thoracoscopic operative time, we perform mediastinal lymph node dissection via the cervical and transhiatal approach whenever possible before thoracoscopic approach. Recently totally mediastinoscopic transhiatal middle and lower lymph node dissection has been performed, and we will report the method involving constant esophageal traction and esophageal transection in the mediastinum. The mediastinal operational field obtains a clear view by transecting the esophagus on the cranial side. Futhermore, towing the thread sutured the transected esophagus to outside the abdominal cavity makes it possible to achieve good visualization of the mediastinum using the assistant's two retractors. The median total operative time was 507 minutes, and the median thoracoscopic operative time after transhiatal approach was 105 minutes. It is possible to safely perform totally mediastinoscopic middle and lower lymph node dissection with this method.

Disclosure

All authors have declared no conflicts of interest.
RA02.01: COMPARISON OF THREE-FIELD VERSUS TWO-FIELD LYMPHADENECTOMY FOR THORACIC MIDDLE AND LOWER ESOPHAGEAL CANCER: POST-OPERATIVE RESULTS OF A RANDOMIZED CONTROLLED TRIAL
Authors: Li Bin , Xiang Jiaqing , Zhang Yawei , Zhang Jie , Sun Yihua , Hu Hong , Miao Longshegn , Ma Longfei , Luo Xiaoyang , Ye Ting , Zhang Yiliang , Shao Longlong , Li Hang , Zhang Yang , Chen Haiquan
Published: September 2018

Background

Patients with esophageal cancer can benefit from extended lymphadenectomy. However, the role of 3-field lymphadenectomy is unclear, and the extent of lymphadenectomy for thoracic esophageal cancer is still under discussion.

Methods

From June 2013 to November 2016, 400 patients with middle and lower thoracic esophageal cancer were randomly assigned to receive 3-field (3FL, n = 200) or the 2-field (2FL, n = 200) lymphadenectomy. The postoperative complications, according to the Clavien-Dindo classification, and lymph node metastasis were compared on the basis of intention-to-treat principle.

Results

Baseline characteristics were balanced between the 2 arms. There were 187 patients (93.5%) had squamous cell carcinoma in 3FL arm, and 192 (96.0%) in the 2FL arm, P = 0262. According to the pathological reports, T staging in the 2 arms were comparable, however more N3 patients in the 3FL arm (10.5%, 21/200) than that in the 2FL arm (10%, 5/200), P = 0040. Consequently, less TNM staging I patients in the 3FL arm (16.0%, 32/200) than that in the 2FL arm (25.5%, 51/200), P = 0.019. Operating time was significantly longer in the 3FL arm (median, 183 vs. 168 [2FL] minutes, P < 0.001). Six patients in the 3FL arm (3%, 6/200) had reintubation, whereas no reintubation in the 2 FL arm (0%, 0/200), P = 0.030. Other postoperative complications were comparable in the 2 arms. One patient in the 2-field arm died of chyloperitoneum. According to the Clavien-Dindo classification of surgical complications, the distribution of severity were similar between the 2 arms, P = 0.416. More lymph nodes were resected in the 3FL arm (Median, 37 vs. 24 [2FL], P < 0.001). Lymph nodes resected in the mediastinum and upper abdomen were comparable between the 2 arms. 44 patients (22%) in the 3FL arm had positive lymph nodes.

Conclusion

Compared with 2-field lymphadenectomy, 3-field lymphadenectomy doesn’t increase the surgical risks for patients with thoracic esophageal cancer. 3-field lymphadenectomy can be performed safely, removing unforeseen cervical positive lymph node, and offering more accurate tumor staging. Long-term survival analysis under protocol will clarify the role of 3-field lymphadenectomy for esophageal cancer.

Disclosure

All authors have declared no conflicts of interest.
RA02.04: UTILIZATION OF ENHANCED RECOVERY AFTER SURGERY (ERAS) PROTOCOL IN PATIENTS UNDERGOING ESOPHAGEAL RESECTION: META-ANALYSIS OF RANDOMIZED TRIALS
Authors: Triantafyllou Tania , Singhal Saurabh , Olson Michael , Bhirud Deepak
Published: September 2018

Background

ERAS protocol for esophageal surgeries has gained recognition in the past decade with reported benefits of shortened hospital stay, quick recovery of function, improved quality of life, lower morbidity, and reduced overall cost. A meta-analysis was conducted to establish weighted-pooled analysis of current literature comparing ERAS protocol against standard management following esophageal resection.

Methods

A systematic search of literature databases was completed from January-1990 to January-2018 using predetermined keywords. Inclusion criteria were randomized controlled trials (RCTs) with sample size of > 30 patients in each arm and with overlapping ERAS protocols. Primary outcome variables were mean hospital stay (days), mean time to passage of flatus (hours), bowel motion (days), and rate of anastomotic leak. Secondary outcome variables were cardiac arrhythmia, pulmonary complications and overall morbidity. Mean difference (MD) for continuous variables and Odds ratio (OR) or Risk Difference (RD) for dichotomous variables with 95% confidence interval (CI) were calculated. Between-study heterogeneity was assessed by the I2 statistics and χ2 Q-test. Random effect model was used for substantial heterogeneity (I2 > 40% or P < 0.10) and otherwise, fixed effect model was used.

Results

Three RCTs were identified with a total of 358 patients (179 in each group). Hospital stay [MD = 4.47(95%CI = 2.39–6.55; P < 0.00001; I2 = 98%)] and time to passage of first flatus [MD = 20.56(95%CI  = 1.05–40.07; P  < 0.00001; I2 = 99%)] were reported by all three studies and pooled analysis favored ERAS group with substantial heterogeneity. Time to first bowel motion significantly favored the ERAS group with the least heterogeneity [MD = 1.36(95%CI = 0.94–1.78; P = 0.63; I2 = 0%)]. All dichotomous variables showed minimal between-study heterogeneity. ERAS group showed better outcome with regards to overall morbidity [RD = 0.10(95%CI = 0.03–0.18; P = 0.45; I2 = 0%)], pulmonary complications [OR = 0.26(95%CI = 0.10–0.63; P = 0.91; I2 = 0%)] and rate of anastomotic leak [OR = 0.12(95% CI = 0.01–0.94; P = 0.47; I2 = 0%)]. There was no difference between the two groups for cardiac arrhythmias [OR = 0.77(95% CI = 0.19–3.18; P = 0.32; I2 = 0%)]. Other outcome variables of interest, including quality of life, patient satisfaction, hospital cost, and in-hospital or 30-day mortality were inadequately reported by studies to be amenable to pooled analysis.

Conclusion

ERAS protocol shows significant improvement in post-operative recovery and lower complication rates as compared with standard management, without any increase in anastomotic leak rate. However, variability and discrepancy in protocols followed by different institutions is noteworthy. Establishment of standardized ERAS protocols is warranted.

Disclosure

All authors have declared no conflicts of interest.
RA02.05: IS ROUTINE SUBCARINAL LYMPH NODE DISSECTION NECESSARY IN SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA?
Authors: Tang Han , Tan Lijie , Wang Hao , Shen Yaxing
Published: September 2018

Background

Esophageal squamous cell carcinoma (ESCC) tends to metastasize in a multidirectional fashion through the extensive submucosal lymphatics, even in early stage. Subcarinal lymph nodes (LNs) is regarded as one of regional lymph node stations for esophageal cancer and suggested to be dissected by Guildlines. However, the metastatic rate of subcarinal LNs is relatively low and dissection reportedly may increase pulmonary complications. The purpose of this study was to investigate the impact of subcarinal LN dissection on short-term and long-term outcomes in patients with superficial ESCC and aimed at illustrating the value of subcarinal LN dissection in superficial ESCC.

Methods

From January 2010 to December 2015, 490 patients with pT1 ESCC were enrolled in the study. Patients in subcarinal dissection (Group 1) or non-dissection group (Group 2) were matched randomly in a 2:1 ratio, eventually, 255 patients were selected for further statistical analysis.

Results

The metastasis rate of subcarinal LNs in superficial ESCC was 1.24% and significantly lower than perigastric, paraesophageal or bilateral recurrent laryngeal nerves station (7.14–9.96%). Compared with Group 1, Group 2 had shorter operation time (193 ± 35 vs. 204 ± 39, P = 0.016), less blood loss (157 ± 48 vs. 178 ± 29, P = 0.011), less harvested LNs (20.7 ± 8.8 vs. 24.5 ± 9.5, P = 0.002) as well as lower incidence of pulmonary complications (9.4 vs. 20%, P = 0.032). At a median follow-up of 46 months, the recurrent rates in two groups were similar (16.5 vs. 15.3%, P = 0.809). The 3-year overall survival(OS) rate of Group 1 and 2 was 89.7% and 90.4%, correspondingly, the 3-year disease-free survival (DFS) was 83.5% and 88.5%, respectively. Survival analysis revealed no OS (P = 0.992) and DFS (P = 0.665) reductions in Group 2. Subgroup analyses stratified by pT and pN status also confirmed no significant differences in OS and DFS. In univariate and multivariate analyses, subcarinal LN dissection was not a predictive factor of prognosis in superficial ESCC.

Conclusion

The present study was the first available analysis investigating values of subcarinal LN dissection in superficial ESCC. Our results showed subcarinal LN dissection did not contribute to improved survival, whereas may increase the risk of postoperative pulmonary complications in superficial ESCC. Therefore, subcarinal LN dissection could be omitted for patients with superficial ESCC.

Disclosure

All authors have declared no conflicts of interest.
RA02.07: A TWO-STAGE OPERATION USING A FREE JEJUNAL FLAP FOR GASTRECTOMIZED ESOPHAGEAL CANCER
Authors: Yagi Koichi , Nishida Masato , Sugawara Kotaro , Seto Yasuyuki
Published: September 2018

Background

The stomach is not available as a reconstruction organ in previously and synchronously gastrectomized esophageal cancer patients. In these patients, a pedicled jejunum or colon is mainly used for the reconstruction organ instead of the stomach, however, its reconstruction procedure is different among the institutes. In our department, a two-stage operation using a free jejunal flap (FJF) is performed when the stomach is unavailable.

Methods

A two-stage operation using a FJF for gastrcectomized esophageal cancer performed between 2010 and 2016 were retrospectively analyzed to evaluate a safety and feasibility of our operation.

Results

A two-stage operation using a FJF was performed for 30 cases, 19 for previously gastrectomized cases, and 11 for synchronous cases, respectively. Among 30 cases, thoracic and cervical esophageal cancer cases were 25 and 5, respectively. For 25 cases of the thoracic esophageal cancer, a subtotal esophagectomy, making a cervical esophagostomy and a jejunal tube placement was performed at the first stage, a reconstruction through the subcutaneous route using a FJF with vascular anastomoses by plastic surgeons was performed at the second stage. Median operation time of first and 2nd stage was 334 and 503 minutes, respectively. An internal thoracic artery was used for a recipient artery in all cases. In 4 of 5 cases of cervical esophageal cancer, a subtotal esophagectomy, esophago-jejuno anastomosis, making a jejunostoma using a FJF was performed at the first stage, the reconstruction of the anal side of a jejunostoma was performed by using a pedicled intestine at the second stage. Median operation time of first and second stage was 640 and 260 minutes, respectively. Clavien-Dindo grade IIIb or IV postoperative complication was seen in 3 cases (10%) after the first stage, 3 cases (10%) after the second stage. Necrosis of a FJF and anastomotic leakage was seen in 0 (0%) and 5 cases (17%), respectively.

Conclusion

A two-stage operation using a FJF needs plastic surgeon's cooperation, but is considered to be safe and feasible operation when a stomach is not available.

Disclosure

All authors have declared no conflicts of interest.
RA03.04: COMPARISON OF THE CLINICAL OUTCOMES OF ESOPHAGECTOMY AND CHEMORADIOTHERAPY AFTER NONCURATIVE ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Koterazawa Yasufumi , Nakamura Tetsu , Oshikiri Taro , Kanaji Shingo , Yamashita Kimihiro , Matsuda Takeru , Suzuki Satoshi , Kakeji Yoshihiro
Published: September 2018

Background

Endoscopic submucosal dissection (ESD) is widely used to treat esophageal cancer, but some patients require additional definitive treatment owing to the possibility of residual tumor cells or lymph node metastasis. The aim of this study was to elucidate the efficacy and clinical outcomes of these additional treatments.

Methods

ESD was performed for cT1a esophageal cancer, and additional definitive treatment was recommended for patients who had undergone noncurative ESD for submucosa (SM) or muscularis mucosae cancers with lymphovascular invasion and a positive resection margin. The study included 59 patients who developed superficial esophageal squamous cell carcinoma after noncurative ESD treated between 2005 and 2016, of whom 28 underwent esophagectomy with lymph node dissection and 31 received chemoradiotherapy (CRT) by choice or because their conditions did not permit surgery.

Results

The median follow-up periods were 45 months (range, 3–89 months) in the esophagectomy group and 41 months (range, 12–84 months) in the CRT group. Overall survival didn’t differ between the groups (P = 0.46). But there were no recurrences in the esophagectomy group, and the disease-specific survival rate was significantly higher in this group (P = 0.042). Among the patients at high risk for recurrence owing to massive tumor invasion (≥ SM2) with lymphovascular invasion (esophagectomy group, 6 patients; CRT group, 10 patients), none in the esophagectomy group had a recurrence, whereas 4 in the CRT group died of esophageal cancer (P = 0.031).

Conclusion

Overall survival did not differ between the esophagectomy and CRT groups after noncurative ESD. However, compared with CRT, esophagectomy provided more favorable disease control for patients with massive tumor invasion (≥ SM2) with lymphovascular invasion.

Disclosure

All authors have declared no conflicts of interest.
RA04.02: THE COMPLICATIONS AND LONG-TERM SURVIVAL IN TRANS-MEDIASTINAL RADICAL ESOPHAGECTOMY
Authors: Konishi Hirotaka , Fujiwara Hitoshi , Shiozaki Atsushi , Shoda Katsutoshi , Kosuga Toshiyuki , Kubota Takeshi , Okamoto Kazuma , Otsuji Eigo
Published: September 2018

Background

(Bachground) The radical esophagectomy for esophageal cancer is an invasive therapy for a long one-lung ventilation. We have been stylized trans-mediastinal radical esophagectomy in order to relieve the pulmonary complications.

Methods

(Candidates) The radical esophagectomy (R0/1, gastric tube reconstruction) by thoracotomy/thoracoscopy (groupT) or mediastinoscopy (groupM) were performed for 120/58 or 131 esophageal cancer patients. The long-term therapeutic results of trans-mediastinal radical esophagectomy and complications (Clavien-Dindo classification≧ 2) are investigated.

Results

(Results) In clinicopathological features, neoadjuvant therapy, cStage III/IV advanced cases, or R1 resection was significant in groupT (P < 0.01). The frequency of anastomotic leakage and recurrent nerve paralysis were not different in both group (P = 0.94, 0.69, respectively), whereas pulmonary complication was significantly decreased (25.2 vs 10.9%, P = 0.003). Any complications were slightly frequent in groupT than in group M (32.4 vs 29.5%, P = 0.59). The 5-years overall survival was slightly better in group M than in group T due to the effects of disease stage (53.5% vs 63.4%, P = 0.19). In the subgroup analysis, the overall survival rate was similar in each clinical stage.

Conclusion

(Discussion) The trans-mediastinal radical esophagectomy was effective for the relief of pulmonary complication, and was not inferior to the esophagectomy by thoracotomy or thoracoscopy in the prognosis.

Disclosure

All authors have declared no conflicts of interest.
RA04.07: A NOVEL TECHNIQUE FOR CERVICAL GASTROESOPHAGEAL ANASTOMOSIS DURING MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: Jiang Yuequan
Published: September 2018

Background

Anastomotic leakage, fibrous stricture and gastroesophageal reflux are three major complications of gastroesophageal anastomosis, particularly in cervical anastomosis. Our aim was to evaluate the safety and efficacy of a novel cervical anastomosis technique (NA) by comparing it to the traditional side-to-side anastomosis (SS), and the end-to-side anastomosis using a circular stapler (CS) in terms of postoperative leakage, stricture and reflux.

Methods

A total of 390 patients with thoracic esophageal cancer underwent a minimally invasive esophagectomy with cervical anastomosis (192 with NA, 34 with SS and 164 with CS) in our institute from January 2013 and May 2016. The new anastomotic technique was improved from a type of side-to-side anastomosis technique which was reported by Collard et al. The difference of our new technique is that the part of the anastomotic stump was pushed into the tubular stomach. It let the end part of esophagus was embedded in the gastric tube while the end portion of the stomach was also reversed into the gastric tube (figure 1, 2, 3). The major postoperative complications including postoperative leakage, stricture and reflux were compared using three armed controlled study.

Results

With regard to the incidence of anastomotic leakage and reflux, the patients who underwent Jiang's anastomosis had a significantly lower rate than those in the SS group and CS group (Leaks: 1.0% vs. 8.8% and 8.5%, P = 0.025, 0.001; Reflux: 5.7% vs. 23.5% and 18.3%, P = 0.003, 0.001). The incidence of dysphagia was 10.4% with an occurrence rate of 1.5% for anastomotic strictures in the NA group. It was significant lower than that in the CS group (41.5% vs. 18.9%, P < 0.05) but not significantly different from that in SS group (11.8% vs. 2.9%).

Conclusion

The novel anastomotic technique remarkably reduced the incidence of gastroesophageal-anastomotic leakage, stricture and reflux and was a safe and effective technique for minimally invasive esophagectomy.

Disclosure

All authors have declared no conflicts of interest.
RA05.09: THE INFLUENCE OF AGE ON OVERALL SURVIVAL AND COMPLICATIONS AFTER IVOR LEWIS TOTALLY MINIMALLY INVASIVE ESOPHAGEAL SURGERY
Authors: Baranov Nikolaj , Van Workum Frans , Van Der Maas Jolijn , Kouwenhoven Ewout , Van Det Marc , Van Den Wildenberg Frits , Polat Fatih , Nieuwenhuijzen Grard , Luyer Misha , Rosman Camiel
Published: September 2018

Background

Worldwide, the number of elderly patients suffering from esophageal cancer is increasing due to the increasing incidence of esophageal cancer and increasing life expectancy of the general population. The effect of age on morbidity, mortality and survival after Ivor Lewis totally minimally invasive esophagectomy (TMIE) with curative intention are not well known since elderly patients have been excluded in randomized trials.

Methods

A retrospective analysis of a prospectively documented database from December 2010 to June 2017 was performed, including all patients who underwent Ivor Lewis TMIE with curative intent for esophageal cancer in three Dutch hospitals. Patients younger than 75 years (younger group) were compared to patients aged 75 years or older (elderly group). Postoperative complications, in-hospital mortality, 30 and 90 days mortality, long-term complications and survival were compared between these two groups.

Results

Four hundred and forty-six patients were included, 89 patients in the elderly group and 357 patients in the younger group. In the elderly group, a significantly higher incidence of non-surgical complications (77.5% versus 66.7%; P = 0.048), cardiovascular complications (24.7% versus 14.0%; P = 0.014) and delirium (27.0% versus 11.8%; P = 0.000) was found. There was no significant difference in surgical complications, overall complications, 30-day mortality, 90-day mortality, 1-year survival and 2-year survival.

Conclusion

Although Ivor Lewis TMIE in elderly patients is associated with a higher rate of non-surgical complications, it can be safely performed without increasing postoperative mortality.

Disclosure

All authors have declared no conflicts of interest.
RA06.04: THE DEVELOPMENT AND NATURAL HISTORY OF A HIATA HERNIA
Authors: Abdelmoaty Walaa , Dunst Christy , Walters Jarvis , Tugulan Carmen , Doan Huy , Zihni Ahmed , Filicori Filippo , Davila Bradley Daniel , Reavis Kevin , Swanstrom Lee , Demeester Steven
Published: September 2018

Background

Little is known about the initial development and natural history of a hiatal hernia.

Methods

A database containing 12,050 upper gastrointestinal (UGI) studies dating from 1991 to 2013 was queried to identify patients that had more than one study a minimum of 5 years apart showing a hernia. The x-ray films or digital images were reviewed and the type and size of any hernia determined.

Results

There were 56 patients with 133 UGI studies. On initial UGI; 13 patients had no hernia, 35 patients had a sliding hernia (SH), and 8 patients had a paraesophageal hernia (PEH). Follow-up UGI results are shown in the Figure. A third or fourth UGI study was available for 17 patients. Over a median of 41 months, the most recent UGI showed that the majority (78%) of SH increased in size, with 1 changing to PEH. Among patients with PEH, 2 were already completely intrathoracic stomachs and on most recent UGI 4 of the remaining 6 increased in size with 1 turning into complete intrathoracic stomach.

Conclusion

Most PEHs (77%) started out as a SH. Over time the majority of both SH and PEH increase in size, with many PEH becoming completely intrathoracic stomachs. Given the risks associated with a PEH, patients with SH should be re-evaluated for progression of their hernia.

Disclosure

All authors have declared no conflicts of interest.