bluuebunny/crossref_metadata_2025 huggingface dataset:
351. CONVERSION SURGERY FOR PATIENTS WITH ESOPHAGEAL CANCER AFTER ICI TREATMENT
Authors: Momose Kota , Yamashita Kotaro , Saito Takuro , Tanaka Koji , Makino Tomoki , Yamamoto Kazuyoshi , Takahashi Tsuyoshi , Kurokawa Yukinori , Nakajima Kiyokazu , Eguchi Hidetoshi , Doki Yuichiro
Published: September 2024

Background

As more and more immuno checkpoint inhibitor (ICI) agents are used in clinical practice for the treatment of esophageal cancer these days, we are becoming more likely to see a patient with initially unresectable but currently resectable tumor through the treatment with ICIs. Little is known about such conversion surgery for esophageal cancer. So, we here report our experiences.

Subjects and Methods

The patients who underwent esophageal cancer surgery after the treatment with ICI from 2020 to 2023 who had initially been diagnosed as unresectable were enrolled. Electronic medical records were retrospectively reviewed to collect clinicopathological findings.

Result

There were 15 eligible cases; 12 male and 3 female, median age 70 (51-81). Histology was SCC in all cases; 7 primary, 7 recurrent and 1 residual tumors. Involved distant metastatic organ was lymph node in 4 cases, liver in 4 cases, and lung in 1 case. Involved recurrent organ was lymph node in all the 7 recurrent cases. Clinical response to ICI treatment was detected in 12 cases (PD in 3 cases). R0 resection was achieved in 14 cases and pCR was detected in 3 cases. No irAE-suspected event was detected in all cases during postoperative course.

Conclusion

Since the patients' background, number and duration of the ICI treatment, treatment history before the conversion surgery were miscellaneous, it is still hard to lead conclusive statement on the conversion surgery for esophageal cancer after ICI treatment. So, it is necessary to keep going to experience conversion surgery cases for esophageal cancer to assess its efficacy.
357. OUTCOMES OF TWO-COURSE NEOADJUVANT CHEMOTHERAPY WITH DOCETAXEL, CISPLATIN, AND 5-FLUOROURACIL ON ADVANCED ESOPHAGEAL CANCER: A SINGLE INSTITUTION STUDY
Authors: Hashimoto Masashi , Noma Kazuhiro , Kawasaki Kento , Kunitomo Tomoyoshi , Maeda Naoaki , Tanabe Shunsuke , Fujiwara Toshiyoshi
Published: September 2024

Background

The CROSS trial established neoadjuvant chemoradiotherapy (CRT) as a cornerstone in treating esophageal cancer, making it the standard approach worldwide. However, in Japan, the JCOG1109 trial, a three-arm study, redefined the standard by showing the superiority of neoadjuvant chemotherapy (NAC) with docetaxel, cisplatin, and 5-fluorouracil (DCF) over the conventional cisplatin and 5-fluorouracil (CF) regimen. Notably, it found no significant difference between neoadjuvant CRT with CF and CF. This trial adopted a 3-week cycle of 3 courses for the DCF regimen. Nonetheless, subsequent findings by Makino et al. suggested no difference in outcomes between 2-course and 3-course DCF regimens. This report presents the results of a 2-course neoadjuvant DCF regimen at our institution.

Method

This study included esophageal cancer patients who underwent esophagectomy after a 2-course NAC-DCF regimen at Okayama University Hospital from January 2014 to December 2019. Eligible participants were 20 to 80 years old, with a performance status of 0–1, histologically confirmed esophageal squamous cell carcinoma (ESCC), and adequate organ function. The stages ranged from cT1-4a N0-3 M0. We evaluated recurrence patterns, overall survival (OS), and recurrence-free survival (RFS) using the Kaplan-Meier method and explored histopathological factors associated with RFS through COX regression analysis.

Results

Out of 209 cases, 63 were eligible. The median follow-up was 71 months, with 17 instances of recurrence observed, categorized as lymphatic (6 cases), hematinic (3 cases), local (2 cases), dissemination (2 cases), and multiple (4 cases). The 5-year RFS was 64.5%, and the 5-year OS was 65.8%. Univariate analysis identified pathological T, N, Stage, and chemotherapy response grade as significant factors related to RFS, with multivariate analysis highlighting pathological N as an independent factor. Kaplan-Meier analysis demonstrated significant survival differences across N stages, particularly between N1 and N2.

Conclusion

Our findings from the 2-course neoadjuvant DCF regimen highlight pathological N stage as a crucial independent predictor of recurrence in ESCC patients treated with NAC-DCF. Specifically, patients above N2 exhibited notably poorer prognoses, underscoring the need for adjuvant treatment strategies.
358. IMPLICATIONS ON OVERALL SURVIVAL FROM POSITIVE CIRCUMFERENTIAL RESECTION MARGINS IN OESOPHAGEAL CANCER PATIENTS AT A TERTIARY REFERRAL CENTRE IN ENGLAND
Authors: Vaz Osborne Peter , Nair Beena , Ibison Frances , Sarantitis Ioannis , Singh Mohan , Turner Paul , Ward Jeremy , Pursnani Kishore , Shetty Vinutha Daya
Published: September 2024

Background

The oesophagogastric (OG) tertiary referral centre at our Trust was established in March 2009.It caters to a catchment population of approximately 1.6 million. Oesophageal cancer is a morbid disease contributing to 18% of cancer mortalities worldwide. Involvement of circumferential resection margin (CRM) is an indicator of poor prognosis. The aim was to calculate the microscopic positive resection rate in patients undergoing resections for oesophageal cancers, assess disease free survival (DFS) and overall survival (OS) in this cohort.

Methods

Patients undergoing oesophageal resections for cancer at our OG unit who satisfied the inclusion criteria - age>18, operation with curative intent, adenocarcinoma and squamous cell cancer with a microscopic positive resection margin (R1) were included. Data was collected from the electronic patient record (Quadramed). Retrospective analysis was performed using MS Excel and IBM SPSS statistics Ver 27.

Results

A total of 640 oesophageal cancer resections performed between April 2009 - March 2023, who satisfied the inclusion criteria were included. Median age at surgery was 66 years. The R1 rate was 40% in our cohort (R0:R1 =380:260). Male to female ratio in the R1 cohort was 4:1. 98% (255 patients) had T3/T4 disease. 47.7% (124 patients developed recurrence. Of these, 83.8% (104 patients) developed distant metastasis and 16.2 %(20 patients) had locoregional metastasis. Median time to recurrence was 12 months and disease-free survival was also12 months. The OS at one year of 81% (140/260) was comparable to national data.

Conclusion

We conclude that locally advanced tumour staged T3 and above is the most likely cause for higher rate of CRM positivity. Other factors that could contribute is the lack of serosal layer in the oesophagus and the practise of ex situ removal of nodes from the main specimen in theatre which could potentially lead to stripping of the adventitia thus making the CRM falsely R1 during pathological staging. The R1 status however does not seem to affect the overall survival rate.
362. DELAY IN SOLID GASTRIC EMPTYING IS ASSOCIATED WITH SILENT REGURGITATION EVENTS, PULMONARY MICROASPIRATION AND LARYNGOPHARYNGEAL REFLUX DISEASE
Authors: Khoma Oleksandr , Burton Leticia , Gooley Susanna , Weerasinghe Daminda , Falk Gregory , Van der Wall Hans
Published: September 2024

Background

Pulmonary micro-aspiration (PMA) is a feared complication of severe and sometimes silent gastroesophageal reflux disease (GORD). A novel scintigraphic test that shows refluxate contamination of the pharynx, upper and lower airways has recently been developed. This test and multiple observations allowed the development of a hypothesis that prolongation in solid gastric emptying (SGE) may be a more critical than delays in liquid gastric emptying (LGE) in micro-aspiration into the airways.

Methods

Standard LGE and SGE studies together with the novel microaspiration test were evaluated in paired studies in patients with medially resistant symptoms GORD to measure rates of micro-aspiration after each meal. Either water labelled with 99m Technetium Phytate for the LGE or a labelled egg sandwich for the solid meal was utilised. Major symptoms were noted and the cough and reflux severity index (CSI & RSI) obtained in all patients.

Results

A total of 131 patients were included in this study (59M/72F). The age range was 21 to 83 years with a mean of 52 years. Patients were in the overweight range for body mass index (BMI), with a mean of 26.8. Major symptoms were of bloating, nausea, belching and dyspepsia as well as cough, throat clearing and globus. Less than 20% complained of heartburn.

Results. SGE was abnormal in 92% (Mean 766 min) and LGE was abnormal in 53% (Mean 82 min). PMA was shown in 35% after the SGE and in 71% after the LGE. PMA positive patients were older. SGE and PMA were significantly correlated (p<0.00) but not LGE. The only significant symptom in the PMA group was bloating. RSI was abnormal in 64% and CSI in 46%.

Conclusion

The majority of patients with PMA do not complain of heartburn. Bloating in patients with severe GORD should raise the possibility of gastroparesis and PMA. Prolonged SGE may be critical in the physiology of atypical reflux and present another treatment goal with addition of pyloroplasty to anti-reflux procedure of choice.
367. IMPACT OF NEOADJUVANT IMMUNOTHERAPY ON POSTOPERATIVE COMPLICATIONS IN RESECTABLE ESOPHAGEAL ADENOCARCINOMA
Authors: Scarton Alessia , Moletta Lucia , Capovilla Giovanni , Uzun Eren , De Pasqual Carlo Alberto , Hadzijusufovic Edin , Pierobon Elisa Sefora , Salvador Renato , Provenzano Luca , Zanchettin Gianpietro , Tagkalos Evangelos , Berthl Felix , Lang Hauke , Giacopuzzi Simone , Grimminger Peter P , Valmasoni Michele
Published: September 2024

Background

Several studies are ongoing on the use of immunotherapy in the neoadjuvant setting for esophageal and gastroesophageal junction cancer but it is unclear the effect of an increased activation of the immune system on surgery and the postoperative course.

Methods

This multicenter retrospective cohort study included data from 3 high-volume centers for upper-GI surgery. Only patients with esophageal adenocarcinoma who underwent neoadjuvant therapy and radical surgery between 2015 and 2022 were included. Clinical characteristics and the postoperative outcomes were compared between patients who received standard neoadjuvant therapy or chemotherapy plus immunotherapy. A 1-to-1 matched comparison was also performed.

The difference in overall survival (OS) and disease free survival (DFS) between the two groups was also evaluated.

Results

Overall, 563 patients were included and 21 received preoperative Pembrolizumab or Trastuzumab combined with at least a couple of chemotherapy drugs. The incidence of complications was 47% in the group with immunotherapy and 40.7% in the other group (p=0.53). The matched analysis confirmed no differences in rate of complications (p>0.99), gravity of complications (p=0.17) and pulmonary complications (p>0.99). Anastomotic leak rate was 4.7% in the immunotherapy group and 19% in the other one (p=0.34).

Overall survival and disease free survival were comparable (respectively p=0.4 and p=0.9) also after the matched analysis (respectively p=0.15 and p=0.52).

Conclusion

Neoadjuvant immunotherapy-based regimen does not affect the postoperative course, in particular it does not appear to aggravate the major complications of esophagectomy.
392. MACHINE LEARNING TO PREDICT LYMPH NODE METASTASIS IN T1 ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A MULTICENTER STUDY
Authors: Xu Wenyi , Liu Fangyi , Tang Han , Tan Lijie , Yin Hao
Published: September 2024

Background

Lymph node metastases (LNM) is a relatively uncommon but possible complication of T1 esophageal squamous cell carcinoma (ESCC). Existing models do poorly when it comes to quantifying this risk. As a branch of artificial intelligence, machine learning (ML) algorithms have developed and become more prominent. Up to now, no individualized ML prediction model aimed at predicting LNM in T1 esophageal squamous cell carcinoma patients is available. This study aimed to develop a machine learning model for LNM in patients with T1 esophageal squamous cell carcinoma.

Methods

Patients with T1 squamous cell carcinoma treated with surgery between January 2010 and September 2021 from 3 institutions were included. Machine-learning models were developed using data on patients’ age and sex, depth of tumor invasion, tumor size, tumor location, macroscopic tumor type, lymphatic and vascular invasion, and histologic grade. Elastic net regression (ELR), random forest (RF), extreme gradient boosting (XGB), and a combined (ensemble) model of these was generated. Use Area Under Curve (AUC) to evaluate the predictive ability of models. The contribution of each factor was calculated. To meet clinical needs, we designed the model as a user-friendly website.

Results

926 and 341 patients were included in the derivation and validation cohorts. The lymph node metastasis rate was 14.8%. The models all exhibited potent discriminating power. The elastic net regression model performed best with externally validated AUC of 0.803 (AUC 0.773 for RF, 0.791 for XGB, 0.799 for ensemble) whereas the NCCN guidelines identified patients with LNM with an AUC of 0.576 and logistic model with an AUC of 0. 670. The most important features were lymphatic and vascular invasion as well as depth of tumor invasion.

Conclusions

The model created utilizing machine learning approaches had excellent performance estimating the likelihood of LNM in T1 ESCC, which can help patients achieve personalized treatment options.
394. ESOPHAGEAL STENTING IN ESOPHAGEAL CANCER PATIENTS WITH PERFORATION AND FISTULA
Authors: Chaiyakul Monwadee , Sunpaweravong Somkiat , Ruangsin Sakchai , Laohawiriyakamol Supprerk
Published: September 2024

Background

Esophageal perforation and fistula to the respiratory system are serious problems in esophageal cancer patients. Esophageal self-expandable metal stent (SEMS) placement has become a popular treatment for this problem. This retrospective study aimed to evaluate the factors associated with clinical outcomes following the placement of a SEMS in esophageal cancer patients with perforation and fistula.

Methods

Data from 43 esophageal cancer patients with perforation and fistula who underwent esophageal SEMS placement at Prince of Songkla University Hospital between January 2008 and June 2023 were reviewed. Statistical analyses, including chi-square tests and Kaplan-Meier methods, were employed for comparisons and survival calculations.

Results

The SEMS location was the middle esophagus in 76.8% and 11.6% in each of the lower and upper esophagus. The disease was stage IV in 62.8% and stage III in 37.2%. 46.5% had a history of chemoradiotherapy. The perforation and fistula penetrated into the left bronchus in 39.5%, right bronchus 18.6%, trachea 16.3%, lung 14% and mediastinum 11.6%.

The SEMS technique was successful in all patients. The median stent patency was 38.5 days. Tumor overgrowth was the major cause of stent obstruction. The median overall survival was 40 days. Initial success of the SEMS placement was the only predictor of better survival.

Conclusion

Esophageal SEMS placement in esophageal cancer perforation and fistula cases is technically uncomplicated. Although these advanced esophageal cancer patients had a poor prognosis, the esophageal SEMS provided symptom relief and improved quality of life for their remaining time.
396. SHORT-TERM REVIEW: REAL-WORD EXPERIENCE OF PEMBROLIZUMAB AS FIRST-LINE CHEMOTHERAPY FOR ADVANCED ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Yoshii Takako , Hara Hiroki , Takahashi Naoki , Matsushima Tomohiro , Inamoto Rin , Asayama Masako , Kumekawa Yosuke , Suzuki Yuko , Shimizu Satoshi
Published: September 2024

Background

In Japan, Pembrolizumab, combined with standard chemotherapy (fluorouracil and cisplatin), was approved for first-line treatment of esophageal squamous cell carcinoma (ESCC) in November 2021. In advanced ESCC cases, modifications like omitting cisplatin or adding the palliative radiotherapy for malignant stenosis are sometimes necessary. The real-world application of Pembrolizumab with chemotherapy (Pem+C) in these scenarios remains uncertain. This review presents an overview of Pem+C’s short-term clinical outcomes in practice.

Methods

We retrospectively studied nineteen patients treated with Pem+C as the first-line chemotherapy for advanced ESCC from Nov. 2021 to Dec.2023. Response evaluation was primarily based on RECIST v1.1. Clinical worsening factored into some progression disease (PD) assessments. Adverse events were graded using CTC-AE v5.0. Kaplan-Meier survival curves were calculated by SPSS, with data cutoff on Dec. 31. 2023.

Results

Median age was 70 (49-83 years), PS (0/1/2):0/8/1, TPS (1≤/1≤/NE):1/2/16. Disease Status (Recurrence [locoregional/distant metastasis] /metastatic):3 [2/1] /16. Sequence of treatments (Pem+C alone/ concurrent palliative radiotherapy (pRT) consisting of 30-40Gy/ maintenance after chemoradiotherapy ):10/5/4. Three received only fluorouracil as backbone chemotherapy due to frailty. Median follow-up time, overall survival (OS) and progression free survival (PFS) were 8.3, 14.4, and 6.5 months, respectively. Responses in evaluable eighteen (CR/PR/nonCRnonPD/SD/PD):2/8/1/3/4. No unexpected severe adverse events (≥Grade3) were found. Among limited cases, concurrent pRT didn’t increased life-threatening AE; however, neutropenia ≥G3 seemed to be slightly frequent (2/5). One patient’s survival exceeded 24.8 months.

Conclusion

Our real-world experience with Pem+C in advanced ESCC includes diverse approaches clinical practices. The outcomes, while prelimiary, compare favorably with existing literature, without significant inferiority. The safety data and success case in the concurrent pRT group are significant, though limited by the small number of cases and short observation period.

While further, more rigorous studies are necessary, adaptable Pem+C could be viable in practice.
420. MESH REINFORCEMENT IN HIATAL HERNIA REPAIR: CLINICAL RESULTS OF OUR EARLY EXPERIENCE
Authors: Kitsou Ms Eleni , Saliaris Konstantinos , Triantafyllou Tania , Karikis Ioannis , Katsila Sofia , Kakounis Konstantinos , Pachos Nikolaos , Xiromeritou Vasiliki , Theodorou Dimitrios
Published: September 2024

Background

Approximately one-third of the population develops diaphragmatic hernias among which only 10% are symptomatic. Restoration of the normal anatomy, hiatus closure and fundoplication are effective methods in the surgical treatment of diaphragmatic hernia repair. Placement of absorbable meshes to cover the hiatal closure emerges as a new, albeit controversial in the literature, technique for reinforcement. This study aims to assess the quality of life of patients diagnosed with hiatal hernia who underwent Nissen or Toupet fundoplication with absorbable biosynthetic mesh placement covering the suturing of the hiatus as an additional step during the laparoscopic or robotic hiatal hernia repair.

Methods

Data of all patients who underwent Nissen or Toupet fundoplication with absorbable mesh reinforcement at the hiatus between 2020-2023 at our specialised unit was collected and analysed. Thirteen patients who had completed their 6-month and 1-year postoperative follow-up, were interviewed. GERD score, PPI use and postoperative endoscopy were evaluated.

Results

Occasional use of PPI was reported by one patient, whereas those who had already undergone endoscopy of the upper gastrointestinal tract presented no signs of esophagitis, recurrence of hernia or Barrett esophagus. One patient reported symptom improvement after the operation with a GERD score of 13, while the rest of the patients had a GERD score of 0 (12/13).

Conclusion

The treatment of diaphragmatic hernias with Nissen or Toupet fundoplication using absorbable mesh reinforcement of the hiatus after closure with sutures seems to be an effective therapeutic method with a success rate over 90% in our case series provided that the rest of the surgical steps are identical between the cases through a well-established technique by our surgical team. However, further studies with larger number of patients and longer follow-up are mandatory aiming to further investigate the potential benefits when mesh reinforcement is applied.
427. THE ROLE OF CROSS-SECTIONAL IMAGING IN PATIENTS WITH PULMONARY MICRO ASPIRATION
Authors: Goonawardhana Dulani , Khoma Oleksandr , Falk Gregory , Van der Wall Hans
Published: September 2024

Background

There is increasing evidence of a strong relationship between pulmonary microaspiration of refluxate and pulmonary diseases such as bronchiectasis and lung fibrosis. This group has demonstrated the presence of co-location of pulmonary aspiration on modified reflux scintigraphy with lobar parenchymal lung changes on high resolution computed tomographic imaging of the lung (HRCT-L) in patients with typical and atypical reflux symptoms. There is, however, a cohort of patients who demonstrate evidence of reflux aspiration without evidence of parenchymal changes on HRCT-L. This study aims to demonstrate a group of patients with confirmed reflux micro-aspiration without corresponding changes in lung parenchyma on HRCT.

Methods

Data were obtained from a prospectively populated database of patients with treatment resistant typical and atypical GORD and suspected reflux pulmonary microaspiration. Modified novel digital technique of reflux pulmonary microaspiration scintigraphy using a previously validated technique was performed to evaluate the possibility of significant GORD or extra-oesophageal symptoms, including typical symptoms such as heartburn and reflux and atypical symptoms such as throat symptoms, cough, globus, mucous, throat clearing, dysphonia and recurrent respiratory infections. Patients who underwent microaspiration studies and had normal HRCT-L for chest symptoms were included. The group was compared to patients with lung changes on HRCT-L corresponding with micro-aspiration studies.

Results

Inclusion criteria were met by 14 patients (86% female, 14% male). The mean age was 54 years (range: 36 – 81 years). All patients demonstrated reflux microaspiration on scintigraphy in the supine delayed phase and all had intermittent or continuous full column gastro-oesophageal reflux. Lung parenchymal changes on HRCT-L corresponding to site of reflux micro-aspiration on scitigraphy were demonstrated in 66 out of 80 patients listed in the database. Amongst patients with normal HRCT-L typical reflux symptoms were reported in 1 patient, atypical symptoms in 6 patients, both in 5 patients and 2 did not report symptoms. Most common presenting symptom was cough. There was no difference in symptomatology of patients with or without HRCT-L pulmonary parenchymal changes. Patients with pulmonary changes on HRCT were on average 13 years older than patients without CT changes (mean age 67, range 31-91).

Conclusion

HRCT-L is an important additional investigation in patient with reflux micro-aspiration detected on scintigraphy to identify patients with reflux related lung parenchymal changes. Younger age of patients with normal HRCT-L suggests that parenchymal changes may be developing as a result of prolonged exposure to reflux micro-aspiration over time.
457. EVALUATING THE ACCURACY OF CLINICAL SIEWERT CLASSIFICATION, A RETROSPECTIVE REVIEW OF 807 PATIENTS
Authors: Walmsley James , Ariyarathenam Arun , Berrisford Richard , Humphreys Lee , Sanders Grant , Tham Ji Chung , Wheatley Tim , Chan David SY
Published: September 2024

Background

Adenocarcinoma of the gastro-esophageal junction (GEJ) is increasingly common in Western societies. GEJ tumours are typically categorized using the Siewert classification, which divides the tumours in to 3 types based on location relative to the GEJ. Studies have shown that there is improved survival with a proximal surgical resection such as esophagectomy for type 1 tumours while type 3 tumours have improved survival when managed as other gastric cancers with a total or extended total gastrectomy. This requires accurate clinical classification. This study aims to evaluate the accuracy of commonly used staging modalities in the clinical classification of GEJ tumours.

Methods

A review of 807 consecutive patients undergoing curative resection for GEJ cancer was performed. Patient data was obtained from a prospectively maintained database between February 2010 and April 2023. Siewert type was established clinically as part of the staging process. The standard staging modalities used for every patient included computerized tomography (CT) and endoscopy, with most patients also undergoing positron emission tomography (PET). Endoscopic ultra-sonography (EUS) and staging laparoscopy was also used selectively. Accuracy was determined by comparing clinical classification to pathological classification following surgery.

Results

807 patients were included [319 type 1, 401 type 2, 87 type 3]. Clinical classification was the same as pathological classification in 59.5% of cases [69.6% for type 1, 48.6% for type 2, 71.3% for type 3 (p<0.001).

The use of different staging modalities for each sub-type is presented in table 1. For patients that underwent EUS, Siewert type was accurate in 59.4% of cases overall. The failure rate for EUS was 2.9%. For patients undergoing staging laparoscopy Siewert type was accurate in 69.3% and for patients that underwent PET, EUS and staging lap the accuracy was 74.4%.

Conclusion

Accurately determining Siewert type clinically is challenging. This is particularly relevant for type 2 tumours which had the least accurate comparison of clinical to pathological type. The use of additional modalities including EUS, and staging laparoscopy improves accuracy but may not be feasible in all patients.
464. OUTCOMES AFTER CURATIVE RESECTION FOR GASTRO-ESOPHAGEAL JUNCTION ADENOCARCINOMA
Authors: Walmsley James , Ariyarathenam Arun , Berrisford Richard , Humphreys Lee , Sanders Grant , Tham Ji Chung , Wheatley Tim , Chan David SY
Published: September 2024

Background

Gastro-Esophageal Junction (GEJ) adenocarcinoma is becoming increasingly common in the west. Given the anatomical location of the junction there are several surgical approaches that can be used to treat these tumours, this is often guided by the sub-type of tumour, categorised using the Siewert classification. While overall survival for GEJ cancer tends to be poor compared with other solid organ cancers, changes in diagnosis and treatment have led to improvements in recent years. This study represents one of the largest retrospective reviews of its type to focus on the short- and long-term outcomes of patients undergoing curative resection for GEJ cancer.

Methods

Information was collected on 807 consecutive patients undergoing curative resection for gastro-esophageal junction adenocarcinoma between February 2010 and April 2023. The primary outcome was overall 5- and 10-year survival. Secondary outcomes included: disease free survival, survival based on surgical resection, 30- and 90-day mortality, post operative complications, oncology and pathology outcomes. For each outcome overall results and analysis comparing Siewert types was performed.

Results

807 patients were included [319 type I cancers (39.5%), 401 type II (50%) and 87 type III (10.8%)]. Type I and II were predominantly managed with Esophagectomy (Type I = 100%, Type II = 97.5%). For Type III tumours 49% had esophagectomy and 51% had either a total or extended total gastrectomy.

Siewert groups had comparable short-term outcomes, presented in table 1. Overall survival was 46% at 5 years and 37% at 10 years with no significant difference between Siewert types (p=0.24). Disease free survival was 55% at 5 years and 50% at 10 years with no significant difference between Siewert type (p=0.34).

Conclusion

The 3 Siewert classification subtypes of gastro-esophageal junction adenocarcinoma have similar short-term outcomes, overall and disease-free survival.
466. ROBOT-ASSISTED CERVICAL ESOPHAGECTOMY (RACE) FOR ESOPHAGEAL CANCER: THE FIRST TWO CASES OF AN ITALIAN HIGH-VOLUME CENTER
Authors: Turolo Cecilia , Voltarel Guerrino , Collizzolli Alice , Canepari Elia , Milazzo Martina , De Pasqual Carlo Alberto , Weindelmayer Jacopo , Giacopuzzi Simone
Published: September 2024

Background

Closed thorax esophagectomy is an alternative to conventional two or three-field esophagectomy in patients with esophageal cancer and pulmonary comorbidities, previous thoracic surgery or cervical tumor spread without thoracic involvement. We describe our first two cases of robotic trans-hiatal and trans-cervical esophagectomy.

Methods

We performed a robotic assisted abdominal D2 lymphadenectomy and trans-hiatal esophageal dissection until the tracheal carina with en bloc mediastinal lymphadenectomy. Then we did left cervicotomy and, using a gelPort, we continued robotic esophageal dissection in superior mediastinum until the carina, preserving left recurrent nerve. Subsequently, in abdomen, we completed esophageal dissection and gastric tubulization. After section of the esophagus we pulled up the gastric conduit and in one case we performed a esophago-gastric 23 mm termino-lateral mechanical circular anastomosis and in the other hypopharyngeal-gastric handsewn double layer anastomosis.

Results

One patient had distal esophageal adenocarcinoma and we chose RACE because of previous pleuritis. Pathology reported ypT2N1 (35 lymph nodes retrieved) with R0 resection. Post operative complications were cervical anastomotic leak, chylous ascites and atrial fibrillation treated conservatively; total length of stay (LOS) was 25 days. The second patient had cervical squamous cell carcinoma spreading to the neck without thoracic involvement. In addition to RACE, we performed tracheostomy after cervical lymphadenectomy. Pathology reported ypT0N0 (17 lymph nodes) with R0 resection. A post-operative Bernard Horner syndrome was noted; total LOS was 16 days.

Conclusion

Our first experience in performing RACE with the Da Vinci Xi robotic system shows that this can be a feasible procedure with adequate surgical and oncological outcomes. Further comparison studies are needed.
517. INTERNATIONAL CONSENSUS AND CLINICAL CARE ALGORITHM FOR THE DIAGNOSIS AND TREATMENT OF ANASTOMOTIC LEAK AFTER ESOPHAGECTOMY
Authors: Stuart Sanne K , Lemmens Jobbe , Nieuwenhuijzen Grard AP , Evans Richard PT , Kamarajah Sivesh K , Wijnhoven Bas , Wong Ian YH , Griffiths Ewen A , Ubels Sander , Klarenbeek Bastiaan R , Rosman Camiel
Published: September 2024

Background

Anastomotic leak (AL) is a common and severe complication after esophagectomy. Guidelines for the management of AL are lacking due to limited evidence, in which case consensus can provide a sound base for guiding clinical practice. This study aimed to develop a consensus-based guideline and clinical algorithm on the diagnosis and treatment of AL after esophagectomy.

Methods

A three-stage modified Delphi study was performed. Stage 1 comprised a scoping systematic review to find available evidence and formulate statements. Methodological quality was assessed using the Newcastle-Ottawa scale. Stage 2 comprised a two-round Delphi survey, globally distributed to surgeons and gastro-enterologists experienced in diagnosing and treating AL. During stage 3, clinical recommendations were formulated by an international expert panel, based on the Delphi consensus and a strength was assigned following GRADE principals. A clinical care algorithm was developed based on these recommendations. This study was performed in collaboration with the ISDE Guidelines Committee.

Results

A total of 5.843 articles were screened, and 118 included to formulate Delphi statements. The Delphi survey was completed by 106 participants in the first round and 136 in the second. Consensus was achieved on 13 statements on diagnosis and 21 statements on treatment of AL. During the guideline development stage, 12 diagnostic recommendations were formulated covering screening, clinical signs, biochemical tests, and imaging for the diagnosis of AL. 15 recommendations were formulated regarding treatment strategies of AL and indications and techniques for supportive care, drainage and defect closure. A clinical care algorithm on diagnosis and treatment of AL was designed.

Conclusion

This study developed clinical recommendations based on consensus and available evidence, and designed a clinical care algorithm for the diagnosis and treatment of AL after esophagectomy. The developed recommendations and clinical care algorithm, may provide clinical support and aid standardized decision-making in clinical practice and potentially improve patient outcomes.
535. AUDITING THE PATIENTS OUTCOMES AFTER SURGERY FOR ESOPHAGEAL AND GASTRIC CARDIA CANCER WITHIN THE 18 YEARS PERIOD. SINGLE CENTER EXPERIENCE
Authors: Pazdro Alexandr , Snajdauf Martin , Faltova Hanka , Wolesky Jakub , Harustiak Tomas
Published: September 2024

Background

Malignant tumor of the esophagus and gastroesophageal junction is a long-term survival limiting disease. Although over the years there has been a significant shift in the quality of surgical care, oncological approach and treatment protocols, despite it is still disease with a very poor prognosis.

Methods

Evaluation of a retrospective database of consecutive patients at our surgical departement from 2005 to 2022. We divided these 18 years into three periods A (2005 – 2010), B (2011 – 2016) and C (2017 – 2022) in which we evaluated overall survival, morbidity, anastomotic complications, 30- and 90-day mortality and number of removed nodes. The difference in the number of patients with adneocarcinoma was between periods A and C, higher by almost 30%, squamous cell carcinoma without an increase.

Results

During the observed period, radical surgery was performed on 1252 patients, 881 patients with adenocarcinoma (70.37%) and 316 patients with squamous cell carcinoma (25.24%) and 4.39% (n=55) with another histological type.

The period A N=384 (2005 – 2010), period B N=405 (2011 – 2016) and C N=463 (2017 – 2022).

Between periods A and C, we recorded an increase in frequency of adenocarcinoma by almost 30%, squamous cell carcinoma without any increase.

62.3% of patients (N=780) underwent neoadjuvant oncological treatment. The indication for its performance was the clinical TNM classification (cT2 and more or cN+), histological type, general condition of the patient and as well patients age.

We indicated for chemoradiotherapy 271 patients (21.65%), CHT 491 (39.22%) RT only in 17 patients and 472 (37.7%) patients designated for surgery without any other treatment.

• 5-year survival in the entire group was 37.20% (Graph No 1) and median survival was 974 days for adenocarcinoma and 909 days for squamous cell carcinoma.

• 30-day mortality for the entire monitored period was 1.92% (24 out of 1252) and 90-day mortality was 5.27% (66 out of 1252).

• Other results are in the attached table.

Conclusion

During the observed period, it is clear that the quality indicators of surgical resection are improving, as well as the 30- and 90-day mortality, but this trend is not clearly manifested in the length of survival.
538. COMPARISON OF EARLY POSTOPERATIVE OUTCOMES OF CERVICAL ANASTOMOSIS TO HIGH INTRATHORACIC ANASTOMOSIS AMONG PATIENTS WITH UPPER THORACIC ESOPHAGEAL CANCER
Authors: Son Jeonga , Lee Genehee , Lee Junghee , Jeon Yeong Jeong , Park Seong-Yong , Cho Jong Ho , Choi Yong Soo , Kim Jingook , Kim Hong Kwan , Shim Young Mog
Published: September 2024

Background

For upper thoracic esophageal cancer, esophagectomy combined with cervical esophagogastrostomy (cervical anastomosis, CA) and three-field lymph node dissection (3FLND) has been proposed as the standard surgical approach. However, while CA provides sufficient length of proximal resection margins, it is associated with a higher incidence of postoperative complications such as anastomotic leaks, recurrent laryngeal nerve (RLN) injury, and increased mortality. As an alternative, high-intrathoracic esophagogastric anastomosis (high-ITA) with 3FLND has been performed. We aimed to evaluate the benefits and limitations of high-ITA compared to conventional CA in terms of early postoperative outcomes.

Methods

A total of 232 patients, who underwent curative esophagogastrostomy with 3FLND and either of high-intrathoracic anastomosis (high-ITA) or cervical anastomosis (CA) for upper thoracic esophageal cancer a tertiary hospital from January 2010 to December 2021. Collected data from medical records were analyzed retrospectively regarding morbidity and mortality rates. The primary end point was recurrence. Anastomotic leak, RLN palsy, hospital stay, and 90-day mortality and in-hospital mortality were evaluated using Chi-squared test, Fisher’s exact test, and T-test. The risk of mortality and recurrence were analyzed using Cox-proportional hazard regression with a median follow-up of 39.1(IQR 17.8, 80.2) months.

Results

Among the fifty patients with high-ITA and 182 patients with CA, the high-ITA group reported fewer anastomotic leaks (6.0% vs. 19.8%, p=0.02) and a shorter hospital stay (median 12days vs. 15 days, p<0.001). No significant difference was observed in RLN palsy (6.0% vs. 13.7%, p=0.22) and the 90-day or in-hospital mortality rate (2.0% vs. 2.2%, p=1.0). The number of lymph nodes dissected (LND) was similar between the groups (47.4(±15.4) vs. 52.7(±18.3), p=0.06), and there was no difference in the risk of mortality and recurrence according to the high-ITA method (HR 0.9, 95% CI 0.6-1.6; HR 1.0, 95% CI 0.6-1.7) after adjustment for age, sex, and stage.

Conclusion

In the esophagogastrostomy with three-field lymph node dissection, performing high-intrathoracic anastomosis may reduce the incidence of anastomotic leaks and shorten the hospital stay without adversely affecting overall survival.
571. A PHASE I/II MULTICENTER STUDY EVALUATING THE EFFICACY AND SAFETY OF INDUCTION IMMUNOCHEMOTHERAPY FOLLOWED BY CONCURRENT IMMUNO-CHEMORADIOTHERAPY IN UNRESECTABLE LA-ESCC
Authors: Song Xinyun , Li Yue , Feng Wen , Cai Xuwei , Zhang Qin , Fu Xiaolong , Yu Wen
Published: September 2024

Background

Despite advances in radiotherapy techniques, the prognosis for patients undergoing definite chemoradiotherapy remains suboptimal. There exists an urgent and unmet need to enhance the efficacy of concurrent chemoradiotherapy for patients with unresectable Locally Advanced Esophageal Squamous Cell Carcinoma (LA-ESCC). Immunotherapy, when combined with chemotherapy, has emerged as the established first-line treatment for advanced esophageal cancer. Significant tumor shrinkage and reduced tumor residual observed after induction immunotherapy might provide the potential to enhance locoregional control of radiotherapy as well as better protection of critical organs and circulating lymphocytes.

Methods

We conducted a multicenter, phase I/II study aiming to assess the efficacy and safety of induction immunochemotherapy followed by immuno-chemoradiotherapy (ICRT) for unresectable LA-ESCC (SCR-ESCC-002, NCT06173986) (Figure 1). Eligible patients will initiate treatment with 2-3 cycles of immunochemotherapy. Within 4 weeks after completing the induction treatment, patients without disease progression will proceed to receive concurrent radiotherapy (45-50Gy in 25 fractions), weekly chemotherapy, and PD-1 inhibitor on day1,22. Following immuno-chemoradiotherapy, patients will continue with immunotherapy maintenance until disease progression or unacceptable toxicity, for a maximum duration of one year. The study's dual primary endpoints are progression-free survival and treatment completion rate.

Results

As of January 2024, 13 eligible patients were enrolled in our trial, with median follow-up of 7.8 months. Due to tumor shrinkage of induction immunochemotherapy, radiation doses to normal tissues were significantly reduced, particularly for the lungs, heart, and vertebrae. All 13 patients completed the planned induction treatment and radiotherapy, with 8 completing more than 4 weekly chemotherapies. During ICRT, 10 of 13 patients experienced grade 3-4 adverse events. These included lymphopenia (69.23%), myelosuppression (46.15%), hepatitis (7.69%), esophagitis (7.69%), and pneumonitis (7.69%). Nine patients achieved a complete response, and 3 partial response 4 weeks after ICRT according to RECIST v1.1.

Conclusion

Decreased radiation volumes due to tumor regression brought by induction immunochemotherapy diminish the occurrence of non-hematological adverse events during ICRT. Preliminary analysis suggests that this therapeutic modality exhibits favorable safety profiles and yields a superior clinical complete response rate compared to definitive chemoradiotherapy alone. The trial is presently enrolling participants, and the confirmation of efficacy and survival outcomes necessitates larger sample sizes and extended follow-up durations.
613. LAPAROSCOPIC MANAGEMENT OF TYPE IV HIATAL HERNIA WITH MESH AUGMENTATION CRUROPLASTY - EXPERIENCE AT A TERTIARY CARE CENTRE
Authors: Parthasarathi R , Ramesh N , Cumar Bharath , Palanivelu C
Published: September 2024

Background

Type IV para-esophageal hernias, which are characterized by herniation of other organs in addition to stomach, are rare - comprising only 2-5% of all para-esophageal hernias. They are associated with life-threatening complications such as strangulation or perforation of stomach. Laparoscopic treatment of these hernias requires excellent advanced laparoscopic suturing and dissecting skills. Although laparoscopic approach is now universally accepted, the role of mesh augmentation remains debated.

Methods

Case records of patients who underwent Laparoscopic mesh augmentation cruroplasty for Type IV hiatal hernia since 2012 were retrospectively analyzed.

Results

Out of 340 patients who underwent hiatal hernia repair, 7 patients (3males,

4females) fulfilled the selection criteria. Median age was 64(53-89) years. Median duration of symptoms was 2months (15days-6months). All patients complained of heartburn. Vomiting was present in 5(71%) patients; only 1(14%) patient had persistent vomiting with dysphagia.

Respiratory symptoms were present in 2(29%) patients. No patient had features of peritonitis or sepsis. One patient had undergone laparoscopic heller’s cardiomyotomy twice before. All patients underwent MDCT which confirmed type IV paraesophageal hernia.

Median operating time was 150(100-280) minutes. Median blood loss was 150(50-400) ml.

6(85%) patients had herniation of omentum in addition to stomach while 1 patient had herniation of omentum and transverse colon. No patient had ischemia/perforation of stomach. Median hiatal defect was 6(5-8) cm. Sac was excised completely in all cases following reduction of contents. Crural repair was done with1-0 polyester interrupted sutures.

In some patients, anterior cruciate ligament repair was done to avoid tenting of esophagus.

Rectangle shaped Composite mesh with key-hole slit in upper border was placed. Mesh was anchored with interrupted 1-0ethilon sutures. Fundoplication (Nissen’s/Toupet) was done in all patients, none required esophageal lengthening procedure.

Median post-operative stay was 5(2-8) days, median ICU stay was 1(0-4) days. Oral liquids were started on 2 nd (1-3) post-op day and solids on 4 th (2-5) day. 2(29%) patients had post- operative complications - atrial fibrillation and transient respiratory failure respectively.

Median follow-up was 14(1-40) months. No patient had symptomatic recurrence. OGDscopy at 6months was normal in 5 patients. No mesh related complication was observed.

Discussion

Wide hiatal defects were noted in all patients. This necessitated mesh augmentation of crural repair. Both short-term (morbidity, mortality) and long-term outcomes (recurrence, patient satisfaction) were excellent.
739. SIGNIFICANCE OF COX2 INHIBITOR FOR ESOPHAGEAL CANCER FROM THE CLINICAL AND EXPERIMENTAL ESTIMATE
Authors: Hashimoto Naoki
Published: September 2024

(Aims) We report experimental and clinical evidence that COX2 represent a potential molecular target for the treatment and prevention of esophageal cancer.

(Methods) (A)Experiment: Thirty 8-week male wistar rats were exposed to duodenal content esophageal reflux. All animal underwent an esophagoduodenal anastomosis (EDA) with total gastrectomy in order to produce chronic esophagitis. In ten rats the sham (Control). They were sacrified at 40th week. Their esophagi were examined for HE, COX2,PGE2, PCNA and total bile acids in the esophageal lumen was measured. (B)Clinical: The expression of COX2 was examined for 68 specimens of esophageal squamous cell carcinoma (SCC) and the correlation of COX2 expression with clinicopatholigic features was examined.

(Results) (A) After 40 weeks of reflux, columnar dysplasia, squamous cell carcinoma and adenocarcinoma were found. Total bile acid in the esophageal lumen was significantly increased in the EDA group compared with the sham operated rats. PCNA LI and esophageal tissue PGE2 were higher in dysplastic and cancer tissue than that of control. Overexpression of COX2 was shown in dysplastic and cancer tissue. COX2 may play an important role in esophageal cancer by duodenal content reflux.(B) COX2 immunoreactivity was weak in 27(40%) and strong in 41(60%) of the carcinomas. The proportion of poorly differentiated SCC among tumors with a strong expression of COX2 (34%) was significantly higher than among tumors with a weak expression of COX2 (19%, p=0.02). The depth of tumors (p=0.004), lymph node metastasis (p=0.0009) and the stage of the tumors (p=0.001) were advanced significantly more progressively in ECCS with a strong COX2 expression. Moreover, survival was significantly reduced (p=0.02) among patients with strong COX2 expression when compared with the COX2 weak group. This study showed that strong expression of COX2 was correlated with tumor progression and poor differentiation in ESCC. (Conclusion) In this experimental study, we demonstrate that bile reflux of duodenal contents induce COX2 and increase prostaglandin synthesis in dysplastic and cancer tissue. Our study suggests that COX2 may play a role in esophageal carcinoma development and progression, COX2 inhibitors may be potential targets for the prevention or treatment of esophageal carcinoma.