bluuebunny/crossref_metadata_2025 huggingface dataset:
676 NECESSITY OF EXTENDED LOWER PARATRACHEAL LYMPH NODE RESECTION DURING ESOPHAGECTOMY FOR CANCER
Authors: Mann C , Berlth F , Hadzijusufovic E , Uzun E , Tagkalos E , Lang H , Grimminger P
Published: September 2021

Objective

To evaluate the impact of lower paratracheal lymph node resection on oncological radicality and complication rate during esophagectomy for cancer.

Backround

The ideal extend of lymphadenectomy (LAD) in esophageal surgery is debated. Until today, there has been no proof for improved survival after standardized paratracheal lymph node resection performing oncological esophagectomy.

Methods

Lymph nodes from the lower paratracheal station are not standardly resected during 2-field Ivor-Lewis esophagectomy for esophageal cancer. Retrospectively, we identified 200 patients operated in our center for esophageal cancer from January 2017—December 2019. Histopathologically, 143 patients suffered from adenocarcinoma, 53 patients from squamous cell carcinoma, two patients from neuroendocrine carcinoma, and one from melanoma of the esophagus. Patients with and without lower paratracheal LAD were compared to patients regarding demographic data, tumor characteristics, operative details, postoperative complications, tumor recurrence and overall survival.

Results

103 of 200 patients received lower paratracheal lymph node resection. On average, six lymph nodes were resected in the paratracheal region with histopathological cancer positivity in two patients. Those two patients suffered from neuroendocrine carcinoma and melanoma, none of the AC or SCC patients were positive. There was no significant difference between both groups regarding age, gender, BMI, or comorbidity. Harvesting of lower paratracheal lymph nodes was associated with less postoperative overall complications (p-value 0,029). Regarding overall survival and recurrence rate no difference could be detected between both groups (p-value 0,168, respectively 0,371).

Conclusion

The resection of lower paratracheal lymph nodes during esophagectomy seems not mandatory for distal squamous cell carcinoma or adenocarcinoma of the esophagus. It may be necessary in NEC, Melanoma of the esophagus or on demand if suspicious LN are detected in the CT scan. No increase of morbidity was caused by paratracheal dissection.
677 ROBOTIC-ASSISTED HIATAL HERNIA AND GASTROESOPHAGEAL REFLUX DISEASE RE-DO SURGERY: A SINGLE INSTITUTION EXPERIENCE
Authors: Font Arantxa Clavell , Farrarons Sara Senti , Martin Marta Viciano , Savall Elisenda Garsot
Published: September 2021

Hiatal hernia recurrence (HHR) after surgical repair associated with dysphagia, gastroesophageal reflux disease or other symptoms represents a non-negligible disease that frequently needs a reoperative solution. The repair of a relapsed hiatal hernia represents a surgical challenge due to anatomic changes and fibrosis, and the robotic approach seems to provide benefits because offers enhanced visualization and dexterity.

Methods

Between June 2019 and February 2021, 7 patients (1 male, 6 female) underwent redo robotic approach surgery for hiatal hernia recurrence after being pre operative diagnosed. All surgeries were elective and all patients had both clinical and radiologic recurrence. Biosynthetic tissue absorbable mesh was applied in one patient with double time recurrence hernia. Four patients underwent total fundoplication (Nissen), 2 patients had Toupet fundoplication, and one patient had hiatus repair without fundoplication.

Results

The mean age of the patients was 62.7 years and the main expressed symptom for the patient was dysphagia. Time to clinical recurrence was 13 months. Biosynthetic mesh was used in one patient. The mean operative time was 143 minutes (80–240) and no intraoperative complications were described. There were no conversions to open or laparoscopic procedures. The early and 30 day mortality rate was 0% and mean hospital stay was 2.7 days.

Conclusion

Robotic support, when available, can be beneficial in redo surgery for GERD and hiatal hernia recurrence. Despite our short experience, we believe the robotic approach for redo hiatal surgery is safe and effective with low complication rates even in high-risk patients.
680 ACUTE GASTRIC DILATATION: A LIFE-THREATENING EARLY COMPLICATION FOLLOWING LAPAROSCOPIC HIATUS HERNIA REPAIR
Authors: Wee Melissa Yun , Liu David S , Thompson Sarah K
Published: September 2021

Laparoscopic anti-reflux surgery prevents reflux of gastric fluid into the oesophagus but it may also inhibit belching. Gastric outflow impairment may lead to a closed-loop obstruction and life-threatening acute gastric dilatation.

Methods

We report a case of a 69-year-old female who underwent a laparoscopic giant hiatus hernia repair and anterior 180° fundoplication. Post operatively, she suffered from gastroparesis that resulted in a closed-loop obstruction. This was managed successfully with nasogastric tube insertion and commencement of prokinetic agents. A review of the literature of acute gastric dilatation and hiatus hernia repair was made.

Results

In the last 30 years, there have been 7 cases of acute gastric dilatation following hiatus hernia repair. Timing was 7 months to 14 years following a 360 degree fundoplication. In most cases, the ensuing gastric dilatation led to venous congestion, tissue necrosis and perforation, necessitating emergency gastrectomy for control of sepsis. All patients required a prolonged hospital stay and one mortality was reported. Our case is unique, characterized by its early presentation, and occurring after a partial 180° fundoplication. Our patient was successfully managed non-operatively with nasogastric decompression and supportive measures.

Conclusion

Surgeons should be aware that acute gastric dilatation is a life-threatening complication which may occur following laparoscopic partial fundoplication. Early diagnosis and prompt nasogastric decompression are required to avoid gastric necrosis and significant morbidity.
682 ENDOFLIP TAILORED PER-ORAL ENDOSCOPIC MYOTOMY (POEM): EXPERIENCE IN TWO UK CENTRES.
Authors: Knight William , Kandiah Kaveetha , Couch Jennifer , Tewari Nila , Ragunath Krish , Catton James , Botha Abraham
Published: September 2021

Per-oral endoscopic myotomy (POEM) is an effective treatment for achalasia. Efficacy is equivalent to Laparoscopic Heller’s myotomy with the advantage of minimal access and shorter length of stay. Post-operative reflux rates are higher in POEM. The Functional Luminal Imaging Probe (FLIP) allows the measurement of lower oesophageal distensibility during per-oral endoscopic myotomy. In theory, this enables the operator to tailor the myotomy to ensure adequate distensibility whilst minimising post-operative reflux risk.

Methods

Two prospectively collected POEM databases were analysed from 2 UK tertiary upper GI centres. The operators in each centre used intraoperative FLIP measurements to ensure adequate myotomy. Outcome measures included Eckardt score (where ≤3 indicated clinical success) and proton pump inhibitor use (PPI), collected at the first post-operative appointment. Length of stay was recorded, as were complications.

Results

142 patients underwent POEM between 2015 and 2019 with 90% (128/142) clinical success. This improved to 93% (68/73) in the latter half of each series. 79% of the poor responders had previous interventions compared to 55% of responders (p = 0.09). Average post myotomy distensibility was 5.2 mm2/mmHg in responders and 3.11 in non-responders(p = 0.11). DI of >4.5 mm2/mmHg was associated with 100% clinical success. Myotomy length of <7 cm was associated with 93% clinical success and 40% post op PPI use compared to 60% with longer myotomies. There were 2 type IIIa, 2 type IIIb and one type IV Clavien-Dindo complications.

Conclusion

This study represents one of the largest UK series of FLIP tailored per-oral endoscopic myotomy. FLIP allows intraoperative monitoring of oesophageal distensibility allowing tailoring of myotomies. Tailored myotomies ≤6 cm were effective and were associated with less PPI use post operatively. Early referral of patients to high volume centres, where myotomies can be tailored using FLIP may lead to improved outcomes. More collaborative data from high volume centres is needed to decipher optimal myotomy profiles.
687 ADVERSE EVENTS DURING MINIMALLY INVASIVE ESOPHAGECTOMY IN PRONE POSITION
Authors: Hernandez Norberto Daniel Velasco , Rivaletto Lucas Alberto , Saenz Alan Erasmo , Zicavo Maria Micaela , Peña Carla , Dominguez Roberto Julio
Published: September 2021

Since the initial description of laparoscopic fundoplication in 1991 for the treatment of gastroesophageal reflux disease, different minimally invasive procedures have been developed until nowadays, when esophagectomy is performed using combined thoracoscopy and laparoscopy. Objective: The aim of our study is to analyze the intraoperative complications of minimally invasive esophagectomy in prone position.

Methods

Between November 2011 and January 2021, 70 patients underwent minimally invasive esophagectomy in prone position in the Hospital Interzonal General de Agudos General San Martín and private practice of La Plata city.

Results

During the abdominal stage one patient presented coronary vessel injury and the other with short vessel injury. The complications occurring in the thoracic stage included lung injury, azygos arch injury, thoracic duct section, laryngeal recurrent nerve lesion, main stem bronchus injury, and pericardium lesion, during lymph node resection. Most of these complications occurred in the first 30 patients, while in the remaining 40 cases only two complications (p value = 0.4).

Conclusion

Minimally invasive esophagectomy in prone position is a feasible and safe procedure that can cause serious intraoperative complications due to its complexity. Although the results of our series did not show statistically significant differences, the number of complications during surgeries performed by the same team showed an important reduction associated with better training.
697 ESOPHAGECTOMY ANASTOMOTIC LEAKS DECREASE LONG TERM SURVIVAL AFTER SURGERY FOR ESOPHAGEAL CANCER: MOVING FROM RESCUE TO PREVENTION.
Authors: Cheang Catherine , Patil Pradeep
Published: September 2021

Multimodal therapy including esophagectomy is the standard of care for esophageal cancer with a view to achieve long-term survival. Leaks from esophageal anastomoses are associated with major short-term morbidity and mortality. The aim of this study was to analyse our anastomotic leaks following esophagectomy for cancer, their effect on short-term mortality and any effect on long term survival.

Methods

All patients undergoing esophagectomy for esophageal cancer over 10 years from 2011 to 2020 in our centre were selected for this study from a prospectively maintained database. Patients with leaks were identified by reviewing their case records, electronic records, endoscopy and radiological results. All leaks including non-clinical radiological leaks were included in the study. Overall survival was calculated from date of surgery to death or otherwise censored. Statistical analysis was carried out using SPSS.

Results

104 consecutive patients were identified of whom 10 patients (9.6%) had anastomotic leaks. 8 of these patients (80%) were rescued and were well enough to be discharged home. The median survival of patients with leaks was 11.6 months compared to 52.9 months for patients without leaks. The 3-year survival was 30% in patients with leaks compared to 59.9% (p = 0.23, Fisher’s exact) in patients without leaks. The Kaplan Meier survival analysis curves are shown here and the difference in survival was very close to being statistically significant with p = 0.089 (Log Rank) and p = 0.056 (Breslow).

Conclusion

Esophageal anastomotic leak rates are still exceedingly high at 10%. The rescue rate of 80% is significantly better compared to previous decades. Despite the high rescue rate, these patients have extremely poor long-term survival rates. The future should aim for innovative technology and strategies to eliminate esophageal anastomotic leaks for optimal short- and long-term outcomes.
721 DOES AGE AFFECT OESOPHAGECTOMY SURVIVAL: A COHORT STUDY
Authors: Park Jin-soo , Van der Wall Hans , Falk Gregory
Published: September 2021

Oesophagectomy is the mainstay in the curative management of oesophageal cancer. Curative surgery is associated with considerable morbidity and potential mortality. Surgeons are increasingly treating older patients presenting with oesophageal cancer as the population ages. This study aimed to assess the effect of age on short term surgical outcomes, mortality, as well as overall and disease-free survival, in patients undergoing curative oesophagectomy for cancer.

Methods

Patient data were analysed from a prospectively maintained database. Demographic, surgical, and survival outcomes were compared between groups according to age less than 75 years or 75 and older.

Results

Oesophagectomy was performed in 351 patients between 1990 and 2019 (283 patients <75 years, 68 patients ≥75 years). There was a higher rate of neoadjuvant chemotherapy in the <75 year old group than the ≥75 group (37.7% vs. 7.4%; p < 0.001); the two groups were otherwise similar. The 30-day mortality between younger and older groups was similar (2.5% and 2.9%; p = 0.827). There was no statistically significant difference in 5-year survival rates between groups (50.3% vs. 38.6%; p = 0.063), or median survival (22.6 vs. 19.3 months; p = 0.053). There was no difference in 5-year disease-free survival (45.1% and 35.7%; p = 0.158).

Conclusion

Overall survival, disease-free survival, and 30-day mortality rates in patients 75 years old and older were similar to their younger counterparts. Based on these results, older patients should not be precluded from consideration of potentially curative oesophagectomy on age alone, providing surgery may be performed at reasonable risk.
722 SAFE (SUPERCHARGED CERVICAL ANASTOMOSIS FOR ESOPHAGECTOMY AND GASTRIC PULL-UP) PROCEDURE: LONG TERM RESULTS FROM 61 PATIENTS
Authors: Takeda F , Tutihashi R , Aissar Sallum R , Busnardo F , Ribeiro U , Cecconello I , Nahas S
Published: September 2021

Esophagectomy still represents a challenge surgical procedure. Anastomotic leakage is the most feared complication and is likely related to diminished anastomotic perfusion. ‘Supercharged’ microvascular anastomosis has been performed in select patients to supplement the blood supply to the graft and anastomosis, after esophagectomy. This study aimed to evaluate results after performing the supercharged cervical anastomosis for esophagectomy procedure.

Methods

This prospective cohort study evaluated patients who underwent esophagectomy with gastric reconstruction and cervical anastomosis for locally advanced esophageal carcinoma. Patients were selected in which cervical anastomosis using the supercharged cervical anastomosis for esophagectomy procedure was performed. The anastomotic perfusion areas were evaluated using indocyanine and SPY before and after supercharged cervical anastomosis for esophagectomy. Post esophagectomy complications were also recorded.

Results

The study enrolled 61 patients, which included 47 (77.0%) men, with a mean age of 67.3 years. Median additional surgical time was 112 min (IQ 90–180), Leakage occurred in 1.6% of the patients (microanastomosis thrombosis), whereas the corresponding anastomotic stricture rates were 3.2% (mean follow-up was 25 mounths). Perfusion analyses showed a 28% improvement in the anastomotic area after venous anastomosis and a 37% improvement after arterial and venous anastomosis.

Conclusion

The supercharged cervical anastomosis for esophagectomy procedure may be related to low occurrence of anastomotic leakage and improve perfusion in the anastomotic area via vein and arterial microanastomoses.
729 RELATION OF POSTOPERATIVE MORBIDITY WITH QUALITY OF LIFE FOLLOWING ESOPHAGEAL SURGERY FOR CANCER: A EUROPEAN MULTICENTER STUDY
Authors: Schuring Nannet , Markar Sheraz R , Jezerskyte Egle , Sprangers Mirjam A G , Johar Asif , Berge Henegouwen Mark I , Gisbertz Suzanne S
Published: September 2021

Despite improvements in perioperative esophageal cancer care, severe postoperative complications occur in 17.2% of the patients. Postoperative complications are associated with reduced health-related quality of life (HR-QoL), and severe complications may have a profound negative effect on the HR-QoL.The aim of this study was to investigate the relation between postoperative morbidity and reported HR-QoL in patients following esophagectomy for cancer.

Methods

Disease-free patients at least one year following esophagectomy for cancer in one of the participating LASER study centers between 2010 and 2016 were included. Patients completed the LASER, EORTC-QLQ-C30 and QLQ-OG25 questionnaires at least one year following surgery. The primary outcome was the relation between reported HR-QoL and occurrence of postoperative complications and to compare the HR-QoL in the study population with the reference values of the general population. Subgroup analysis was performed in patients with ‘no’ or ‘minor’ (Clavien-Dindo grade I-IIIa) and ‘severe’ (Clavien-Dindo grade ≥ IIIb) complications, using univariable and multivariable logistic regression analysis.

Results

Among 645 included patients, 283 patients with ‘no’, 207 patients with ‘minor’ and 155 patients with ‘severe’ postoperative complications were included. The mean age of the patients was 64 years (SD 9), with a mean time since surgery of 4.4 years (SD 1.7). Neither significant or clinically relevant differences were found in the HR-QoL scores between patients with and without complications, nor were differences observed in subgroup analysis for severity of postoperative complications. Compared to the general population, patients reported worse HR-QoL in all domains except ‘Global Health’ and ‘Emotional Functioning’, and more symptomatology in all symptom domains except ‘Pain'.

Conclusion

HR-QoL between patients at a median of 4.4 years after esophagectomy for cancer did not differ. Differences were neither significant nor clinically relevant and furthermore, no differences were observed in subgroup analysis for severity of postoperative complications according to Clavien-Dindo.
74 LAPAROSCOPIC MANAGEMENT OF A PULSION EPIPHRENIC OESOPHAGEAL DIVERTICULUM SECONDARY TO ACHALASIA.
Authors: Tan Jeremy , Yeung Baldwin , Ong Lester , Toh Bin Chet , Wong Wai Keong , Lim Chin Hong
Published: September 2021

This is a video submission of a laparoscopic resection of an epiphrenic oesophageal pulsion diverticulum secondary to achalasia. A Heller’s cardiomyotomy is also performed together with a Toupet fundoplication.

Methods

The patient is a 40 year old woman with a 12 month history of worsening dysphagia, reflux symptoms, as well as occasional regurgitation of food, worse at night. Barium swallow showed a distal oesophageal diverticulum and oesophageal manometry confirmed type 1 achalasia. Upper GI endoscopy showed no other intra-luminal findings.

Results

The patient underwent a laparoscopic resection of the diverticulum, together with a Heller’s cardiomyotomy and Toupet fundoplication. There were no post-operative complications. She remains well and asymptomatic at 9 month follow-up.

Conclusion

Pulsion diverticula secondary to achalasia are a known but rare entity. A few variations exist on how to manage this condition surgically, especially with respect to the type of fundoplication. We present our preferred technique for dealing with this condition.

Video

https://www.dropbox.com/s/dg4edkamykugupn/Oesophagealdivert.mp4?dl=0
740 CAMRELIZUMAB IN COMBINATION WITH PREOPERATIVE CHEMOTHERAPY FOR LOCALLY ADVANCED ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A SINGLE-ARM, OPEN-LABEL, PHASE II STUDY
Authors: Wang Feng , Qi Yu , Meng Xiangrui , Fan Qingxia
Published: September 2021

At present, ESCC has a dismal prognosis with huge unmet clinical needs. With the potential benefit of combining PD-1 inhibitor with nCT, we conducted a phase II trial to assess the efficacy and safety of Camrelizumab plus nCT for locally advanced ESCC.

Methods

45 patients (pts) with histologically confirmed stage II/III/IVa(cT2-4aN0-3 M0) ESCC were enrolled from February 2020 to March 2021.The study was divided into two stages, stage1: we administered 1 cycle of Camrelizumab for induction therapy (200 mg q2 weeks); stage2: pts received 2 cycle of Camrelizumab (200 mg every 3 weeks) plus docetaxel and nedaplatin, followed by surgery within 4 ~ 6 weeks after neoadjuvant therapy completion. Primary endpoint was major pathologic response (MPR). Secondary endpoints included pathologic complete response (pCR), R0 resection rate, disease-free survival (DFS) and overall survival (OS).

Results

At the cutoff date of Mar 9, 2021, 45 eligible pts were enrolled, neoadjuvant treatment was completed in 39 pts. Thus far 32 pts were resected, all patients underwent an R0 resection. Postoperative pathology showed that TNM stage decreased in 28 pts with 87.5% reduction rate. 19 pts (59.38%) reached major pathologic response, 9 pts (28.13%) reached pathologic complete response (no surgery related mortality). A total of 75.56% had AEs with 13.33% of grade ≥ 3 AEs. Date for median DFS and OS were not matured.

Conclusion

Camrelizumab in combination with preoperative chemotherapy followed by surgery for locally advanced ESCC showed promising downstaging effect and MPR with good tolerance, and its efficacy and safety could be further studied in later trials. Clinical trial information: NCT03917966.
743 SIEWERT TYPE II GASTRIC CARDIA CANCER: ANALYSIS OF THE RESULTS OF DIFFERENT SURGICAL OPTIONS
Authors: Navío-Seller Ana , Abelló-Audí David , Navasquillo-Tamarit Mireia , De Jesús-Acosta Milton Emmanuel , Bruna-Esteban Marcos , Vaqué-Urbaneja Javier , Mingol-Navarro Fernando , García-Granero-Ximénez Eduardo
Published: September 2021

The management of gastric cardia tumors should be carried out from a multidisciplinary approach, there is currently a clear controversy regarding the most appropriate surgical approach to use in type II tumors. Depending on their topographic anatomical characteristics based on the degree of gastric invasion and esophageal, the surgical technique may change: esophagectomy, gastrectomy with distal esophagectomy, or total esophageal gastrectomy.

Methods

Retrospective and analytical study of patients diagnosed with type II gastric cardia adenocarcinoma (based on the results of the pathological study of the resection specimen) who underwent surgical treatment in our center from June 2012 to June 2020. Different preoperative parameters, the surgical techniques used and the results obtained were analyzed.

Results

25 patients were studied, 84% male. 60% were locally advanced tumors with 56% affected nodes. 12 Ivor-Lewis esophagectomies, 5 esophagogastrectomies with coloplasty, and 5 extended total gastrectomies were performed. There was no resection proximal or distal margin involvement, but circumferential margin was affected in 60% of cases of extended gastrectomy and in 1 case of Ivor-Lewis esophagectomy. Median number of lymph nodes removed was 22(5–37) and 2(0–12) affected, being higher in total esophagogastrectomy. Postoperative morbidity was 40% and 90-day mortality 4% (1 case). The mean follow-up was 37 months, noting recurrence in 9 cases (36%), with disease-free survival of 44%.

Conclusion

The surgical treatment approach in type II gastric tumors is controversial, and there are multiple options to consider. According to the results of this study, the Ivor-Lewis esophagectomy shows to be a safe approach with satisfactory oncological results in tumors that do not require a total esophagogastrectomy.
745 YIELD OF EXTENDED AND TOTAL MEDIASTINAL LYMPHADENECTOMY IN OESOPHAGEAL CANCER
Authors: Abelló David , Aguilar Karen Stephanie , Navío Ana , Avelino Lourdes , Cholewa Hanna , Mingol Fernando , Bruna Marcos , Vaqué Javier , García-Granero Eduardo
Published: September 2021

The extent of lymphadenectomy in oesophageal cancer surgery is currently controversial, although current evidence shows that survival is directly related to the number of lymph nodes removed during surgery.

Methods

Descriptive study of patients with oesophageal cancer who underwent oesophagectomy with extended and total mediastinal lymphadenectomy using a minimally invasive approach (right prone thoracoscopy, laparoscopy and left cervicotomy) in our hospital for 2 years (2019 and 2020). Extended lymphadenectomy was indicated in patients with adenocarcinoma of the distal oesophagus, while total lymphadenectomy was indicated in patients with squamous tumours and adenocarcinoma of the middle oesophagus. The characteristics of the series studied and the results obtained in the 90 days postoperatively are described.

Results

26 patients, mean age 65 ± 7.8 years, were operated. 21 with total mediastinal lymphadenectomy and 5 with extended lymphadenectomy. 80.7% received neoadjuvant treatment (CROSS scheme). The mean number of lymph nodes removed was 33.6 ± 14.3, with a 50% probability of being affected. As much in the lymphadenectomy of the right (106R) as in the left (106 L) recurrent groups, it was more frequently affected in the distal oesophagus adenocarcinomas. Postoperative morbidity was not negligible, with anastomotic leak rate of 7.7% (thoracic location) and 23.1% (cervical location) the majority mild, 23.1% of recurrent injury and 11.5% of chylothorax. Mortality at 90 days was 15.38%.

Conclusion

Based on our results, extended and total lymphadenectomy increases as much the global number of lymph nodes removed as the lymph nodes cancer-positive. In addition, it supports the performance of wide lymphadenectomies also in adenocarcinomas of the distal oesophagus. We cannot forget the greater radicalism is taxed with significant morbidity. We should remember the limitation of this study is the low number of cases, the extent of lymphadenectomy continues to be a matter of controversy.
757 AN APPROACH TO ACCELERATE HEALING AND SHORTEN THE HOSPITAL STAY OF PATIENTS WITH ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY
Authors: Luo KongJia , Luo KongJia , Zhong JiuDi , Tan ZiHui , Wei YiTong , Su XiaoDong , Wen ZheSheng , Rong TieHua , Hu Yi
Published: September 2021

To explore the comprehensive role of systemic endoscopic intervention in healing esophageal anastomotic leak. To our knowledge, this paper is the first to discuss the outcome of anastomotic leaks and the association with healing time rather than whether the leak was fully healed.

Methods

In total, 3919 consecutive patients with esophageal cancer who underwent esophagectomy and immediate esophageal reconstruction between January 2012 and August 2019 at Sun Yat-Sen University Cancer Center were screened. In total, 203 patients (5.10%) diagnosed with postoperative anastomotic leakage were included. The participants were divided into three groups according to differences in diagnosis and treatment procedures. Ninety-four patients received conventional management, 87 patients received endoscopic diagnosis only, and the remaining 22 patients received systematic endoscopic intervention, including transnasal inner drainage, endoscopic fibrin glue repair and endoscopic clipping. The primary endpoint was overall healing of the leak after oncologic esophageal surgery.

Results

In total, 173 (85.2%; 95% CI, 80.3–90.1%) of the 203 patients were successfully healed, with a mean healing time of 64.42 ± 3.82 days (median: 51 days; range: 13 368 days), and the overall healing rates differed significantly among the three groups according to the stratified log-rank test (P < 0.001). The median healing time of leakage was 44 days (95% CI: 27.15–60.86 days) in the endoscopic intervention group, 51 days (95% CI: 44.86–57.14 days) in the endoscopic diagnostic group, and 66 days (95% CI: 58.09–73.91 days) in the conventional group.

Conclusion

Tailored endoscopic treatment for postoperative esophageal anastomotic leakage based on endoscopic diagnosis is feasible and effective. Systematic endoscopic intervention shortened the treatment period and reduced mortality and should therefore be considered in the management of this disease.
779 USE OF INDOCYANINE GREEN TO ASSESS THE CORRECT VASCULARIZATION OF GASTROPLASTY IN MCKWEON ESOPHAGECTOMY
Authors: González Lourdes Avelino , Tamarit Mireia Navasquillo , Audí David Abelló , Cholewa Hanna , Esteban Marcos Bruna , Navarro Fernando Mingol , Urbaneja Javier Vaqué
Published: September 2021

Cervical anastomostic leakage in esophageal surgery is one of the most serious complications and its incidence is 10–30% according to series. ndocyanine green is being used in multitude of surgical procedures in colorectal and hepatobiliary surgery. In this video we try to prove its usefulness to assess the adequate vascularization of the gastroplasty with the aim of reducing anastomotic leak due to not-well perfusion.

Methods

A left lateral cervicotomy was performed and proximal esophagus was divided. Then a handsewn purse-string suture was performed and the anvil of CEA 25 stapler was introduced into the esophagus. Gastroplasty was performed with endoGIA section by minilaparotomy. An intravenous infussion of Indocyanine green was used to assess the vascularization "in situ" of the gastroplasty. The gastroplasty was pull up through the retrosternal space and when the plasty was positioned in a correct way, the optimal site for the anastomosis was chosen. Mechanical T-L anastomosis with CEA 25 stapler was performed and it was covered with an omental flap.

Video

https://drive.google.com/file/d/1kqmNzJCdlJFOcxKBYRp0jamoHz6Gwgt7/view?usp=sharing.
794 DOES TRACHEOSTOMY PREDISPOSE GASTROESOPHAGEAL REFLUX?
Authors: Bianchi Edno Tales , Tustumi Francisco , Szachnowicz Sergio , Nasi Ary , Lopes Leticia Nobre , Duarte Andre Fonseca , Seguro Francisco Carlos Bernal Costa , Cardoso Paulo Francisco Guerreiro , Sallum Rubens Antonio Aissar , Cecconello Ivan , Nahas Sergio Carlos
Published: September 2021

Lung diseases have a strong relationship with gastroesophageal reflux disease (GERD). It has been previously demonstrated that conditions such as tracheal stenosis, asthma and even lung transplantation may worsen with reflux and these patients have few symptoms of GERD. With the COVID-19 pandemic, the number of people who needed mechanical ventilation and tracheostomy increased. Our objective was to demonstrate the prevalence of gastro-oesophageal reflux in patients with tracheostomy and describe its characteristics.

Methods

Esophageal manometry and 24 h pH-metry was performed in 137 consecutive patients with a tracheostomy already in a chronic phase, independent of symptoms. Inquire on respiratory and digestive symptoms was also carried out at the time of the examination. Prevalence of gastroesophageal reflux was identified in this population and description of the groups with reflux and without it, as well as comparison between them.

Results

Of the 137 patients, 49 were male, the average age was 40.94 ± 17.3 and the body mass index was 26.3 ± 4.85. The prevalence of gastroesophageal reflux was 45.2%. Baseline characteristics were similar between the groups with and without reflux. In the reflux group, the mean DeMeester score was 36.5 ± 20.8 and the presence of lower sphincter hypotonia was found in only 31% of the patients and was not correlated with reflux between the groups (p = 0.285). Regarding the symptoms, 48% had heartburn symptoms and only 30% had a combination of typical symptoms (heartburn + regurgitation).

Conclusion

The presence of tracheostomy is related to an increased prevalence of reflux, even without typical symptoms most of the time. The mechanism for this is still unknown, perhaps the altered respiratory dynamics has a role. These patients should be investigated with functional exams if they develop any condition that may be affected by reflux.
800 ASSOCIATION OF MULTIPLE RAPID SWALLOW PARAMETERS WITH SYMPTOMS IN PATIENTS WITH INEFFECTIVE AND NORMAL ESOPHAGEAL MOTILITY
Authors: Razia Deepika , Razia Deepika , Mittal Sumeet K
Published: September 2021

Multiple rapid swallows (MRS) is a provocative test to assess inhibitory swallowing mechanisms and esophageal peristaltic reserve. MRS response has been purposed to predict post-fundoplication dysphagia and has been associated with increased acid exposure time. Recently it was added to the Chicago classification v 4.0 protocol as an adjunctive test. This study aimed to understand the association of MRS parameters with symptoms in patients within ineffective (IEM) or normal esophageal motility (NEM).

Methods

After IRB approval, a prospectively maintained esophageal motility database was retrospectively reviewed to identify patients with IEM and NEM who also had an MRS evaluation. Patients with previous gastroesophageal surgery, manometric hiatal hernia, or a diagnosed motility disorder (except IEM) were excluded. Patient-reported symptoms (0–4) (heartburn, regurgitation, dysphagia, and chest pain) were grouped by score: 0, 1–2, or 3–4. We compared the prevalence of normal or abnormal MRS and individual MRS parameters (distal contractile integral [DCI], integrated relaxation pressure, distal latency, adequate inhibition, and post-MRS DCI/mean single swallow DCI ratio) with patient-reported symptoms.

Results

From 2019–2020, a total of 531 patients (254 = IEM, 277 = NEM) met the inclusion criteria and formed the study cohort. The presence of normal or abnormal MRS results was not associated with any patient-reported symptom in either the NEM or IEM group. Furthermore, patient-reported symptoms were not associated with individual MRS parameters in either group.

Conclusion

In patients with IEM and NEM, adjunct assessment with MRS does not correlate with patient-reported symptoms. Further studies are needed to assess the role of MRS as an adjunctive test during routine manometry.
806 CERVICAL ESOPHAGEAL PERFORATION: MULTIMODAL APPROACH TO A RARE AND MORBID CONDITION
Authors: Tang Chee Chuan , Voon Kelvin , Premnath Nagalingam
Published: September 2021

Cervical esophageal perforation (CEP) is an uncommon but serious surgical condition. It is associated with a high morbidity and mortality if not managed timely, partly due to its close proximity with vital structures in the neck and mediastinum. The common causes include trauma, foreign body ingestion and iatrogenic perforation. The diagnosis and management of CEP remain challenging despite advances in surgery.

Methods

We present a series of 3 cases of CEPs, with multimodal approach for the management.

Results

In this series of 3 cases of CEPs with different presentations, tailored management strategies resulted with successful outcomes. Post-procedure/operative oral contrast study revealed no contrast leakage.

Conclusion

The diagnosis and management of CEP remain challenging despite advances in surgery. Contrasted CT scan and endoscopy are the mainstay of investigations. The treatment options of CEP range from conservative management to endoscopic intervention to surgical repair often with drainage procedures due to its frequent association with collections in the neck, pleural or mediastinal cavity. Prompt detection and early management with multimodal intervention ensure a better outcome in these patients.
81 ANTI-REFLUX SURGERY: TOUPET AND DOR TECHNIQUES
Authors: Lisboa Fernando , Silva Pedro , Gomes Nathan , Lisboa Fernando , Miranda Kim
Published: September 2021

Gastroesophageal reflux disease (GERD) is one of the most important digestive disorders, in view of the high incidence, intensity of symptoms and severity of complications. GERD is probably one of the most prevalent diseases in the world that compromises quality of life. It is a common disease that affects between 20–40% of the population of the United States of America at least weekly. In Brazil, the incidence is 12%, corresponding to 20 million individuals.

Methods

Prospective and retrospective cohort study, which aims to assess the regression of symptoms in patients undergoing surgical technique to correct GERD. The present study was carried out in Natal, Rio Grande do Norte, Brazil, in two hospitals: one in the private network and another study at the State University Hospital, with 130 patients between 2014 and 2020. The study population consisted of patients with GERD confirmed by clinical symptoms, upper gastrointestinal endoscopy, manometry and/or pH monitoring, with the inclusion criteria: patients with GERD refractory to clinical treatment, with hiatus hernia, with atypical symptoms and/or need for surgical intervention.

Results

We studied 130 patients undergoing GERD correction surgery, 122/130 (93%) Nissen-Toupet, 03/130 (2%) Collis-Dor, 03/130 (2%) Dor and 02/130 (1.5%) Collis-Toupet, with 18/130 (13%) REDO Nissen to Toupet, 13/130 (10%) with mesh reinforcement (TABLE-I) and 01/130 (0.7%) performed Toupet + VSS + gastroenteroanastomosis. In addition, 45/123 (36%) did not have hiatus hernia and 78/123 (63%) did, 40/78 (51%) type 01, 14/78 (17%) type 02 and 18/78 (23%) type 03; 107/130 (82%) performed a manometric study. In short-term complications, 02/130 (1.5%) presented gas bloat syndrome, 01/130 (0.7%) grade 1 dysphagia, fistula 01/130 (0.7%) and mortality 01/130 (0,7%).

Conclusion

In conclusion, it is observed that the partial fundoplication technique, Toupet and Dor, maintains a competent anti-reflux mechanism with the advantage of reducing postoperative dysphagia, the inability to belch and gas bloat syndrome, in addition to decreasing the rates of postoperative recurrence.
815 PL02.09 THE BEST PRACTICE OF RECONSTRUCTION METHODS AFTER ESOPHAGECTOMY WITHOUT STOMACH
Authors: Narumiya Kosuke , Kudo Kenji , Yagawa Yosuke , Maeda Shinnsuke , Toyoshima Noriyuki , Ogawa Kyohei , Ide Hiroko , Osugi Harushi , Yamamoto Masakazu
Published: September 2021

Generally we use the stomach after esophagectomy as an organ of reconstruction. But we could not use it after we performed gastrectomy. We investigated the usefulness of the reconstruction with pedicled jejunum or pedicled right colon.

Methods

We performed esophagectomy from 2000 to 2015.15 patients use the reconstruction with pedicled jejunum as a A.10 patients use the reconstruction with pedicled right colon as a B. We study (1) background (2) complication.

Results

Average Age A:67.1 B:65.5 location (upper:middle:Lower) A:0:14:1 B:1:4:5 depth of tumor invasion (T1:T2:T3:T4) A:9:3:3:0 B:3:5:2 Stage (0:I:II:III:IVa) A:2:6:4:3:0 B:0:1:3:4:2 Reconstruction route (posterior mediastinal:retrosternal:antethoracic) A:4:2:9 B:0:5:5 The reason of the gastrectomy (ulcer: cancer) A 10:5 B 0:10 (distal gastrectomy:total gastrectomy) A:15:0 B:4:6 Reconstruction (BillrothI: BillrothII: Roux-Y) A:12:3:0 B:2:2:6 Complication (leakage)A:B = 3:0 (ileus)A:B = 2:0(weight loss)A:B = 10:0 (diarrhea)A:B = 3:5.

Conclusion

The best practice of reconstruction method is a reconstruction with pedicled jejunum without stomach. We can use the jejunum without damage of the vessel in the mesenteri of the jejunum.
834 ENDOSCOPIC VACUUM THERAPY IN THE MANAGEMENT OF OESOPHAGEAL PERFORATIONS AND POST-OPERATIVE LEAKS
Authors: Mastoridis S , Zanna A , Owen R , Antonowicz S , Sgromo B
Published: September 2021

Oesophageal perforations and post-oesophagectomy anastomotic leaks are associated with high morbidity and mortality. Endoscopic vacuum therapy (EVT) is a novel treatment strategy with the potential to promote healing and ameliorate sepsis. Few instances of the use of EVT have been reported in the UK, wioth only two cases published outside our centre representing a limited aetiological and demographic spectrum.

Methods

From May 2019 to November 2020 8 patients aged 27–85 years underwent EVT for disparate oesophageal wall defects. Data regarding technical success and feasibility were analysed. Video recordings of procedures were undertaken with patient consent.

Results

Complete defect resolution was achieved in cases (87%), requiring median of 13 days of treatment (range 6–23), and necessitating 3 replacement procedures (range 1–4). Significant improvement in C-reactive protein was achieved in all patients undergoing treatment (P = 0.015). Over an average follow up of 360 days, no severe complications resulted directly from sponge placement, however 2 individuals (25%) developed oesophageal stricture necessitating endoscopic balloon dilatation, and one died whilst undergoing treatment.

Conclusion

Here we provide a video demonstration of the application of EVT in patients with oesophageal perforation or post-operative leak. Our data demonstrate this approach to be a safe, valuable tool for the management of a spectrum of oesophageal wall defects, with the potential to reduce associated morbidity and mortality in selected patients.

Video

Video of safe application of EVT. https://www.dropbox.com/s/rgypt6o1z93iui5/EVT.mp4?dl=0.
854 OPTIMIZATION OF SURGICAL DELAY AFTER INDUCTION CHEMORADIATION FOR ESOPHAGEAL CANCER: 10 YEARS RETROSPECTIVE MULTI-CENTER STUDY
Authors: Legault-Dupuis Alexis , Bouchard Philippe , Nicodeme Frederic , Gagne Jean-Pierre , Simard Serge , Lacasse Yves , Hache Pier-Luc , Couture Christian , Laliberte Anne-Sophie
Published: September 2021

The treatment of esophageal cancer is in constant evolution. Most of the esophageal cancer receive induction chemoradiation therapy. Surgical delay has been studied but the optimal timing has not been clarified. Through the years, surgical delay has been modified by surgeons in our institutions, going from an average of 6 weeks delay to an average of 10 weeks delay. It is time to ask if this change has a real positive impact on our patient.

Methods

In this retrospective multi-center study, we combined data from two center in Quebec city that performs oncologic esophagectomy. The surgical delay went from 6 to 10 weeks around 2014. All surgeons changed their practice at that moment. We retrospectively analysed 5 years before and after the change of practice and created two cohorts of patients. Our primary outcome compared complete pathologic response rate. Our secondary outcomes were surgical complications, anastomotic leak, disease free survival and overall survival.

Results

Thirty-eight patients had surgery under 8 weeks (mean: 6 weeks) after their induction chemoradiation compared to 64 patients that had surgery after 8 weeks (mean: 10 weeks). There was no statistical significant difference between groups for the complete pathologic response (32% vs 25%, p = 0,16). Important complications were similar, with a rate of 24% vs 28% (p = 0,69). Anastomotic leaks were less frequent in the less than 8 weeks group, but no statistical significance was obtained (13% vs 27%, p = 0,14). No difference in disease-free survival rate and overall survival rate was noted (DFS 40% vs 55% (p = 0,32), OS 38% vs 38% (p = 0,29)).

Conclusion

The treatment of esophageal cancer is in constant evolution, induction therapy and surgical technics involve over time. Surgical delay has no impact on complete pathologic response, complication and overall survival. There is no advantage to wait longer before surgery.
Inter-Temporal Aggregation for Spatially Explicit Optimal Harvest Scheduling under Area Restrictions
Authors: Yoshimoto Atsushi , Asante Patrick
Published: September 2021

We propose a new approach to solve inter-temporal unit aggregation issues under maximum opening size requirements using two models. The first model is based on Model I formulation with static harvest treatments for harvest activities. This model identifies periodic harvest activities using a set of constraints for inter-temporal aggregation. The second model is based on Model II formulation, which uses dynamic harvest treatments and incorporates periodic harvest activities directly into the model formulation. The proposed approach contributes to the literature on spatially constrained harvest scheduling problems as it allows a pattern of unit aggregation to change across multiple harvests over time, as inter-temporal aggregation under a maximum opening size requirement over period-specific duration. The main idea of the proposed approach for inter-temporal aggregation is to use a multiple layer scheme for a set of spatial constraints, which is adapted from a maximum flow specification in a spatial forest unit network and a sequential triangle connection to create fully connected feasible clusters. By dividing the planning horizon into period-specific durations for different spatial aggregation patterns, the models can complete inter-temporal spatial aggregation over the planning horizon under a maximum opening size requirement per duration.
Genetic screen for suppressors of increased silencing in rpd3 mutants in Saccharomyces cerevisiae identifies a potential role for H3K4 methylation
Authors: Kleinschmidt Richard A , Lyon Laurie M , Smith Samantha L , Rittenberry Jonah , Lawless K Maeve , Acosta Anabelle A , Donze David
Published: September 2021

Several studies have identified the paradoxical phenotype of increased heterochromatic gene silencing at specific loci that results from deletion or mutation of the histone deacetylase (HDAC) gene RPD3. To further understand this phenomenon, we conducted a genetic screen for suppressors of this extended silencing phenotype at the HMR locus in Saccharomyces cerevisiae. Most of the mutations that suppressed extended HMR silencing in rpd3 mutants without completely abolishing silencing were identified in the histone H3 lysine 4 methylation (H3K4me) pathway, specifically in SET1, BRE1, and BRE2. These second-site mutations retained normal HMR silencing, therefore, appear to be specific for the rpd3Δ extended silencing phenotype. As an initial assessment of the role of H3K4 methylation in extended silencing, we rule out some of the known mechanisms of Set1p/H3K4me mediated gene repression by HST1, HOS2, and HST3 encoded HDACs. Interestingly, we demonstrate that the RNA Polymerase III complex remains bound and active at the HMR-tDNA in rpd3 mutants despite silencing extending beyond the normal barrier. We discuss these results as they relate to the interplay among different chromatin-modifying enzyme functions and the importance of further study of this enigmatic phenomenon.
Chromosome-scale reference genome assembly of a diploid potato clone derived from an elite variety
Authors: Freire Ruth , Weisweiler Marius , Guerreiro Ricardo , Baig Nadia , Hüttel Bruno , Obeng-Hinneh Evelyn , Renner Juliane , Hartje Stefanie , Muders Katja , Truberg Bernd , Rosen Arne , Prigge Vanessa , Bruckmüller Julien , Lübeck Jens , Stich Benjamin
Published: September 2021

Potato (Solanum tuberosum L.) is one of the most important crops with a worldwide production of 370 million metric tons. The objectives of this study were (1) to create a high-quality consensus sequence across the two haplotypes of a diploid clone derived from a tetraploid elite variety and assess the sequence divergence from the available potato genome assemblies, as well as among the two haplotypes; (2) to evaluate the new assembly’s usefulness for various genomic methods; and (3) to assess the performance of phasing in diploid and tetraploid clones, using linked-read sequencing technology. We used PacBio long reads coupled with 10x Genomics reads and proximity ligation scaffolding to create the dAg1_v1.0 reference genome sequence. With a final assembly size of 812 Mb, where 750 Mb are anchored to 12 chromosomes, our assembly is larger than other available potato reference sequences and high proportions of properly paired reads were observed for clones unrelated by pedigree to dAg1. Comparisons of the new dAg1_v1.0 sequence to other potato genome sequences point out the high divergence between the different potato varieties and illustrate the potential of using dAg1_v1.0 sequence in breeding applications.