bluuebunny/crossref_metadata_2025 huggingface dataset:
PS02.245: GLUTATHIONE S-TRANSFERASE PI 1 (GSTP1) IS ONE OF VALUABLE PREDICTORS RELATED TO POOR PROGNOSIS AND RESISTANCE TO CHEMOTHERAPY IN ESOPHAGEAL CANCER
Authors: Ogino Shinpei , Konishi Hirotaka , Matsubara Daiki , Shoda Katsutoshi , Arita Tomohiro , Kosuga Toshiyuki , Shiozaki Atsushi , Okamoto Kazuma , Otsuji Eigo
Published: September 2018

Background

Esophageal squamous cell carcinoma (ESCC) is one of the most aggressive malignancies worldwide, however, there is no useful marker for diagnosis and treatment. Glutathione S-transferase Pi 1 (GSTP1) is a member of GST family, a phase-II metabolic enzyme, and has reported as a predictor of malignancy and sensitivity to anti-cancer drugs in some cancers. In this study, we investigated the association of GSTP1 expression with malignancy and resistance to chemotherapy in ESCC patients.

Methods

The ability of proliferation and sensitivity to anti-cancer drugs regarding GSTP1 expression were examined in ESCC cell lines, KYSE170 and TE13. Proliferation assay and apoptosis assay using fluorescent activated cell sorting (FACS) were performed. In addition, immunohistochemistry assays of tissue samples were performed in 75 ESCC patients without neoadjuvant chemotherapy and 71 patients with neoadjuvant chemotherapy.

Results

The proliferation of GSTP1 knockdown cells were significantly decreased compared to that of control cells in KYSE170 and TE13. Similarly, the frequency of early apoptosis in GSTP1 knockdown cells were higher than that of control cells. Survival rate of GSTP1 knockdown cells treated with cisplatin was lower than that of control cells in chemoresistance assays. Moreover, the frequency of early apoptosis in GSTP1 knockdown cells treated with cisplatin were markedly higher than that of control cells. In immunohistochemistry assay of ESCC patients without neoadjuvant chemotherapy, high GSTP1 expression was an independent predictor of a poor prognosis (P = 0.029). Regarding immunohistochemistry assay of tissue samples with neoadjuvant chemotherapy, GSTP1 expression significantly associated with downstaging of clinical stage (P = 0.042).

Conclusion

GSTP1 related to the prognosis and resistance to chemotherapy in ESCC patients. However, accurate assessment of resected specimen with chemotherapy was difficult because tumor cells sensitive to chemotherapy were already absent. Further analysis using samples without chemotherapy such as biopsy samples would be more appropriate for the assessment of the sensitivity to chemotherapy.

Disclosure

All authors have declared no conflicts of interest.
PS02.246: SURGICAL OUTCOMES OF SURGICAL T4B THORACIC ESOPHAGEAL CANCER
Authors: Uemura Norihisa , Abe Tetsuya , Higaki Eiji , Hosoi Takahiro , An Byonggu
Published: September 2018

Background

Patients with surgical T4b (sT4b) thoracic esophageal cancer undergo exploratory thoracotomy or non-curative resection. However, in some cases, it is difficult to decide whether to perform exploratory thoracotomy without resection, or perform non-curative resection to the extent possible. The purpose of this retrospective study was to analyze surgical outcomes of sT4b thoracic esophageal cancer to clarify the optimal treatment strategy.

Methods

A total of 12 patients with sT4b thoracic esophageal cancer underwent exploratory thoracotomy (n = 7) or non-curative resection (n = 5) between January 2011 and December 2015. Of the seven patients who underwent exploratory thoracotomy, two underwent bypass surgery. In the five patients who underwent non-curative resection, gastric reconstruction was performed. Clinical data from these 12 patients were analyzed retrospectively.

Results

Compared to the seven patients who underwent exploratory thoracotomy (Ex group), the five patients who underwent non-curative resection (NC group) had a significantly longer period until the start of post-treatment (median, 23/57 (Ex/NC) days; P = 0.0027). No significant difference was observed in the postoperative survival period between the two groups (Median survival time (MST), 9/12 (Ex/NC) months; P = 0.55). In the prognostic factor analysis, patients with progressive disease (PD) responsiveness to preoperative treatment had a significantly poorer prognosis (MST, 13.5/5.5 (partial response-stable disease/PD) months; P = 0.01). On the other hand, patients with cStage 3 disease and who received postoperative chemoradiotherapy had a relatively good prognosis (cStage 3/4; MST 12.5/5.5 month, P = 0.09, postoperative chemoradiotherapy received/not received; MST 13/5 month, P = 0.11). The period until the start of post-treatment was not a prognostic factor.

Conclusion

Responsiveness to preoperative treatment was found to be a prognostic factor in patients with sT4b thoracic esophageal cancer. Thus, if patients show a poor response to preoperative treatment, R0 resection should be performed without exploratory thoracotomy. On the contrary, for patients with a good response to preoperative treatment, administration of post-operative chemoradiotherapy should be considered, while maintaining performance status without causing serious secondary injury.

Disclosure

All authors have declared no conflicts of interest.
RA01.03: HAND-SEWN INTRATHORACIC ESOPHAGO-GASTRIC ANASTOMOSIS IN 2-STAGE TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER
Authors: Charalabopoulos Alexandros , Lawrence Justin , Kordzadeh Ali , Lorenzi Bruno
Published: September 2018

Description

This is a video of a hand-sewn 2-layer end-to-side intra-thoracic esophago-gastric anastomosis performed thoracoscopically during a totally minimally invasive 2-stage esophagectomy for cancer. The suture material used is the barbed V-Lock. We routine perform this anastomosis in all 2-stage minimally invasive esophagectomies in our Unit since 2016. We have performed about 50 consecutive esophagectomies with this anastomosis with < 3% leak rate.

Disclosure

All authors have declared no conflicts of interest.
RA01.05: MINIMALLY INVASIVE ESOPHAGECTOMY AND 3-FIELD LYMPH NODE DISSECTION (ESOPHAGEAL SUSPENSION METHOD)—FUJIAN MEDICAL UNIVERSITY UNION HOSPITAL EXPERIENCE
Authors: Zheng Bin , Zhang Shuliang , Zeng Taidui , Zheng Wei , Chen Chun
Published: September 2018

Description

We have modified our procedures of lymphadenectomy, with the purpose of radical lymph node dissection, because we believe that radical lymph node dissection along bilateral RLNs may be crucial for post-operative accurate staging, local control and better prognosis. Programmed lymphadenectomy includes several steps. Programmed extensive lymphadenectomy along right RLN included 3 steps: (1) Location of the right vagus nerve. (2) Loaction of the root of the right RLN. (3) Extensive lymphadenectomy. Programmed extensive lymphadenectomy along left RLN was conducted subsequently, which included 4 steps. (1) Esophageal suspension. (2) Lymph node rolling.(3) Location and identification of left RLN. (4) Extensive lymphadenectomy. During the whole procedure, we preferred to use blunt separation in the zones near the RLN, and preferred to use the ultrasound knife and scissors rather than electrical knife. The thoracic esophagus was not cut off during the procedure. After the thoracic procedures, we do the laparoscopic gastric dissociation and lymph node dissection. When metastasis to either RLN chains was confirmed by routine intra-operative frozen section, bilateral cervical lymphadenectomy was also performed. We divided the procedures into steps, which could have following advantages: more radical lymph node clearance with skeletonization of the nerves, reduced injuries due to definite location and identification of the nerves, more easier for surgeons to expose the surgical field and more easier for new-hands to master the procedures. Minimally invasive esophageactomy and thoracoscopic programmed extensive lymphadenectomy along the left and right RLNs in esophagectomy was feasible and safe. According to our study, programmed extensive lymphadenectomy yielded sufficient lymph nodes, with acceptable postoperative complications.

Disclosure

All authors have declared no conflicts of interest.
RA01.08: LAPAROSCOPIC ROUX-EN-Y GASTROJEJUNOSTOMY FOR GASTRIC CONDUIT OUTLET OBSTRUCTION FOLLOWING ESOPHAGECTOMY FOR CANCER
Authors: Bernardi Daniele , Porta Matteo , Asti Emanuele , Lazzari Veronica , Ceriani Chiara , Bonavina Luigi
Published: September 2018

Description

After Ivor Lewis esophagectomy, gastric outlet obstruction refractory to prokinetic therapy and/or endoscopic pyloric dilatation is a challenging clinical problem. Thoracoscopic implant of a gastric neurostimulator has been reported to be effective, but long-term results are lacking. The patient, a 57-year-old woman, underwent a Ivor Lewis esophagectomy for T1N0 adenocarcinoma in 2007. Postoperatively, the patient complained of persistent dysphagia, regurgitation, and 29-kg weight loss. A mechanical obstruction was ruled out by barium swallow study and upper gastrointestinal endoscopy. Several conservative attempts with prokinetic agents and endoscopic dilatations failed, and the patient was exclusively fed through jejunostomy until the thoracoscopic implant of a gastric neurostimulator in October 2015. The postoperative course was uneventful. At six-months follow-up, the patient was able to assume a soft diet and reported a weight gain of 3 kg, with a significant improvement of the total symptom score and gastric emptying scintigraphy. Nevertheless, this encouraging clinical benefit gradually disappeared after the first year of follow-up. At the beginning of 2017, the patient experienced persistent episodes of vomiting and returned to jejunostomy feeding. The video shows the technique of laparoscopic Roux-en-Y gastrojejunostomy. After adhesiolysis and transhiatal mobilization of the distal gastric conduit, a 50 cm long Roux-en-Y alimentary limb was fashioned and anastomosed to the antrum. Post-operative course was uneventful and a gastrographin swallow study showed a satisfactory emptying of the conduit. At the 3-month follow-up the patient was able to resume a soft oral diet. Laparoscopic Roux-en-Y gastrojejunostomy appears to be safe and effective in treating refractory gastric outlet obstruction following Ivor-Lewis esophagectomy.

Disclosure

All authors have declared no conflicts of interest.
RA02.02: RANDOMISED OESOPHAGECTOMY: MINIMALLY INVASIVE OR OPEN: THE ROMIO STUDY
Authors: Berrisford Richard
Published: September 2018

Background

Oesophagectomy is the mainstay of curative treatment for oesophageal cancer; however, surgery is followed by a reduction in health-related quality of life (HRQL). Whether minimally invasive approaches improve HRQL is unknown and limited comparative evidence available. The ROMIO study is a pragmatic multi-centre randomised controlled trial (RCT) aiming to establish the clinical and cost effectiveness of laparoscopically-assisted (LAO) versus open oesophagectomy (OO) in patients with oesophageal cancer in terms of HRQL, complications and survival. It includes an exploratory study of totally minimally invasive oesophagectomy (TMIO).

Methods

Adult participants referred for primary oesophagectomy or oesophagectomy following re-staging after neoadjuvant chemotherapy or chemoradiotherapy for oesophageal or oesophago-gastric adenocarcinoma or squamous cell cancer are eligible. Consenting patients are randomised 1:1 to receive OO or LAO except in two centres where participants are randomised to LAO, OO or TMIO (1:1:1). The primary outcome is the EORTC QLQ-C30 physical function scale, assessed at 3, 6 and 12 weeks after randomisation. Secondary outcomes include hospital stay, blinded assessment of pain, surgical complications, other aspects of HRQL and survival to 24 months. Quality assurance of surgery is assessed with, i) surgeon entry criteria based on provision of two operative videos, ii) 7 standard intra-operative photographs, and, iii) histopathological assessment of the specimen. A qualitative intervention is being used to train surgeons to recruit and communicate clinical equipoise. 406 patients are required to examine whether the minimum clinically important difference on the QLQ-C30 physical function scale is detected, allowing for 5% of patients allocated to LAO to undergo OO and a proportion to be inoperable or not followed up (90% power, 5% significance). This will also detect a clinically important reduction in length of stay.

Results

Seven UK centres involving 33 surgeons are recruiting. 288 patients have been screened, of which 206(73%) are eligible and 117(56%) eligible randomised. 21 surgeons have submitted at least two videos for assessment. Of the 102 patients operated on, 1058 photographs have been returned from 85 different patients. Follow up is currently at 79% for all time points.

Conclusion

This RCT will provide evidence to inform decision-making and informed consent for oesophagectomy.

Disclosure

All authors have declared no conflicts of interest.
RA02.06: PREVENTION OF ATRIAL FIBRILLATION AND POSTOPERATIVE COMPLICATIONS USING LANDIOLOL HYDROCHLORIDE AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Ojima Toshiyasu , Nakamori Mikihito , Nakamura Masaki , Katsuda Masahiro , Hayata Keiji , Yamaue Hiroki
Published: September 2018

Background

The aim of this study was to evaluate if landiolol hydrochloride is effective and safe in the prevention of atrial fibrillation (AF) after esophagectomy and that the reduction of AF incidence would reduce other postoperative complications. No prospective data exist regarding the efficacy of landiolol in preventing new-onset AF and translating low morbidity in esophageal cancer patients after esophagectomy.

Methods

One hundred patients scheduled for transthoracic esophagectomy were enrolled in a randomized, double-blind, placebo-controlled trial between March 2013 and January 2016 in our institute. Enrolled patients were randomized with 1:1 parallel allocation ratio to either with or without landiolol prophylaxis. The primary endpoint was the occurrence of AF after esophagectomy. The secondary endpoints were incidence of postoperative complications, hemodynamics and inflammatory index.

Results

Postoperative AF occurred in 15 patients (30%) in the placebo group versus five patients (10%) in the landiolol group. The landiolol group showed a significantly lower incidence (P = 0.012). Overall incidence of postoperative complications was significantly lower in the landiolol group (P = 0.046). In the landiolol group, postoperative heart rate was effectively suppressed, while the decreased of blood pressure was not harmful. IL-6 level was significantly lower in the landiolol group after the administration (P < 0.01).

Conclusion

This is the first comparative trial that proved landiolol is indeed effective and safe in preventing AF after esophagectomy. We recommend that landiolol to be a part of the regimen for perioperative management of esophageal cancer patients undergoing transthoracic esophagectomy. Registration number: UMIN000010648 (http://www.umin.ac.jp/ctr/)

Disclosure

All authors have declared no conflicts of interest.
RA02.09: THE EFFECT OF PREOPERATIVE BREATHING EXERCISE IN PATIENTS UNDERGOING ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Takuya Hamakawa , Hirao Motohiro , Nishikawa Kazuhiro , Fujiwara Ayako , Maeda Sakae , Uemura Mamoru , Miyake Masakazu , Hama Naoki , Miyamoto Atsushi , Kato Takeshi , Takami Koji , Nakamori Shoji , Sekimoto Mitsugu
Published: September 2018

Background

Patients with esophageal cancer often have impaired respiratory function. Postoperative pulmonary complications frequently occur in patients undergoing esophagectomy. We instructed patients undergoing esophagectomy to do breathing exercise with Incentive Spirometer Coach 2 (Smiths medical) for at least two weeks before surgery, as well as smoking cessation.

Methods

We retrospectively reviewed medical records of 52 esophageal cancer patients who underwent spirometry both pre- and post- Coach 2 exercise between 2009 and 2017. We evaluated the change of respiratory function and postoperative complications. The influence of exercise was analyzed between patients who underwent neoadjuvant chemotherapy (NAC group, n = 36) and those treated without NAC (non-NAC group, n = 16).

Results

39 males and 13 females were included. Median age was 65 (45–82). Surgical procedures were 48 subtotal esophagectomy, 3 transhiatal esophagectomy, and 1 pharyngo-laryngo-esophagectomy. Vital capacity (VC) and forced expiratory volume in one second (FEV1.0) were significantly improved through exercise; 3405 to 3600ml (P = 0.021) and 2485 to 2555 ml (P = 0.008), respectively. NAC group included more advanced-staged cases but age and baseline respiratory function were not significantly different from non-NAC group. Interval between first and second spirometry was 31 days for non-NAC group, 69 days for NAC group. After exercise, non-NAC group showed significant improvement in VC (3135 to 3600ml, P = 0.006), FEV1.0 (2255 to 2565ml, P = 0.004), whereas NAC group showed little change in VC (3560 to 3630ml, P = 0.514), FEV1.0 (2585 to 2555ml, P = 0.514). Postoperative complication occurred in 27 of 52 cases. Postoperative pneumonia occurred in 7 (13.5%) in the present cohort, which was less frequent than 42% in the historical control cohort without breathing exercise.

Conclusion

Preoperative breathing exercise with Coach 2 improved respiratory function in patients without NAC. In patients with NAC, the effect of exercise was smaller than non-NAC group, still exercise might suppress the decrease of respiratory function during NAC. Breathing exercise may reduce postoperative pulmonary complications.

Disclosure

All authors have declared no conflicts of interest.
RA04.01: PRONE POSITION IN THORACOSCOPIC ESOPHAGECTOMY IMPROVES POSTOPERATIVE OXYGENATION AND REDUCES PULMONARY COMPLICATIONS
Authors: Kakeji Yoshihiro , Otsubo Dai , Takiguchi Gosuke , Oshikiri Taro , Nakamura Tetsu
Published: September 2018

Background

While thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest.

Methods

A total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis.

Results

Two patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P.

Conclusion

From a surgical point of view, artificial pneumothorax and gravity improves the operative field view in the prone position without any compression of the right lung, thereby resulting in no mechanical damage to the lungs. Prone position esophagectomy is a useful surgical technique, which appears to preserve the postoperative pulmonary function. The patients are able to endure the surgical procedure and present with less respiratory complications.

Disclosure

All authors have declared no conflicts of interest.
RA04.04: EVOLUTION FROM THORACOSCOPIC ESOPHAGECTOMY (MIE) TO ROBOTIC-ASSISTED (RAMIE): ANALYSIS OF EARLY AND LATE RESULTS 195 CASES
Authors: Sallum Rubens , Takeda Flavio , Santo Marco , Cecconello Ivan
Published: September 2018

Background

RAMIE by Transthoracic and Abdominal robotic approach (TT-r) or Transhiatal robotic (TH-r) are options and gained evidence among the major oncological procedures as well as lymph nodal dissection. The concept of esophagectomy and extensive lymphadenectomy with low morbidity boosted by the videothoracoscopic esophagectomy(MIE) is now focused on the new robotic approachs.

Methods

41 cases of RAMIE were studied. The TT-r approach (prone position- three arms and abdominal robotic) was performed in 37 and TH-r approach in 5 (most elderly AC patients - 75 to 86y.o.). Conversion to open or laparoscopic procedures, morbidity and mortality as well as the length of the lymphadenectomy were evaluated. These data were compared to the first 154 cases of MIE operated by the same surgical team in those early results. Also the late survival of the MIE group is presented.

Results

All RAMIE except 2 cases were Siewert I or II Adenocarcinoma, 34 post neoadjuvancy: MAGIC (7) or CROSS (27). There was no conversion to lap or open procedures. No patient received blood transfusion. One complication was observed: a partial rotation of gastroplasty in the thorax, that required thoracoscopic approach in the day 7. Mortality (90 days) was zero. Mean resected lymph nodes was 40 (22–76) and less in TH-r (23 × 43). In the MIE group, complications were: respiratory (26.2%), infectious (8.4%), cervical fistula (17.7%), vocal cord palsy (8.4%). 30 and 90 days mortality were one (0.93%) and 3 (2.8%). Mean dissected lymph nodes = 31.6 (± 14.3), 1:57 positives (± 3.21) and RAD 00:05 (± 0:09). The overall five-year survival was 69% (95% CI: 57% - 83%), 75% in stage 0/I/II and 42% in III/IV.

Conclusion

RAMIE with TT-r or TH-r technical proposals, seems to be safe without mortality. Lymph nodal achieved was equal to greater than the practiced through MIE and both higher than TH-r cases. No mortality or major complications were observed on elderly patients (mean 80.5yo.) submitted to TH-r Esophagectomy

Disclosure

All authors have declared no conflicts of interest.
RA04.05: PREVALENCE OF LYMPH-NODE METASTASIS IN T1B ESOPHAGEAL SQUAMOUS CELL CANCER: IMPLICATIONS FOR ADDITIONAL RADIOTHERAPY DESIGN FOLLOWING ENDOSCOPIC SUBMUCOSAL DISSECTION
Authors: Liu Jun , Fu Xiaolong , Li Hongxuan , Cheng Yan , Li Zhigang
Published: September 2018

Background

Endoscopic submucosal dissection (ESD) can be used as a less invasive treatment option for early esophageal cancer. But how to prevent lymph node metastasis is essential in these patients. This study aimed to analyze prevalence of lymph nodes metastasis for T1b thoracic esophageal squamous cell carcinoma(TESCC) patients treated in Shanghai Chest Hospital(SCH) and to propose a clinical target volume (CTV) for additional radiotherapy Clinical Target Volume design following endoscopic submucosal dissection(ESD) in these patients.

Methods

From 2012 to 2017, consecutive patients with T1b TESCC patients who underwent complete resection in SCH were identified. The prevalence of lymph-node metastasis were assessed and evaluated whether these metastasis areas would be encompassed by our proposed CTV. We proposed lymph-node stations (JEOG) 101, 104, 105, 106, 107 for upper TESCC, lymph-node stations 106, 107, 108, 1, 2, 3, 7, 8, 9, 10 for middle TESCC, and lymph-node stations110, 112, 1, 2, 3, 7, 8, 9, 10 for lower TESCC.

Results

There were 240 patients (80.4% male) who met the inclusion criteria, with a mean age of 62 ± 7 years. Of the total, 27.1%(65/240) patients presented with lymph nodes metastasis. Single lymph-node and single station lymph-node metastasis among positive nodes patients were 63.1%(41/65) and 70.8%(46/65), respectively.Tumor length exceeding 20mm and poor tumor differentiation but not age, gender, tumor position and tumor thrombus were independently associated with the risk of nodal disease. Among positive nodes patients, 89.2% (58/65) lymph-node metastasis for T1b TESCC patients could be covered by proposed CTV.

Conclusion

Prevalence of lymph node metastasis is high in patients with T1b TESCC. It seemed additional radiotherapy after ESD for those patients with high risk factors is needed to prevent lymph node metastasis. Majority positive nodes area could be covered by our proposed CTV. However, the value of radiotherapy and the proposed CTV should be investigated in further prospective studies.

Disclosure

All authors have declared no conflicts of interest.
RA04.06: ESOPHAGECTOMY IN PATIENTS WITH EARLY STAGE ESOPHAGEAL CANCER AFTER NON-CURATIVE ENDOSCOPIC SUBMUCOSAL DISSECTION
Authors: Tschoner Andreas , Ziachehabi Alexander , Spaun Georg , Adelsgruber Peter , Schöfl Rainer , Függer Reinhold
Published: September 2018

Background

Early stage esophageal cancer has a low risk of lymph node metastasis. Therefore, an organ preserving endoscopic submucosal resection for tumors staged uT1 N0 has already been established. In case of non-curative dissection according to oncologic criteria esophagectomy has to be performed to achieve an oncologic resection.

Methods

Between 2010 and 2016 42 patients with early stage esophageal cancer underwent endoscopic submucosal dissections (ESD). We retrospectively evaluated the operative and pathologic outcome as well as disease free and overall survival in patients, who were operated on with esophagectomy because of non-curative endoscopic resection.

Results

5 of 42 (11.9%) had to be operated on: 3 patients with open abdominothoracal resektion with intrathoracal anastomosis, 1 patient with an open approach and a cervical anastomosis and 1 patient with an laparoscopic/thoracoscopic approach but open intrathoracic anastomosis. Reasons for ongoing resection were three times R1 endoscopic resection, one L1 infiltration and one sm1-infiltration in a squamous cell carcinoma. There was no perioperative mortality. One anastomotic leakage was treated interventionally, one thoracic surgical site infection conservatively. One anastomotic leakage had to be resected, put on a saliva fistula and reconstructed with a colonic interponate. No recurrence of cancer is observed so far.

Conclusion

Esophagectomy after non-curative ESD shows no evidence for a worse oncologic outcome. There is no higher peri- and postoperative risk. This legitimates our step-up approach.

Disclosure

All authors have declared no conflicts of interest.
RA05.01: SURGICAL MANAGEMENT OF ESOPHAGEAL SARCOMA: A MULTICENTER EUROPEAN EXPERIENCE
Authors: Mege Diane , Depypere Lieven , Piessen Guillaume , Slaman Annelijn E , Wijnhoven Bas P L , Hölscher Arnulf , Nilsson Magnus , Van Berge Henegouwen Mark I , Van Lanschot J Jan B , Schroeder Wolfgang , Thomas Pascal , Nafteux Philippe , D'Journo Xavier Benoit
Published: September 2018

Background

Esophageal sarcomas (ES) are rare and evidence in literature is scarce making their management difficult. The objective is to report surgical and oncological outcomes of ES in a large multicenter European cohort.

Methods

This is a retrospective multicenter study including all patients who underwent en-bloc esophagectomy for ES in 7 European tertiary referral centers between 1987 and 2016. The main outcomes and measures are pathological results, early and long-term outcomes.

Results

Among 10,936 esophageal resections for cancer, 21 (0.2%) patients with ES were identified. The majority of tumors was located in the middle (n = 7) and distal (n = 9) third of the esophagus. Neoadjuvant chemoradiotherapy was performed in 5 patients. All the patients underwent en-bloc transthoracic esophagectomy (19 open, 2 minimally invasive). Postoperative mortality occurred in 1 patient (5%). One patient received adjuvant chemotherapy. Definitive pathological results were carcinosarcoma (n = 7), leiomyosarcoma (n = 5), and other types of sarcoma (n = 9). Median tumor length was 5 cm [1–10]. Microscopic R1 resection was present in 1 patient (5%) and 7 patients (33%) were N + . Median follow-up was 16 (3–79) months in 20 of 21 patients (95%). One-, 3- and 5-year overall survival (OS) rates were 74%, 43% and 35%, respectively. One-, 3- and 5-years disease-free survival (DFS) rates were 58%, 40% and 33% respectively. Median overall survival (OS) was 33 months for patients with a tumor ≤ 5 cm and 13 months for patients with a tumor > 5 cm (P = 0.54). Median OS was 6 months in N + patients vs. 37 months for N0 patients (P = 0.06). At the end of the follow-up period, 9 patients had died from cancer recurrences (43%), 3 patients from other reasons (14%), 1 patient was still alive with recurrence (5%) and the 7 remaining patients were free of disease (33%). Recurrence was local (n = 3), metastatic (n = 3) or both (n = 4).

Conclusion

Carcinosarcoma and leiomyosarcoma were the most common ES histological sub-types. Tumor size and N + disease seemed prognosis factors. Transthoracic en-bloc esophagectomy with radical lymphadenectomy should be recommended to achieve complete resection. Long-term survival remained poor with a high local and distant recurrence rate.

Disclosure

All authors have declared no conflicts of interest.
RA05.03: THE INFLUENCE OF ANASTOMOSIS ON THE BLOOD SUPPLY OF STOMACH AND THE OPTIMIZATION OF WIDTH OF TUBULAR STOMACH IN END-TO-SIDE ESOPHAGEAL-GASTRIC ANASTOMOSIS
Authors: Hu Yang
Published: September 2018

Background

End-to-side esophageal-gastric anastomosis is the most commonly used method of anastomosis in esophagectomy. Narrow gastric tube, especially 3cm-wide one, is thought to improve the blood supply of stomach. But with the combine use of these two techniques, we found alimentary tract leakage became more common. The reason was obscure. Few have considered the influence of anastomosis-induced gastric wall defect on the blood supply of gastric tube (Figure 1). We carried out this research to prove this hypothesis and to find out method to resolve this problem.

Methods

Animal experiment and clinical cohort study have been carried out. Narrow gastric tube group (3cm wide) and baseball-bat-shaped gastric tube group (5cm in avascular area) were compared. In animal experiment, 3 pigs in each group. Impaired blood supply will slow down blood flow and cause metabolic acidosis. So blood gas analysis (with the blood collected in gastric wall distal or proximal to the anastomosis) and arteriography with methylene blue were performed. pH and BE(from blood gas analysis) and time required for methylene blue to reach the tip of gastric tube were used to evaluate the blood supply of these areas. In cohort study, 176 patients were enrolled with 24 in narrow gastric tube group and 152 in bat-like gastric tube group. The incidence of leakage was compared.

Results

In animal experiment, before anastomosis, no metabolic acidosis was found in both groups. But after anastomosis, methylene blue couldn’t reach the gastric wall distal to the anastomosis, and the blood gas analysis shows metabolic acidosis with the blood from the same area, only in narrow group, These indicated insufficient blood supply in this area. In the cohort study, the incidence of leakage was much higher in narrow group.

Conclusion

Anastomosis can influence the blood supply of the gastric tube distal to it. It's the reason of the increase of alimentary tract fistula incidence with the use of 3cm-wide narrow gastric tube. Widen the gastric avascular area is an effective way to prevent this. So for end-to-side anastomosis, 5cm-wide gastric tube is preferred, while narrower gastric tube is suitable for other mode of anastomosis which do not cause gastric wall defect

Disclosure

All authors have declared no conflicts of interest.
RA05.04: MANAGEMENT & OUTCOMES OF ANASTOMOTIC LEAKS FOLLOWING ESOPHAGECTOMY: A PROSPECTIVE 10-YEAR SINGLE-SITE EXPERIENCE
Authors: Lambert Joel , Caratella Sanya , Lawrence Eloise , Alkhaffaf Bilal
Published: September 2018

Background

Anastomotic leak after esophagectomy is associated with high levels of morbidity and may impact negatively on oncological outcomes. The aim of this single centre study was to describe our experience in managing these complications

Methods

From 2007–2017 data was reviewed retrospectively from our prospectively maintained electronic database. All patients underwent either 2 or 3 phase esophagectomy for cancer of the oesophagus or esophago-gastric junction. All histological sub-types and stage of cancer were included in the analysis. Anastomotic leaks were classified according to the Esophagectomy Complications Consensus Group (ECCG) guidelines; type I—conservative management, type II—non-surgical intervention, type III—surgical intervention.

Results

224 esophagectomies were included in our analysis (104 (46%) minimally invasive, 120 (54%) open approach). The incidence of all anastomotic leaks was 10% (23/224). Surgical approach did not influence the incidence of anastomotic leak (minimally invasive 10 (43%), open approach 13(57%), P = 0.76). Five patients (22%) had a type I leak, 9 patients (39%) type II and 9 (39%) had a type III leak. There was an increase in the number of leaks managed non-surgically over the last 5 years compared to those in the first five years of our dataset (2012–2017: 11/23 (48%) vs 2007–2012: 4/23 (17%) P = 0.08). The median time for leak diagnosis was 8 days. Most leaks were diagnosed with oral contrast CT 19 (83%). Median hospital stay after anastomotic leak was 58.5 days. Type III leaks were associated with an increased length of stay (median 84 days) compared to type I&II leaks (median (38.5 days) (P = 0.002 95% CI 18.19- 74.41). There was no significant difference in 30-day mortality between type I&II (0 patients) and type III leaks (1 patient) P = 0.260.

Conclusion

Low mortality rates with anastomotic leak can be achieved. In centres with experienced radiological and endoscopic skills, most anastomotic leaks can be managed non-surgically.

Disclosure

All authors have declared no conflicts of interest.
RA05.05: STOMACH PRESERVED ILEOCOLIC INTERPOSITION AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Ueno Masaki , Haruta Syuusuke , Tanaka Tsuyoshi , Okura Yu , Iizuka Toshiro , Udagawa Harushi
Published: September 2018

Background

A stomach is the first choice as an esophageal substitute after esophagectomy for cancer. In case with a history of gastrectomy, concurrent gastric disease, the ileo-colon is used as an esophageal substitute in our hospital. From 2007, as a method of preservation of the gastrointestinal function, we have provided the reconstruction of stomach preserved ileo-colic interposition.

Methods

1990–2017.12, 227 patients underwent colon interposition after esophagectomy with extended lymphadenectomy. Until 1997, we selected the colon graft based on colon vessel finding during surgery. From 1998, we assumed ileo-colon first choice. From 2007, we started stomach preserved ileo-colic interposition. Between 2007 and 2017, we performed this method in 108/142 colon interposition patients. We examined these 108 patients to know the recent result of ileo-colon interposition.

Results

An average of 108 patients is 61 years. The cases without preoperative treatment was 38 cases (35%). Endoscopic resection was done in 23 cases (21%). 38 received preoperative chemo and 9 CRT. Clinical TNM was I/II/III/IV = 62/20/24/2. We performed lymphadenectomy with three field in 70 and two in 38. Route of reconstruction was retrosternal in 99(92%), a posterior mediastinal in 8. Microvascular anastomosis was conducted in one. The anastomosis of all cases performed hand-sewn end-to-side anastomosis in neck. The incidence of postoperative morbidity is one patient had anastomotic minor leakage (1%), one had pneumonia to need intubation. 4 patients experienced bowel obstruction, 1 required surgery. Endoscopy had done 4–12 month later, there were no patients have reflux esophagitis or anastomotic stenosis. 12 patients had colon-gastric anastomotic ulcer. PPI was started. The weight rate of decline of the 12 months after surgery was an average of 9%. 32% patients have diarrhea.

Conclusion

Stomach preserved ileo-colic interposition after esophagectomy with extended lymphadenectomy is feasible and have a favorable outcome. Keep up long-term quality of life and decrease in complications after the long-term progress is expected.

Disclosure

All authors have declared no conflicts of interest.
RA05.08: OPTIMAL RADIATION DOSE IN THE NEOADJUVANT TREATMENT OF ESOPHAGEAL CANCER: A COMPARATIVE EUROPEAN STUDY
Authors: Mantziari Styliani , Allemann Pierre , Winiker Michael , Messier Marguerite , Demartines Nicolas , Piessen Guillaume , Schäfer Markus
Published: September 2018

Background

Current guidelines recommend the use of neoadjuvant chemo-radiation (NCR) for the treatment of locally advanced esophageal cancer, both types, adenocarcinoma (AC) and squamous cell carcinoma (SCC). So far, the optimal dose of radiotherapy to achieve a maximal tumor response within an acceptable toxicity is not yet determined. The aim of this study was to assess the impact of preoperative radiation dose on postoperative outcomes and long-term survival.

Methods

Consecutive patients operated in two European tertiary centers for AC or SCC, treated with NCR and surgery from 2000–2016 were assessed. Specific postoperative complications (i.e. anastomotic leakage, atrial fibrillation), histological tumor regression grade (TRG, Mandard score), overall and disease-free survival were compared among three patients groups: group A (41.4Gy), group B (45Gy), and group C (50.4Gy). The x2 or Fisher test were used for categorical variables and ANOVA for continuous variables. Survival analysis was done with the Kaplan-Meier method and log-rank test.

Results

There were 294 patients included; 41.5% (n = 122) had AC and 58.5% (n = 172) SCC. Overall, 9.2%/27 patients received 41Gy, 57.8%/170 patients 45Gy and 33%/97 patients received 50.4Gy. Carboplatin-Paclitaxel was the most frequently used chemotherapy for group A (62.9%), and 5FU-Cisplatin for groups B (69.4%) and C (51.5%). Postoperative anastomotic leakage was lower for group B (7.1%) compared to group A (22.2%) and C (13.4%) (P = 0.036), as was the occurrence of atrial fibrillation (11.8% group B, 33.3% group A and 19.6% group C, P = 0.013). Complete or excellent response (TRG 1–2) was significantly better for group B (58.2%), followed by group C (49.5%) and A (25.9%) patients (P = 0.012). Median overall survival was 48, 27 and 29 months for group A, B and C (P = 0.498), and median disease-free survival was 13, 27 and 18 months (P = 0.411), respectively.

Conclusion

Preoperative radiotherapy dose of 45Gy with 5FU-Cisplatin was associated with a better histological response and less postoperative adverse outcomes compared to 41Gy and 50.4Gy, with no significant differences in long-term recurrence and survival. The role of the type of chemotherapy and histological tumor type are important co-factors affecting outcome and must be further assessed.

Disclosure

All authors have declared no conflicts of interest.
RA06.02: DETECTION OF ALTERED BOLUS TRANSPORT THROUGH THE ESOPHAGUS AND ESOPHAGO-GASTRIC JUNCTION IN PATIENTS WITH HIATUS HERNIA AND DYSPHAGIA
Authors: Estremera-Arevalo Fermin , Dent John , Omari Taher , Myers Jennifer
Published: September 2018

Background

Dysphagia can occur in patients with a small hiatus hernia (HH). Whether this relates to a pressure-flow variation through the esophagus or esophago-gastric junction (EGJ) is unknown.

Methods

High-resolution impedance manometry (HRIM) performed off therapy in 210 reflux patients and 25 age-matched healthy volunteers, recorded 10 × 5mL saline and likewise viscous bolus swallows. Esophageal pressure flow analysis (PFA) with AIMplot v8.0 was undertaken for valid bolus swallows. HRIM EGJ-subtype and endoscopic + /- fluoroscopic imaging enabled HH diagnosis (2–5 cm, > 5 cm excluded). Dysphagia was scored for difficulty swallowing 9 food types (Dakkak and Bennett; 0 none to 45 severe). ANOVA assessed differences in biomechanics of controls and HH + /- patients and dysphagia (D + , > 10/45).

Results

To date, findings for 135 patients (74M 61F, BMI 28, 19–41) with 70 HH + positive were compared with the 65 HH- negative and 25 healthy controls (7M 18F, BMI 27, 19–37)—see Table.

In HH + there was increased resistance (intrabolus pressure) to bolus flow through the esophagus, while pressure during bolus clearance was lower. Further, a higher impedance ratio suggests less effective esophageal emptying, in addition to reduced EGJ outflow time. HH impairs transport of viscous and liquid swallows, affecting patients with HH + and troublesome dysphagia the most.

Conclusion

A small hiatus hernia alters biomechanics of bolus transport and hinders esophageal and esophago-gastric junction outflow, more so in patients with both dysphagia and hiatus hernia. These findings may relate to altered longitudinal muscle function associated with a short, flaccid esophagus when a hiatus hernia is present.

Disclosure

All authors have declared no conflicts of interest.
RA06.03: SURGICAL OUTCOMES OF GIANT HIATAL HERNIA REPAIR IN PATIENTS OVER THE AGE OF 80
Authors: Khoma Oleksandr , Mugino Miho , Falk Gregory
Published: September 2018

Background

Patients with giant hiatal herniae are often symptomatic and have significantly reduced quality of life (QoL). Laparoscopic fundoplication is an established treatment of giant hiatal hernia. Advanced age has been previously shown to be the most significant predictor of mortality and morbidity in hiatal hernia repair. Reported outcomes of laparoscopic fundoplication in patients over the age of 80 are limited to case reports and small case series.

Methods

Data was extracted from a prospectively populated single surgeon database of laparoscopic fundoplication procedures between 1995 and 2014. Patients who were operated for giant HH (> 30% of stomach in the chest) that were aged 80 or older at the time of surgery were included. Quality of life (QOL) data was collected pre-operatively, in early post-operative period (within 12 months) and late post-operative period (24 months or later). QOL data included gastro-intestinal quality of life index (GIQLI), Visick score, dysphagia score and overall satisfaction with surgery. Search of Ryerson index (was conducted to establish month and year of death and calculate post-operative life expectancy.

Results

Inclusion criteria were met by 89 patients. Average age was 84 (80–93). The proportion of herniated stomach was 70.9% on average (range 30–100%; SD 27.25), the hiatal defect was large in all patients. There was 1 perioperative death from myocardial infarction at 30 days after surgery. There were no other major complications (Clavien-Dindo Grade III-IV). Post-operative survival was an average of 74.5 months (SD 47.8; range 1–233). GIQLI was reduced pre-operatively (mean 91.8; SD 19.4). There was improvement in GIQLI scores on early (mean 101.45; SD 21.2) and late (mean 106.7; SD 19.2; P = 0.005) post-operative follow up. Pre-operative Visick scores (mean 2.92; SD 0.98) have improved significantly in early (mean 1.94; SD 0.97; P = 0.000) and late (mean 2.03; SD 0.99; P = 0.001) post-operative periods. During early post-operative follow up 97% of the patients were satisfied with overall outcome of their operation, whilst 3% were dissatisfied. Overall satisfaction scores remained high on late follow up (93.3% satisfied, 6.7% dissatisfied).

Conclusion

Findings of this study demonstrate that in carefully selected patients with giant HH surgery is safe and results in improved quality of life post operatively.

Disclosure

All authors have declared no conflicts of interest.
RA06.05: LAPAROSCOPIC GIANT PARAESOPHAGEAL HERNIA REPAIR: CT SCAN AND QUALITY OF LIFE TOOL EVALUATION OF SUCCESS
Authors: Hietaniemi Henriikka , Ilonen Ilkka , Kauppi Juha , Andersson Saana , Räsänen Jari
Published: September 2018

Background

Our objective was to analyze the results of laparoscopic giant paraesophageal hernia (GPEH) repair in tertiary hospital setting. The main endpoints were recurrence of the hernia, postoperative quality of life, symptoms and satisfaction with the operation. To assess radiographical recurrence we used computerized tomography imaging, which has not been used in previous studies.

Methods

We identified all non-emergent giant (more than 30% of stomach in the chest) esophageal hernia repairs in our hospital from medical records. The patients were sent standardized 15D health-related quality of life and Gastroesophageal reflux disease (GERD-HRQL) questionnaires. Patients who gave their consent were assigned to a non-contrast computerized tomography (CT)-study to assess radiographical recurrence.

Results

Altogether 165 patients were reviewed. 74% of the patients were female, with a mean age of 67. 1 patient (0.6%) had died perioperatively. Complications were reported in 28 patients (17%). 10 patients (6.1%) had to undergo reoperation within 30 days. 7 patients (5.9%) were dissatisfied with the operation. 66% had an excellent result on GERD-HRQL. 4 patients had a major recurrent hernia in CT, but the radiographic findings did not correlate with symptoms. The mean D15 score was 0853 for our patients and 0896 for the age-adjusted control population (P < 0001).

Conclusion

The complication rate was comparable to previous studies. Perioperative mortality was low, significant radiographical recurrences were rare and only few patients were dissatisfied with the result. However the overall quality of life of the study group was slightly below age-adjusted population average.

Disclosure

All authors have declared no conflicts of interest.
RA07.02: IDENTIFYING TUMOR MARKERS IN ESOPHAGEAL ADENOCARCINOMA AND LYMPH NODE METASTASES FOR TARGETED FLUORESCENCE IMAGING
Authors: De Gouw Didi , Klarenbeek Bastiaan , Rijpkema Mark , Verrijp Kiek , Rovers Maroeska , Rosman Camiel , Van Der Post Chella
Published: September 2018

Background

Neoadjuvant chemoradiotherapy (nCRT) followed by resection of the tumor with two field lymphadenectomy is a standard treatment for esophageal cancer. After nCRT, however, in more than 70% of patients no lymph node metastases are found, suggesting extensive overtreatment. Tumor-targeted fluorescence imaging is a promising technique to detect lymph node metastases intra-operatively and guide personalized resection. The aim of this study is to identify potential viable tumor markers for fluorescence imaging of lymph node metastases in patients with esophageal adenocarcinoma (EAC).

Methods

Immunohistochemistry (IHC) was performed on tissue microarrays from EAC’s patients that underwent surgical resection between 2007 and 2016. Patients were subdivided in five groups, non-pretreated patients with and without metastatic lymph nodes, complete responders, partial responders and non-responders after nCRT. Five membranous markers, c-MET, CAIX, EGFR, EpCAM, HER2, and two cytoplasmic markers, VEGF-A and VEGF-A receptor were included. Tumor marker expression was scored on intensity (none (0), slight (1), moderate (2), strong (3)) and the percentage of positive cells (estimation). Threshold for positive detection rate was defined as an intensity of ≥ 2 in more than 10% the cells.

Results

EpCAM showed the highest expression in metastastic lymph nodes, with a median intensity of 3 (range 2–3) in > 70% of the tumor cells. Expression was found in 37 out of 39 EAC’s (95%). VEGF-A and CAIX expression was observed in 28 of 33 (85%) and 10 of 33 (30%) of metastatic lymph nodes and 34 of 39 (87%) and 17 of 39 (44%) in the primary EAC’s, respectively. For the other tumor biomarkers the detection rate ranged between 0 and 11% for metastatic lymph nodes and primary EAC’s. Only EpCAM and VEGF-A showed weak, non-specific staining in the fibrotic tissue.

Conclusion

High expression rates in primary EAC and metastatic lymph nodes were observed using immunohistochemical antibodies for EpCAM, VEGF-A and CA-IX, making these clinically relevant viable EAC tumor markers. A phase 1 dose finding study targeting VEGF-A by Bevacizumab-800-CW in patient with EAC is in preparation.

Disclosure

All authors have declared no conflicts of interest.