bluuebunny/crossref_metadata_2025 huggingface dataset:
P37 LIMITED MEDIASTINAL LYMPHADENECTOMY FOR ELDERLY PATIENTS OVER 75 YEARS OLD WITH THORACIC ESOPHAGEAL CARCINOMA IS PERMISSIBLE
Authors: Naoto Ujiie , Yusuke Taniyama , Chiaki Sato , Kai Takaya , Hiroshi Okamoto , Toshiaki Fukutomi , Takuro Konno , Takeshi Naitoh , Michiaki Unno , Takashi Kamei
Published: November 2019

Aim

The aim of this study is to investigate the influence on postoperative complications and survival rate by the difference in the number of mediastinal lymph node dissection for elderly patients over 75 years old with thoracic esophageal carcinoma.

Background & Methods

In esophagectomy for thoracic esophageal carcinoma, mediastinal lymphadenectomy is an essential procedure for the radical cure and also an invasive procedure. In elderly patients, especially, the postoperative complications are likely to be serious, and less-invasive surgical procedure is preferred. We sometimes perform limited mediastinal lymphadenectomy for elderly patients with thoracic esophageal carcinoma depending on the case, but the influence on survival rate is controversial. 55 patients who underwent esophagectomy for thoracic esophageal carcinoma over 75 years old between 2007 and 2015 were included in this study. Patients were divided into two groups by number of mediastinal lymph node dissection: normal group (15 or more: n=28) and limited group (less than 15: n=27). The short- and long-term outcomes were retrospectively examined to those groups.

Results

The median age of the normal and limited group were 76.5 and 79, respectively. No significant differences were demonstrated in clinical stage, operation time and estimated blood loss between these groups. The incidences of postoperative circulatory complications were 37.0% in the normal group and 25.0% in the limited group, but there was no statistically significant difference (P = 0.43). In the normal group, the postoperative respiratory complications (46.4 vs. 14.8%, P = 0.011) and recurrent laryngeal nerve paralysis (21.4 vs. 3.7%, P = 0.049) were significantly higher than that of the limited group. The 5-year overall survival rate (OS) and the 5-year relapse free survival rate (RFS) did not show statistical differences between the normal and limited group (OS: 45.0 vs. 46.0%, P = 0.44; RFS: 39.7 vs. 37.7%, P = 0.57).

Conclusion

In the limited mediastinal lymphadenectomy group, the postoperative respiratory complications and recurrent laryngeal nerve paralysis have a low occurrence rate. There was no difference in the survival rate between these groups. It was considered that limited mediastinal lymphadenectomy for elderly patients with thoracic esophageal carcinoma is permissible to prevent postoperative complications.
P38 RESECTION MARGINS AFTER ONCOLOGICAL ESOPHAGECTOMY ; DOES THE DEFINITION OF THE R STATUS MATTER?
Authors: Penelope St-Amour , Michael Winiker , Christine Sempoux , Nicolas Demartines , Markus Schäfer , Styliani Mantziari
Published: November 2019

Aim

This study aimed to compare long-term survival and recurrence of patients depending on their R status: R0 (>1mm of clearance), R1 (positive margins with 0mm clearance) and R0+ (margins with <1mm clearance).

Background & Methods

Resection margin (R) status is a known prognostic factor after curative esophagectomy. Different definitions of microscopic margin involvement are currently used. The American College of Pathologists defines R1 as a direct contact of the tumor with the resection margin (0mm), whereas the Royal College of Pathologists considers a positive margin as being within 1mm distance (<1mm) from the tumor.

All consecutive patients between 2012-2018 undergoing a curative esophagectomy for squamous cell cancer or adenocarcinoma of the esophagus or gastroesophageal junction were included. Clinical features, overall survival and recurrence were compared between patients with R0, R1 and R0+ status, with a specific subgroup analysis of locally advanced (cT3/4) tumors to eliminate baseline differences. Categorical variables were compared with the x2 or Fisher’s exact test, continuous variables with the ANOVA tests, whereas the Kaplan-Meier method with the log rank test was used for survival analyses.

Results

Among the 174 included patients, 126 (72.5%) resections were R0, 14 (8%) R1 and 34 (19.5%) R0+ resection. R0 patients had a better overall (OS) (median 59 months, 95%CI 34-84) and disease-free survival (DFS) (median not reached) compared to R1 (OS 20 months, 95%CI 8-32, DFS 9 months, 95%CI 7-11) and R0+ patients (OS 24months, 95% CI 19-29, DFS 13, 95%CI 3-23). Pairwise comparison revealed a similar OS (p=0.47) but a trend to better median DFS for R0+ patients compared to R1 (p=0.051). Within the locally advanced subgroup, R0 patients also had a better OS (median 59 months versus 20 months for R1 and 24 months for R0+, p=0.012) and DFS (33 months versus 9 and 18 months respectively, p<0.001).

Conclusion

R0 resection has a superior overall and disease-free survival after esophagectomy than R1 and R0+. A margin clearance of <1mm had a similar overall survival as a direct positive margin, whereas in more advanced tumor stages, the distinction between R1 and R0+ only seems relevant regarding tumor recurrence.
P40 CONDITIONAL SURVIVAL AFTER CURATIVE TREATMENT OF ESOPHAGEAL CANCER
Authors: Hagens E R C , Feenstra BSc M L , van Berge Henegouwen M I , Eshuis W J , Hulshof M C C M , van Laarhoven H W M , Gisbertz S S
Published: November 2019

Aim

To assess conditional survival and design a nomogram predicting the conditional probability of survival for esophageal cancer patients after surgery.

Background and methods

Conditional survival accounts for the time already survived after surgery and may be informative in addition to conventional static survival estimates during follow-up.

Consecutive patients with esophageal cancer who received neoadjuvant chemoradiation followed by an esophagectomy between January 2004 and 2019 in the Amsterdam UMC, The Netherlands were included. Conditional survival was defined as the probability of surviving “y” years after already surviving for “x” years. Cox proportional hazard models were used to evaluate predictors for overall survival. A nomogram was constructed to predict 5-year survival correcting for time already survived.

Results

660 patients were included in this study. The median overall survival was 46.4 months (95%CI 39.1–53.8). The probability to achieve 5-year overall survival after resection increased from 46% directly after surgery to 55%, 67%, 79% and 88% per additional year survived. ypN-stage was the strongest predictor for overall survival (HR6.50, p<0.001, for ypN3 with ypN0 as reference), followed by pulmonary complications (HR1.16, p=0.002), cardiac comorbidity (HR1.27, p=0.040) and ypT-stage (HR1.461, p=0.039 for ypT2-3 with ypT0 as reference). These variables were included in the nomogram (figure 1), which predicts survival with a C-statistic of 0.70.

Conclusion

The proposed nomogram showed an accurate prediction of survival in patients after esophageal cancer surgery, taking the years already survived after surgery into account. This nomogram can be helpful in counselling patients in the follow-up after esophageal cancer surgery.
P42 EFFICACY OF ENDOSCOPIC TREATMENT FOR CONTAINED LEAKAGE AFTER IVOR LEWIS ESOPHAGECTOMY
Authors: Lubbers M , van Workum F , Berkelmans G , Rosman C , Luyer MD , Nieuwenhuijzen GAP , van Det MJ , Kouwenhoven EA
Published: November 2019

Aim

Anastomotic leakage after esophagectomy (AL) is a severe complication that often needs aggressive and invasive treatment. However, there is no consensus on what strategy is best. The aim of this study was to analyse the different treatment strategies for AL and evaluate their outcomes.

Background and methods

A retrospective analysis was performed on all patients who developed AL after Ivor Lewis Esophagectomy (IL) from January 2011 until September 2016 in three high volume hospitals. Treatment of AL was based on local expertise, without common guideline. The different treatment strategies (surgical and endoscopic) were compared for patients with contained (confined to the mediastinum) and uncontained AL (leakage with intrapleural complications).

Endpoints were the amount of re-interventions, readmission to the ICU, ICU- and hospital stay, time to restart oral feeding and mortality.

Results

Seventy-three patients with AL were identified in this multicentre cohort with either a contained or an uncontained leak. Basic variables were similar in both groups.

A contained leak was identified in 39 patients. An endoscopic approach was chosen in 25 patients (64%) and was successful in 19 (76%). Fourteen patients (36%) were primarily treated with a surgical approach that was successful in 11 (79%). Significantly more patients were (re)admitted to the ICU in the surgical group versus the endoscopic group (100% vs 52%, p=0.003). The ICU and hospital stay, time to restart oral intake and mortality were not significantly different in both groups.

An uncontained leak was seen in 34 patients. Endoscopic treatment was chosen in 14 patients (41%) and was successful in 10 (71%). A surgical approach was performed in 20 patients (59%) and was successful in 12 (60%). (Re)admission rate to the ICU was significantly higher in the surgical group (95% vs 57%, p=0.012). The ICU- and hospital stay and time to restart oral intake were similar. There was no mortality in this cohort.

Conclusion

The classification of leakages into contained and uncontained might help to determine treatment strategy. In this multicentre cohort, the endoscopic approach for contained leaks appears to be feasible and successful. The operative approach remains the preferred option for uncontained anastomotic leakage.
P43 IS THERE AN OPTIMAL DEFINITION FOR POSITIVE CIRCUMFERENTIAL RESECTION MARGIN IN LOCALLY ADVANCED OESOPHAGEAL CANCER?
Authors: B Brac , F Renaud , H Behal , M Messier , E Leteurtre , C Mariette , C Eveno , G Piessen
Published: November 2019

Aim

The utility of Circumferential Resection Margin (CRM) status in predicting prognosis in oesophageal cancer remains controversial, with two different definitions of a positive CRM, one from the College of American Pathologists (CAP) (tumour at margin) and the other from the Royal College of Pathologists (RCP) (tumour within 1 mm)1-3. This study aimed to analyze the validity of these definitions in oesophageal tumours and explore the optimal cutoff value for CRM to predict survival.

Background & Methods

Patients who underwent curative radical oesophageal resection for locally advanced (>pT2) adenocarcinoma or squamous cell carcinoma of the oesophagus were selected from 2007 to 2016. Patients with positive longitudinal resection margins were excluded. CRM was histologically reassessed using an ocular micrometer. Overall survival (OS) and disease-free survival (DFS) were estimated with uni and multivariate analyses.

Results

From 860 resected patients, 283 fulfilling the inclusion criteria were selected. CRM was measured as follows: CRM=0mm (n=48), 01mm (n=112). In univariate (figure 1) and multivariate analysis R1 resection, according to both definitions was significantly associated with poor OS (CAP: HR=2.26,p<0.001; RCP: HR=1.42,p=0.035). However only CAP definition accurately predicted DFS (CAP: HR=2.25,p<0.001; RCP: HR=1.28,p=0.094). When comparing the 3 CRM groups and taking 0 < CRM ≤1mm as reference, only CRM=0 predicted OS and DFS (p<0.001). A CRM cutoff at 0.1 mm was the best to predict OS and differed according to histology.

Conclusion

Among existing definitions of CRM, CAP definition was more accurate to predict prognosis and recurrence. New cutoffs are promising.
P44 THE EXTENT AND CONSEQUENCES OF LYMPHADENECTOMY IN ESOPHAGEAL CANCER SURGERY: A CASE VIGNETTE SURVEY
Authors: Didi J J.M. de Gouw , Mirre Scholte , Suzanne S  Gisbertz , Bas P L. Wijnhoven , Maroeska M  Rovers , Bastiaan R  Klarenbeek , Camiel Rosman
Published: November 2019

Background

Lymph node dissection (LND) is part of standard operating procedure in resectable esophageal cancer patients regardless of lymph node status. The aim of this case vignette survey was to acquire expert opinions on current practice of LND, and to determine potential consequences of non-invasive lymph node staging on the extent of LND and postoperative morbidity.

Methods

An online survey including 5 short clinical cases (case vignettes) was sent to 272 esophageal surgeons worldwide. Extent of standard LND, potential changes in LND based on accurate lymph node staging and consequences for postoperative morbidity were evaluated.

Results

86 esophageal surgeons (median experience in esophageal surgery of 15 years) participated in the survey (response rate 32%). Standard LND varied considerably between experts, for example pulmonary ligament, splenic artery, aortopulmonary window and paratracheal lymph nodes are routinely dissected in less than 60%. The omission of (parts of) LND is expected to decrease the number of chyle leakages, pneumonias laryngeal nerve pareses and reduce operating time. In order to guide surgical treatment decisions, a diagnostic test for lymph node staging after neoadjuvant therapy requires a minimum sensitivity of 92% and specificity of 90%.

Conclusion

This expert case vignette survey study shows that there is no consensus on the extent of standard LND. Esophageal surgeons seem more willing to extend LND rather than omit LND, based on accurate lymph node staging. The majority of surgeons expect that less extensive LND can reduce post-operative morbidity.
O45 THE ASSOCIATION OF PERIOPERATIVE QUALITY-OF-CARE PARAMETERS (TEXTBOOK OUTCOME) WITH LONG TERM OUTCOME AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Kalff M C , Vesseur I , Eshuis W , Heineman D , Daams F , van der Peet D L , Gisbertz S S , van Berge Henegouwen M I
Published: November 2019

Aim

The objectives of this study were to confirm the association of textbook outcome (TO) and overall long-term survival after esophagectomy for esophageal cancer, to investigate the relationship of TO and recurrence rates and to identify clinicopathological predictors for not achieving TO.

Background & Methods

Despite current improvements in the multimodal treatment of esophageal cancer, surgery remains the key component. Therefore, it is essential to optimize the surgical procedure and to pursue the highest surgical quality. TO is a composite measure of ten perioperative parameters reflecting the quality of surgical care concerning esophagectomy.

All patients with esophageal cancer who underwent a transthoracic or transhiatal esophagectomy with curative intent in two tertiary referral centers in The Netherlands between 2007-2016 were included. Patients with a carcinoma in situ, patients undergoing salvage or emergency procedure and patients that applied for opt-out were excluded. Clinicopathological predictors for not achieving TO were identified using univariate and multivariate logistic regression. Survival was compared using Kaplan-Meier life-table estimates and cox regression.

Results

In total, 1057 patients were included. Over time, the percentage of patients who achieved TO increased from 28.9% in 2007 to 37.5% in 2016. BMI under 18.5, ASA score above one and age above 65 years were associated with a worse TO rate (OR 2.72 [1.02-7.24], ASA 2 OR 1.57 [1.13-2.17] and ASA 3+4 OR 2.33 [1.56-3.48], OR 1.387 [1.06-1.81], respectively), whereas neoadjuvant treatment predicted a better TO rate (OR 0.58 [0.41-0.81]). The median overall survival was 53 months (95% CI 42 – 63) for patients with TO and 35 months (95% CI 29 – 41) for patients without TO; resulting in an overall survival benefit of 18 months (HR 0.759, 95% CI 0.636 – 0.906, P = 0.002). The recurrence rates between TO and no-TO differed, but was not statistically significant (47.1% vs 42.8%, P = 0.177).

Conclusion

BMI less than 18.5, ASA-score higher than one and age older than 65 were characteristics associated with not achieving TO. Neoadjuvant therapy was associated with a better TO rate. Achieved TO resulted in a better overall five-year survival indicating the importance of pursuing TO.
P46 TRANSTHORACIC VERSUS TRANSHIATAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A NATION-WIDE PROPENSITY SCORE MATCHED COHORT ANALYSIS
Authors: MC Kalff , AC Mertens , WJ Eshuis , MI van Berge Henegouwen Prof , SS Gisbertz
Published: November 2019

Aim

The current study aims to compare transthoracic and transhiatal esophagectomy in a propensity score matched nation-wide cohort study.

Background & Methods

Chemoradiotherapy followed by resection is the standard therapy for resectable esophageal carcinoma in the Netherlands. The optimal surgical approach remains a matter of debate.

Data was acquired from the Dutch Upper-GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma from 2011-2016 were included. Patients with missing baseline data and patients undergoing emergency or hybrid surgery were excluded. Patients who underwent a transthoracic (TTE) or transhiatal (THE) esophagectomy were compared after propensity score matching.

Results

After propensity score matching, 1532 patients were included for analysis. The transthoracic approach yielded more lymph nodes (median 19 vs 14; p<0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher after TTE (p=0.044). The TTE group experienced more chyle leakage (9.7% vs 2.7%, p<0.001) and more pulmonary (35.5% vs 26.1%, p<0.001) and cardiac complications (15.4% vs 10.3%, p=0.003). The TTE group required a longer hospital stay (median 14 vs 11 days, p<0.001), ICU stay (median 3 vs 1 day, p<0.001) and had a higher early mortality rate (4.0% vs 1.7%, p=0.009). Subgroup analysis on anastomotic level showed that TTE with intrathoracic anastomosis (TTEi) had a significantly lower recurrent nerve lesion incidence (0.5%) compared to TTE with cervical anastomosis (TTEc) (7.4%, p=<0.001) and THE (5.9%, p=<0.001). There was no statistical difference in anastomotic leakage rates on anastomotic level, however incidence was lowest after TTEi (TTEc 21.5%, TTEi 15.1%, THE 19.5%). The higher early mortality rate after TTE was mainly caused by TTEc (4.6%), however, only the difference of early mortality between TTEc and THE (1.7%) reached statistical significance (p=0.006).

Conclusion

TTE provided a more extensive lymph node dissection which resulted in a higher N-stage, at the cost of increased morbidity and short-term mortality. Although results in high-volume centers are often superior, these data reflect nationwide results. Future research should investigate if a more extensive lymph node dissection leads to an improved long-term survival.
P47 A PREDICTION MODEL OF HOSPITAL STAY AFTER ESOPHAGECTOMY WITHIN AN ENHANCED RECOVERY AFTER SURGERY (ERAS) PATHWAY
Authors: Parise Paolo , Cossu Andrea , Puccetti Francesco , Palucci Marco , Cerchione Raffaele , Olivari Greta , Rosati Riccardo
Published: November 2019

Background and aims

ERAS principles have been applied even in oesophageal surgery, however low compliance and high rates of deviation from protocols are often reported. Aim of this study was to assess whether ERAS protocol deviation and other perioperative factors could be associated with a delayed discharge.

Methods

Patients who underwent esophagectomy at our Institution between 2014 and 2017 were included in the study. All patients were managed according to our perioperative ERAS protocol. In-hospital deaths were excluded. All data were prospectively entered in an electronic database. The 8th postoperative day (POD) was considered as the ideal day for discharge and therefore our outcome. A retrospective analysis of most relevant ERAS items and clinical features was conducted in order to identify variables positively or negatively associated to a delayed discharge. Variables associated with our outcome were exploited to build a score able to predict delayed discharge. An initial validation of the accuracy of the score was carried out on a separate patients’ sample. A χ2 test assessed association between outcome and categorical variables. Adapted standardized residuals of multilevel categorical variables allowed a dichotomous division. A new χ2 test confirmed the association. A ROC curve approach evaluated the role of continuous variables as markers of hospitalization longer than outcome. A χ2 test assessed the presence of association between the dichotomized variable and outcome. Backward logistic binary regression selected significant predictors with a selection criteria of p-value of <.05.

Results

286 esophagectomies were included in the study. ASA score *** 3, surgery duration *** 255 minutes and failure to mobilize within 24 hours were associated with a delayed discharge. “Hybrid” oesophagectomy was linked to a discharge within the target day. The logistic regression model was statistically significant (p < 0,001) and correctly classified 81,9% of cases. Sensitivity was 96,6%. Positive predictive value was 83,6% and negative 45,4%. The predictive score system, once applied to control population, correctly identified 100% of those discharged after 8th POD.

Conclusions

Our results seem to be clinically meaningful. All these parameters can be retrieved within the first 24 hours. The initial validation revealed good predictive properties.
P48 MEDIASTINOSCOPY-ASSISTED ESOPHAGECTOMY FOR AN UPPER THORACIC SQUAMOUS CELL CARCINOMA IN A PATIENT WITH LIVER CIRRHOSIS
Authors: Faiz Z , Rihuete-Caro C , Daiko H
Published: November 2019

Background

The standard treatment for T1a esophageal cancer (EC) is endoscopic submucosal dissection (ESD), whereas in T1b cancer is esophagostomy with lymph node dissection performed. The lesions infiltrated into the middle one-third (SM2) have in 36% of cases lymph node metastasis. Moreover, 41% of patients with SM2 cancer and lymphovascular invasion can develop recurrent cancer. Surgical resection is the recommended treatment. However, surgery could deteriorate the general condition and quality of life of patients with several chronic diseases. Hence, it is necessary to develop less invasive surgical approaches for this category of patients [1-2].

Methods

Mediastinoscopy-assisted esophagectomy (MAE) is one of the less invasive surgical approaches for EC patients with severe co-morbidities [3]. MAE facilitates direct visualization of the mediastinal organs and dissection of the mediastinal lymph nodes [3]. Thoracotomy could be avoided in MAE with less retention time and reduced volume of drainage in 24 h. However, MAE is still not widely performed because of the controversy about lymphadenectomy. This disadvantage could be covered by improving the surgical technique and instruments [4, 5].

Results

A 49-year-old man with Child Pugh Class A liver cirrhosis and portal hypertension underwent MAE with side to end anastomosis after ESD of an upper (23-30 cm) pT1b (SM2) well differentiated squamous cell carcinoma with lymphovascular invasion. The considerations for the mediastinoscopy-assisted esophagostomy were the presence of co-morbidities, not having lymph node metastasis in the clinical stage and the presence of lymphovascular invasion in the specimen. After esophagectomy, pathological investigation revealed squamous cell carcinoma in-situ (Tis, 12 x 8 mm) of the upper part of esophagus with no ductal involvement, absence of lymphovascular invasion and no lymph node metastasis (0/9). The patient had no postoperative complications.

Conclusion

MAE is a feasible and less invasive surgical approach in EC patients with severe co-morbidities, although there is a limitation in curative dissection of the mediastinal nodes. Direct vision of the mediastinal structures during MAE predicts organ injury and may affect postoperative morbidity and mortality.
P49 A HIATAL HERNIA >3CM IS ASSOCIATED WITH WORSE RESPONSE TO NEOADJUVANT TREATMENT IN ESOPHAGEAL CANCER PATIENTS
Authors: Styliani Mantziari , Penelope St-Amour , Michael Winiker , Clarisse Drmain , Sebastien Godat , Alain Schöpfer , Nicolas Demartines , Markus Schäfer
Published: November 2019

Aim

The aim of this study was to assess whether a preoperative HH≥3cm had an impact on histopathologic tumor response after neoadjuvant treatment, as well as on overall and disease-free survival.

Background & Methods

Hiatal hernia (HH) and long-term gastroesophageal reflux are known risk factors for esophageal cancer. Previous data suggest a negative impact of large hiatal hernias on survival after esophagectomy, as well as an increased toxicity after neoadjuvant treatment (1), although evidence remains scarce and the mechanism is not fully elucidated.

All consecutive patients who underwent surgical esophagectomy for adenocarcinoma or squamous cell cancer of the esophagus and gastro-esophageal junction from 2012-2018 were assessed. Baseline oesogastroduodenoscopy reports and CT-scan images were retrospectively reviewed to identify the presence of a HH of ≥3cm (2). Response to neoadjuvant treatment as assessed by the Mandard score (3), postoperative outcomes and survival were compared between HH and non-HH patients (defined as HH<3cm or no HH at all). Categorical variables were compared with the x2 or Fisher’s test, whereas continuous ones with the Mann-Whitney-U test. The Kaplan-Meier method and log-rank test were used for survival analyses.

Results

Among the 174 included patients, 44 (25.3%) had a HH≥3cm upon diagnosis. HH patients compared to the non-HH had significantly more Barrett’s metaplasia (52.3% vs 20%, p<0.001), although no differences in baseline stage were observed. HH patients presented a worse response to neoadjuvant treatment compared to non-HH patients (TRG 4-5 in 40.5% vs 21.3%, p=0.033). Among HH patients, perioperative chemotherapy compared to radiochemotherapy showed a trend to higher complete response rates (TRG 1 in 25% vs 11.5%, p=0.059). In the radiochemotherapy subgroup (n=112), HH patients had worse complete response rates than non-HH patients (TRG 1 in 11.5% vs 26.7% respectively, p=0.050). However, no differences in overall or disease-free survival were observed between HH and non-HH patients in the whole cohort or in subgroup analyses.

Conclusion

A HH≥3cm is frequently encountered in esophageal cancer patients. The presence of HH was associated with worse response to neoadjuvant treatment, especially radiochemotherapy. However, the presence HH did not have an impact on long-term survival and recurrence.
P51 NUTRITIONAL DEFICIENCY POST OESOPHAGO-GASTRIC SURGERY IN CANCER PATIENTS
Authors: Pushpa Veeralakshmanan Ji Chung Tham , Himanshu Wadhawan , Amy Wright , Marilyn Bolter , Richard Berrisford , Lee M Humphreys , Tim Wheatley , Grant Sanders , Arun Ariyarathenam
Published: November 2019

Aim

Postoperative nutritional status is an important prognostic factor in patients undergoing oesophagectomy or gastrectomy for malignant tumours. The deterioration in nutritional status post oesophagectomy is seen more profoundly after 6 months of surgery [1]. In our unit, we successfully implemented Allied Health Professionals (AHP) led clinics consisting of cancer nurse specialist and specialist dietician to conduct routine follow-up for 5 year duration post oesophago-gastric surgery to help identify and manage nutritional deficiencies.

Background & Methods

AHP led outpatient clinic was established in February 2017. Between February 2017 and February 2018, all patients who were eligible and who attended the AHP clinic at our tertiary unit were included in the study. All patients who attended the clinic, had micronutrient screening in particular ferritin, folate, vitamin B12 and vitamin D. Patients were screened for exocrine pancreatic insufficiency (EPI) through series of questions related to symptoms of EPI including steatorrhea, flatulence, loose stools and urgency to defecate. All patients included in the study were started on A-Z multivitamin tablets from their first visit. Patients reporting symptoms indicative of EPI were started on Creon. Patients found deficient in any micronutrients were invited for a follow-up measurement of the respective deficiency.

Results

A total of 52 patients were included in the study period with a median follow-up of 17 months post oesophago-gastric cancer surgery. Proportion of patients with deficiency in ferritin, folate, vitamin B12 and vitamin D were 51.92%, 11.54%, 7.69% and 42.31% respectively. Proportion of patients identified with symptoms indicative of EPI was 36.54%. At re-test follow-up, 64.71% patient noticed settlement of symptoms of EPI and 85.91% of patients improved their ferritin levels at retest. Folate, Vitamin B12 and D levels significantly improved post initial AHP follow-up (significance level p<0.05).

Conclusion

Despite the study’s limitation of a small sample size of 52, it highlights that nutritional deficiencies post oesophago-gastric surgeries are prevalent. AHP run follow-up clinics in our unit helps identify these deficiencies and manage them accordingly. Study shows statistically significant improvement in deficiencies thereby making AHP led follow-up clinics to be cost effective and improve patient outcome.
P52 LIVER REDUCTION DIET IN PATIENTS UNDERGOING GASTRO-OESOPHAGECTOMIES
Authors: Pushpa Veeralakshmanan , Himanshu Wadhawan , Grant Sanders , Lee M Humphreys , Richard Berrisford , Tim Wheatley , Arun Ariyarathenam
Published: November 2019

Aim

The prevalence of obesity has nearly doubled in the last 10 years and is a known risk factor for oesophageal adenocarcinoma [1]. There is an increasing popularity with minimally invasive esophagectomies employing laparoscopic and/or thoracoscopic approach [2]. Obesity can complicate technical aspects of surgery. There is increased risk of retraction trauma from fatty livers and the operative field of the gastro-oesophageal area is limited in obese patients. Pre-operative liver reduction diet (LRD) is a common practice in patients undergoing bariatric surgery. We propose a pre-operative LRD for obese patients undergoing oesophago-gastric surgery for cancer to be safe and can help with the overall complexity of the surgery.

Background & Methods

In our regional tertiary unit, we adopted a 2-week pre-operative LRD for patients undergoing oesophago-gastric surgery with BMI >30 Kg m-2. Data was collected prospectively from January 2017 to January 2019 for all patients undergoing oesophago-gastric surgery.

Results

142 patients underwent oesophago-gastric surgery in the study period, 31 with a BMI >30 Kg m-2. 20 of the 31 (64.5%) received and completed LRD prior to their operation. For 9 patients, no reason was documented for incompletion of diet and 2 were unable to manage the diet. For 75% (15/20) of these patients, surgery was randomized and completed using the hybrid approach (laparoscopic abdomen and open chest) and the rest undergoing open procedure, as per the ROMIO trial [3].

Although a small number of cases for comparison, there were no significant differences observed in length of stay (LOS), complications including pneumonia, chyle leak and anastomotic leak in our patient group receiving LRD compared to high BMI patients in the literature without LRD.

Conclusion

Oesophago-gastric surgeons in our unit find pre-operative LRD in obese patients leads to improved flexibility of the liver for easier retraction and a better exposure of the operating field, especially around the hiatus. Implementation of pre-operative LRD in obese patients undergoing oesophago-gastric cancer surgery has been shown to be safe. We aim to continue to record post-operative complications, peri-operative death and LOS and expand the sample size for our study.
P53 MINIMALLY INVASIVE TECHNIQUES FOR TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCERS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS
Authors: Kwabena Siaw-Acheampong , Sivesh K Kamarajah , Rohan Gujjuri , James R Bundred , Pritam Singh , Ewen A Griffiths
Published: November 2019

Aim

To evaluate the clinical outcomes for open, minimally invasive and robotic esophagectomy techniques for esophageal cancers.

Background & Methods

Esophagectomy is a demanding operation which can be performed by employing different approaches including open surgery or a combination of minimal access techniques. Each approach has specific reported advantages and disadvantages. A systematic literature search was conducted for studies reporting open, laparoscopic hybrid esophagectomy (LHE), thoracoscopic hybrid esophagectomy (THE), totally minimally invasive esophagectomy (MIE) or robotic MIE (RoMIE) for esophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, length of hospital stay), oncological outcomes (R0 resection, lymphadenectomy) and survival were performed.

Results

Ninety-eight studies including 32,296 patients were included in the network meta-analysis, of which 55% (n=17824), 5% (n=1576), 7% (n=2421), 30% (n=9558) and 3% (n=917) were open, LHE, THE, MIE and RoMIE respectively. Both MIE and RoMIE were associated with less blood loss, significantly lower rates of pulmonary complications, shorter length of stay and higher lymph node yield. There were no significant differences between surgical techniques for surgical site infections, chyle leak, and 30-day and 90-day mortality. MIE and RoMIE had better 1-year and 5-year survival rates compared to open respectively.

Conclusion

Minimally invasive and robotic techniques for esophagectomy are associated with reduced perioperative morbidity and length of stay with no compromise on oncological outcomes but no improvement in perioperative mortality. There are suggestions of improved long-term survival with MIE and RoMIE but these associations are not consistent across 1-, 3- and 5-year survival.
P54 INCIDENCE AND OUTCOME OF HIATAL HERNIA AFTER OESOPHAGECTOMY: COMPARISON OF TRADITIONAL OPEN AND MINIMALLY INVASIVE APPROACH
Authors: Jonas Sanberg Ljungdalh , Nicolaj Markus Stilling , Alan Patrick Ainsworth , Michael Hareskov Larsen
Published: November 2019

Aim

The primary aim of this retrospective study is to evaluate the incidence of symptomatic and asymptomatic hiatal hernia (HH) in patients who have undergone intended curative open or minimally invasive oesophagectomy (MIO) for cancer of the oesophagus in a high-volume surgical centre. The secondary aim is to describe the treatment and outcome after HH treatment.

Background & Methods

MIO for the treatment of oesophageal cancer has emerged as an alternative to traditional open oesophagectomy without compromising disease free or overall survival1.

HH of abdominal viscera other than the gastric conduit is an infrequent but potentially life-threatening complication following oesophagectomy. HH may present with grievous complications, such as severe respiratory failure, intestinal ischemia with perforation, bowel obstruction, and strangulation leading to emergency surgery2,3. Surgical repair of these HHs is associated with a high morbidity rate and in the emergent setting even a high mortality4.

In meta-analysis, the pooled incidence of symptomatic HH after MIO was 4.5 %, compared to a pooled incidence of 1.0 % after open oesophagectomy5. However, studies on the subject, often do not describe whether patients are asymptomatic or simply have not been examined for the existence of HH. The actual HH incidence may therefore be underestimated and may be more sufficiently reported when including patient material with comprehensive follow-up.

This retrospective cohort study includes all patients (n≈455) who have undergone curative intended resection for malignant disease in the oesophagus at The Department of Surgery, Odense University Hospital, from 1th January 2012 – 31th December 2018. Patient demography, perioperative data including surgical approach and follow-up, including occurrence and treatment of hiatal hernia, mortality and recurrence of malignant disease will be extracted from complete electronic patient records. Follow-up ranges from 6-84 months. Primary outcome is occurrence of hiatal hernia after oesophagectomy determined by CT-scan or during surgery.

Results

As of abstract deadline for ESDE 2019, we have only just received permission for the study from The Danish Patient Safety Authority and can unfortunately not present our results yet. However, we expect that results are ready for presentation at ESDE 2019 and hope for your understanding.
O55 COMPUTED TOMOGRAPHY CAN PREDICT OUTCOMES AFTER CAUSTIC INGESTION?
Authors: Weindelmayer J , Veltri A , Zenzaro M , Gobbi L , Ceccherini G , Deguidi G , Gervasi M , Casella F , Strazimiri E , De Manzoni G , Giacopuzzi S
Published: November 2019

Aim

our aim was to evaluate if CT could predict outcomes in terms of treatment in patient with caustic ingestion injury.

Background and methods

endoscopy has long been the gold standard for initial evaluation of caustic ingestion injury. Lately several studies suggested CT-scans to have an equal or even superior accuracy in emergency evaluation and prediction of esophageal stricture formation. Wishing to avoid complications of endoscopic procedures, new radiological grading system are being defined to supplement or replace the ones currently used. On the basis of the available evidence, we proposed a radiological 3 grade-score: grade I (well-defined visceral wall, homogenous post-contrastographic enhancement, no wall/perivisceral fat tissue edema), grade IIA (thickened and hypointense mucosa with post-contrastographic enhancement, wall/perivisceral fat tissue edema), grade IIB (necrotic mucosa with slight post-contrastographic external wall enhancement), grade III (transmural necrosis, defined by two of three between: lack of post-contrastografic wall enhancement, not defined visceral wall, blurred perivisceral fat tissue). Retrospectively we collected patients’ CT-scans which were reviewed by a radiologist, two senior surgeons and six resident surgeons; CT-scans performed within 48 hours after the ingestion were considered significant. We also tracked patients’ clinical history and compared the outcomes.

Results

of 50 patients that were admitted in our division in the last 10 years, we reviewed CT-scans of 23 patients; 15 were performed within 48 hours after the caustic ingestion. From the analysis of the data we observed that clinicians scored similarly, especially for grades I and III. Of these patients, 26,6 % had elective surgery (I: 0%; IIA: 0%; IIB: 75%; III: 25%), 20 % underwent emergency surgery (I: 0%; IIA: 33%; IIB: 0%; III: 66%), 53,4 % had conservative management (I: 25%; IIA: 12,5%; IIB: 37,5%; III: 25%). For what concerns the effectiveness of the score, we found high negative predictive value for grade I (all patients were treated conservatively), although highest grade had good specificity (0,86) regarding the needs of reconstructive surgery.

Conclusion

our radiological classification seems a worthwhile tool at the two extreme grades; on the contrary, for intermediate scores is still necessary an endoscopic-integrated approach to define which treatment achieve.
P57 MOTILITY DISORDERS OF THE ESOPHAGUS - A RISK FACTOR FOR THE DEVELOPMENT OF BARRETT'S ESOPHAGUS?
Authors: Laura Knepper , Anne-Kathrin Bär , Dolores Müller , Hans Fuchs , Claudia Fuchs , Sebastian Brinkmann , Seung-Hun Chon , Wolfgang Schröder , Christiane J  Bruns , Jessica M  Leers
Published: November 2019

Aim

This study aims to investigate the extent to which esophageal motility affects the development and progression of Barrett's mucosa in GERD patients.

Background and Methods

The Barret´s esophagus is becoming even more important against the background of an increasing incidence of adenocarcinoma of the esophagus1. The question as to why only a few patients with gastroesophageal reflux disease (GERD) develop a Barrett's esophagus has not been clarified. A cohort of 315 GERD patients with and without Barrett's esophagus who received High Resolution Manometry (HRM) as part of their regular diagnostics was therefore examined in this study. The evaluation of the HRM results was based on the Chicago classification version 3.02 and was compared with endoscopic and histological findings.

Results

Out of the 315 GERD patients, 67 had a Barrett's esophagus. The two patient groups (GERD without Barrett and GERD with Barrett) did not differ in demographic data and risk profile (hiatal hernia 71.4% vs 10.2%). In pH metry, both groups achieved a comparable DeMeester score as well as a similar fraction time (49.6 vs 44.2, 13% vs 11.7%). In both groups, approximately 40% of patients showed motility disorders. The mean basal pressure and the mean DCI also showed comparable values (21.2 vs 21.3, 1189.2 vs 1249.2). However, when comparing patients within the Barrett cohort with a long and a short segment Barrett (LSB, SSB), differences in peristalsis and pressure build-up of the distal esophagus become clear. Patients with an LSB showed a lower basal pressure of the lower esophageal sphincter (LES) and lower mean DCI (12.9 vs 25.0, 1230.0 vs 1389.3). In addition, they presented a hypotonic LES more frequently (54.6% vs 17.4%). Patients with LSB also showed motility disorders more often (54.6 vs 39.1), especially ineffective motility and fragmented peristalsis (18.2% vs 10.9%, 9.1% vs 2.2%).

Conclusion

The differences in motility disorders between Barrett and non-Barrett patients already described in other publications3 could not be confirmed in this study, despite the large cohort of 315 patients. However, the differences between LSB and SSB patients suggest that esophageal motility disorders can at least influence the severity of this disease.
P58 IMPACT OF SYSTEMATIC ENTERAL NUTRITION IN OESOPHAGEAL OR OESOGASTRIC JUNCTION (OG) CANCERS INVOLVED IN A CURATIVE STRATEGY
Authors: Hélène Marin , Maxime Warlaumont , Guillaume Pieesen
Published: November 2019

Aim

In the absence of severe dysphagia or major weight loss, most patients treated for OG cancer do not have enteral nutrition (EN) instituted before neoadjuvant treatment. The aim of this work was to compare the impact of a systematic NE (NES) or on demand (NED) on the course of the therapeutic sequence, the post-operative follow-up: post-operative complications of grade Clavien-Dindo> II and Complication Comprehensive Index (CCI); and oncologic results (median follow-up: 36 months).

Background & Methods

Among 682 patients with OG cancer operated between 2007 and 2015, 313 patients with <20% weight loss and no severe dysphagia (Atkinson <IV) were included. Control group with NES (n = 140) and group with NED (n = 173) were compared with propensity score adjustment.

Results

In the NES group, the tumor stage was more advanced (clinical stage III: 78.6% vs 61.4% p = 0.001) and the more frequent undernutrition (28.6% vs 14.6% p = 0.002). After adjustment, there was no significant difference between the two groups regarding the risk of severe complications (25.7% vs 24.9% p = 0.682), the median CCI (20.9 vs 20.9, p = 0.08) and 90-day mortality (4.3% vs. 5.2% p = 0.706). In case of perioperative chemotherapy, the rate of patients benefiting from the complete therapeutic sequence was higher in the NES group (80.4% vs 62.2% p = 0.0192 ie OR = 2.5). Overall survival was similar between the 2 groups (p = 0.509).

Conclusion

In OG cancers, systematic NE does not modify the operative and oncological follow-ups with respect to an on-demand NE, but more frequently makes it possible to achive the therapeutic sequence in the case of perioperative chemotherapy.
P59 PREDICTORS FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY AND IMPACT ON SURVIVAL
Authors: Eliza R C. Hagens , Maud A  Reijntjes BSc , Anderegg M C J , Suzanne S  Gisbertz , van Berge Henegouwen Mark I
Published: November 2019

Aim

To identify predictors for anastomotic leakage after esophagectomy and to determine the influence of anastomotic leakage on short-term and long-term survival.

Background and methods

Identifying predictors of anastomotic leakage after esophagectomy may contribute to its prevention. The influence of anastomotic leakage on long-term survival is unclear. A retrospective cohort study was conducted in consecutive patients who underwent an esophagectomy with reconstruction in the Amsterdam UMC, location AMC, between January 1993 and January 2019. Logistic regression and Cox regression models were used to assess predictors for anastomotic leakage and to assess survival.

Results

1747 patients were included, of which 326 (18.7%) developed anastomotic leakage. Independent predictors of cervical anastomotic leakage were diabetes mellitus, cT4-stage and a gastroesophageal junction tumor. ASA grade 3-5, a non-radical resection, pT2-stage, pN+ and hand sewn anastomosis were independent predictors of intrathoracic anastomotic leakage (table 1). 30-day mortality was 2% in patients without, and 4% of patients with anastomotic leakage (p=0.076). Anastomotic leakage did not significantly influence long-term survival when corrected for confounders (HR 0.96 95%CI 0.81 – 1.14, p=0.618).

Conclusion

Independent risk factors for anastomotic leakage after esophagectomy are diabetes mellitus, cT4-stage and a gastroesophageal junction tumor for cervical anastomosis, and ASA grade 3-5, a non-radical resection, pT2-stage, pN+ and hand sewn anastomosis for intrathoracic anastomosis. 30-day mortality was higher in the anastomotic leakage group. We found no correlation between anastomotic leakage and long term survival.
P61 CARDIAC TAMPONADE - A SERIOUS COMPLICATION AFTER COLON CONDUIT INTERPOSITION: A CASE REPORT
Authors: Jarosciakova S , Harustiak T , Tvrdon J , Lischke R
Published: November 2019

Aim

Graft redundancy and anastomotic stricture after colon interposition are well-known late complications. Cardiac compression by distended colon conduit is uncommon. There is a few reports in the literature. We present a case of 58-year-old patient with a major dilatation of colon conduit occurred 7 years after esophagectomy and gastrectomy.

Case report

The patient was admitted to district general hospital with 4-hour history of abdominal pain. Chest X- ray and abdominal computer tomography (CT) scan revealed distended colon conduit, pneumomediastinum, small-bowel ileus and pneumoretroperitoneum. An attempt to insert a nasogastric tube failed and an emergency laparotomy was performed. At operation, a band causing small bowel strangulation and adhesions were divided. The bowel appeared viable and a clear perforation was not found. Resection was not necessery. For next 10 hours, progressing hemodynamic instability and sepsis required intravenous vasoactive medication and orotracheal intubation. Chest CT scan showed massive distention of substernal colon conduit with compression of heart and pulmonary arteries. The patient was referred to our institution. Prompt endoscopy was performed with suction of air and liquid content from colon and nasogastric tube was inserted. The colonic mucosa was viable without necrosis and perforation. Hemodynamics improved immediately after decompression of colonic roll. An exploratory laparotomy revealed fatal extensive ischemia infarction of the bowel and the patient died within 4 hours after surgery.

Concluson

Extrapericardial cardiac tamponade is a rare complication after substernal esophageal reconstruction and could lead to bowel hypoperfusion or ischemia. Early recognition of symptoms and management with conduit decompression are important.