bluuebunny/crossref_metadata_2025 huggingface dataset:
PS02.230: CLOSURE OF POSTESOPHAGECTOMY GASTROTRACHEAL FISTULA FOLLOWING MINIMALLY INVASIVE ESOPHAGECTOMY THROUGH THE STOMACH CONDUIT OPENING
Authors: Lee Junhee , Yi Eunjue , Lee Sungho , Ho Chung Jae
Published: September 2018

Background

The prevalence gastro-tracheal fistula following esophagectomy is rare, however, very difficult to cure, and often results in fatal outcomes. We experienced surgical repair of gastro-tracheal fistula after minimally invasive esophagectomy, thereby reported here.

Methods

A 66 year-old male patient had undergone VATS esophagectomy combined with cervical esophagogastrostomy through posteromediastinal route for his esophageal cancer (pT2N2M0). After concurrent chemo-radiation therapy for local recurrence in subcarinal area, gastro-tracheal fistula was developed between the posterior membranous wall of trachea just above carina and gastric conduit. Surgical correction was performed through right posterolateral thoracotomy. After longitudinal incision on the gastric conduit near the location of gastro-esophageal fistula, the fistula tract was exposed, and closed using three layer sutures with vicryl 3–0.

Results

The patient stayed at intensive care unit for only one day. During the periods of nil per os, the nutrition had supported by intravenous administration and jejunostomy. After 2 weeks of nil per os, postoperative bronchoscopy and endoscopy was performed. No remnant fistula was noted on both examinations suggesting successful fistula closure. And, the patient was discharged without any complications on postoperative day 28.

Conclusion

Conduit-airway fistula could be caused by diverse risk factors such as thermal injury during the dissection, external beam irradiation, and severe malnutrition. Less invasive procedures including endoscopic interventions could be amenable, however, direct surgical repairs might be required for prompt closure of fistula and minimizing further complications.

Disclosure

All authors have declared no conflicts of interest.
PS02.238: POSTOPERATIVE PROGNOSTIC NUTRITIONAL INDEX CAN PREDICT A LONG-TERM PROGNOSIS OF ESOPHAGEAL CANCER
Authors: Takahashi Jun , Saito Masaaki , Obitsu Tamotsu , Ishioka Daisuke , Kiyozaki Hirokazu , Rikiyama Toshiki
Published: September 2018

Background

Recent reports indicate the nutritional and immune status often affect the long-term prognosis of patients with cancer. The preoperative prognostic nutritional index(PNI) is used as an evaluation of the perioperative nutritional status, and it is reported that the PNI level correlates with postoperative results. However, only a handful of reports have discussed the predictive prognostic potential of postoperative PNI. The aim of this study is to clarify the correlation of postoperative PNI level and long-term prognosis of patients with esophagus cancer who underwent esophagectomy.

Methods

A total of 29 patients with esophageal cancer who received neoadjuvant chemotherapy followed by radical esophagectomy from January 2011 to December 2014 were retrospectively reviewed. The calculation of PNI level is as follows: 10 × serum albumin level (g/dL) + 0.005 × total lymphocyte count (/mm3). The postoperative PNI level was measured three months after radical esophagectomy. The patients were stratified by postoperative PNI level by two groups using calculated cutoff level (PNI = 43.9) by receiver operating characteristic curve. The correlation of 3-year disease-free survival (DFS) and postoperative PNI level was evaluated.

Results

Of the total, 25 were male and 4 were female. The median age of patients was 68 years (31–79 years). Overall, patients received 1–2 cycles of preoperative chemotherapy with 5-FU and cisplatin. Of these 29 patients, 9 (31.0%) responded to chemotherapy (8 patients had a partial response and 1 had a complete response). The median postoperative PNI level was 47.2 (38.0–58.9). Univariate analyses showed that 3-year DFS was worse in patients with low postoperative PNI level (P = 0.017), advanced pathological stage (P = 0.029) and younger age (< 70 years) (P = 0.02). Multivariate analyses showed that low postoperative PNI level[hazard ratio (HR) 0.224, 95% confidence interval (CI) 0.060–0.83, P = 0.026] and advanced pathological stage (HR 3.197, 95% CI 1.13–9.06, P = 0.029) were independent predictors of 3-year DFS.

Conclusion

Our findings suggest that the postoperative PNI level may be a useful marker to predict a prognosis of patients with esophagus cancer. Nutrition intervention for undernourished patients after surgery may improve prognosis of patients with esophagus cancer.

Disclosure

All authors have declared no conflicts of interest.
RA01.07: SALVAGE ESOPHAGECTOMY IN SQUAMOUS CELL ESOPHAGEAL CARCINOMA: TECHNICAL SURGICAL ASPECTS OF A HIGH-RISK PROCEDURE
Authors: Takeda Flavio , Cecconello Ivan , Ribeiro Jr Ulysses , Mariano Rocha Julio , Catapreta Lucas , Duarte Andre , Sallum Rubens
Published: September 2018

Description

Background: The concept of salvage esophagectomy after definitive chemoradiotherapy treatment has traditionally been recognized as a feasible option, but due to the associated unfavorable morbidity and mortality profile, this indication has been limited. Methods: The experience of 27 cases of salvage esophagectomy were summarized in this VIDEO. The thoracic field performed in the prone position and abdominal field performed laparoscopically. Lessons learned concerning improvement of safety and lymphadenectomy are particularly shown Results: The cases of thoracic and abdominal robotic esophagectomy summarized in this VIDEO were squamous cell mid third esophageal carcinoma post definitive chemo- radiotherapy. It this video, we particularly show the relationship to left broncqueal side and the effects of scars in mediastinum after the high dose of radiotherapy. Discussion: Salvage esophagectomy is feasible, but it still needs an intensive care during surgery to avoid secondary lesions, such as air way tree, vascular and pleural injuries.

Disclosure

All authors have declared no conflicts of interest.
RA03.01: A POPULATION-BASED STUDY ON LYMPH NODE RETRIEVAL IN PATIENTS WITH ESOPHAGEAL CANCER: RESULTS FROM THE DUTCH UPPER GASTROINTESTINAL CANCER AUDIT
Authors: Van Der Werf Leonie , Dikken Johan , Van Berge Henegouwen Mark I , Lemmens Valery , Nieuwenhuijzen Grard A P , Wijnhoven Bas P L
Published: September 2018

Background

For esophageal cancer, the number of retrieved lymph nodes (LNs) is often used as a quality indicator. The aim of this study was to analyze the number of retrieved LNs in the Netherlands, to assess factors associated with LN yield and to explore the association with short-term outcomes.

Methods

For this retrospective national cohort study, patients with an esophageal carcinoma who underwent esophagectomy between 2011–2016 were included. Primary outcome was the number of retrieved LNs. Associations were tested with univariable and multivariable regression analysis for the association with ≥ 15 LNs.

Results

3970 patients were included. Between 2011–2016 the median number of LNs increased from 15 to 20. Factors independently associated with ≥ 15 LNs were: 0–10 kg preoperative weight loss (versus: unknown weight loss, odds ratio [95% confidence interval]: 0.71[0.57–0.88]), Charlson-score 0 (versus: Charlson-score 2: 0.76[0.63–0.92]), cN2-category (reference: cN0, 1.32[1.05–1.65]), no neoadjuvant therapy and neoadjuvant chemotherapy (reference: neoadjuvant chemoradiotherapy, 1.73[1.29–2.32], 2.15[1.54–3.01]), minimally invasive transthoracic (reference: open transthoracic, 1.46[1.15–1.85]), open transthoracic (versus open and minimally invasive transhiatal, 0.29[0.23–0.36] and 0.43[0.32–0.59], hospital volume of 26–50 or > 50 resections/year (reference: 0–25, 1.94[1.55–2.42], 3.01[2.36–3.83]) and year of surgery (reference: 2011, ORs: 1.48, 1.53, 2.28, 2.44, 2.54). There was no association of ≥ 15 LNs with short-term outcomes.

Conclusion

The number of LNs retrieved increased between 2011 and 2016. Weight loss, Charlson score, cN-category, neoadjuvant therapy, surgical approach, year of resection and hospital volume were all associated with increased LN yield. The retrieval of ≥ 15 LNs was not associated with increased postoperative morbidity/mortality.

Disclosure

All authors have declared no conflicts of interest.
RA03.02: ACUTE KIDNEY INJURY AFTER ESOPHAGEAL CANCER SURGERY: INCIDENCE, RISK FACTORS, AND IMPACT ON ONCOLOGIC OUTCOMES
Authors: Murphy Conor , Dunne Talulla , Elliott Jessie , King Sinead , Ravi Narayanasamy , Reynolds John
Published: September 2018

Background

Surgery remains the cornerstone of treatment for esophageal cancer. Esophagectomy serves as an exemplar of major operative trauma, yet there is a paucity of literature regarding postoperative renal outcomes. We aimed to study the incidence of acute kidney injury (AKI) after esophageal cancer surgery, and to determine independent risk factors for postoperative renal impairment.

Methods

Consecutive patients undergoing potentially curative surgery for esophageal cancer from 2006–2016 were studied. AKI was defined according to AKIN criteria. Complications were recorded prospectively and comprehensive complications index (CCI) was determined. Multivariate linear and logistic regression were performed to determine factors independently predictive of postoperative AKI.

Results

661 patients (72.9% male), a mean age of 63.5 ± 9.7 years, underwent surgery (2-stage esophagectomy, 307 [46.4%]; 3-stage esophagectomy, 117 [17.7%]; transhiatal esophagectomy, 112 [16.9%]; extended total gastrectomy, 122 [18.5%)], pharyngolaryngoesophagectomy, 3 [0.5%]), with a CCI of 21.3 ± 19.7 and an in-hospital mortality of 1.4%. Baseline prevalence of chronic kidney disease was 1.8%. Postoperative AKI occurred in 174 (26.3%) patients, with AKIN 1, 2 and 3 in 122 (18.5%), 41 (6.2%) and 11 (1.7%), respectively. Of these, 5 (2.9%) required renal replacement therapy during admission. Preoperatively, greater BMI (P = 0.02, OR 1.05 [95% CI 1.01–1.10]), male sex (P = 0.05, OR 1.68 [1.01–2.78]), age (P = 0.001, OR 1.04 [1.02–1.07]), hypertension (P = 0.005, OR 1.85 [1.20–2.84]), and transthoracic approach (P = 0.01, OR 1.82 [1.14–2.89]) independently predicted postoperative AKI. After surgery, while CCI was predictive of AKI on univariable analysis (P < 0.001 OR 1.03 [1.02–1.04]), atrial fibrillation (P = 0.001 OR 3.25 [1.57–6.72]) and prolonged intubation (P = 0.016 OR 3.61 [1.28–10.21]) were independently associated with AKI on multivariable logistic regression. On multivariable linear regression, neoadjuvant treatment (surgery only, 13.5 ± 35.8%; chemotherapy, 25.3 ± 42.2%; chemoradiation 18.7 ± 31.9%, P = 0.02), transthoracic approach (P = 0.006), and baseline BMI (P = 0.02) predicted postoperative %Δcreatinine. Postoperative AKI did not impact survival outcome on univariable or multivariable analysis.

Conclusion

Major AKI is rare after esophageal cancer surgery, with risk independently associated with increasing age, features of the metabolic syndrome, and postoperative morbidity.

Disclosure

All authors have declared no conflicts of interest.
RA03.03: THE IMPACT OF ENHANCED RECOVERY AFTER SURGERY (ERAS) ON PATIENTS UNDERGOING OESOPHAGECTOMY
Authors: Dent Barry , Sturrock Jillian , Mckenna Janine , Taylor Claire , Jaretzke Helen , Michael Griffin S , Immanuel Arul
Published: September 2018

Background

Enhanced recovery after surgery (ERAS) is defined as a multimodal care pathway designed to achieve early recovery for patients undergoing surgery. For patients undergoing oesophagectomy such pathways are complex and must involve a wide multi-disciplinary team. The importance of peri-operative nutrition is especially relevant in this patient group. We describe our experience of the impact of an ERAS pathway in a high volume oesophago-gastric unit on both short and medium term patient outcomes.

Methods

Consecutive patients undergoing open 2 phase subtotal oesophagectomy with two field lymphadenectomy in a 12 month period following the introduction of an ERAS pathway were included in the study. Outcomes were compared with consecutive patients undergoing the same procedure over a 12 month period prior to the introduction of the ERAS pathway. All patients were treated in a single UK unit. Adherence to the ERAS pathway was monitored by a dedicated ERAS coordinator. All data were collected prospectively. Statistical analysis was performed using the Mann-Whitney U test for continuous and Chi2 for categorical data.

Results

189 patients were included (97 pre-ERAS and 92 ERAS). There were no demographic differences between the patient groups. The rate of severe post-operative complications (Accordion score 3 + ) was identical between groups (29%). Median length of hospital stay was significantly reduced with ERAS (10 days v 14 days pre-ERAS (P < 0.001)) as was the total readmission rate (21% v 39% P = 0.006). Weight loss following surgery was significantly reduced with ERAS. At 2 weeks 1% of patients had lost over 10% of their pre-operative weight compared with 32% pre-ERAS (P < 0.001). A significant difference was maintained at 6 weeks (9% v 55%), 3 months (19% v 66%) and 6 months (35% v 71%).

Conclusion

Our results demonstrate the positive impact of ERAS for patients undergoing oesophagectomy. Despite no reduction in post-operative complication rates, both hospital stay and readmission rates were reduced, suggesting a positive impact of ERAS on patients’ response to complications. Far fewer patients were readmitted for nutritional reasons/failure to thrive following the introduction of ERAS. Implementing an ERAS pathway requires a dedicated multi-disciplinary team to provide the required peri-operative care both in the hospital and community.

Disclosure

All authors have declared no conflicts of interest.
RA03.06: IMPROVED SURVIVAL AFTER ESOPHAGECTOMY FOR ESOPHAGEAL OR GASTROESOPHAGEAL CANCER IN THE LAST 25 YEARS
Authors: Slaman Annelijn , Pirozollo Giovanni , Eshuis Wietse , Gisbertz Suzanne , Van Berge Henegouwen Mark I
Published: September 2018

Background

Many things have changed in treatment for patients who underwent esophagectomy for cancer in the last decades, such as neoadjuvant chemoradiotherapy and minimally invasive esophagectomy. This study was performed to evaluate developments in survival after esophagectomy for cancer over the last 25 years.

Methods

Patients who underwent esophagectomy for esophageal or gastroesophageal junction (GEJ) carcinoma between January 1993 and February 2017 were selected from a prospectively maintained database of a tertiary referral center, guaranteeing minimum follow-up of 12 months at time of the analyses. Patients were divided in different groups according to year of esophagectomy: A) 1993–1997, B) 1998–2002, C) 2003–2007, D) 2008–2012, and E) 2013–2017. Follow-up was truncated at a maximum of 60 months. Survival outcomes were assessed by Kaplan Meier estimate, using log-rank tests to compare survival curves between groups.

Results

A total of 1503 patients were included. Median follow-up was 55.8 months (IQR 31.5–60.0). Median estimated overall survival for all patients was 36.4 months (95% CI 31.8–40.9) and improved from 26.1 months (95% CI 19.3–32.8, period A) to 46.1 months (95% CI 36.9–55.3) in period E (P = 0.001). Cumulative 1- and 3-years survival increased from 69.3% and 42.4% (period A) to 79.2% and 54.6% (period E, P < 0.05) respectively. The cumulative 5-years survival improved from 30.5% (period A) to 43.4% in period D (P = 0.007).

Conclusion

Survival after esophagectomy for cancer improved significantly in the last 25 years. Additional investigations should be performed to assess predictive factors for survival, in order to further improve survival.

Disclosure

All authors have declared no conflicts of interest.
RA04.03: MINIMALLY INVASIVE ESOPHAGECTOMY IN THE LEFT LATERAL DECUBITUS POSITION
Authors: Otsuka Koji , Goto Satoru , Ariyoshi Tomotake , Yamashita Takeshi , Motegi Kentaro , Kato Rei , Kohmoto Masahiro , Saito Akira , Date Hiromi , Yamazaki Kimiyasu , Aoki Takeshi , Murakami Masahiko
Published: September 2018

Background

We initially performed minimally invasive esophagectomy in a left lateral decubitus position through 5 ports in 1996, and we have now treated over 900 cases using this approach. This position has many benefits, but it also has some drawbacks. We were able to operate with good results after we introduced artificial pneumothorax with CO2 insufflation in 2010. We investigated the short- and long-term outcomes of thoracoscopic surgery for esophageal cancer in the left lateral decubitus position at our institution.

Methods

From 1996 to 2016, 807 esophageal cancer patients were treated with minimally invasive esophagectomy in the left lateral decubitus position at our hospital. We compared the 289 cases treated in the early period (1996–2005) and 518 cases treated in the late period (2006–2016), in which the procedure was standardized and operator training was established

Results

The completion rate of thoracoscopic surgery was 99.5%, with the procedure switched to thoracotomy in only 3 patients in whom hemorrhage occurred. The mean intrathoracic operative time was 205.0 min, mean intrathoracic blood loss was 127.3 mL, and mean number of dissected mediastinal lymph nodes was 24.7. The postoperative complications were pneumonia (8.5%), anastomotic leakage (7.5%), and recurrent nerve paralysis (7.8%). The 5-year overall survival rate was 69.5%. Comparison of 289 cases treated in the early period (1996–2005) and 518 cases treated in the late period (2006–2016), revealed significant differences in mean intrathoracic blood loss (174.0 vs. 94.2 mL); number of dissected mediastinal lymph nodes (20.0 vs. 28.4); postoperative hospital stay (33.4 vs. 20.0 days, all P < 0.001); and postoperative anastomotic leakage (13.9% vs. 1.6%, P < 0.0001). In recent operation, we do not have recurrent laryngeal nerve paralysis and hoarseness after we take care of the micro anatomical layer, stretch and thermal damage of recurrent laryngeal nerve when we dissect the lymph node.

Conclusion

These data indicate significant improvements in intrathoracic blood loss, number of dissected mediastinal lymph nodes, anastomotic leakage, and postoperative hospital stay, reflecting continued improvement of minimally invasive esophagectomy performed in the left lateral decubitus position at our institution.

Disclosure

All authors have declared no conflicts of interest.
RA05.02: PRELIMINARY STUDY ON SCOPE OF CERVICAL LYMPHADENECTOMY OF PATIENTS WITH ESOPHAGUS CARCINOMA UNDER THORACOSCOPE
Authors: Hong Peng
Published: September 2018

Background

Objective: To explore scope of cervical lymphadenectomy of patients with esophagus carcinoma under thoracoscope.

Methods

Select patients underwent routine bilateral cervical lymph node dissection under thoracoscope.The highest location of cervical lymphadenectomy was marked by titanium clip and recorded anatomic landmark around it.After surgery, CT scan of neck was contributed to estimate the location.

Results

The results: The upper boundary of lymph node dissection on right neck located on the upward side of the crosspoint of right inferior thyroid artery and right recurret laryngeal nerve, which was adjacent to the midpoint position between the upper pole and lower pole of right thyroid, the lower side of musculi omohyoideus and the plane of transverse cervical artery. The upper boundary of left scope of cervical lymphadenectomy was adjacent to the upper position of lower pole of left thyroid, which was about the same level as that of right titanium clip. Postoperative CT scan on neck and chest suggested that bilateral titanium clip was located on midpoint between the upper pole and lower pole of thyroid on the same side.

Conclusion

Bilateral cervical paraesophageal lymph nodes (101 group)under inferior thyroid artery could be finished by thracoscope for radical resection of esophageal carcinoma.But we still need more evidence to discover the difference between the 2.5 field lymph node dissection and the 3 field lymph node dissection.

Disclosure

All authors have declared no conflicts of interest.
RA05.06: CHANGES IN SKELETAL MUSCLE AND PHYSICAL FUNCTION AFTER ESOPHAGECTOMY: PROSPECTIVE SINGLE-CENTER COHORT STUDY
Authors: Nishigori Tatsuto , Tsunoda Shigeru , Obama Kazutaka , Kobayashi Ami , Nobori Yukiko , Hisamori Shigeo , Hashimoto Kyoichi , Itatani Yoshiro , Tashiro Naohiro , Shide Kenichiro , Inagaki Nobuya , Sakai Yoshiharu
Published: September 2018

Background

Sarcopenia (loss of muscle mass) has been shown to be associated with postoperative outcomes following esophagectomy. However, the impact of esophagectomy on postoperative muscle mass and function remains unclear. The prospective study aimed to evaluate the change in muscle mass and physical function after esophagectomy in sarcopenic patients in comparison with nonsarcopenic patients.

Methods

The subject of the study was patients with cStage I-III primary esophageal cancer who were scheduled to undergo curative esophagectomy. Sarcopenia was diagnosed by measuring preoperative muscle mass with bioelectrical impedance analysis. Physical function was evaluated by measuring grip strength and walking speed. Postoperative muscle mass and function were evaluated between 1 and 3 months after surgery. Perioperative changes in muscle mass and function were compared between patients with and without sarcopenia

Results

Among all 71 enrolled patients, 30 (41%) had sarcopenia. Sarcopenic patients had significantly lower muscle strength (34 vs 41 kg in male, 21 vs 26 kg in female) and a higher rate of postoperative complications (Clavien-Dindo grade 2 or higher, 77% vs 49%, P = 0.018) compared to nonsarcopenic patients. Sarcopenic patients had a trend to lose greater amount of grip strength (-10.0% vs -5.6%, P = 0.10) and walking speed (-8.2% vs -1.1%, P = 0.18), while muscle mass decreased generally in both sarcopenic and nonsarcopenic patients (-8.0% vs -6.8%, P = 0.46).

Conclusion

Sarcopenic patients had a higher risk of postoperative complication and may lose further physical function following esophagectomy. Perioperative interventions such as nutrition exercise therapy should be considered for sarcopenic patients.

Disclosure

All authors have declared no conflicts of interest.
RA05.07: ESOPHAGEAL RECONSTRUCTION BY PEDICLED TERMINAL ILEUM AND RIGHT COLON WITH PRESERVED ILEOCOLIC VESSELS
Authors: Hiramatsu Masako , Kobayashi Toshihiro , Tsunematsu Ichiro , Kono Emiko , Imai Yoshiro , Suzuki Yusuke , Kawai Masaru , Tashiro Keitaro
Published: September 2018

Background

In the case of esophageal cancer patient whose stomach is not available for reconstruction, we had been using pedicled jejunum for lower esphageal cancer or right colon reconstruction as an alternative. However, high incidence of postoperative anastomotic leakage regarding insufficient blood supply was a great distress. We started the unique reconstruction technique using terminal ileum and right colon with preserved ileocolic vessels in 2011. Based on our experience, we considered benefits of our method.

Methods

After esophagectomy and lymphadenectomy, the ascending colon was mobilized. The mid colic, right colic (if exist) and ileocolic vessels, as well as marginal vessels of terminal ileum, were preserved, the ileum was cut at the point approximately 20–30cm from the ileum end. The final ileal artery and vein may be ligated and cut, if necessary. The pedicled ileo-colon was, then, carefully lifted isoperistaltically via subcutaneous route. Esophagoileostomy was usually performed by functional end to end anastomosis. Additional anastomoses were performed by Billroth II or Roux en Y method.

Results

In total of 383 patients who were underwent transthoracic esophagectomy between 1998 and 2017, 15 pedicled jejunum (J), 4 traditional right colon (C) and 6 ileo-colon preserved ileocolic vessels (IC) were used for reconstruction. The incidence of esophagoileostomy-related complications were 6.7% (1/15) in J, 50.0% (2/4) in C and 33.3% (2/6) in IC. One in IC showed ileal necrosis caused by sclerotic obstruction on the root of ICA, then remained right colon was used for free flap salvage reconstruction. Two in C suffered from pneumonia at early post-operative days, probably because of microaspiration of colic bacterium, interestingly, there was no caces of pneumonia in IC. In addition, the subcutaneous space was occupied only with the ileum, therefore the antesternal skin bloating was not bulky.

Conclusion

The advantages of our technique are; i) less anastomotic complications, ii)possibility of less aspiration pneumonia, iii) better cosmetic appearance, and iv) no microvascular surgery required. Our technique could be used as the standard method of reconstruction after esophagectomy for patients in whom stomach is not available.

Disclosure

All authors have declared no conflicts of interest.
RA06.01: PATHOLOGICAL IMPLICATIONS OF SWALLOW-ASSOCIATED TRANSIENT LOWER ESOPHAGEAL SPHINCTER ELEVATION
Authors: Masuda Takahiro , Kovacs Balazs , Bremner Ross , Mittal Sumeet
Published: September 2018

Background

We have previously reported that swallow-induced transient hiatal hernia (tHH) is associated with pathological gastroesophageal reflux. In this study, we built upon our previous study of tHH, assessing the pathological implications of swallow-induced tHH in a new, larger cohort.

Methods

We queried a prospectively maintained database to identify patients who underwent both 24-hour pH monitoring and high-resolution manometry (HRM) between January 2017 and December 2017. We excluded patients with end-stage lung disease, inadequate LES relaxation, major esophageal motility disorders, or manometric hiatal hernia. Significant swallow-induced LES–CD separation was defined as ≥ 1 cm separation in ≥ 30% swallows or ≥ 2 cm separation in ≥ 10% swallows. We used HRM to separate patients into 3 groups, as follows: 1. Persistent tHH (p-tHH): Significant LES–CD separation at the 2nd inspiration after the conclusion of swallow-induced esophageal peristalsis. 2. Incident tHH (i-tHH): Significant LES–CD separation at the 1st inspiration after the conclusion of peristalsis without meeting p-tHH criterion. 3. Non-tHH: Neither p-tHH nor i-tHH was observed.

Results

In total, 472 patients underwent both HRM and a 24-hour pH study during the study period. Of these, 74 patients met inclusion criteria. The mean age was 51.6 years, and 45 patients (60.8%) were women. Forty-two patients (56.8%) had an abnormal DeMeester score (ie, > 14.72). Fourteen patients (18.9%) were categorized into the p-tHH group, 36 (48.6%) were in the i-tHH group, and 24 (32.4%) were in the non-tHH group. LES pressure, LES pressure integral, esophageal peristaltic vigor, and prevalence of dysmotility were similar among the groups. No significant differences were observed in the pH studies for patients with i-tHH and non-tHH; however, patients in the p-tHH group had a higher prevalence of abnormal DeMeester score and longer total acid reflux time than patients in the non-tHH cohort (78.6 vs 45.8%, P < 0.05; 8.0 vs 3.8%, P = 0.016, respectively).

Conclusion

We confirm that p-tHH is associated with pathological distal esophageal acid exposure and appears to be an early indicator of LES dysfunction.

Disclosure

All authors have declared no conflicts of interest.
RA06.06: PATHOGENESIS OF POTASSIUM-COMPETITIVE ACID BLOCKER (P-CAB)-RESISTANT NON-EROSIVE REFLUX DISEASE, AND GASTRIC ACID SECRETION-INHIBITORY EFFECTS OF P-CAB
Authors: Kawami Noriyuki , Hoshino Shintaro , Hoshikawa Yoshimasa , Kaise Mitsuru , Iwakiri Katsuhiko
Published: September 2018

Background

In PPI-resistant NERD patients with symptoms related to acid reflux due to insufficient acid suppression, the symptoms may be improved by the administration of potassium-competitive acid blocker (P-CAB), which is a potent acid inhibitor. However, there are patients with P-CAB-resistant NERD, in whom symptoms persist despite the administration of P-CAB. The objective of this study was to clarify the pathogenesis of P-CAB-resistant NERD.

Methods

Forty-three patients with NERD (20 males, mean age 57.7 ± 2.5 years old), who had persistent reflux symptoms despite the administration of P-CAB (vonoprazan, 20 mg/day for 2 to 4 weeks), were included in this study. After excluding eosinophilic esophagitis (EoE) and primary esophageal motility disorders, esophageal impedance-pH monitoring was performed on P-CAB therapy. The relationship between reflux and symptoms was evaluated according to the symptoms index (SI). Reflux episodes were characterized by pH measurement as acid, weakly acidic or weakly alkaline according to a published consensus report. In symptom index (SI)-positive patients, the mechanism of SI positivity and percent time with intragastric pH > 4 and with esophageal pH < 4 were investigated according to the presence or absence of Helicobacter pylori infection.

Results

One (2.3%) of 43 patients had a primary esophageal motility disorder (Jackhammer esophagus). Eighteen (41.9%) and 3 (7%) patients were SI-positive for liquid- and gas-only reflux, respectively, and the remaining 21 patients who were SI-negative (48.8%) had functional heartburn. All patients SI-positive for liquid reflux were SI-positive for weakly acidic reflux. The percent time with intragastric pH > 4 and esophageal pH < 4 were 98.1 ± 0.8% and 0.18 ± 0.1% (mean ± SE), respectively, in H. pylori-positive patients and 79.9 ± 4.3% and 0.28 ± 0.1%, respectively, in H. pylori-negative patients, demonstrating that gastric acid was sufficiently suppressed by P-CAB regardless of the presence or absence of H. pylori infection.

Conclusion

The pathogenesis of P-CAB-resistant NERD was elucidated in 51% of patients. Symptoms in all patients SI-positive for liquid reflux were related to weakly acidic reflux, and symptoms related to acid reflux may be ruled out by the administration of P-CAB.

Disclosure

All authors have declared no conflicts of interest.
RA06.08: PATIENTS WITH FUNCTIONAL REFLUX SYMPTOMS DO NOT DIFFER SUBJECTIVELY FROM PATIENTS WITH GERD
Authors: Ciftci Sedat , Weitzendorfer Michael , Kalcheva Dariya , Manzenreiter Lisa , Emmanuel Klaus , Koch Oliver
Published: September 2018

Background

Patients with gastroesophageal reflux disease (GERD) often suffer greatly from their symptoms. The aim of this study was to determine if there is a difference in quality of life and gastrointestinal symptom complexes between patients with purely functional complaints and patients with objective GERD

Methods

Included were all patients with typical reflux symptoms who had GERD examination in 2017 at our department. All patients underwent high resolution manometry, 24-h ph-metry impedance measurement and gastroscopy. Quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI) and gastrointestinal symptoms using a Symptom Checklist (SCL) assessing the severity and intensity of 14 different symptoms. Based on the results of the 24-h ph-metry impedance measurement, patients were divided into 2 groups. Patients with functional reflux symptoms and patients with GERD. These two groups were compared.

Results

Complete data was available in 162 patients, of whom 86 patients (52.2%) were objectively reflux sick (DeMeester score mean: 37.85, SD ± 29.11) and 76 patients (46.1%) had a normal DeMeester score (Mean: 7.01, SD ± 4.09). Between the two groups no significant difference in quality of life was found (mean GIQLI of GERD patients: 94.81, SD ± 22.40, and mean GIQLI of patients with functional reflux symptoms: 95.26, SD ± 20.33, P = 0.988).Furthermore no significant difference could be found in symptoms (mean general SCL score of reflux patients:46.97, SD ± 29.23, of patients with functional reflux symptoms: 48.03, SD ± 29.17, P = 0.827).

Conclusion

Patients with functional complaints suffer just as much from their symptoms as patients who are objectively reflux sick. A differentiation between gastroesophageal reflux disease and functional reflux symptoms is only possible by means of functional diagnostics.

Disclosure

All authors have declared no conflicts of interest.
RA06.09: MAGNETIC SPHINCTER AUGMENTATION VERSUS LAPAROSCOPIC NISSEN FUNDOPLICATION: A MATCHED-PAIR ANALYSES OF 186 PATIENTS
Authors: Nikolic Milena , Schwameis Katrin , Kristo Ivan , Semmler Georg , Semmler Lorenz , Steindl Ariane , Schoppmann Sebastian
Published: September 2018

Background

Magnetic sphincter augmentation (MSA) has been proven a safe and efficient alternative to laparoscopic Nissen fundoplication (LNF) in patients with gastro-intestinal reflux disease (GERD). Aim of this study was to compare the matched outcome of patients with GERD following MSA and LNF, respectivelyMagnetic sphincter augmentation (MSA) has been proven a safe and efficient alternative to laparoscopic Nissen fundoplication (LNF) in patients with gastro-intestinal reflux disease (GERD). Aim of this study was to compare the matched outcome of patients with GERD following MSA and LNF, respectively

Methods

Out of a prospective database, an analysis was conducted including patients that underwent MSA and LNF, respectively, between 2012 and 2017 at our institution. Patients were matched using propensity scores including selected criteria. Postoperative outcomes were assessed through reflux-symptoms, proton pump inhibitor (PPI) intake, GERD-Health-related-Quality-of-Life (GERD-HRQL) and Alimentary Satisfaction (AS).

Results

From a total of 323 patients, 186 patients that met our inclusion criteria were matched. At a median follow-up of 1.5 years there was no difference in the GERD-HRQL (2.5 MSA vs. 1 LNF, P = 0.341), AS (8/10 MSA vs 9/10 LNF, P = 0.175), regular PPI-intake (15% MSA vs. 6% LNF, P = 0.058) or heartburn elimination (73% MSA and LNF) between the two groups. We observed similar side-effect rates concerning persistent dysphagia (1% MSA and LNF) and gas-bloating (17% MSA vs. 15% LNF, P = 0.690). However, in patients after MSA the ability to belch and/or vomit was higher (87% MSA vs. 70% LNF, P = 0.05).

Conclusion

Mid-term outcome of patients after MSA for the treatment of GERD is comparable to patients treated with LNF. Patients after MSA showed a higher ability to belch and/or vomit when compared to patients after LNF. This study encourages MSA as alternative first-line treatment in patients with non-severe GERD

Disclosure

All authors have declared no conflicts of interest.
RA07.01: CHANGE OF METABOLIC TUMOR VOLUME PREDICTS LONG-TERM SURVIVAL AND HISTOLOGICAL RESPONSE TO PREOPERATIVE CHEMOTHERAPY IN LOCALLY-ADVANCED ESOPHAGEAL CANCER
Authors: Makino Tomoki , Yamasaki Makoto , Tanaka Koji , Masuike Yasunori , Mori Masaki , Doki Yuichiro
Published: September 2018

Background

The present study was aimed to assess the value of metabolic tumor volume (MTV) measured by 18F-fluorodeoxyglucose to evaluate response to neoadjuvant chemotherapy in patients with locally-advanced esophageal cancer (EC).

Methods

A total of 102 EC patients without distant metastasis who underwent 18-fluorodeoxyglucose (FDG)-positron emission tomography (PET) both before and after the series of preoperative chemotherapy were analyzed.

Results

The median value of MTV in primary tumor before and after preoperative chemotherapy were 22.55 (range: 0.4 -183.1) and 2.75 (0–52.9), respectively and the median reduction rate of MTV was 86.5%. The most significant difference in survival between PET responders and non-responders was at 60% of MTV reduction as a cutoff value based on every 10% stepwise cutoff analysis (2-year progression-free survival [PFS]: 79.2 vs 44.4%; hazard ratio [HR] = 3.397; P < 0.0001). With this cutoff value, histological complete response (P = 0.0091) in addition to tumor location (P = 0.0102), pT (P = 0.0011), and pN (P = 0.0110) were significantly associated with PET response. Univariate analysis of PFS indicated a correlation between PFS and tumor size, cT, decrease of primary lesion by CT, SUVmax reduction rate, MTV reduction rate, pT, pN, pM. Multivariate analysis further identified MTV reduction rate (HR = 2.471; P = 0.0263) but not decrease of primary lesion by CT or SUVmax reduction rate to be independent prognostic predictors along with pM (HR = 3.063; P = 0.0279).

Conclusion

By determining the optimal cutoff value based on survival analysis, change of MTV was shown to be clinically useful in predicting both long-term survival and histological response to preoperative chemotherapy in EC patients.

Disclosure

All authors have declared no conflicts of interest.
RA07.09: THE EFFICACY OF ASSESSING METASTATIC LYMPH NODES BY COMPUTED TOMOGRAPHY IN ADVANCED ESOPHAGEAL CANCER WITH NEOADJUVANT CHEMOTHERAPY
Authors: Urakawa Shinya , Makino Tomoki , Tanaka Koji , Miyazaki Yasuhiro , Takahashi Tsuyoshi , Kurokawa Yukinori , Yamasaki Makoto , Mori Masaki , Doki Yuichiro
Published: September 2018

Background

Although various modalities including CT, endoscopy, and positron emission tomography (PET) have been used to predict pathological tumor response (pTR) to neoadjuvant chemotherapy (NACT) or prognosis in esophageal cancer patients, an optimal method of response evaluation remains to be established.

Methods

A total of 97 non-T4 thoracic esophageal cancer patients who underwent curative surgery after NACT from 2011 to 2014 with both measurable primary tumors (PT) and metastatic lymph nodes (LNs) by CT (≥ 10mm in short axis or ≥ 5mm in short axis with SUV-max ≥ 2.5) were analyzed. Patients with ≥ 50% decrease in size of the PT (two-direction measurement) and ≥ 30% decrease in size of LNs (sum of short diameter based on RECIST criteria) were defined as PT- and LNs-responders, respectively.

Results

The median reduction rate of PT and LNs were 62.0% (5.5–93.4) and 26.7% (60.9–13.6), respectively. Of 97 patients, 62 (69%) and 45 patients (45%) were classified as PT- and LNs-responders respectively. The concordance rate between CT response of PT and LNs was 66% (P = 0.01). CT response of PT was correlated with pTR (P<0.0001) while CT response of LNs was associated with pT (P = 0.0011), pN(P = 0.0004), and pTR (P < 0.0001). Receiver operating characteristic (ROC) curves demonstrated the highest accuracy (AUC 0.75), sensitivity (88.9%) and specificity (60.9%) at the reduction rate of 53% (P = 0.007) which was approximated to the cutoff value we used. In univariate analysis of recurrence free survival (RFS), pT, pN, pM, CT response of both PT and LNs, and pTR were significantly correlated with RFS. Multivariate analysis further identified CT response of LNs (HR 2.68 P = 0.003) and pTR (HR 2.72 P = 0.022) to be independently associated with RFS. When classified into three groups by histological grade and CT response of LNs [group A (grade2–3/LNs-responders), group B (grade1a-1b/LNs-nonresponders), and group C (others)], 2-year RFS were 83% in the groupA, 59% in groupC and 29% in groupB (P < 0.0001), respectively.

Conclusion

In locally-advanced esophageal cancer patients with NACT followed by surgery, CT response of PT and LNs significantly correlated with pTR. Especially, CT response of LNs was important to predict prognosis in addition to pTR.

Disclosure

All authors have declared no conflicts of interest.
RA08.03: LYMPH NODE METASTASIS RISK IN SUPERFICIAL ESOPHAGOGASTRIC JUNCTIONAL ADENOCARCINOMA
Authors: Akazawa Naoki , Yamasaki Akira , Fujisaki Junko
Published: September 2018

Background

We have reported that lymph node metastasis risk in cases of superficial Barrett's esophageal cancer (BC) was of submucosal invasion within 500μm without other risk factors (lymphovascular involvement, a poorly differentiated component, and lesion size) through a multicenter retrospective study in 13 facilities. Cardiac cancer (CC) was included in the gastric cancer criteria of the Japanese Gastric Cancer Association. Since BC and CC near the esophagogastric junction (EGJ) show almost the same biological behavior, we elucidated the metastasis risk factors in patients with EGJ adenocarcinoma.

Methods

Patients who underwent ESD for superficial EGJ adenocarcinoma as Siewert typeII between January 2011 and April 2017 were included.

Results

A total of 120 patients were analyzed. Fifty-three patients (44.1%) had BC and 67 patients (55.8%) had CC. Of the 120 lesions, the median size was 16.7 ± 8.5 mm; 10 (8.3%; 4 BC, 6 CC) were greater than 30 mm in size. Thirty-five (29.1%; 17 BC, 18 CC) were submucosal (SM) cancers. Twenty-one (17.5%; 13 BC, 8 CC) had poorly differentiated components and 19 (15.8%; 14 BC, 5 CC) had lymphovascular involvement. Of the 19 cases with lymphovascular involvement, 11/22 (50%) were SM cancers with > 200μm of invasion, and 8/98 (8.1%) were mucosal (M)/SM cancers within SM200μm of invasion. Of the BCs with DMM invasion, 7/17 (41.1%) had lymphovascular involvement. Of the patients initially treated through ESD, 33 (27.5%) had lymphovascular involvement, positive horizontal/vertical margins, or SM > 200μm of invasion. Of these, 26 were treated with additional surgery. Metastasis was confirmed from 2 patients. Both were BCs, with SM > 501μm of invasion, positive lymphovascular involvement, and with poorly differentiated components. One was > 30 mm in size. Metastasis was not identified in CC and in cases with SM < 200μm of invasion.

Conclusion

For superficial esophagogastric cancer, we did not identify metastasis in patients with SM > 501 μm of invasion. There were no cases of metastasis in patients without risk factors. ESD might be indicated for lesions within SM 500μm of invasion without risk factors. Among DMM cases of BC, lymphovascular involvement was highly frequent. Therefore, histopathological surveillance for lymphovascular involvement is important.

Disclosure

All authors have declared no conflicts of interest.
RA09.04: THE LYMPH NODE STATUS OF PT1 ESOPHAGOGASTRIC JUNCTIONAL ADENOCARCINOMA
Authors: Mayanagi Shuhei , Kawakubo Hirofumi , Suda Koichi , Kitagawa Yuko
Published: September 2018

Background

There is no consensus regarding the optimal extent of lymphadenectomy for the esophagogastric junctional (EGJ) cancer. The Japanese esophagogastric cancer treatment guideline showed the tentative standard in the extent of lymphadenectomy based on the location, histology and T-categories. The purpose of this study is to identify the lymph node status in patients with pT1 EGJ adenocarcinoma.

Methods

From January 2000 to November 2016, we underwent radical resection with or without sentinel lymph node (SN) mapping for esophagogastric cancer at Keio University Hospital. We identified 38 patients with pT1 adenocarcinoma with its center located within 2cm of the junction. We then analyzed the lymph node status and SN distribution.

Results

The primary tumor that had their epicenter within the proximal of the cardia in 37%, that had their epicenter within the distal of the cardia in 63% of all patients (n = 12, 26). The surgical procedures were proximal gastrectomy (n = 30); subtotal esophagectomy (n = 4); and total gastrectomy(n = 4). Two patients (5%) had positive lymph node metastasis. Of the 2 patients with positive node, one patient had the metastatic lymph node along the short gastric vessels and the other patient had the metastatic lymph nodes along both the left gastric artery and the celiac artery. Those 2 patients with positive node had no recurrence. However, liver or local (anastomotic) recurrence occurred in 1 patients, respectively. SN was accomplished in all patients who underwent SN mapping and diagnostic accuracy based on the SN status was 100% (17/17).

Conclusion

Our results suggested that lower mediastinal lymphadenectomy was of limited significance in patients with pT1 EGJ adenocarcinoma. SN mapping may be contributory to the optimal extent of lymphadenectomy.

Disclosure

All authors have declared no conflicts of interest.
RA09.08: EVALUATION OF THE EIGHTH YPTNM CLASSIFICATION SYSTEM IN ESOPHAGEAL CANCER PATIENTS
Authors: Nomura Motoo , Tsunoda Shigeru , Sakanaka Katsuyuki , Tamaoki Masashi , Amanuma Yusuke , Miyamoto Shinichi , Fujii Kohta , Hisamori Shigeo , Obama Kazutaka , Muto Manabu , Sakai Yoshiharu
Published: September 2018

Background

The 7th edition of the Union for International Cancer Control (UICC) TNM staging system is based on pathologic data from esophageal cancers treated by surgery alone. In the 8th edition of UICC-TNM staging system, there is no information available for treatment modality (surgery alone or neoadjuvant therapy [NAC] followed by surgery [NAC-S]), although clinical stage, neoadjuvant pathologic stage, and pathologic stage were analyzed and identified. The objective of this study was to evaluate the prognostic impact of the new staging system on esophageal squamous cell cancer (ESCC) patients treated by NAC-S.

Methods

Database of 140 consecutive ESCC patients in our hospital was retrospectively restaged in 7th and 8th UICC-TNM system. The prognostic impacts of pathologic stage after NAC according to the both staging systems were compared.

Results

The median follow-up period was 4.8 years (range 0.2–9.7), with 49 patients dead at the time of analysis. In 7th edition, the 3-year overall survival rates (3y-OS) of ypStages 0, I, II, III, and IV were 100%, 93.5%, 93.5%, 43.9%, and 0.0%, respectively. In 8th edition, the 3y-OS of ypStages 0, I, II, III, and IV were 100%, 96.5%, 90.2%, 51.7%, and 29.6%, respectively. There were no marked differences between 7th and 8th edition in the prognoses. The both editions poorly distinguish the prognoses of ypStages 0, I, and II. For pathological prognostic group in 7th edition, the 3y-OS of Groups 0, I, II, III, and IV were 100%, 97.0%, 90.6%, 43.9%, and 0.0%, respectively. For pathological prognostic group in 8th edition, the 3y-OS of Groups 0, I, II, III, and IV were 100%, 96.7%, 89.8%, 51.7%, and 29.6%, respectively. For patients with ypStages 0-II, pretreatment higher CEA was poor prognostic factor (HR 7.1, 95% confidence interval 1.9–25.9).

Conclusion

Our study indicates the problem that the ypStage in the 8th TNM staging system poorly distinguish the prognoses of ypStages 0, I, and II in patients undergoing NAC-S. Additional study is needed to evaluate the role of ypStage 0-II incorporation of new prognostic factors.

Disclosure

All authors have declared no conflicts of interest.
VS01.02: MEDIASTINAL LYMPH NODE DISSECTION DURING MINIMAL INVASIVE ESOPHAGECTOMY
Authors: Noshiro Hirokazu , Yoda Yukie
Published: September 2018

Description

As esophageal cancer reveals aggressive characteristics of lymph node metastasis, esophagectomy with extensive lymph node dissection is required as the optimal management in most cases. In spite of improvements in the survival rate, however, the procedure is still associated with significant postoperative morbidity and mortality. As minimally invasive surgery reduces both pain and the systemic inflammatory response, minimally invasive esophagectomy has been developed in an obvious attempt to reduce the incidence of postoperative complications. In addition, the magnified and clear views by thoracoscopy accelerate recognition for the fine and minute surgical anatomy of the mediastinum. Thoracoscopic mobilization of the esophagus and mediastinal lymph node dissection as part of a three-stage procedure was reported in the early 1990s. Recently, thoracoscopic esophageal mobilization and mediastinal dissection in the prone position has been developed. Enhanced visualization and improved ergonomics for surgeons in the prone position provide higher-quality mobilization and lymphadenectomy and contribute to enhancement of the learning curve. Especially, it is favorable during the procedures of upper mediastinal lymph node dissection which are the most complicated ones. During this lymph node dissection, the concept of lymphatic flow is very important. Now, it takes 3 hours and 15 minutes for the thoracic procedure, but the blood loss is less than 100 ml in our recent series. In the presentation, the surgical procedures of thoracoscopic or robotically-assisted esophagectomy in the prone position for esophageal cancer will be demonstrated and our surgical results of over 300 cases will be shown.

Disclosure

All authors have declared no conflicts of interest.