bluuebunny/crossref_metadata_2025 huggingface dataset:
223. OUR SURGICAL TECHNIQUE OF TRACHEAL RESECTION AND ANTERIOR MEDIASTINAL TRACHEOSTOMY (AMT) IN THE MULTIDISCIPLINARY TREATMENT OF ESOPHAGEAL CANCER INVADING TRACHEA
Authors: Makino Tomoki , Momose Kota , Yamashita Kotaro , Tanaka Koji , Eguchi Hidetoshi , Doki Yuchiro
Published: September 2024

Combined tracheal resection and anterior mediastinal tracheostomy (AMT) for esophageal cancer with tracheal invasion is a challenging treatment and technically demanding. Herein, we introduce our surgical procedure of AMT and its tips to reduce postoperative complications. Briefly, in a supine position with cervical approach, the manubrium, the medial half of the clavicle, and the adjacent first and second ribs on both sides were removed to achieve an open cervico-thoracic view. After completion of tumor resection, AMT was performed; after encircling brachiocephalic artery and transected innominate vein if needed, the tracheal stoma was translocated from the left to right side of the brachiocephalic artery to avoid postoperative hemorrhage caused by tracheal compression. In a case of free-jejunum reconstruction, we usually harvest mesentery as much as possible to fill in the surrounding dead space in the upper mediastinum around trachea and major arteries to prevent infection (we also use the pectoral myocutaneous flap and omentum for this purpose). The tracheal stoma was finally created using interrupted stitched to attach the tracheal stump to the native chest skin.

https://photos.google.com/photo/AF1QipNDuxhBpSYDIDydLYD_0Vk917Kd13bG5t6ILtb6
227. CAUSES OF IN-HOSPITAL MORTALITY FOLLOWING TRANSTHORACIC ESOPHAGECTOMY FOR CANCER
Authors: Straatman Jennifer , Babic Benjamin , Klevebro Frederik , Fuchs Hans , Gisbertz Suzanne , Schmidt Thomas , Bruns Christiane , van Berge Henegouwen Mark , Nafteux Phillipe , Nilsson Magnus , Schröder Wolfgang
Published: September 2024

Background

Rates of peri-operative mortality following esophagectomy for cancer have markedly decreased over the last few decades, with a 90-day mortality rate below 5% considered a benchmark for quality of care. Although studies have focused on mortality rates, little is known about the causality. The aim of this study was to perform a multicenter, in-depth analysis of peri-operative mortality following esophagectomy for cancer.

Methods

Data was obtained multicenter, from prospective databases, between January 2010 – June 2020. All patients with a lethal postoperative course (Clavien-Dindo V) following elective transthoracic esophagectomy were included. Data collection included baseline characteristics, preoperative comorbidities, surgical procedures, postoperative complications and their management. In each participating center, two surgeons independently reassessed patient work-up and the management of intra-operative and postoperative complications to finally classify the management of each section as adequate, non-adequate or undetermined. Statistics encompassed descriptive analysis.

Results

One-hundred and twenty-one out of 3899 patients died in-hospital following oesophagectomy; a mortality rate of 3.1%. Patients deceased on a median of 32 days after surgery (IQR: 18-60). In preoperative work up: 24 patients (19.7%) had a Charlson-Comorbidity-Index (CCI) of 5 of higher; with cardiac comorbidity reported most often, in 39% of patients. Reassessment revealed work-up was not adequate in two patients (1.4%).

During surgery, 6 patients (4.6%) suffered complications, all managed adequately in reassessment. Following surgery, a total of 343 major complications were identified in the 121 patients (mean 2.4 ± 1.2) with anastomotic leakage (AL) reported most often, in 65 patients (53.7%). AL was reported as cause of death in 44 patients (36.5 %). In eight patients (6.6 %) postoperative management was reassessed to be non-adequate, in these cases recognition and initiation of treatment for AL (n=7) or conduit necrosis (n=1) was delayed.

Conclustion

In contrast to other published series, reassessment of this homogenous patient cohort with a lethal clinical course in expert centers revealed only a low rate of preventable mortality with respect to the preoperative patient selection and postoperative complication management. However, anastomotic leakage was identified to be the leading cause of death following esophagectomy contributing to a significantly prolonged clinical course and lethal outcome. As the development of surgical procedures with complex anastomotic techniques is inevitably associated with an increasing leakage rate expressed by prolonged learning curves, modification of complication management might be considered in order to reduce overall death rates.
242. BRD4 INHIBITION ENHANCES THE RADIOSENSITIVITY OF ESOPHAGEAL SQUAMOUS CELL CARCINOMA THROUGH REGULATING ATF3-MEDIATED SERINE AND NUCLEOTIDE SYNTHESIS
Authors: Zhao Lei , Gao Tiantian , Zhang Zewei
Published: September 2024

Background

Radioresistance is a major culprit for radiotherapy failure in esophageal squamous cell carcinoma (ESCC). This study aimed to investigate the underlying mechanism of Brd4 in radiosensitivity of ESCC.

Methods

Brd2/3/4 proteins were assessed in radiosensitive and radioresistant ESCC tissues using IHC. A serial of functional experiments was performed to verify the significance of Brd4 in ESCC. RNA-seq and bioinformatics analyses were used to determine the potential downstream targets. The dual-luciferase reporter and ChIP assay were further examined the underlying regulatory mechanism among targets. Besides, we further verified the importance of ATF3-mediated serine and nucleotide metabolism in radiated ESCC cells.

Results

Brd4 is highly expressed in radio-resistant ESCC tissue. Knockdown of Brd4 led to increased DNA damage and cell apoptosis in irradiated ESCC cells. RNA-seq analyses exhibited that ATF3 was a potential downstream target of Brd4. The dual-luciferase reporter and ChIP assay demonstrated that Brd4 upregulated ATF3 expression via activation its promoter region. Besides, we found that ATF3 could facilitate the enzyme activities involved in serine and nucleotide biosynthesis pathway to promote radiation-induced DNA damage repair.

Conclusion

Brd4 facilitates ATF3 expression via binding to and activating ATF3 promoter region. Enhanced ATF3 further increases crucial enzymes activity in serine and nucleotide biosynthesis pathway to promote radiation-induced DNA damage repair. Targeting Brd4 is a promising treatment strategy to improve radiosensitivity in ESCC.
247. INVESTIGATION ON THE RECURRENCE AND PROGNOSIS WITH MM/SM1 OESOPHAGEAL SUPERFICIAL CANCER AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION
Authors: Toyokawa Tatsuya , Fujita Isao
Published: September 2024

Background

The therapeutic strategy for MM/SM1 oesophageal superficial cancer (OSC) after endoscopic submucosal dissection (ESD) still remains controversial, but there are some opinions that cut-end positive, vascular invasion positive, infiltrative growth pattern (INF) c, and poorly differentiated carcinoma are the risk factors for the recurrence of lymph-node (LN) or distal metastases.

Methods

This study aimed to investigate the recurrence and prognosis after ESD in patients with MM/SM1 OSC who do not have the risk factors. We performed ESD in 167 patients with OSC, and among these, we enrolled 15 patients with MM/SM1 OSC who did not have cut-end positive, vascular invasion positive, INF c, or poorly differentiated carcinoma in this study. The clinical background characteristics, endoscopic findings, additional therapy after ESD, recurrence, and prognosis of these patients were investigated.

Results

The median age of the patients, including 11 males and 4 females, was 69 years (range: 59–84). The mean follow-up duration was 75 months (range: 17-137). Of these, 3 patients had chronic obstructive pulmonary disease, 1 had cerebrovascular disease, and 1 had chronic heart failure. Regarding the lesion location, 2 patients had the lesion at Ut, 11 had at Mt, and 2 had at Lt. In 3 patients, the lesion occupied more than 3/4 of the lumen. We found 2 patients with elevated-type lesions, 10 with flat-type lesions, and 3 with depressed-type lesions. The mean long diameter of the lesions was 29 mm (range: 11-47). Regarding the lesion depth, there were 12 lesions in MM and 3 lesions in SM1. A total of 4 patients received additional radiation therapy, and the remaining 11 patients were followed up without additional therapy. The patients who received additional therapy did not have recurrences; however, 4 among the 11 patients without additional therapy manifested LN and lung metastases. Furthermore, 3 patients died because of the progression of oesophageal cancer, and another patient received chemotherapy.

Conclusion

In this study we showed that follow-up without additional therapy after ESD in patients with MM/SM1 OSC is unlikely to be acceptable despite not having risk factors. Therefore, we should urgently develop a treatment strategy for patients with MM/SM1 OSC after ESD.
249. OVERALL SURVIVAL OF PATIENTS WITH ESOPHAGEAL CANCER TREATED WITH DEFINITIVE CHEMORADIOTHERAPY: INSIGHTS FROM A RETROSPECTIVE STUDY
Authors: Van Der Zijden Charlène , Bouwman Anna , Mostert Bianca , Nuyttens Joost , van der Sluis Pieter , Spaander Manon , Mens Jan Willem , Homs Marjolein , van Doorn Leni , Wijnhoven Bas , Lagarde Sjoerd
Published: September 2024

Background

Neoadjuvant chemoradiotherapy followed by esophagectomy is the standard of care for patients with locally advanced esophageal cancer. However, definitive chemoradiotherapy (dCRT) may be considered as an alternative for those with unresectable disease, cervical location of the tumor or if a non-surgical approach is preferred based on the patient's condition. Heterogeneity in indications for dCRT makes it challenging to draw generalized conclusions regarding outcomes and survival. The aim of this study was to evaluate overall survival (OS) and recurrence patterns in patients with specified homogeneous indications for dCRT.

Methods

Patients with esophageal cancer treated with dCRT (50.4 Gy radiotherapy concomitant with 6 cycles of carboplatin/paclitaxel) between 2012-2022 in a tertiary referral center were identified from our institutional database. Primary endpoint was OS calculated from date of diagnosis until date of death or last day of follow-up, using the Kaplan Meier method. Secondary endpoints included the proportion of patients that completed the dCRT regimen, 30- and 90-day mortality following dCRT and disease recurrence.

Results

162 patients were included, median follow-up was 74.6 months (IQR 46.2-99.3). The full dCRT regimen was completed by 116 (73.9%) patients. The 30- and 90-day mortality were 2.5% and 8.3%, respectively. The median OS was 23.7 months (95% CI 6.65-40.66) for cervical location of the tumor, 13.7 months (95% CI 7.92-29.8) for irresectable disease, 28.2 months (95% CI 12.10-44.22) for patients unfit for surgery and 20.6 months (95% CI 14.14-27.13) for those with preference for dCRT (p=0.15). Disease recurrence was observed in 74 patients (46%), located locoregional (46%), distant (19%) or both locoregional and distant (35%).

Conclusion(s)

Treatment with dCRT resulted in a 5-year OS of 35% and is associated with a high 90-day mortality. Disease recurrence was mostly locoregional located and was observed in 46% of patients. This emphasizes the critical necessity for enhanced treatment strategies centered on improving locoregional disease control.
253. CLINICAL USEFULNESS OF ENDOSCOPY, BARIUM FLUOROSCOPY, AND CHEST COMPUTED TOMOGRAPHY FOR THE CORRECT DIAGNOSIS OF ACHALASIA
Authors: Ishii Tadashi , Kamei Takashi , Nakano Toru , Koseki Ken
Published: September 2024

Background

The definite diagnosis of esophageal achalasia is established using manometry, which is per- formed in patients with suspected achalasia based on the findings of screening examinations, such as upper gastrointestinal endoscopy, chest computed tomography (CT), or a barium swallow test. However, the exact values of test characteristics in these supportive diagnostic examinations remain unclear.

Methods

We estimated the sensitivity and specificity of characteristic findings in the supportive diagnostic examinations for achalasia by comparing the data of a large number of achalasia patients and others with digestive symptoms.

Patients

Achalasia patients (n=119) and non-achalasia patients with suspected achalasia and repeated feelings of chest discomfort (n=37) who were treated in a single university hospital.

Results

Characteristic findings on chest CT (i.e. dilated esophagus, air-fluid level formation) and barium swallow tests were observed in more than 80% of achalasia patients but in less than 10% of non-achalasia patients. In contrast, conventional characteristic findings of upper gastrointestinal endoscopy (i.e. intra- esophageal food debris, feeling of resistance at the esophagogastric junction) were seen in only 40%-70% of achalasia patients. In particular, the feeling of resistance at the esophagogastric junction was observed by the examiner in only 30%-50% of patients.

Conclusion

Intra-esophageal food debris or resistance at the esophagogastric junction on upper gastrointestinal endoscopy will be positive in only about half of patients with achalasia. Other supportive diagnostic examinations, such as chest CT or barium fluoroscopy, should therefore be included in order to avoid overlooking the disease.
261. CONVERSION ESOPHAGECTOMY FOR CT4B ESOPHAGEAL CANCER - MIE VS OPEN -
Authors: Ishiyama Koshiro , Kurita Daisuke , Oguma Jyunya , Daiko Hiroyuki
Published: September 2024

Background and Aims

The standard treatment for locally advanced unresectable esophageal cancer is definitive chemoradiotherapy (dCRT), however, after induction chemotherapy with a triplet chemotherapy regimen (docetaxel, cisplatin, and 5-FU: DCF) or dCRT, conversion surgery could be performed if esophageal cancer is considered resectable. Furthermore, minimally invasive surgery such as robot-assisted or thoracoscopic procedures are expected to improve the outcome of patients with advanced esophageal cancer.

We investigated the feasibility of minimally invasive esophagectomy (MIE) in conversion surgery.

Materials and Methods

Sixty-six patients who underwent conversion thoracic esophagectomy for cT4b esophageal cancer from 2007 to 2023 were included. The short-term outcomes of 25 open esophagectomy group and 41 MIE group (8 robot-assisted and 33 thoracoscopic) were compared.

Results

No differences in age, gender, PS, tumor location, histology, cN, or cM were observed between the two groups. cT4b organs tended to be in the airway in the MIE group (airway 70.7% vs 44%, major vessels 19.5% vs 24%, both 9.7% vs 32%, p=0.04) and DCF therapy was significantly performed in the MIE group for induction therapy (DCF 87.8% vs 56%, dCRT 12.2% vs 44%, p<0.001). On the other hand, salvage surgery was significantly associated with open esophagectomy (24.3% vs. 52%, p=0.003).

There was no difference in surgical outcomes regarding thoracic operation time (157 min vs. 180 min, p=0.09), whereas the total operation time was significantly shorter in the MIE group (392 min vs. 439 min, p=0.02). Blood loss was significantly lower in the MIE group (79 ml vs. 470 ml, p<0.001), and R0 resection rate did not differ (82.9% vs. 72%, p=0.357).

There were no significant differences in postoperative complications including pneumonia (26.8% vs. 44%, p=0.183) and recurrent nerve palsy (21.9% vs. 36%, p=0.260), but anastomotic leakage was significantly lower in the MIE group (4.8% vs. 24%, p=0.04). There was no difference in median postoperative hospital stay (16 [11-20] vs. 16 [14-29] days), however, median ICU stay (3 [3-4] vs. 4 [3-4] days, p=0.03) and readmission within 1 month after discharge (2.4% vs. 16%, p=0.04) were significantly lower in the MIE group. In-hospital mortality was observed in 1 case in the MIE group and 3 in the open esophagectomy group.

Conclusion

Despite the bias associated with the transition of treatment modalities and surgical techniques, MIE may contribute to improved short-term outcomes in conversion surgery.
371. ENDOFLIP: THE FUTURE OF DYSPHAGIA DIAGNOSIS AND MANAGEMENT
Authors: Gonçalves Ana Raquel , Cardoso Pedro , Peixoto Armando , Macedo Guilherme , Santos Ana Luísa
Published: September 2024

Background

High-resolution manometry (HRM) is the gold standard for characterizing esophageal motility disorders, but it’s frequently associated with poor patient tolerance. A newer diagnostic tool, the Endoscopic Functional Lumen Imaging Probe (EndoFLIP), has emerged to assess esophagogastric junction (EGJ) distensibility and distension-mediated peristalsis. Also, for motility disorders such as EGJ outflow obstruction (EGJOO), HRM-isolated features aren’t enough for the diagnosis. The diagnosis also requires symptom correlation and additional investigations like EndoFLIP.

Methods

We conducted a single-center prospective cohort study for patients with dysphagia and inconclusive or intolerant to HRM. The inclusion criteria were patients with an elevated median integrated relaxation pressure (IRP) on HRM and patients with an inconclusive or intolerant to HRM. Patients with isolated IRP on HRM were included, as this isolated finding does not allow for the definitive diagnosis of EGJOO. These patients underwent EndoFLIP testing from January 2022 to February 2024 at a tertiary center.

Results

We performed EndoFLIP on 42 patients (50% male; 50% female), 23,8% with EGJOO diagnosis on HRM, 21,4% with inconclusive HRM, and 54,8% patients intolerant to HRM. Twenty-three patients intolerant to HRM underwent EndoFLIP, enabling diagnosis in all cases. Four patients were diagnosed with EGJOO, 6 with achalasia, and 4 with ineffective esophageal motility (IEM). On 88% of patients, the EndoFLIP allowed a correct diagnosis and treatment, with 29% undergoing endoscopic treatment during the same procedure. 9 patients with inconclusive HRM were diagnosed after EndoFLIP: 3 were diagnosed with EGJOO, 4 with IEM, and 3 with achalasia.

We report a significant discordance between EGJOO diagnosis on HRM and EndoFLIP results. 50% of patients diagnosed with EGJOO on HRM showed normal EndoFLIP results, with only 20% confirming the diagnosis, while 20% raised the possibility of the diagnosis being achalasia. 43,8% of patients diagnosed with EGJOO confirmed by EndoFLIP underwent endoscopic therapy with botulinum toxin or balloon dilation during the same procedure, resulting in clinical improvement for all patients.

Discussion

The discordance between HRM and EndoFLIP may arise from HRM's tendency to overdiagnose EJGOO, leading to unnecessary testing and treatments for EGJOO. Many EGJOO HRM diagnoses don't require therapy, as symptoms often resolve spontaneously or with dietary education, casting doubt on the isolated HRM finding's clinical significance. It's particularly beneficial for patients with inconclusive/intolerance to HRM, allowing correct diagnosis and treatment in cases of obstructive symptoms. These results support EndoFLIP as a screening tool for patients undergoing endoscopy, enabling better selection of those benefiting from subsequent HRM.
373. FLIPPING THE SCRIPT: ENDOFLIPPING THROUGH ESOPHAGEAL CHALLENGES WITH A TWIST!
Authors: Gonçalves Ana Raquel , Cardoso Pedro , Peixoto Armando , Santos Ana Luísa , Macedo Guilherme
Published: September 2024

Background

High-resolution esophageal manometry (HRM) is the gold standard for studying esophageal motility disorders but isn't universally available, and it's also reported as invasive and uncomfortable. The EndoFLIP system offers a dynamic evaluation of the esophagogastric junction (EGJ), crucial for patients with inconclusive HRM or undergoing endoscopic or surgical therapy such as myotomy or fundoplication. EndoFLIP is a practical tool in patients with dysphagia with normal upper endoscopy, allowing diagnostic assessment during the same procedure, and better selecting patients for subsequent HRM.

Methods

We conducted a retrospective study where we analyzed EndoFLIP procedures performed at a tertiary center from January 2022 to February 2024, for multiple indications, including characterization of findings on HRM, primary investigation of patients with dysphagia undergoing diagnostic upper endoscopy, motility study in patients intolerant to HRM, and post-therapeutic endoscopic/surgical assessment.

Results

Sixty-nine patients submitted to EndoFLIP procedures were included (39.1% male; 60.9% female) with a median age of 62 years. The primary indication was dysphagia, with 17.3% of patients being intolerant or referred with inconclusive HRM. EndoFLIP enabled diagnosis in all patients, even with an inconclusive HRM. Endoflip was performed on patients with treated achalasia with recurrence of dysphagia (16%), of which 55% exhibited reduced distensibility of EGJ. The evidence of reduced distensibility allowed patient selection for further treatment.

Seven patients underwent EndoFLIP to characterize EGJOO. Comparing paired data from HRM and EndoFLIP, overall concordance was only 47,1%. Endoflip showed a large discordance for the EGJOO group, with 50% having normal findings and 20% confirming EGJOO. 43,8% of patients diagnosed with EGJOO confirmed by EndoFLIP underwent endoscopic therapy during the same procedure, allowing the diagnosis and treatment at the same time. Four patients with gastroesophageal reflux disease, intolerant to HRM and proposed for Nissen fundoplication, underwent EndoFLIP for EGJ and esophageal motility evaluation. Currently, they are proposed for surgery due to the normal findings on EndoFLIP.

Conclusion

The use of EndoFLIP in evaluating esophageal motility disorders presents a paradigm shift, overcoming the limitations of traditional methods like HRM. Our retrospective study demonstrates its pivotal role in diagnosing and managing patients with dysphagia submitted to diagnostic endoscopy, especially post-interventions like achalasia or Nissen fundoplication. With its ability to provide comprehensive assessments and guide tailored treatments, EndoFLIP emerges as a valuable tool in clinical practice. Its impact on patient management, evidenced by alterations in treatment strategies in over 80% of cases, underscores its significance.
374. INCIDENCE AND PREDICTORS OF STRICTURE DEVELOPMENT FOLLOWING ESOPHAGECTOMY: A RETROSPECTIVE ANALYSIS
Authors: AlQinai Shamlan , Crump Trafford , Mueller Carmen , Cools John , Spicer John , Ferri Lorenzo , Najmeh Sara
Published: September 2024

Objective

Anastomotic stricture (AS) is a well described complication after esophagectomy and not only affects nutritional status but also has a detrimental impact on long-term quality of life. This retrospective study explores the incidence of clinically relevant AS in patients undergoing esophagectomy for cancer and investigates the potentially reversible factors associated with AS.

Methods

A prospectively entered clinical database of consecutive patients undergoing esophagectomy at a high-volume referral center over a decade (1/2013-12/2022) was queried for the presence of post-operative clinically significant AS, defined as stricture requiring endoscopic dilation. Multiple variables encompassing patient-related risk factors, tumor pathology, prior treatment, operative factors, and post-op complications were included in logistic regression analyses to delineate predictors of stricture formation.

Results

Of 1015 patients in the database, 115 (11.3%) developed AS requiring at least 1 post-op dilation. Although higher American Society of Anesthesiologists (ASA) grading was associated with elevated AS rate impact with most patients being ASA 2 and 3; 24% and 49% respectfully (p < 0.05). Specific patient factors/comorbidities such as age, peripheral or coronary vascular disease, and diabetes mellitus did not emerge as significant predictors. Surprisingly, neither histology, nor neoadjuvant therapy (chemo or chemoradiation) were associated with AS. Both a cervical anastomosis and a intra-operative pyloromyotomy had a higher AS rate than an intra-thoracic anastomosis (OR 13.3, p=0.006) and patients without a myotomy (p=<0.006). Other operative factors including approach (open vs MIE) conduit type (stomach/jejunum/colon) or width (3/4/5/6 cm) did not impact AS rate. All patients had a hand-sewn anastomosis. No post-operative outcome measures (e.g. leak, epidural use, hypotension) was associated with the development of AS.

Conclusion

Our results highlight the interplay of patient-related risk factors, tumor pathology, prior treatment, and operative factors in the development of post esophagectomy strictures. Understanding these predictors could potentially influence risk stratification and may facilitate tailored postoperative care strategies for improved patient outcomes.
376. COMPARISON OF POST-SURGICAL NUTRITIONAL STATUS BETWEEN IVOR-LEWIS ESOPHAGECTOMY AND PROXIMAL GASTRECTOMY
Authors: Sunagawa Hideki , Okabe Hiroshi , Takabe Yuya
Published: September 2024

Background

In our institution, the surgical approach for esophagogastric junction cancer (EG) is determined based on the tumor location and the extent of esophageal invasion, opting for either Ivor-Lewis esophagectomy (IL) or proximal gastrectomy (PG). Both procedures necessitate the mitigation of postoperative weight loss, with nutritional therapy using Elemental diet 300 kcal/day initiated postoperatively and nutritional guidance provided by dietitians before discharge, and at 1, 3, 6, and 12 pos-operative months (POM). Additionally, quality of life (QOL) assessment using the PGSAS-37 questionnaire is conducted, and feedback is provided to patients.

Methods

The aim of this study is to compare the weight changes up to 12 POM and the temporal changes in PGSAS-37 scores following IL and PG procedures in our institution. We analyzed 45 cases who underwent IL or PG in our institution between January 2019 and December 2022, excluding cases of early recurrence within 12 months and those without questionnaire responses. Patient demographics, postoperative complications, anastomotic strictures, duration of Elemental intake (months), percentage of body weight loss (BWL) at 1, 3, 6, and 12 POM, and PGSAS-37 scores were extracted from electronic medical records.

Results

There were 27 IL cases and 18 PG cases. Postoperative complications of Grade 3 or higher were observed in 3 of IL group and 1 of PG group. Anastomotic strictures were observed in 1 of IL group and 6 of PG group. Duration of Elemental intake (months) was 4.5 (0-39) in IL group and 0 (0-8) in PG group (p=0.001). Median BWL (%) at 1/3/6/12 POM was IL: 4.5/8.3/10.3/13.8 and PG: 3.8/8.5/8.7/10.6. Temporal changes in total symptom score were similar in both IL and PG groups, but esophageal reflux subscale at 12 POM was significantly better in PG group (p=0.04).

Conclusion

The questionnaire response rates were approximately 80% at 12 months for both groups, but below 12 months ranged from 22.2% to 50%, indicating difficulty in assessing temporal changes in QOL. At 12 months, the IL group exhibited a greater percentage of weight loss than the PG group (p=0.027), but QOL evaluations, except for reflux symptoms SS, were comparable between the two groups. Both IL and PG groups experienced rapid weight loss up to 3 POM, with continued decline up to 12 months. However, improving questionnaire response rates is deemed necessary for investigating the relationship with QOL.
379. SUCCESSFUL MANAGEMENT OF ANASTOMOTIC LEAKAGE FOLLOWING ESOPHAGECTOMY USING ENDO-VACUUM ASSISTED CLOSURE (EVAC) THERAPY: A CASE REPORT
Authors: Yang Jae Yeong , Park Ki Bum , Park Ji Yeon , Kwon Oh Kyoung
Published: September 2024

Background

Esophagectomy is a crucial curative treatment for potentially resectable esophageal cancer. However, anastomotic leakage poses a significant complication, with reported incidences ranging from 11.4% to 21.2% and mortality rates between 7.2% and 35%. Endoluminal or cavitary type of vacuum therapy (EVAC) represents a minimally invasive approach adapted from negative pressure wound closure techniques. Our case demonstrates the successful application of EVAC in managing a significant postoperative leak.

Methods

A 70-year-old male who underwent esophagectomy for early esophageal cancer. On postoperative day 23, a 20mm-sized large anastomotic leakage was detected, leading to the insertion of Endo-VAC for treatment. Endoscopically exchange was regularly.

Results

Endoscopically exchange was performed seven times, gradually reducing the size of the leakage hole. In the end, the anastomotic leakage was completely healed, and the patient was discharged on postoperative day 86. The patient id currently undergoing outpatient follow-up with no recurrence or metastasis of the disease confirmed.

Conclusion

Through our case, we highlight the potential suitability of EVAC therapy as a less invasive and effective treatment modality for anastomotic leakage following esophagectomy. This approach may be considered as a priority treatment for anastomotic leak.
381. MULTICENTER PAN-CANADIAN EXPERIENCE OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) FOR THE TREATMENT OF ACHALASIA: A RETROSPECTIVE STUDY
Authors: Poole Meredith , Abbad Aghiles , Al-Shamali Hussain , Al-Faraj Zainab , Wen Chuck , Pescarus Radu , Bechara Robert , Hong Dennis
Published: September 2024

Background

Per oral endoscopic myotomy (POEM) has emerged as a modality for the surgical treatment of achalasia using a minimally invasive approach with similar clinical efficacy to laparoscopic Heller myotomy. Japanese, European, American and International clinical practice guidelines now cite POEM as a first line treatment for achalasia. In Canada, single-centre experiences with POEM have shown promising results. This study aims to capture the pan-Canadian national experience with POEM for the treatment of achalasia across multiple institutions.

Methods

This was a retrospective study of patients who underwent POEM for achalasia across four Canadian institutions (St. Joseph's Healthcare Hamilton, Kingston Health Sciences Centre, Surrey Memorial Hospital and Montreal Sacred Heart Hospital) between 2012 to 2022. Pre-operative, procedural and post-operative data was collected. Our primary outcome was the proportion of patients with normal Eckhardt score (≤ 3) at 4 weeks. Secondary outcomes included procedure related adverse events, length of stay in hospital, post-procedure lower esophageal sphincter pressures, post-procedure gastroesophageal reflux disease (GERD) and response rate at further timepoints. Outcomes are reported as either proportions (%) or medians (IQR).

Results

POEM was attempted in 369 patients with a success rate of 99%. The median duration of surgery was 64 (47 – 89) minutes and length of stay was ≤1 day in 88% of patients. Peri-operative complications occurred in 11% of patients, all of which were Clavien-Dindo Grade ≤III. The post-operative response rate (Eckhardt score ≤3) was 100%, 98% and 95% at 1, 6 and 12 months, respectively. Additional interventions for achalasia following POEM were required in 6% of patients. High DeMeester scores, endoscopic esophagitis and symptomatic GERD were reported in 36%, 43% and 44%, respectively. 93% of GERD was treated with PPI therapy.

Conclusions

POEM is safe and feasible in Canadian institutions with efficacy in keeping with current international literature.
383. LOSS OF PERISTALTIC RESERVE DETERMINED BY MULTIPLE RAPID SWALLOWS CORRELATES WITH DYSPHAGIA AND POOR BOLUS TRANSIT IN INEFFECTIVE ESOPHAGEAL MOTILITY
Authors: Sileno Sean M , Crowell Michael D , Vela Marcelo F
Published: September 2024

Introduction

Ineffective esophageal motility (IEM) is a common finding on high resolution esophageal manometry (HRM) and is often of unclear clinical significance as its impact on dysphagia and bolus transit is variable. Multiple rapid swallow (MRS) testing is a provocative maneuver performed during HRM that assesses peristaltic reserve, documented by the presence of contractile augmentation (defined by contractile vigor after MRS greater than that seen with single swallows). Lack of augmentation after MRS is associated with dysphagia after anti-reflux surgery. To date, no studies have evaluated the impact of peristaltic reserve on dysphagia and bolus transit in IEM patients.

Methods

Retrospective review of 159 patients with Chicago classification 4.0 IEM. 52 patients were excluded due to prior esophageal surgery, technically inadequate MRS, or concomitant esophagogastric junction outflow obstruction. Demographics and brief esophageal dysphagia questionnaire (BEDQ) results were obtained from a prospectively maintained database. MRS and bolus transit data were analyzed using a commercially available software. Impedance analysis documented complete versus incomplete bolus transit. Augmentation was defined as the ratio of post-MRS DCI to mean single swallow DCI > 1. Fisher's exact test for continuous data and linear model ANOVA were used to assess for statistical significance.

Results

107 IEM patients were included, 46 of them had loss of peristaltic reserve (no augmentation on MRS). Compared to IEM patients with augmentation, those without augmentation had more severe dysphagia documented by higher mean BEDQ score (6.8 versus 4.8, p= 0.045), and increased rates of impaired bolus transit (73% versus 55%, p-= 0.013).

Discussion

IEM patients without augmentation on MRS have more severe dysphagia and more frequent incomplete bolus clearance. These findings support adding MRS response to the diagnosis of IEM or using it to describe a subset of patients with more severe disease.
385. TRANSLATING MOLECULAR-TARGETING FLUORESCENT PROBES IN OESOPHAGEAL CANCER PRE-CLINICAL MODELS
Authors: Bozin Mike , Edgington-Mitchell Laura , Clemons Nicholas , Wright Gavin , Phillips Wayne , Duong Cuong
Published: September 2024

Background

Intra-operative molecular imaging (IMI) is an emerging field that utilises tumour-targeting fluorescent probes to improve oncological outcomes. A novel class of probe known as quenched activity-based probes (qABP), developed to measure enzyme activity in-vitro, has been repurposed to target tumour-expressed proteases known as cathepsins. Unlike other tumour-targeting probes, fluorescence is inhibited up until the qABP covalently bonds to cathepsins, releasing an inhibitory quencher which results in fluorescence. This may improve the contrast between normal tissue and tumour. Our laboratory group sought to obtain pre-clinical evidence to eventually translate qABP’s into the operating room for oesophageal, junctional and gastric cancer.

Methods

Cathepsin activity was screened in cell lines from the normal oesophagus, Barrett’s metaplasia, oesophageal adenocarcinoma (OAC), squamous cell carcinoma (SCC) and gastric adenocarcinoma (GAC) with two qABP’s known as BMV109 and VGT309. We additionally screened patient biopsies from oesophageal, junctional and gastric cancers. Cell line and tissue samples were analysed using in-gel fluorescence (Amersham Typhoon®) and Western blot. In-vivo, cell line xenografts were established in NSG mice using subcutaneous and orthotopic models. Tumour-bearing mice were then injected with VGT-309 and then imaged at specific timepoints using the IVIS® spectrum imager.

Results

Cathepsin activity was found in all oesophago-gastric cell lines and selectivity proven with a cathepsin inhibitor. Matched biopsies were collected from patients prior before and after neoadjuvant chemo-radiotherapy. Baseline tumour biopsies exhibited significantly higher cathepsin activity than normal biopsies, with these differences preserved in biopsies collected after chemo-radiotherapy (p <0.001). In-vivo, OAC and GAC xenografts were identified in NSG mice as early as 12 hours post injection of VGT-309, exhibiting a 2.5-fold increase in fluorescence compared to normal background stomach. Bio-distribution analysis demonstrated that VGT-309 accumulated in liver and kidney, but less so in the murine oesophagus and stomach.

Conclusion

Translating qABP’s into the operating room has the potential to detect early cancers in Barrett’s metaplasia, reduce positive margin rates and identify lymph node metastasis. Our research group continues to investigate qABP’s, including determining their sensitivity to detect lymph node metastasis with the aim of translating this technology into a phase 1 clinical trial.
410. THE RELATIONSHIP BETWEEN GASTRIC CONDUIT EMPTYING, FUNCTIONAL ANATOMY AND PERISTALSIS: A DETAILED ANALYSIS USING DYNAMIC MAGNETIC RESONANCE IMAGING
Authors: Lourensz Kaleb , Bigwood Shalini , Johari Yazmin , Wickremasinghe Ms Anagi , Beech Paul , Hebbard Geoffrey , Burton Paul , Brown Wendy
Published: September 2024

Background

Gastric conduit peristalsis post oesophagectomy is an important mediator of conduit emptying and consequently gastrointestinal symptoms and quality of life. The relationship between anatomical variations of the conduit, peristaltic function and transpyloric flow are incompletely defined. We aimed to analyse gastric conduit function using dynamic MRI to evaluate functional anatomy, quantify peristaltic function and measure emptying.

Methods

Eighteen patients with gastric conduit reconstruction post oesophagectomy and 12 controls with normal gastric anatomy were recruited. Dynamic and static sequences of MRI following ingestion of a semi solid meal were obtained. Peristalsis variables including Gastric Motor Index (GMI - Velocity x Amplitude) were measured at 4 time points throughout the MRI, and volume scans were taken at the beginning and end of the 20-minute scanning period. Nuclear Scintigraphy conduit emptying studies were obtained from 17/18 (94%) of patients. Quality of Life questionnaire data was collected.

Results

Nine (50%) conduits demonstrated coordinated peristalsis, 3(16.7%) had no measurable peristalsis and 6 (33.3%) had incoordinate peristalsis. Regarding conduits vs controls, there was no difference in peristaltic wave frequency (5 vs 5/90 seconds) or GMI (35.45 vs 36.5, p=0.61), but emptying was decreased (0.10% vs 15% p=0.01). Acute angulation of the conduit was associated with a slower emptying half time (444 vs 127 min, p=0.025). Conduit width and location of the pylorus relative to the hiatus made no significant difference to peristalsis or emptying. Quality of life scores were significantly better in controls compared with conduits.

Conclusion

Although coordinate peristalsis was present in many conduits, it did not appear to be a key mediator of conduit emptying. Conduit shape and location within the mediastinum significantly affected emptying. These data demonstrate that construction of the conduit at the index operation may be a key factor in long term function and reducing gastrointestinal symptoms. Dynamic MRI is a promising research and diagnostic tool to assess conduit function due to its capacity to accurately delineate the key elements of conduit function.
416. SUCCESSFUL TREATMENT OF ESOPHAGO-MEDIASTINAL FISTULA DUE TO ESOPHAGEAL CANCER WITH IMMUNE CHEMOPOINT INHIBITOR FOLLOWED BY ROBOTIC RADICAL ESOPHAGECTOMY
Authors: Kim Dong Jin
Published: September 2024

Background

Esophagomediastinal fistula caused by intrathoracic esophageal cancer perforation poses significant challenges in treatment. We present a case of such a patient successfully treated by achieving complete resolution through surgical resection following chemotherapy with 5-FU, cisplatin, and pembrolizumab.

Methods

Clinical and surgical findings of the patient were reviewed through chart analysis. A 46-year-old male presented to the emergency room with fever and cough. Computed tomography (CT) indicated esophageal-mediastinal fistula due to mid-thoracic esophageal cancer and perforation. Endoscopic examination revealed a 5cm circumferential mass 20cm from the upper incisors, along with perforation. Biopsy confirmed poorly differentiated squamous cell carcinoma, with a PD-L1 CPS score of 80. The patient received multidisciplinary treatment involving chemotherapy followed by planned surgical intervention.

Results

First of all, the patient underwent peroral endoscopic gastrostomy for dietary intake. After 3-weeks interval three cycles of 5-FU (800mg/BSA, Day1-5), cisplatin (80mg/BSA, Day1), and pembrolizumab (200mg, Day1), complete resolution of the abscess cavity and significant reduction in esophageal cancer lesions were observed. Robotic transthoracic esophagectomy and Mckeown operation were performed, achieving complete resection of the esophagus including the primary lesion. Pathological examination revealed complete remission of the primary lesion and absence of metastatic nodes among the 51 dissected lymph nodes. After subsequent additional three cycles of anticancer-immunotherapy combined therapy were done, no signs of recurrence were found on CT scan performed 3 months post-surgery.

Conclusion

We report a case of successful treatment of a patient with thoracic esophageal cancer complicated by difficult-to-treat esophago-mediastinal fistula, managed effectively with concurrent chemotherapy and surgical intervention.
421. MODIFIED DOR FUNDOPLICATION IN ACHALASIA PATIENTS: LONG-TERM OUTCOMES FROM A HIGH-VOLUME CENTRE
Authors: Saliaris Konstantinos , Triantafyllou Ms Alexandra , Kitsou Ms Eleni , Karikis Ioannis , Katsila Sofia , Kakounis Konstantinos , Theodorou Andreas , Xiromeritou Vasiliki , Triantafyllou Tania , Theodorou Dimitrios
Published: September 2024

Background

Heller myotomy combined with Dor fundoplication remains the gold standard in the treatment of achalasia. Dor fundoplication serves as a floppy partial fundoplication which, at the same time, prevents recurrence of dysphagia due to outflow obstruction to the myotomised esophagus. In this study, we propose a modified floppier anterior wrap and present our unit’s experience in a series of consecutive patients with achalasia.

Methods

The prospectively collected surgical achalasia database of our department was retrieved. All patients had manometric confirmation of the diagnosis and were operated by the same surgical team. Data regarding preoperative Eckardt, GERD and Quality of Life assessment scores were collected. Patients attended regular follow-up appointments. Those with abnormal Eckardt and GERD scores were subjected to objective testing using manometry and 24h impedance pHmetry.

Results

118 patients with achalasia were subjected to Heller myotomy and modified Dor fundoplication from 01/2014 to 12/2020. 97 patients completed the follow-up appointments. Median follow-up was 72 months (28-120 months). 97% of patients reported a positive influence in their quality of life and did not regret undergoing surgery. 7/97 (7.2%) presented with an abnormal Eckardt score and 5/97 (5.2%) patients demonstrated an abnormal GERD score. Objective testing results with manometry and pH-studies of patients with abnormal scores will be completed within the next two months.

Conclusion

Our modified Dor fundoplication after Heller myotomy is a safe and efficient surgical method for treating achalasia. Long-term follow-up suggests significant and long-lasting improvement in Quality of Life and very low incidence of symptom relapse.
422. MANAGEMENT OF ANASTOMOTIC LEAK AFTER TOTAL GASTRECTOMY WITH THE “RENDEZ-VOUS” HYBRID TECHNIQUE: PRESENTATION OF OUR APPROACH AND RESULTS
Authors: Katsila Sofia , Saliaris Konstantinos , Triantafyllou Alexandra , Theodorou Andreas , Kakounis Konstantinos , Linardoutsos Dimitrios , Smparounis Spyridon , Xiromeritou Vasiliki , Triantafyllou Tania , Theodorou Dimitrios
Published: September 2024

Background

Anastomotic dehiscence following total gastrectomy and Roux-en-Y reconstruction remains a demanding clinical scenario, associated with high morbidity and mortality rates. Management options focus on controlling systemic and local sepsis while allowing for proper anastomotic healing. Optimal treatment algorithm remains to be determined and therapeutic strategy is being individualized. The primary goal of the present study is to present the modified rendezvous stenting technique, a technique implemented in our department during reoperation for washout, in critically ill anastomotic leak patients.

Methods

We performed a retrospective descriptive analysis of severely ill patients suffering an anastomotic leak from an esophagojejunal anastomosis, who had been operated in our department during the last five years (01/2018-12/2023). All patients were operated on by the same surgical team and endoscopy was performed by the same endoscopist. Data regarding patients who had been subjected to the modified rendezvous technique were collected.

Results

Since 2018, five anastomotic leak patients underwent stenting over the anastomosis using the modified rendezvous technique during relaparotomy. Stenting was effective in controlling local contamination in 4 out of 5 patients (80%). One patient required repeat stent placement due to stent migration. Overall the 30 day mortality rate was 20% and no deaths directly attributed to the leak were observed. Stents remained in position for an average of 4.25 weeks.

Conclusion

Anastomotic stenting using the rendezvous technique is a safe and feasible technique. It can prove useful in controlling local abdominal contamination in severe anastomotic leak patients, while minimizing the risk of stent migration. Further implementation of the technique will allow for more reliable conclusions to be drawn, regarding the technique’s actual effectiveness.
423. ROBOTIC SURGERY FOR BENIGN ESOPHAGEAL DISEASE: PROMOSING OUTCOMES OF AN EARLY CASE SERIES
Authors: Saliaris Konstantinos , Karikis Ioannis , Varsos Panagiotis , Smparounis Spyridon , Linardoutsos Dimitrios , Katsila Ms Sofia , Pachos Nikolaos , Theodorou Andreas , Triantafyllou Tania , Theodorou Dimitrios
Published: September 2024

Background

Laparoscopic surgery is a well-established approach in the treatment of benign gastroesophageal junction (GEJ) disease. Robotic platforms have only recently been incorporated in surgery for esophageal motility disorders and their exact value remains to be determined. In the present study, we present our initial experience through a case series of patients with benign GEJ disease treated using the DaVinciXi robotic system in our department.

Methods

Patients undergoing surgery for benign GEJ disease during the last 5 years (01/2029-12/2023) were prospectively collected. Data regarding their perioperative and postoperative course was evaluated. All patients attended regular follow-up appointments. Patients with relapse or deterioration of their symptoms were referred for objective testing using high-resolution manometry or 24-h impedance pHmetry.

Results

12 patients with achalasia were subjected to robotic Heller myotomy and modified Dor fundoplication, 13 patients underwent hiatal hernia repair and 2 patients underwent Nissen fundoplication due to severe reflux. Median operative time was 110min (96-150) and no intraoperative or postoperative complications were observed. All patients demonstrated resolution of their symptoms, with a median postoperative Eckardt score of 2 for patients with achalasia and median GERD score of 1 for patients with GERD. 2 patients with achalasia were subjected to impedance manometry due to temporary symptom relapse, without any abnormal findings.

Conclusion

The incorporation of robotic platforms in the treatment of achalasia, reflux and hiatal repair is safe with excellent perioperative and postoperative functional results, when performed in a high-volume center. Further experience will demonstrate potential advantages and disadvantages of the method and will allow for reliable comparison to the laparoscopic approach.