bluuebunny/crossref_metadata_2025 huggingface dataset:
P22 PRELIMINARY EXPERIENCE WITH PROPHYLACTIC THORACIC ENDOVASCULAR AORTIC REPAIR (PRO-TEAVAR) IN PATIENTS AFFECTED BY ADVANCED ESOPHAGEAL CANCER
Authors: Gervasi Maria Clelia , De Pasqual Carlo Alberto , Weindelmayer Jacopo , Mezzetto Luca , Scrsone Lorenzo , Giacopuzzi Simone , Veraldi Gian Franco , de Manzoni Giovanni
Published: November 2019

Bleeding from the thoracic aorta is potentially fatal in patients with advanced esophageal cancer (AEC). Esophageal malignancy is the third most common cause of aorto-esophageal fistula (AEF), after thoracic aortic aneurysm and ingestion of foreign body. The involvement of aortic wall often contraindicates chemo-radiotherapy (CRT) treatment, thus reducing life expectancy of these patients. Thoracic endovascular aortic repair (TEVAR) is a well described mini-invasive technique that can be also applied for coverage of aortic lumen in case of invasion by esophageal cancer (EC). Only few cases have been published with this atypical indication. Between 2016 and 2018, in our tertiary hospital three patients affected by AEC involving the thoracic aorta were treated by means of prophylactic TEVAR (ProTEVAR). We did not observe procedure-related complications and all patients were reconsidered fit for preoperative or definitive CRT.
P23 MALNUTRITION INDICES AS PROGNOSTIC FACTORS FOR POSTOPERATIVE COMPLICATIONS IN ESOPHAGEAL CANCER PATIENTS
Authors: Irene Lidoriki , Dimitrios Schizas , Efstratia Mpaili , Maria Mpoura , Natasha Hasemaki , Adamantios Michalinos , Alkistis Kapelouzou , Ioannis Karavokyros , Theodore Liakakos
Published: November 2019

Aim

To investigate the impact of malnutrition on postoperative complications in esophageal cancer patients.

Background and Methods

Malnutrition is common in esophageal cancer patients due to the debilitating nature of their disease. Several methods of nutritional assessment have emerged as significant prognostic factors for short-and long-term outcomes in patients operated for esophageal cancer. The study sample consisted of 85 patients with esophageal (n=11) and gastroesophageal junction (n=74) cancer who were admitted for surgery in the First Department of Surgery, Laikon General Hospital, Athens, Greece, between September 2015 and March 2019. Out of them, 65 patients underwent esophagectomy, while 20 patients underwent total gastrectomy. The assessment of nutritional status included the Geriatric Nutritional Risk Index (GNRI), the Patient Generated Subjective Global Assessment (PG-SGA) and sarcopenia. GNRI was based on preoperative values of patients’ serum albumin and body weight. The preoperative assessment of sarcopenia was based on Skeletal Muscle Index (SMI) derived from analysis of CT scans using SliceOmatic® Software version 4.3 (Tomovision, Montreal, Canada). Postoperative complications were graded according to Clavien-Dindo classification. Minor complications included categories I-II, whereas major complications included categories III-V.

Results

Thirty nine patients (47.6%) developed postoperative complications. More specifically, 21 patients (24.7%) developed minor complications and 18 patients (21.2%) developed major complications, while anastomotic leakage occurred in 10 patients (11.8%). Eighty patients (94.1%) had a high-risk GNRI (<92), while 5 patients (5.9%) had a low-risk GNRI (≥92). Forty four patients (51.8%) were diagnosed with sarcopenia. The mean PG-SGA score was 8.82 ± 5.57. Patients with a high-risk GNRI demonstrated significantly higher rate of overall complications compared to low-risk GNRI patients (100% vs 44.2%, p<0.05 respectively). Moreover, the rate of anastomotic leakage was significantly higher in the sarcopenia group than in the non-sarcopenia group (29% vs 3.4%, p<0.05). Nonetheless, PG-SGA was not significantly associated with postoperative outcomes.

Conclusion

Higher-risk scores on the GNRI are associated with an increased risk for developing postoperative complications, while sarcopenia is associated with higher risk for anastomotic leakage among esophageal cancer patients. Preoperative assessment of GNRI and sarcopenia should be performed in all patients in order to detect patients who are at greater risk of postoperative morbidity.
P25 DETECTION OF CIRCULATING TUMOR CELLS IN POTENTIALLY RESECTABLE ADENOCARCINOMA OF DE DISTAL ESOPHAGUS AND THE GASTRO-ESOPHAGEAL JUNCTION DOES NOT INCREASE IN PORTAL VENOUS BLOOD SAMPLES COMPARED TO PERIPHERAL VENOUS BLOOD SAMPLES
Authors: Lieven Depypere , Annouck Philippron , Katleen De Preter , Willy Coosemans , Hans Van Veer , Piet Pattyn , Philippe Nafteux
Published: November 2019

Aim

To compare the number of circulating tumor cells (CTCs) in portal venous blood samples of patients with potentially resectable adenocarcinoma of de distal esophagus and the gastro-esophageal junction (EAC) with the number of CTCs in peripheral venous blood samples.

Background and Methods

Detection of (CTCs) in potentially resectable (EAC) is rare in peripheral venous blood samples(1). In lung carcinoma patients, the number of circulating tumor cells was more than 300 fold in the pulmonary vein, compared to the number in peripheral venous blood samples (2).

In patients undergoing esophagectomy for cancer, peripheral blood was sampled immediately preoperatively and portal vein blood was sampled intraoperatively during abdominal lymph node dissection. Samples were analyzed for CTCs using the parsortix device (ANGLE): a semi-automated microfluidic system that captures cells based on their size and rigidity. A four-color immunofluorescence technique was used and CK positive, CD45 negative, Hoechst positive and morphologically intact cells with the morphology of a CTC were counted manually.

The method was previously compared with the commercially available Cellseach® system and no difference in CTC yield between both methods.

Results

20 patients with potentially resectable EAC were evaluated. One peripheral venous sample and two portal venous samples were not applicable. In 5 out of 19 peripheral venous samples (26,3%), one or more CTC’s could be detected, while in this was only the case in 3 out of 18 portal venous samples (16.7%).

Conclusions

The number of detected CTCs in potentially resectable EAC was not increased in portal venous samples compared to peripheral venous samples. Further research is needed on why detection rate of CTCs in potentially resectable EAC is so low and how detection rate could be increased.
O26 QUALITY OF LIFE FOR ACHALASIA PATIENTS IS THE SAME AFTER PER-ORAL ENDOSCOPIC MYOTOMY (POEM) AND HELLER MYOTOMY
Authors: Gavriella Zoi Vrakopoulou , Francesco Di Maggio , Lavinia Barbieri , Sebastian Zeki , Jason M Dunn , Terence Wong , Jafar Jafari , Abraham Botha
Published: November 2019

Aim

This study aimed to compare the efficacy and safety of LHM and POEM for esophageal achalasia.

Background & Methods

Laparoscopic Heller’s myotomy (LHM) has been the gold standard of treatment, however per-oral endoscopic myotomy (POEM) was recently established as a treatment option for achalasia. A prospective review was performed for all patients submitted to LHM or POEM in our institution from 10/2012 to 06/2018, and have completed a minimum follow up period of 6 months. The diagnostic work-up included gastroscopy, barium study and high-resolution manometry (HRM). All patients underwent a clinical evaluation 6 weeks after treatment and a surveillance gastroscopy in the 1st postoperative year. HRM and pH studies were offered to all patients after 6 months. Standardized questionnaires evaluating Eckardt, GERD and achalasia QoL (Urbach) scores were completed pre- and postoperatively. Statistical analyses were performed with SPSS version 23.0. Repeated measurements analysis of variance was used to compare changes in mean values during follow up and between the two types of surgery. P values < 0.05 were considered significant.

Results

Eighty patients (34 women and 46 men) with mean age 42.6 years (16.2) underwent POEM (n=39) or LHM (n=41). QoL score was significantly improved in both study groups (p<0.001) with a similar degree of improvement (p=0.486). Eckardt scores showed a significant improvement in both groups, but repeated measurements analysis revealed a significant effect with time (p=0.038) with a greater improvement in POEM group. Moreover, Eckardt score change was similar between LHM and POEM patients without prior treatments (p=0.724), but in those with prior treatments the improvement trended higher in POEM group (p=0.087). GERD score had a similar and significant decrease in both groups (p=0.439), but in those with prior treatments the improvement was greater in LHM group (p=0.018). There was no significant difference regarding the complication rates for both groups (Clavien-Dindo I-IIIa).

Conclusions

POEM compares favorably with LHM as treatment for achalasia, as statistically significant improvement in QoL, GERD and Eckardt scores was recorded in both groups. In patients with prior treatments, POEM tends to achieve a greater improvement of Eckardt score and LHM a greater reduction regarding GERD score.
P36 DE NOVO GORD AFTER ROUX Y GASTRIC BYPASS: UNCOMMON BUT POSSIBLE – A LOOK AT THE WHY FACTORS
Authors: Hatem Al Saadi , Alistair Sharples , Bridie Cornes , Vittal Rao , Balaji Nagammapudur
Published: November 2019

Background

Roux Y gastric bypass (RYGB) is the preferred bariatric surgical option in patients with Gastro oesophageal reflux disease (GORD). However, de novo GORD after RYGB although uncommon is possible and present challenges in further management. Proposed mechanisms have been a large gastric pouch or a short alimentary limb.

Objective

Analyse anatomical causes of De Novo GORD post RYGB

Methods

Data of patients who presented with new onset GORD after RYGB were collected and analysed.

Results

Specific and remediable anatomical factors contributing to de novo GORD was found in 8 patients post RYGB (3 Males and 5 Females). Onset of symptoms ranged from 1.16-15 years. Mean age was 53.14 and mean BMI 37.39. One patient had R-Y gastric bypass for peptic ulcer disease in the past.

Diagnostic work up included; Barium swallow (85.7%), CT Abdomen (42.9%), OGD (57.1%).

Diagnosis of candy cane (CC) syndrome was seen in 50 % of cases (n=4) followed by Gastro-gastric fistula (n=1), gastric pouch herniation (n=1) and pouch herniation with CC syndrome (n=2). Excision of excess CC limb achieved resolution in symptoms of reflux. 4 patients are awaiting surgical anatomical correction.

Conclusion

De novo GORD after RYGB can be challenging. These patients need thorough anatomic and physiologic assessment to identify potentially correctable anatomical causes. A long CC, herniated gastric pouch, gastro-gastric fistula are anatomical causes identified in our study. Identification and evaluation of this sub group of patients has not been reported in the past but are likely to be increasingly encountered.
P41 C-REACTIVE PROTEIN AS A PREDICTOR FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGEAL SURGERY
Authors: Hagens E R C , Lam MSc W C , Eshuis W J , Lameris W , van Berge Henegouwen M I , Gisbertz S S
Published: November 2019

Aim

To determine the accuracy and optimal cut-off values of CRP to predict anastomotic leakage.

Background and methods

CRP is commonly used by surgeons to raise suspicion of anastomotic leakage and other infectious complications in gastrointestinal surgery, but optimal cut-off values and diagnostic accuracy are undetermined.

A prospective observational study was conducted including consecutive patients with an esophageal carcinoma scheduled for an esophagectomy with gastric tube reconstruction between April 2016 and October 2018 in the Amsterdam UMC, location AMC, The Netherlands. CRP was measured routinely on post-operative day (POD) 3, 5 and 7. Anastomotic leakage was confirmed if a defect or leakage of oral contrast was seen on a CT-scan or by endoscopy or if saliva was draining form the neck incision in clinical suspicion of leakage. The diagnostic accuracy of CRP was assessed by receiver operator curve (ROC) analysis. Youden’s index was adopted to determine the cut-off value.

Results

200 patients were included. POD 5 showed the highest area under the ROC to predict anastomotic leakage with a cut-off value of 120 mg/L. The optimal cut-off value for CRP to predict anastomotic leakage or any complication is shown in table 1 with the corresponding area under the ROC, sensitivity, specificity, positive predicting value and negative prediction value.

Conclusion

CRP on postoperative day 5 is a feasible marker to predict anastomotic leakage, using a cut-off value of 120 mg/L, resulting in a negative predicting value of 96% and a specificity of 92%. When CRP exceeds 120 mg/L on postoperative day 5 additional investigations should be considered.
P60 CRITICAL APPRAISAL OF GASTRIC CONDUIT ISCHAEMIC CONDITIONING PRIOR TO OESOPHAGECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Sivesh K Kamarajah , Charlie Boyle , James R Bundred, , Benjamin HL Tan
Published: November 2019

Aim

Anastomotic leaks remain a major complication following oesophagectomy, accounting for high morbidity and mortality. Recently, gastric ischaemic conditioning (GIC) has been proposed to improve anastomotic integrity through neovascularisation of the gastric conduit. This systematic review aims to determine the impact of GIC on postoperative outcomes after oesophagectomy.

Background & Methods

A systematic literature search was performed to identify studies reporting GIC for any indication of oesophageal resection. Random-effects meta-analyses were conducted for main outcomes.

Results

Nineteen studies were included reporting GIC, of which 13 were comparative studies. GIC were performed through ligation in 13 studies and embolisation in six studies. GIC did not appear reduce anastomotic leakages (OR 0.80, CI95: 0.51 - 1.24, p=0.3), anastomotic strictures (OR 0.75, CI95: 0.35 - 1.60, p=0.5), overall complications (OR 1.02, CI95: 0.48 - 2.16, p=0.9), major complications (OR 1.06, CI95: 0.53 - 2.11, p=0.9), or in-hospital mortality (OR 0.70, CI95: 0.32 - 1.53, p=0.4). However, preconditioning reduced the rates of conduit necrosis (OR 0.30, CI95: 0.11 - 0.77, p=0.013).

Conclusion

Gastric preconditioning through does not appear to reduce overall rates of anastomotic leakage after oesophagectomy but seems to reduce severity of leakages. More in depth studies are recommended.
P65 USPIO-MRI FOR PRE-OPERATIVE LYMPH NODE STAGING AFTER NEOADJUVANT CHEMORADIOTHERAPY: FEASIBILITY AND VALIDATION FRAMEWORK
Authors: J. J. M. de Gouw D , R. Klarenbeek B , Maas M C , Slagt C , Mühling J , M. Rovers M , van der Post R S , J. Hermans J , Scheenen T W J , Rosman C
Published: November 2019

Background

Extensive lymph node dissections during esophagectomy may be omitted in patients with esophageal cancer without lymph node metastases, reducing associated morbidity. A promising technique to detect lymph node metastases is MRI with ultrasmall superparamagnetic iron oxide nanoparticles (USPIO, ferumoxtran-10). To validate USPIO-enhanced MRI in patients with esophageal cancer, a framework is designed to compare lymph nodes of the MRI scans with histopathology data on a node-to-node level.

Methods

USPIO-nanoparticles are intravenously infused 24 to 36 hours before MRI. USPIO-enhanced MRI is performed before and after nCRT. After nCRT, patients are scanned under general anesthesia immediately prior to surgery in the MR system of the hybrid MITeC operation room with controlled mechanical ventilation. During controlled prolonged apneu, a four-minute iron-sensitive MRI acquisition is used to visualize suspicious esophageal lymph nodes without motion artefacts. Resected specimens, still containing USPIO, are measured ex-vivo in a preclinical 7T MR system before histopathological examination. A radiological assessment of the presence of suspicious lymph nodes in-vivo is matched to the ex-vivo nodes on preclinical MRI, providing the ground truth for the presence of metastases.

Results

Currently, five patients have completed the full study protocol. Two patients underwent the first UPSIO-MRI but did not undergo surgery due to progressive disease. First results show that MRI under anesthesia prior to surgery with controlled mechanical ventilation was possible resulting in a clinically relevant spatial resolution to visualize possibly malignant lymph nodes. In these five patients, the radiologist found 58 lymph nodes with a mean diameter of 8.4 mm before nCRT and 40 lymph nodes with a mean diameter of 7.4 mm after nCRT. In total, 126 lymph nodes were analyzed by histopathology. Suspicious nodes were identified and could be matched using corresponding anatomical landmarks to the ex-vivo MRI, which showed good visual agreement with esophageal specimen after resection.

Conclusions

We performed USPIO-enhanced MRI in patients with esophageal cancer and proposed a method to validate USPIO-enhanced MRI to detect suspicious lymph nodes in these patients. Results on the feasibility of USPIO-enhanced MRI to detect metastatic lymph nodes after nCRT are still awaited.
P71 NUTRITIONAL JEJUNOSTOMY IN ESOPHAGECTOMY FOR CANCER, A NATIONAL REGISTER-BASED COHORT STUDY OF ASSOCIATIONS WITH POSTOPERATIVE OUTCOMES AND SURVIVAL
Authors: Anders Holmén , Masaru Hayami , Eva Szabo , Ioannis Rouvelas , Thorhallur Ágústsson , Fredrik Klevebro
Published: November 2019

Aim

The aim was to increase the knowledge about nutritional jejunostomies in curative intended treatment of esophageal and gastroesophageal junction cancer.

Background and Methods

The insertion of a jejunostomy in conjunction with esophagectomy is performed to decrease the risk for malnutrition and improve recovery. These possible benefits have, however, not been scientifically proven.

All patients in Sweden, treated with esophagectomy due to cancer 2006-2017 in the Swedish National Register for Esophageal and Gastric Cancer, were included in this retrospective population-based cohort study. The indication for jejunostomy was not defined in the register. The patients were stratified into two groups: esophagectomy with jejunostomy, and esophagectomy alone.

Results

A total of 1024 patients (54.73%) had a jejunostomy inserted in conjunction with esophagectomy, while 847 patients (45.27%) were treated without jejunostomy. The median age was 66 years, and 79% of the patients were male. The groups were similar in regard to age, performance status, baseline dysphagia and weight, ASA-score, tumor location, neoadjuvant treatment, and use of minimally invasive technique.

The patients in the jejunostomy group had more squamous cell carcinoma (20.3% vs. 17.8%, P=0.005), and more locally advanced tumors. There were no significant differences in length of hospital stay, postoperative surgical complications, Clavien-Dindo score, or 90-day mortality rate. The risk of pneumonia was increased in the jejunostomy group (11.8% vs. 7.2%, P=0.001). For patients with postoperative anastomotic leaks the risk for postoperative Clavien-Dindo score of IIIb or more was reduced (79.7% vs. 94.7%, P=0.037, adjusted odds ratio 0.20, 95% CI 0.04-0.97).

Conclusions

Jejunostomy is a safe method to ensure postoperative nutrition after esophagectomy, and might reduce the risk for severe outcomes in patients who suffer an anastomotic leak.
P73 CONTRIBUTION TO THE IMPROVEMENT OF CARDIAC LOAD BY RADICAL SURGERY FOR ADVANCED ESOPHAGEAL HIATAL HERNIA
Authors: Shunsuke Tanabe , Yasuhiro Shirakawa , Naoaki Maeda , Kazuhiro Noma , Toshiyoshi Fujiwara
Published: November 2019

Aim

The aim of this study is to clarify whether radical surgery for advanced esophageal hiatal hernia contribute to the improvement of cardiac load.

Background & Methods

In Japan, endoscopic surgery for esophageal hiatal hernia is increasing. In many cases, patients with mixed type hernia have the main symptom of meal passage disorder due to gastric torsion. On the other hand, there are cases in which the contents of hernia squeeze the heart and lung and the symptoms of respiratory and circulatory system get worse. And there are cases where cardiac load is exacerbated and QOL is got worse. Therefore, in addition to conventional surgical adaptation criteria such as vomiting and food loss, cardiac load aggravation may be added to the new surgical adaptation criteria. In this study, we measured BNP before and after surgery in the case of mixed type hiatal hernia who underwent surgery at our hospital, and examined changes in cardiac load. Our surgical procedure of laparoscopic fundoplication is basically toupet fundplication. In the elderly patients, the formation of toupet fundplication is about half a cycle, which is slightly looser than usual, in order to avoid passage obstruction of the wrap. If the esophageal hiatus is too large and it is difficult to suture closure, try to reduce the air pressure of laparoscopic surgery as much as possible to reduce the resistance to the suture closure. And we try not to damage the diaphragm leg.

Results

We experienced 70 esophageal hiatal hernia surgeries in 2012-2018 and 45 patient had mixed type hiatal hernia. In mixed type hiatal hernia case, 18 cases (40.0%) had chest symptoms such as fatigue and dyspnea on exertion. And there were 12 cases in which BNP could be measured before and after surgery as an evaluation for the presence of cardiac load. Postoperative BNP decreased in 11 of 12 cases from preoperative values. Almost all cases chest symptoms improved. In the above 45 cases, there have been no cases of reoperation and very few cases have taken proton pump inhibitors after surgery.

Conclusion

Surgical cases of giant hiatal hernia may increase in the future, especially in the elderly. Surgery for giant hiatal hernia can contribute to the improvement of cardiac load.
P74 A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS OF ANASTOMOTIC TECHNIQUES FOR OESOPHAGECTOMY FOR MALIGNANCY
Authors: Sivesh K Kamarajah , James R Bundred , Pritam Singh , Sandro Pasquali , Ewen A Griffiths
Published: November 2019

Aims

This systematic review and network meta-analysis evaluates the evidence for the techniques for oesophagogastric (OG) anastomosis and their impact on perioperative outcomes.

Background

Current evidence on the benefits of different anastomotic techniques (hand-sewn (HS), circular stapled (CS), triangular stapler (TS) or linear stapler/semi-mechanical (LSSM) techniques after oesophagectomy is conflicting.

Methods

A systematic literature search was conducted to identify randomised and non-randomised studies reporting techniques for the OG anastomosis. Network meta-analysis of postoperative anastomotic leaks and strictures was performed.

Results

This study included 15 randomised and 22 non-randomised studies (n=8,618). LSSM (OR: 0.49, CI95%: 0.33 - 0.74, p=0.001) and CS (OR: 0.68, CI95%: 0.48 - 0.95, p=0.027) and anastomoses were associated with lower anastomotic leak rates than HS anastomosis. LSSM anastomosis was found to be superior to CS (OR: 0.15, CI95%: 0.08 - 0.28, p <0.001), TS (OR: 0.32, CI95%: 0.19 - 0.54, p <0.001) and HS (OR: 0.15, CI95%: 0.05 - 0.46, p=0.001) anastomoses respectively in anastomotic stricture rates. LSSM was ranked the best technique with high probability for anastomotic leaks and strictures.

Conclusions

Stapled anastomoses, specifically LSSM were associated with lower anastomotic leaks and strictures rates following oesophagectomy. Therefore, current evidence suggests superiority of the LSSM technique for OG anastomosis.
P75 CRITICAL APPRAISAL OF THE IMPACT OF OESOPHAGEAL STENTS IN THE MANAGEMENT OF OESOPHAGEAL ANASTOMOTIC LEAKS AND BENIGN OESOPHAGEAL PERFORATIONS: AN UPDATED SYSTEMATIC REVIEW
Authors: Sivesh K Kamarajah , James Bundred , Gary Spence , Andrew Kennedy , Bobby V M Dasari , Ewen A Griffiths
Published: November 2019

Aims

This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios.

Background

Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy.

Methods

A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of postoperative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 hours) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion and mortality rates. Subgroup analysis were performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.

Results

A total of 66 studies (n=1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p=0.001) and repositioning (11% vs 3%, p<0.001) and lower technical success (91% vs 95%, p=0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p=0.034), perforation (2% vs 0%, p=0.013), repositioning (10% vs 0%, p<0.001) and lower technical success (95% vs 100%, p=0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p<0.001).

Conclusions

Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
P77 SIGNIFICANCE OF NEOADJUVANT DOWNSTAGING IN CARCINOMA OF THE ESOPHAGUS AND GASTRO-ESOPHAGEAL JUNCTION
Authors: Kamarajah S K , Navidi M , Wahed S , Immanuel A , Hayes N , Griffin S M , Phillips A W
Published: November 2019

Aim

The aim of this study was to determine the importance of cTNM and ypTNM, and impact of downstaging of disease in patients with esophageal or gastro-eesophageal junction (GOJ) carcinoma who received neoadjuvant treatment followed by surgery.

Background

Most locally advanced esophageal cancers are treated with neoadjuvant therapy (chemotherapy or chemoradiotherapy). TNM staging is used prior (cTNM) and after (ypTNM) neoadjuvant treatment and surgery.

Methods

Data from consecutive patients with esophageal cancer from a single center were evaluated. Patients with either adenocarcinoma or squamous cell carcinoma of the esophagus who were treated with neoadjuvant chemo(radio) therapy followed by transthoracic esophagectomy and two-field lymphadenectomy were included. Comparison of outcomes with those primarily treated with surgery was made. The cTNM and ypTNM were applied and compared according to the American Joint Commission on Cancer (AJCC) 8th edition staging system.

Results

This study included 1115 patients of which 486 patients received surgery alone and 629 patients received neoadjuvant therapy and resection. Of patients receiving neoadjuvant therapy, 9 (1%) had cTNM stage 2 and 451 (72%) had a cTNM stage 3. Rates of downstaging were similar in esophageal adenocarcinoma and SCC (54% vs 62%, p=0.4). Downstaging was associated with significantly longer survival than patients with no change for both adenocarcinoma (median: 48 vs 15 months, p<0.001) and SCC (median: NR vs 17 months, p<0.001). On adjusted Cox regression, downstaging was associated with significantly longer survival in patients for esophageal adenocarcinoma but not SCC.

Conclusion

This study demonstrates ypTNM stage is provides a better estimate of prognosis compared to clinical stage. Downstaged patients may have an improved outcome over those with comparable pathological stage that did not receive neoadjuvant treatment.
P78 CRITICAL APPRAISAL OF THE IMPACT OF SURGICAL REPAIR OF TYPE II - IV PARAOESOPHAGEAL HERNIA ON PULMONARY IMPROVEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Sivesh K Kamarajah , Charlie Boyle , Anantha Madhavan , Maziar Navidi , Alexander W Phillips
Published: November 2019

Aim

This systematic review and meta-analysis aimed at characterising impact of PEH repair on patient reported improvement in pulmonary symptoms

Background

Paraoesophageal hernia (PEH) comprising Type II - IV hiatal hernia often present with pulmonary symptoms such as shortness of breath. However, impact of surgical repair on improvement in pulmonary symptoms is unclear

Methods

This systematic review identified studies reported pulmonary symptoms in patients with undergoing surgical repair for Type II - IV PEH. Primary outcome was improvement in pulmonary symptoms. Secondary outcomes were improvement in other patient-reported outcomes such as heartburn, regurgitation, chest pain, and dysphagia and intraoperative and postoperative outcomes.

Results

This systematic review identified 27 studies, of which 21 studies were included in final meta-analysis. There was significant improvement in patient reported pulmonary symptoms following PEH repair (OR: 8.40, CI95%: 4.91 - 14.35, p<0.001), with improvement in all types of PEH. This was noticed in both patients who had noticed pulmonary symptoms prior to surgery and those that did not complain of these symptoms.

Conclusion

PEH repair is a major upper gastrointestinal procedure, which may be associated with high morbidity. However, pulmonary impairment from PEH warrant surgical repair with acceptable low laparoscopic conversion rates, morbidity, mortality and recurrence rates.
P81 IMPACT OF LYMPHADENECTOMY ON SURVIVAL AFTER UNIMODALITY TRANSTHORACIC ESOPHAGECTOMY FOR ADENOCARCINOMA OF THE ESOPHAGUS
Authors: K Hardy , SK Kamarajah , A Madhavan , M Navidi , A Immanuel , SM Griffin , AW Phillips
Published: November 2019

Aim

The aim of this study was to determine the impact of lymph node yield and location on prognosis in patients with esophageal cancer.

Background

Absolute lymph node yield has been used as a surrogate for the extent of lymphadenectomy for esophagectomy. Ensuring adequate lymphadenectomy requires adequate removal of nodes from surgical fields, thus knowledge of lymph node location is vital to establish the impact of a radical lymphadenectomy.

Methods

Data from consecutive patients with potentially curable adenocarcinoma of the esophagus or gastro-esophageal junction were reviewed. Patients were treated with transthoracic esophagectomy and two-field lymphadenectomy. Outcomes according to lymph node yield were determined. In addition analysis was carried out based on the hypothesis that retained positive nodes would lead to disease recurrence. The prognosis of carrying out less radical lymphadenectomies was calculated according to three groups: Group 1- exclusion of proximal thoracic nodes, Group 2- a minimal abdominal lymphadenectomy and Group 3- a minimal abdominal and thoracic lymphadenectomy.

Results

357 patients were included. Median survival was 78 months(CI 53-103 months). Absolute lymph node retrieval was not related to survival (p=0.920). An estimated additional four (2-6) cancer related deaths was projected if Group 1 nodes were omitted, 15 (11-19) additional deaths if Group 2 nodes omitted, and four (2-6) deaths if Group 3 nodes omitted. A minimal lymphadenectomy (Groups 1,2 and 3) was projected to lead to 19 (15-23) additional cancer related deaths.

Conclusions

Extensive lymphadenectomy allows accurate staging. In patients who do not receive neoadjuvant chemotherapy it may confer a survival benefit. The absolute number of lymph nodes retrieved may not be a good surrogate for extent of lymphadenectomy and correlation with location is required.
P85 QUANTIFICATION OF INTRAOPERATIVE FLUORESCENCE ANGIOGRAPHY TO ASSESS ANASTOMOTIC PERFUSION DURING GASTROINTESTINAL SURGERY: A SYSTEMATIC REVIEW
Authors: Slooter¹ M D , Mansvelders¹ M , Bloemen P R , Gisbertz¹ S S , Bemelman¹ W A , Tanis¹ P J , Hompes¹ R , van Berge Henegouwen¹ M I , de Bruin D M
Published: November 2019

Aim

In this systematic review we aimed to identify all quantitative fluorescent parameters of intraoperative fluorescence angiography (IFA) during gastrointestinal surgery to pave way for a threshold that could predict anastomotic leakage (AL).

Background &Methods

In the last decade quantification of IFA using indocyanine green is attempted to objectively evaluate anastomotic perfusion during gastrointestinal surgery.

In this systematic review, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and Embase was performed. Articles were included when IFA was performed to assess gastrointestinal perfusion in both animal and human and analysed the fluorescence signal using quantitative fluorescent parameters. A fluorescent parameter was defined as ‘quantitative’ when a diagnostic numeral threshold for AL could potentially be produced.

Results

Some 1317 articles were identified, of which 23 were included in this review. Eight applied IFA during upper and fifteen during lower gastrointestinal surgery. The quantitative fluorescent parameters were divided into four categories: (1) time to fluorescence (n=19), (2) contrast-to-background ratio (n=3), (3) pixel intensity (n=3), and (4) numeral classification score (n=2). The first category was subdivided into (a) time to fluorescent enhancement (n=7) and (b) fluorescent-time curves (n=12). Thirteen studies correlated the fluorescent parameters to the occurrence of AL. Cut-off values for AL were derived for time to fluorescent enhancement (speed in gastric conduit wall) and derivatives of the fluorescent-time curves (Fmax, T1/2, TR, and slope).

Conclusion

Of the four categories, time to fluorescent enhancement seems the most promising quantitative parameter for clinical usage, as development of a cut-off value is possible on a large scale in the near future and no software is required. Future research might want to focus on fluorescent-time curves, as many different parameters can be derived and the fluorescence intensity can be bypassed. However, consensus on study set-up, and calibration of the different fluorescent imaging systems and software programs is mandatory to allow future data aggregation.
P88 EXTENDING MYOTOMY BOTH DOWNWARDS AND UPWARDS IMPROVES THE FINAL OUTCOME IN MANOMETRIC PATTERN III ACHALASIA PATIENTS
Authors: Moletta L , Salvador R , Capovilla G , Provenzano L , Pierobon E , Nicoletti L , Nezi G , Valmasoni M , Merigliano S , Costantini M
Published: November 2019

Background

Achalasia is at present classified in 3 manometric patterns. Pattern III is the most unfrequent pattern and is correlated with the worst outcome after all available treatments. We aimed to investigate the final outcome after classic laparoscopic myotomy (CLM) as compared with a longer laparoscopic myotomy both downwards and upwards with (LLM) in patients with pattern III achalasia.

Methods

The study population consisted of 61 consecutive patients with pattern III achalasia who underwent laparoscopic myotomy between 1997-2017. Patients who had already been treated with surgical or endoscopic procedures were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium-swallow, endoscopy, manometry were performed, before and after surgical treatment. In CLM the total length of the myotomy was ≤ 9 cm, while myotomies extended both downwards and upwards to a length >9 cm were defined as LLM.

Results

Of the 61 patients representing the study population, 24 had CLM and 37 had LLM. In addition, all the patients add an anterior, partial fundoplication (Dor). The patients’ demographic and clinical parameters (sex, symptom-score, duration of symptoms, esophageal-diameter) were similar in both groups. One mucosal perforation was detected and repaired intraoperatively in the LLM group. The median length of the myotomy was 8 cm (IQR:8-9) in the CLM and 10 cm (IQR:10-12) in the LLM (p<0.001). The median of follow-up was 94 months (IQR:52-126) in the CLM and 24 months (IQR:16-40) in the LLM.

As a whole, the two groups had a different drop in their symptom score: 22 (17-26) versus 4 (0-8), and 20 (18-27) versus 3 (0-6) for the CLM and LLM respectively (p<0.01). Moreover, failures were 8/24 (33.3%) in the CLM and 4/37 (10.8%) in the LLM (p<0.05). An abnormal acid exposure was detected after the treatment in 4 patients of CLM and in 3 of LLM (p=n.s.).

Conlcusions

The extension of the length of the myotomy both downwards and upwards improves the final outcome of the laparoscopic Heller-Dor procedure in patients with pattern III achalasia. On the other hand, a longer myotomy does not influence the development of postoperative gastroesophageal reflux.
P95 LAPAROSCOPIC ASSISTED LEFT THORACOABDOMINAL OESOPHAGECTOMY (LLTA); AN INNOVATIVE APPROACH FOR TUMOURS OF THE GASTRO-OESOPHAGEAL JUNCTION
Authors: Reyhani A , Zylstra J , Davies A , Gossage J
Published: November 2019

Aim

To report a novel approach for tumours located at the gastro-oesophageal junction (GOJ) using a laparoscopic abdominal phase combined with a left thoracoabdominal approach.

Background and Methods

The standard left thoracoabdominal approach offers excellent exposure and access to GOJ and lower oesophagus. It also involves a single position for the procedure, shortening the operation time. The disadvantages are a large incision, dividing the costochondral junction, and a low level thoracotomy. Laparoscopic Left Thoracoabdominal Oesophagectomy (LLTA) is performed with the patient in the same right lateral decubitus position, but rolled away from the operator at 45xxx. allowing laparoscopic gastric mobilisation and lymphadenectomy. The thoracic phase uses an anterolateral left thoracotomy through the higher 5th intercostal space, giving a higher intrathoracic anastomosis, just below the aortic arch. No disruption of the costochondral junction is made. Consecutive patients treated for GOJ tumours with LLTA operated on during 2013-2019 were analysed and compared to national standards (NOGCA).

Results

This series of 70 consecutive patients had a mean age of 63 years. Median operation time was 235 minutes. Median inpatient hospital stay was 10 days (NOGCA 9 (11-17)). The majority were adenocarcinoma; predominantly located in the GOJ (Siewert Type1 (37.14%), Type2 (45.71%), Type3 (2.86%)); 90% of the tumours were T3 or T4. Postoperative morbidity was low (Clavien-Dindo 0 in 50% of the patients). The median number of total lymph nodes excised was 27.77 (NOGCA >15). Positive nodes were predominantly located in the lesser-curve (40%), Para-oesophageal 34.29%; Sub-carinal 2.86%. Positive circumferential resection margins (<1mm) were present in 28.57% of patients (NOGCA 25.1%). In-Hospital and 30 day mortality was 1.43% (NOGCA 2.7%). Recurrence after LLTA was 24.29% at a mean 371 days (local 5.7%, systemic 15.7%, mixed 2.86%).

Conclusion

This series demonstrates a novel, safe and reproducible left sided approach for cancer of the GOJ. There is good exposure at the hiatus, without the division of the costochondral junction and low thoracotomy.
Gender gap in research: a bibliometric study of published articles in primary health care and general internal medicine
Authors: Sebo Paul , Maisonneuve Hubert , Fournier Jean Pascal
Published: November 2019

Background

Many studies examined gender inequalities in research, but only a few data are available for general biomedical journals. We assessed the prevalence of female first authorship in general biomedical journals and examined its variations across a number of author, article and journal characteristics.

Methods

This study was nested within a larger project designed to analyze the bibliometric characteristics of scientific articles. We retrieved 767 randomly selected articles published in 2016 in high impact factor journals of primary healthcare (n = 9) and general internal medicine (n = 9). We extracted the following data: author (gender, number of publications and affiliation of the first author), paper (number of authors, number of participants and study design) and journal characteristics (journal discipline and 2015 impact factor). We compared the proportion of articles authored by women and men using univariate and multivariate logistic regressions adjusted for intra-cluster correlations.

Results

The female authorship proportion was 48% (63% for primary healthcare and 33% for general internal medicine, P-value < 0.001). In multivariate analysis, women published fewer articles (<5 versus >15 publications: OR 1.6 [95% CI 1.1–2.4]), were more often affiliated with institutions in the Western world (OR 2.2 [95% CI 1.2–3.9]), were more likely to publish qualitative studies (versus systematic reviews or experiments: OR 2.7 [95% CI 1.5–4.8]) and to publish in primary healthcare journals (OR 1.7 [95% CI 1.1–2.7]).

Conclusions

The underrepresentation of women in articles published by general internal medicine journals, in articles from the non-Western world and in systematic reviews and trials should be addressed.
Is there a relationship between length of resection and lymph-node ratio in colorectal cancer?
Authors: Zanghì Antonio , Cavallaro Andrea , Lo Menzo Emanuele , Curella Botta Serena , Lo Bianco Salvatore , Di Vita Maria , Cardì Francesco , Cappellani Alessandro
Published: November 2019

Background

The prognosis of colorectal cancer depends on the number of positive lymph nodes (LN+) and the total number of lymph nodes resected (rLN). This represents the lymph-node ratio (LNR). The aim of our study is to assess how the length of the resected specimen (RL) influences the prognostic values of the LNR.

Methods

We conducted a retrospective study of all the patients operated on for colorectal cancer from 2000 to 2015 at our institution. Pathology details were analysed. The total number of rLN, the number of LN+, and the LNR were calculated and measured against the RL. The receiver-operating characteristic (ROC) curve of patients with LN+ was calculated.

Results

Of the 670 patients included in our study, 337 were men (50.3%) and the mean age was 69.2 years. The correlation with prognosis of the LNR is greater than that of the LNR adjusted to RL (LNR/RL), both in subjects with positive nodes (n = 312) and in all cases (n = 670). The LNR presents a higher prognostic value than LNR/RL and RL in patients with LN+ except for metastatic recurrence, for which the predictive value appears slightly higher for LNR/RL. The statistical significance of the maximal divergence in Kaplan–Meier survival plots was demonstrated for the LNR (P = 0.043), not for LNR/RL (P = 0.373) and RL alone (P = 0.314).

Conclusion

An increase in RL causes an increase in the number of harvested lymph nodes without affecting the number of LN+, thus representing a confounding factor that could alter the prognostic value of the LNR. Prospective larger-scale studies are needed to confirm these findings.
A Small Horizontally Transferred Gene Cluster Contributes to the Sporulation of Alternaria alternata
Authors: Wang Mingshuang , Fu Huilan , Ruan Ruoxin
Published: November 2019

Horizontal gene transfer (HGT) has been identified as an important source of genomic innovation in fungi. However, how HGT drove the evolution of Alternaria alternata, a necrotrophic fungus which can be ubiquitously isolated from soil and various plants and decaying plant materials is largely known. In this study, we identified 12 protein-encoding genes that are likely acquired from lineages outside Pezizomycotina. Phylogenetic trees and approximately unbiased comparative topology tests strongly supported the evolutionary origin of these genes. According to their predicted functions, these HGT candidates are involved in nitrogen and carbohydrate metabolism. Especially, five genes of them were likely transferred as a physically linked cluster from Tremellales (Basidiomycota). Functionally knocking out the five-gene cluster in an A. alternata isolate causing citrus brown spot resulted in an 80% decrease in asexual spore production in the deletion mutant. We further knocked out each of these five genes in this cluster and the resultant single-gene deletion mutants exhibited a various degree of reduction in spore production. Except for conidiation, functions of these genes associated with vegetative growth, stress tolerance, and virulence are very limited. Our results provide new evidence that HGT has played important roles over the course of the evolution of filamentous fungi.
A geothermal aquifer in the dilation zones on the southern margin of the Dublin Basin
Authors: Vozar Jan , Jones Alan G , Campanya Joan , Yeomans Chris , Muller Mark R , Pasquali Riccardo
Published: November 2019

We present modelling of the geophysical data from the Newcastle area, west of Dublin, Ireland within the framework of the IRETHERM project. IRETHERM's overarching objective was to facilitate a more thorough strategic understanding of Ireland's geothermal energy potential through integrated modelling of new and existing geophysical, geochemical and geological data. The Newcastle area, one of the target localities, is situated at the southern margin of the Dublin Basin, close to the largest conurbation on the island of Ireland in the City of Dublin and surrounds. As part of IRETHERM, magnetotelluric (MT) soundings were carried out in the highly urbanized Dublin suburb in 2011 and 2012, and a description of MT data acquisition, processing methods, multidimensional geoelectrical models and porosity modelling with other geophysical data are presented. The MT time-series were heavily noise-contaminated and distorted due to electromagnetic noise from nearby industry and Dublin City tram/railway systems. Time-series processing was performed using several modern robust codes to obtain reasonably reliable and interpretable MT impedance and geomagnetic transfer function ‘tipper’ estimates at most of the survey locations. The most ‘quiet’ 3-hr subsets of data during the night time, when the DC ‘LUAS’ tram system was not operating, were used in multisite and multivariate processing. The final 2-D models underwent examination using a stability technique, and the final two 2-D profiles, with reliability estimations expressed through conductance and resistivity, were derived. In the final stage of this study, 3-D modelling of all MT data in the Newcastle area was also undertaken. Comparison of the MT models and their interpretation with existing seismic profiles in the area reveals that the Blackrock–Newcastle Fault (BNF) zone is visible in the models as a conductive feature down to depths of 4 km. The investigated area below Newcastle can be divided into two domains of different depths, formed as depth zones. The first zone, from the surface down to 1–2 km, is dominated by NE–SW oriented conductors connected with shallow faults or folds probably filled with less saline waters. The conductors are also crossing the surface trace of the BNF. The second depth domain can be identified from depths of 2–4 km, where structures are oriented along the BNF and the observed conductivity is lower. The deeper conductive layers are interpreted as geothermal-fluid-bearing rocks. Porosity and permeability estimations from the lithological borehole logs indicate the geothermal potential of the bedrock, to deliver warm water to the surface. The fluid permeability estimation, based on Archie's law for porous structures and synthetic studies of fractured zones, suggests a permeability in the range 100 mD–100 D in the study area, which is prospective for geothermal energy exploitation.