bluuebunny/crossref_metadata_2025 huggingface dataset:
543 DISSEMINATION AND SAFETY OF ROBOT-ASSISTED ESOPHAGECTOMY IN JAPAN
Authors: Nishigori T , Obama K , Ichihara N , Uyama I , Inomata M , Watanabe M , Kakeji Y , Seto Y , Miyata H , Sakai Y
Published: September 2020

Robot-assisted surgery for gastrointestinal cancers began to be covered by universal health insurance in April 2018 in Japan. However, the current status of this new procedures such as the number of patients and clinical outcomes was unclear. The aim of this study to retrospectively examine the dissemination and safety of robot-assisted esophagectomy (RAE) in Japan using a nationwide web-based database, or the National Clinical Database (NCD).

Methods

The study included patients who underwent RAE or conventional minimum invasive esophagectomy (MIE) and were registered in the NCD in 2018. The outcomes were operative mortality and the numbers of hospitals and surgeons performing the surgeries.

Results

The number of patients undergoing RAE and MIE was 122 and 4799, respectively. RAE was performed at 28 hospitals by 37 surgeons, while MIE was done at 523 hospitals by 837 surgeons. In terms of annual case volume per hospital, RAE was likely to be performed in higher volume centers. The number of patients undergoing RAE per month in Japan was less than 5 before insurance coverage began. It has increased to more than 10 since April. Operative mortality occurred in 2 (1.6%) patients following RAE, while it occurred in 78 (1.6%) following MIE.

Conclusion

RAE was safely introduced in Japan. The number of patients undergoing RAE and surgeons and hospitals performing it were gradually increasing but still limited.
565 POST-OPERATIVE WEIGHT LOSS AND OUTCOMES FOLLOWING ESOPHAGECTOMY
Authors: Khaw R , Munro S , Sturrock J , Jaretzke H , Kamarajah S , Phillips A
Published: September 2020

Oesophageal cancer is the 11th most common cancer worldwide, with oesophagectomy remaining the mainstay curative treatment, despite significant associated morbidity and mortality. Postoperative weight loss remains a significant problem and is directly correlated to poor prognosis. Measures such as the Enhanced Recovery After Surgery (ERAS) programme and intraoperative jejunostomy feed have looked to tackle this. This study investigates the impact of these on mortality, length of hospital stay and postoperative weight loss.

Methods

Patients undergoing oesophagectomy between January 1st 2012—December 2014 and 28th October 2015–December 31st 2019 in a national tertiary oesophagogastric unit were included retrospectively. Variables measured included comorbidities, operation, histopathology, weights (pre- and post-operatively), length of hospital stay, postoperative complications and mortality. Pre-operative body weight was measured at elective admission, and further weights were identified from a prospectively maintained database, during further clinic appointments. Other data was collected through patient notes.

Results

594 patients were included. Mean age at diagnosis was 65.9 years (13–65). Majority of cases were adenocarcinoma (63.3%), with varying stages of disease (TX-4, NX-3). Benign pathology accounted for 8.75% of cases.

Mean weight loss post-oesophagectomy exceeded 10% at 6 months (SD 14.49). Majority (60.1%) of patients were discharged with feeding jejunostomy, and 5.22% of these required this feed to be restarted post-discharge.

Length of stay was mean 16.5 days (SD 22.3). Complications occurred in 68.9% of patients, of which 13.8% were infection driven. Mortality occurred in 26.6% of patients, with 1.83% during hospital admission. 30-day mortality rate was 1.39%.

Conclusion

Failure to thrive and prolonged weight-loss following oesophagectomy can contribute to poor recovery, with associated complications and poor outcomes, including increased length of stay and mortality. Further analysis of data to investigate association between weight loss and poor outcomes for oesophagectomy patients will allow for personalised treatment of high-risk patients, in conjunction with members of the multidisciplinary team, including dieticians.
569 LAPAROSCOPIC REPAIR OF A VOLUMINOUS SYMPTOMATIC HIATAL HERNIA USING AN ABSORBABLE SYNTHETIC MESH
Authors: Cocozza E , Berselli M , Livraghi L , Quintodei V , Latham L
Published: September 2020

In symptomatic voluminous paraesophageal hiatal hernias not only a laparoscopic surgical approach, but also the use of mesh can be considered too.

The use of surgical protesis in hiatal henia repair was a debated surgical topic in the last years

A laparoscopic repair of a symptomatic type III hiatal hernia by plastic of the hiatus, fundoplicatio and use of an absorbable glycolic acid/trimethylene carbonate synthetic mesh is showed.

Methods

The patient was a 59 years old male suffering from recurrent aspiration pneumonias. Surgery was performed by a standardized tecnique in a high volume laparoscopic surgical centre. The hernia sac was removed and the plastic of the esophageal hiatus was performed. After the mesh placement a Nissen fundoplicatio was performed. No drain was placed.

Results

In the postoperative period a contrat-soluble swallow was performed and it resulted in a good transit witout any sign of recurrence. The patient was discharged with an appropiate oral intake. One year after surgery the patient is asymptomatic and in good conditions.

Conclusion

A voluminous symptomatic hiatal hernia can be successfully treated in a high-volume and long-term experienced laparoscopic surgical.

The use of an absorbable, handily positionable and synthetic mesh can help to gain a lower rate of recurrence without any risk for the patients.

The technical skill and all the surgical steps never are renounceable because of the presence of the mesh.

Further studies with a longer-term follow-up and a international live debate are necessary.

Video

https://www.dropbox.com/s/384ujzm3rnoqe0a/Hiatal%20Hernia%20Dr.%20Cocozza%20ISDE%202020.mp4?dl=0
572 NUTRITIONAL PATTERNS MAY AFFECT ESOPHAGEAL ACID EXPOSURE, AND THE NUMBER AND TYPE OF GASTROESOPHAGEAL REFLUXES
Authors: Morozov S , Kropochev V , Isakov V
Published: September 2020

The role of nutritional patterns on esophageal function testing parameters is not widely studied. Earlier published data focused on symptoms of GERD and their association with the food structure.

Aim of the study was to assess the influence of nutritional patterns on esophageal acid exposure and types and number of gastroesophageal refluxes

Methods

The data of complete examination of 165 participants served as a source data for the study. Diagnosis of GERD was based on clinical data (heartburn and acid regurgitation at least once a week for not less than 6 month, actual during last 3 month, history of effective PPI treatment), GERD-Q questionnaire (≥8 points), endoscopic evaluation (Excera II, Olympus, Japan) and 24-hours esophageal pH-impedance studies (Ohmega, MMS, the Netherlands; 2 pH, 6 impedance catheters, UnisensorAG, USA). Food frequency questionnaire was used to analyse food structure. StatSoft (USA) software was used for correlation analysis.

The work has been performed within RSF 19–76-30014.

Results

We enrolled 124 GERD patients and 41 controls.

Significant (P < 0.05) correlation of AET was with energy value of the ration (Spearman rank R = 0.19), amount of fat (R = 0.2).

Significant correlation of number of GERs was with energy values (R = 0.35), protein (R = 0.3), fat (R = 0.33), alcohol (R = 0.28) and dietary fibre (R = -0.22) consumption.

Number of acid GERs correlated with calorie (R = 0.35), fat (R = 0.32), protein (R = 0.25), carbohydrates (R = 0.24) and alcohol (R = 0.24) consumption.

Number of weak-acid GERs correlated with calories (R = 0.22), fat (R = 0.21), protein (R = 0.22), alcohol (R = 0.23) and dietary fibre (R = -0.24) consumption.

High GERs correlated with fat (R = 0.3), protein (R = 0.22), alcohol (R = 0.25) and fibre (R = -0.25).

Conclusion

High energy value, consumption of fat and alcohol showed direct medium-strength correlation with esophageal acid exposure and the total number gastroesophageal refluxes. The total number of gastroesophageal refluxes, number of weak acid and high gastroesophageal refluxes had inverse correlation with the amount of dietary fibre consumed. Found trends are used to establish nutritional patterns for reflux events in GERD patients.
577 EFFECTIVENESS OF CADAVER SURGICAL TRAINING FOR THORACOSCOPIC ESOPHAGECTOMY
Authors: Shichinohe T , Murakami S , Ebihara Y , Kurashima Y , Narazaki H , Hirano S
Published: September 2020

Thoracoscopic esophagectomy (TE) requires advanced surgical skills. Learning TE only through conventional on-the-job- training (OnJT) is difficult. Therefore, it is necessary to establish a safe and efficient educational program to learn the procedure. In our department, cadaver surgical training (CST) has been used to learn our standard procedure of prone position TE. In this presentation, we describe the usefulness of CST as an education tool for the surgical training of TE.

Methods

Cadavers embalmed by Thiel fixation were used for the training. To be eligible, the trainee must possess the surgical skills to perform laparoscopic gastrectomy and have the motivation to perform TE. Our program included self-study and lectures and evaluating the trainee using our original manual and evaluation sheet. During the CST practice, one cadaver was assigned to each trainee, and the trainee experienced whole procedure both as the operator and the assistant. After the training, feedback was given using the same evaluation sheet.

Results

Ten surgeons were evaluated using the technical evaluation sheet (12 items, 5 points per item, total 60 points), the average of the total points increased from 23 to 43 points after the training. The item with largest increase and highest score after the training was “thoracic duct dissection” (1.8 to 4.0). The item “Left recurrent laryngeal nerve (RLN) dissection” was the worst in both pre- and post-training as the average score was only increased from 1.6 to 3.1. On the other hand, the item “Right RLN dissection” score showed a moderate change from 1.7 to 3.5.

Conclusion

CST for mastering the whole surgical procedure of TE was useful in terms of overall quality of the operative performance. On the other hand, it seemed to be insufficient for mastering the lymph node dissection around the left recurrent laryngeal nerve. Development of a comprehensive education program combined with learning the whole procedure by CST and repetition training for a highly difficult procedure by simulation is necessary.
582 ANALYSIS OF FACTORS ASSOCIATED WITH CHANGE IN UES AND LES RESTING PRESSURE IN THE START AND END OF HRM STUDY
Authors: Morozov S , Kropochev V , Bredenoord A
Published: September 2020

Lower and upper esophageal sphincter resting pressures' evaluation is not within Chicago classification, but is a part of a standard esophageal HRM examination. As the results of measurements at the beginning and at the end of examination are often discrepant, national guidelines in Russia recommend to record both. The aim of the study was to analyse possible factors that may affect the change between the results of the recordings of UES and LES resting pressures.

Methods

High-resolution esopophageal manometry examinations were performed in upright position with solid-state 36 channel 10 Fr catheter (Unisensor, USA) and Solar (MMS, the Netherlands) equipment. Resting pressures (RP) were measured at rest for ≥30 seconds at the beginning of the examination and after 10 water swallows. Beck depression inventory (BDI-II) was used to assess psychological status. Correlation analysis by Spearman (StatSoft, USA) was used to reveal factors affecting the change in resting pressures at the beginning and at the end of HRM study. Change of pressure was presented as a quotient of dividing the second P value by the first (ΔP).

Results

Eighty-four patients, age (M ± m) 48.5 ± 13.2 y.o. were enrolled. Hiatal hernia was present in 37 subjects.

UES mean RP differed significantly at the beginning (123.7 ± 76.6 mmHg) and at the end of examination (87.9 ± 64.1), P < 0.0001. LES RP didn’t differ significantly at the start and at the end of examination.

The results of correlation analysis of factors affecting ΔP are shown in the table 1. Those with a decrease of UES resting pressure at the end of examination (n = 63) were younger compared to the group with no change or an increase of it (46.3 ± 12.7 y.o. vs 56.0 ± 13.1 y.o., p = 0.003).

Conclusion

Upper esophageal resting pressure measured at the end of the high resolution esophageal examination is lower compared to the initial values in great proportion of patients. Despite the importance of the finding is unknown, this should be considered when the function of the upper esophageal sphincter is studied.
114 VATS ESOPHAGECTOMY: DOES PATIENT OPERATIVE POSITION DURING THORACOSCOPIC MOBILISATION INFLUENCE OUTCOMES? A PROSPECTIVE COMPARATIVE STUDY
Authors: Choudhary Y , Pokharkar H , Patil A , Mistry R
Published: September 2020

VATS esophagectomy can be done in lateral, prone and semiprone positions. Present evidence available comparing semiprone with lateral position is retrospective. We have conducted this study to provide prospective data on perioperative outcomes in patients undergoing Video Assissted Thoracoscopic (VATS) esophagectomy in Semiprone (SP) and Lateral decubitus position (LP) in a single centre.

Methods

48 patients (SP =24 & LP =24) undergoing VATS esophagectomy (2017 to 2019) were analysed. Preoperative details (tumor characteristics, preoperative treatment and pulmonary function test), intraoperative details [operative time, blood loss, mean EtCO2, arterial blood gas analysis (ABG) at the end of one lung ventilation(OLV), number of ports used, need for lung reinflation and retraction] and postoperative details [duration of ICU stay, cardiovascular and respiratory complications, pain scores (VAS) and tidal volume improvement (spirometry reading) on first five postoperative days, circumferential resection margin (CRM) status, total and recurrent laryngeal nerve (RLN) nodal yield were noted.

Results

Preoperative data in both arms were comparable. Ports used (5 vs 3, p < 0.0001), need for lung retraction (22 vs 4patients, p < 0.0001), duration of ICU stay (2 days vs 1 day, p = 0.0327), spirometry readings for POD 1st-5th (p < 0.05) and pain scores (p < 0.05) for POD 1st-5th was significantly less in SP group. There were fewer respiratory complications in SP group (10 vs 4, p = 0.110). LP group had shorter duration of surgery (3.7 vs 4.2 hours, p = 0.0398). There were no differences in tumor characteristics, blood loss, ABG at the end of OLV, mean EtCO2, lung reinflation rate, cardiovascular complications, CRM involvement, total and RLN nodal yield.

Conclusion

Similar oncological clearance was achieved by both techniques of esophageal mobilization. Semiprone position is associated with lesser postoperative pain and better preservation of respiratory function.
162 IMPACT OF FLOW SPEED OF ICG FLUORESCENCE IN THE GASTRIC CONDUIT AND THORACIC INLET SPACE ON ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY
Authors: Koyanagi K , Ozawa S , Ninomiya Y , Yatabe K , Higuchi T , Yamamoto M
Published: September 2020

We have previously demonstrated that the flow speed of indocyanine green (ICG) fluorescence in the gastric conduit wall could predict anastomotic leakage after esophagectomy. Surround organs via retrosternal route is considered to affect the blood flow in the gastric conduit and anastomotic leakage. In the study, we investigated the impact of the flow speed of ICG fluorescence in the gastric conduit wall and thoracic inlet space on anastomotic leakage after esophagectomy.

Methods

A total of 142 patients, who underwent esophagectomy with three-field lymph node dissection, simultaneous reconstruction using a gastric conduit, and cervical anastomosis via retrosternal route, were prospectively investigated. Using ICG fluorescence imaging, blood flow speed of the gastric conduit wall was assessed before and after anastomosis (pre speed and post speed (cm/s)) and correlated with clinicopathological findings. Parameters of thoracic inlet space was assessed using CT scan and correlated with blood flow speed of the gastric conduit wall and anastomotic leakage.

Results

Median pre speed was 2.54 (0.73–6.10) cm/s and median post speed was dropped by 1.77 (0.32–8.67) cm/s. Speed reduction (pre speed—post speed) and speed reduction rate ((pre speed—post speed)/pre speed) were negatively correlated with thoracic inlet area (TIA) (P = 0.004, P = 0.021). Pre speed and post speed of the patients with anastomotic leakage were significantly slower than those of the patients without anastomotic leakage, respectively (P < 0.001 and P = 0.050). In 115 patients with pre speed more than 1.98 cm/s, TIA was significantly associated with anastomotic leakage after esophagectomy (P < 0.001).

Conclusion

We clearly demonstrated that retrosternal route reduced the blood flow of the gastric conduit wall using ICG fluorescence imaging. Narrow thoracic inlet space might obstruct the blood flow of the gastric conduit wall and cause anastomotic leakage after esophagectomy.
164 EFFECTIVENESS OF ONE-TIME ENDOSCOPIC SCREENING PROGRAM IN PREVENTION OF ESOPHAGEAL CANCER IN CHINA: A MULTI-CENTER POPULATION-BASED COHORT STUDY
Authors: Chen R , Liu Y , Song G , Li B , Zhao D , Hua Z , Wang X , Li J , Hao C , Zhang L , Liu S , Wang J , Zhou J , Zhang Y , Li B , Li Y , Feng X , Li L , Dong Z , Wei W , Wang G
Published: September 2020

Esophageal cancer is one of the most common cancers worldwide and half of all new cases occurred in China. Population-based endoscopic screening has been carried out in some high-risk areas in China since 2005, but previous evidence was based predominately on small-sample, single-center studies. We undertook a population-based, multi-center cohort study to estimate the effectiveness of endoscopic screening program in reducing the incidence and mortality of esophageal in high risks areas in China.

Methods

This study was conducted in six areas in China from 2005 to 2015. All permanent residents aged 40–69 yeas were identified as target subjects. We defined those who were invited and undertook endoscopic screening as the screened group, and those who refused screening as the non-screened group. The target subjects who were not invited to screening was assigned to the control group. The effectiveness of endoscopic screening and screening program were evaluated by comparing the reductions in the incidence and mortality from esophageal cancer in those screened or those invited to screening with reductions in the control group, respectively.

Results

Our cohort analysis included 637 500 people: 299 483 in the control group and 338 017 in the invited to screening group, 113 340 (33.53%) of whom were screened eventually. Compared with subjects in the control group, esophageal cancer incidence and mortality were reduced by 26% (relative risk(RR) 0.74, 95% confidence interval(CI), 0.69–0.79) and 60% (0.40, 0.36–0.45) respectively in those screened, and they were reduced by 15% (0.85, 0.82–0.89) and 33% (0.67, 0.63–0.71) respectively in those invited to screening.

Conclusion

Among individuals aged 40–69 years in high risk areas of esophageal cancer, one-time endoscopic screening program was associated with a significant decrease in esophageal cancer incidence and mortality.
214 OESOPHAGECTOMY POST INDUCTION THERAPY: COMPLETE PATHOLOGICAL RESPONDERS VERSUS OTHERS
Authors: Pokharkar H , Patil A , Mistry R , Choudhary Y , Kaushik T
Published: September 2020

Induction therapy is reported to improve outcomes in patient with loco regionally advanced cancer of oesophagus; benefit is most in patient who respond to neoadjuvant therapy. This study compares outcomes between patients with complete pathological response (Group A) and others (Group B).

Methods

This is a retrospective analysis of prospectively maintained database of 257 patients with cancer oesophagus undergoing surgery after neoadjuvant therapy between 2009 and 2019. Parameters analysed were stage at presentation, type of induction therapy, pTNM stage, pattern of failure and overall survival.

Results

209(81%) patients received chemotherapy alone and 48(19%) chemoradiation. 43(17%) patients had complete pathological response. Of the complete responders 21/209(10%) and 22/48(45.8%) patients had received chemotherapy alone and chemoradiation respectively. Majority of patients in both groups were T3/4 (Group A:93%, Group B:93.9%) and node positive (GroupA:81.4%, GroupB:85%). Median number of lymph nodal yield for Group A and Group B was 22 and 20 respectively. Three(7%) patients in Group A had local recurrence and 2(4.7%) had distant failure. The same for non responders was 34(15.9%) and 49(22.9%). The median survival for Group A is 7.03 years and Group B is 2.1 years.

Conclusion

The overall median survival is significantly higher for complete pathological responder as compared to partial or non responders. Despite complete pathological response some patients will have recurrences. Chemoradiation is associated with higher complete pathological response compared to chemotherapy alone.
233 POSTOPERATIVE DELIRIUM AFTER OESOPHAGECTOMY FOR CANCER: HOW CAN WE PREVENT AND MANAGE IT?
Authors: Rita A , Pinto E , Pomba L , Tolin F , Mattara G , Mazza M , Turchet F , Pilati P
Published: September 2020

Oesophagectomy is associated with high morbidity. One of the postoperative complication observed after esophageal resection is Post Operative Delirium (POD), a psychiatric disease caused by major surgical stress and pharmacological treatments. POD can jeopardize patient healing-process since patients are not collaborative to perioperative care but also because they can harm themselves. Thus the aim of this systematic review was to identify POD factors and its effective management in patients undergone oesophagectomy for oesophageal/oesophagogastric-junction cancer.

Methods

A comprehensive systematic literature search was conducted using PubMed, Cochrane Library, Scopus, psycINFO and psycARTICLES in order to identify all articles published until January 2020. The following combinations of terms were used for the search strategy: neoplasm; esophagus; gastro-esophageal junction; oesophagectomy; delirium. The following inclusion criteria were set: full article published in English; patients with esophageal cancer undergone oesophagectomy; POD observed. Two researchers independently selected studies matching the inclusion criteria. Duplicate studies, non-relevant topic, data from abstracts or unpublished were excluded. Any disagreements between the researchers’ evaluation concerning inclusion of studies were resolved by consensus.

Results

Of 235 studies yielded by systematic literature search, 21 met inclusion criteria. POD incidence was observed between 3 and 38% of patients and was precursor of other complications in 1/3 of POD patients. Preoperative risk factors were older age, cerebrovascular disease and pulmonary disfunction. Anxiety and depression resulted predisposing factors. Perioperative risk factors were duration of surgery, ICU length of stay, colloids infusion and blood transfusion. Open-surgery seemed to influence POD more than minimally-invasive and robotic surgery. Interventions identified to treat POD were pharmacological (prophylactic haloperidol, insomnia treatment) and behavioral (patient reorientation by family involvement, bright-light therapy, early mobilization).

Conclusion

This systematic review identified preoperative, intraoperative and postoperative risk factors of POD after oesophagectomy. No standardized prevention nor treatment of POD was identified.

POD impacts patients’ ability in perceiving postoperative symptoms. The difficulty in communicating with health professionals may lead to delay the diagnosis of others complications and prolong hospital stay. Therefore further trials are required to assess efficacy of different POD treatments aimed to enhance postoperative management.
252 HETEROGENEITY OF CLINICAL LYMPH NODE INVOLVEMENT (CN+) IN ESOPHAGEAL CANCER: A PERSPECTIVE BASED ON METABOLIC VOLUME
Authors: Lin D , Liu G , Tan L
Published: September 2020

Esophageal cancer with clinical lymph node involvement (cN+) is a heterogeneous disease. Although the cN+ category is of vital importance, preclinical staging cannot establish the number of positive nodes. In this study, we aimed to measure the heterogeneity of esophageal cancer with cN+ based on metabolic volume. We investigated its influence on the response to neoadjuvant treatment.

Methods

We retrospectively reviewed the patients received neoadjuvant chemotherapy (nCT) and neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy during January 2016 and November 2018. All patients had received baseline 18F-FDG PET/CT. All patients were restaged according to the 8th TNM Staging System. We measured the metabolic tumor volume (MTV, cm3) of the whole body (MTVwb) and the primary tumor (MTVp) on the workstation. We also calculated the difference of MTVwb and MTVp (MTVn) and the ratio of MTVwb and MTVp (MTVratio). Logistic regression was used to determine the association between the heterogeneity and the response to neoadjuvant treatment.

Results

Among the 102 patients enrolled in this study, 54 patients had clinically suspicious lymph nodes in small diameters with lower uptake (MTVn as 0). The median MTVwb, MTVp, and MTVn of the patients were 22.34 (2.09 to 105.24), 19.62 (1.93 to 98.06), and 0 (0 to 89.00), respectively. In nCT and nCRT groups (all patients), 15 (37.5%) and 38 (61.3%) achieved ypN0, respectively. In nCT and nCRT groups (MTVn as 0), 12 (42.9%) and 20 (76.9%) patients achieved ypN0, respectively. Logistic regression revealed that MTVn (0 vs. >0) was independently associated with ypN status in nCRT group (P = 0.035).

Conclusion

nCRT compared with nCT achieved more effective disease control. In esophageal cancer treated with nCRT, the heterogeneity of cN+ measured by metabolic volume was associated with ypN status. A prospective study was in demand to further validate the findings.

Video

none
268 LIQUID BIOPSY IN ESOPHAGEAL ADENOCARCINOMA: ROLE OF LINE-1 HYPOMETHYLATION
Authors: Alfieri R , Boldrin E , Mazza M , Realdon S , Fassan M , Pilati P , Curtarello M
Published: September 2020

Esophageal Adenocarcinoma (EADC) prognosis is still poor. Clinical staging doesn’t allow accurate prediction of response to neoadjuvant treatment and survival. Molecular characterization of EADC is an expanding field aimed to predict treatment response and prognosis. Hypomethylation of Long Interspersed Nuclear Element 1 (LINE-1) sequences recently emerged as a frequent epigenetic alteration in EADC. Aim of the study was to evaluate methylation patterns of LINE-1 that is considered a good surrogate of global DNA methylation.

Methods

We investigated cell free DNA (cfDNA) of 21 patients, 19 with EADC and 2 with Barrett’s esophagus (BE). To verify the possibility to use LINE-1 methylation status to predict tumor behaviour, we extended the analysis to a few longitudinal cases, one EADC and two BE. One BE patient progressed to low-grade dysplasia (LGD) and high-grade dysplasia (HGD)/EADC during surveillance, while the other remains stable. LINE-1 promoter methylation was analyzed using restriction enzymes and DNA amplification.

Results

Using this approach, we were able to detect the presence of hypomethylated LINE-1 sequences in EADC cfDNA. The difference in methylation level between cfDNA and constitutive DNA was statistically significant (p = 0.0001). In one EADC patient, treated with esophagectomy, LINE-1 hypomethylation was found at lower level after resection and at higher level at recurrence. In another patient affected by BE, LINE-1 hypomethylation increased during the progression from metaplastic epithelium to EADC, switching back to the level of constitutive DNA after endoscopic resection. The third patient, with stable BE during 4 years follow-up, showed non-significant variations in methylation status of LINE-1.

Conclusion

Our study demonstrated the feasibility of our methodological approach to detect hypomethylation events in EADC patient cfDNA. Longitudinal preliminary analysis suggested a correlation between methylation status of LINE-1 and tumor progression. Further studies on larger population are needed to confirm these encouraging data.

LINE-1 methylation analysis could be useful as a new molecular assay to integrate patient monitoring.
272 10-YEAR FOLLOW-UP OF A RANDOMISED CONTROLLED TRIAL COMPARING NEOADJUVANT CHEMORADIOTHERAPY PLUS SURGERY VERSUS SURGERY ALONE FOR OESOPHAGEAL CANCER (CROSS)
Authors: Eyck B , Lanschot J , Hulshof M , Wilk B , Shapiro J , Hagen P , Nieboer D , Berge Henegouwen M , Wijnhoven B , Laarhoven H , Nieuwenhuijzen G , Hospers G , Bonenkamp J , Cuesta M , Blaisse R , Busch O , Kate F , Creemers G , Punt C , Plukker J , Verheul H , Spillenaar Bilgen E , Dekken H , Sangen M , Rozema T , Biermann K , Beukema J , Piet A , Rij C , Reinders J , Tilanus H , Gaast A
Published: September 2020

Neoadjuvant chemoradiotherapy according to the Dutch randomised controlled ChemoRadiotherapy for Oesophageal cancer followed by Surgery Study (CROSS) has become standard of care for patients with cancer of the oesophagus or oesophagogastric junction. The aim of this study was to provide more insight into the ultra-long-term impact of CROSS neoadjuvant chemoradiotherapy on survival and disease recurrence for patients with oesophageal cancer.

Methods

Patients with locally advanced resectable squamous cell carcinoma or adenocarcinoma of the oesophagus or oesophagogastric junction were randomised between neoadjuvant chemoradiotherapy (five weekly cycles of intravenous carboplatin [AUC 2 mg/mL per min] and intravenous paclitaxel [50 mg/m2 of body-surface area]) with concurrent 41.4 Gy radiotherapy given in 23 fractions of 1.8 Gy, 5 days per week) plus surgery (nCRT arm) versus surgery alone (surgery arm). Primary endpoint was overall survival, defined from date of randomisation to date of all-cause death or to last day of follow-up. Secondary endpoints were cause-specific mortality and conditional survival. Analysis was by intention-to-treat.

Results

From 2004 through 2008, 178 patients were randomized to the nCRT arm and 188 to the surgery arm. Median follow-up for surviving patients was 146.6 months (IQR 133.5–157.2). Ten-year overall survival was 38% in the nCRT arm and 25% in the surgery arm (HR 0.68 [95%CI 0.53–0.87]). For patients with squamous cell carcinoma ten-year overall survival was 46% in the nCRT arm compared to 23% in the surgery arm. For patients with adenocarcinoma ten-year overall survival was 36% in the nCRT arm and 26% in the surgery arm. In the nCRT arm, ten-year oesophageal cancer-specific mortality was 47%.

Conclusion

Survival benefit of patients with locally advanced resectable squamous cell carcinoma or adenocarcinoma of the oesophagus or oesophagogastric junction receiving neoadjuvant chemoradiotherapy persists for at least 10 years compared to patients undergoing surgery alone.
274 ASSESSMENT OF THE ANTI-PROLIFERATIVE EFFECTS OF STANDARD CHEMOTHERAPY AND PAN-HER FAMILY TYROSINE KINASE INHIBITORS IN ESOPHAGEAL CANCER CELL LINE MODELS.
Authors: Al Azzawi M , Gaynor N , Crown J , Collins D , Robb W
Published: September 2020

Esophageal cancer is the 9th most common cause of cancer globally with a mortality:incidence ratio of 0.88 and a 5 year mortality rate of 19%. Herceptin, a HER2 targeted monoclonal antibody, is approved for use in metastatic HER2+ gastroesophageal carcinoma. To further examine the benefits of HER family inhibition in esophageal cancer, the effects of pan-HER family TKIs and standard chemotherapy in HER2+ and HER2-low cell line models were examined.

Methods

Two cell lines, OE19 (HER2+) and FLO-1 (HER2-low) were used to examine the effect of the standard FLOT chemotherapy regimen (5 flurouracil (5FU), oxaliplatin and docetaxel) and pan-HER TKIs neratinib and poziotinib. All compounds were from commercial sources. 2D acid phosphatase-based proliferation assays were utilised to assess the anti-proliferative effects of these agents. Triplicates of each assay were performed and standard deviations were determined. IC50 values were calculated using Calcusyn ® software.

Results

The OE19 cell line demonstrated a high sensitivity to neratinib and poziotinib with IC50 values of 3.426+/−0.187 nM and 0.307 +/−0.051 nM), respectively. IC50 values for neratinib (0.147+/−0.080 μM) and poziotinib (2.4+/−0.471 μM) were significantly higher (p < 0.05) in the FLO-1 cell line compared to OE19. The IC50 values for oxaliplatin and docetaxel were comparable between the OE19 and FLO-1. However, both cell lines were insensitive to 5FU with IC50 values greater than 10 μM.

Conclusion

The HER2+ cell line was significantly more sensitive to the pan-HER family TKIs neratinib and poziotinib, compared to the HER2-low cell line. This may indicate a potential use for pan-HER family TKIs in HER2+ esophageal cancer. Further work is being conducted to assess potential synergy between pan-HER family TKIs and chemotherapy in these models.
275 POSTOPERATIVE COMPLICATIONS DO NOT AFFECT QUALITY OF LIFE AFTER ESOPHAGECTOMY
Authors: Jezerskyte E , Laarhoven H , Sprangers M , Eshuis W , Hulshof M , Berge Henegouwen M , Gisbertz S
Published: September 2020

Despite the attempts to reduce postoperative complication incidence after esophageal cancer surgery, up to 60% of patients endure postoperative complications. These patients often have a reduced health related quality of life (HR-QoL) and it may also have a negative effect on long-term survival. The aim of this study is to investigate the difference in short- and long-term HR-QoL in patients with and without a complicated postoperative course.

Methods

A retrospective comparative cohort study was performed with data from the Dutch Cancer Registry (IKNL) and QoL questionnaires from POCOP, a longitudinal patient reported outcomes study. All patients with esophageal and gastroesophageal junction (GEJ) cancer after an esophagectomy with or without neoadjuvant chemo(radio) therapy in the period of 2015–2018 were included. Exclusion criteria were palliative surgery, patients with a recurrence, reconstruction with a colonic or jejunal interposition, no reconstruction and emergency surgery. HR-QoL was investigated at baseline and at 3, 6, 9, 12, 18 and 24 months postoperatively between patients with and without complications following an esophagectomy.

Results

A total of 486 patients were included: 270 with and 216 without postoperative complications. The majority of patients were male (79.8%) with a median age of 66 years (IQR 60–70.25). Significantly more patients had comorbidities in the group with postoperative complications (69.6% vs 57.3%, p = 0.001). A significant difference in HR-QoL over time was found between the two groups in “choked when swallowing” score (p = 0.028). Patients that endured postoperative complications reported more problems with choking when swallowing at 9 months follow-up (mean score 12.9 vs 8.4, p = 0.047). This difference was not clinically relevant with a mean score difference of 4.6 points.

Conclusion

Postoperative complications do not significantly influence the short- and long-term HR-QoL in patients following an esophagectomy. Only one HR-QoL domain showed difference over time, however, this was not clinically relevant.
288 RISK STRATIFICATION OF POSTOPERATIVE DELIRIUM BY SIMPLE QUESTIONNAIRE IN GERIATRIC PATIENTS WITH ESOPHAGEAL CANCER
Authors: Terayama M , Yamada K , Mita H , Wake H , Kataoka A , Enomoto N , Nohara K , Kokudo N
Published: September 2020

Geriatric patients often have cognitive decline which might cause postoperative complications, including delirium, therefore, it is very important to evaluate mental ability before surgery. The Flemish version of the triage Risk Screening Tool (fTRST), which focuses on the assessment of cognitive function, is reported to be useful for identifying patients with geriatric risks. The aim of our study is to predict postoperative delirium easily in geriatric patients with esophageal cancer (EC).

Methods

Patients aged ≥70 years old with EC were retrospectively included who received an operation at National Center for Global Health and Medicine from February 2016 to November 2019. The fTRST were administered to all patients. To evaluate objectively, Yamaguchi University Mental Disorder Scale (YDS), one of the famous exams to assess the patient’s cognitive function, were also performed. The impaired were defined as fTRST ≥2 and YDS ≤ 12. We evaluated postoperative delirium and compared the fTRST with YDS.

Results

Overall, 40 patients were included. Median age was 76 years (range, 70 to 89 years), and 37 patients (85%) were male. Twenty-three patients (58%) were fTRST impaired, 6 patients (15%) were YDS impaired. 21 patients (52%) had postoperative delirium. The abnormal fTRST (p = 0.001) and YDS (p = 0.02) were both at risk for postoperative delirium. In multivariable analysis, the abnormal fTRST was significantly associated with postoperative delirium (OR 5.96; CI 1.33–26.7, p = 0.02).

Conclusion

The fTRST is useful tools to predict postoperative delirium and prior to YDS in elderly patients with EC. Further studies are needed to design interventions to prevent postoperative delirium for those vulnerable patients.
294 LONG TERM OUTCOMES OF THORACOSCOPIC-ASSISTED OESOPHAGECTOMY FOR EARLY OESOPHAGEAL CANCER
Authors: Frankel A , Lamb P , Deans C , McDonald A , Couper G
Published: September 2020

Oesophageal cancer is the 9th most common cancer in Scotland, yet is ranked 5th for cancer mortality. This is in part due to most new patients presenting with locally-advanced or metastatic disease. Early disease is often found during Barrett's surveillance or serendipitously. There is a paucity of literature describing the outcomes of patients who undergo resection for early disease in Europe, particularly morbidity, actual five-year survival rate, recurrence patterns and ultimate causes of death.

Methods

Data for fifty consecutive patients from the Royal Infirmary Edinburgh (RIE) with cN0 disease who underwent thoracoscopically-assisted McKeown (three-stage) oesophagectomy between 2005 and 2013 were recorded in a prospectively-maintained database. 20/50 were in a formal endoscopic surveillance program for Barrett’s oesophagus. Endoscopic ultrasound (EUS) became widely used at RIE in 2007 with the introduction of an endoscopic mucosal resection service, with 39/40 patients operated on since 2007 undergoing pre-operative EUS.

Results

Median age was 67 (range 46–81) with 34 males and 16 females. 44 had ≤pT1b, while 48 patients were pN0 (median node yield of 12). There were 4 anastomotic leaks, 4 recurrent laryngeal nerve palsies and 2 tracheo-oesophageal fistulas. There was one in-hospital death secondary to intra-operative and post-operative myocardial infarctions. As of January 2020, 16/50 patients had died, with a median survival of 9 years; five year survival was approximately 85%. 5 patients died of metastatic disease (1.3 to 6.8 years post-resection). 10 patients died of other causes, the most common being alcoholic liver disease (n = 3).

Conclusion

Patients in this case series received high quality surgery and peri-operative care, and survival rates were high. This dataset demonstrates that a holistic approach to healthcare is vitally important in the long-term care of such a cohort, because most deaths were not related to their cancer. This should be kept in mind when counselling patients with early disease and when liaising with their primary care provider.
349 LAPAROSCOPIC MANAGEMENT OF ACHALASIA CARDIA IN CHILDREN
Authors: Haravu Ramprasad K , Agarwal P
Published: September 2020

Achalasia Cardia is a rare motility disorder of esophagus and is characterized by increased pressure of Lower Esophageal Sphincter (LES) and reduced motility of the body. This results in functional obstruction and failure of relaxation of LES. This condition is relatively rare in young children (about 0.11/100,000 children)

Methods

A retrospective study was done on 16 Paediatric patients with Achalasia Cardia over a 9 year period from 2010–2018. All patients underwent Barium Swallow and also upper GI endoscopy. Among the 16 patients, 8 of the patients underwent CT scanning and 6 patients had undergone manometry which is the gold standard method for diagnosis. Laparoscopic Heller’s Cardiomyotomy is the primary treatment modality for Achalasia Cardia. All patients underwent Cardiomyotomy along with Anterior Dor Fundoplication. Of the 16 patients, 6 had undergone Pneumatic Dilation previously.

Results

Of the 16 patients, 14 underwent Laparoscopic Heller’s Cardiomyotomy and 2 had open surgery. There were no intraoperative or postoperative complications. Normal feeds were started after 24 hours and the feeds were well tolerated. All the patients had complete resolution of dysphagia with score reducing from 4 to 0. All of them were discharged within 2–3 days.

Conclusion

Laparoscopic Heller’s Cardiomyotomy is the gold standard treatment for treating Achalasia Cardia. It is a safe, successful and efficient treatment modality for children with Achalasia Cardia due to shorter hospital stay, lower complication rates due to increased level of expertise and immediate and long lasting symptomatic relief.
356 DIVERTICULECTOMY WITH EXTEND MYOTOMY AND ANTERIOR FUNDOPLICATION AS TREATMENT OF INTRATHORACIC ESOPHAGEAL DIVERTICULUM. CASE REPORT AND REVIEW!
Authors: Szachnowicz S , Lopes L , Fernandes F , Edno Tales B , Sallum R , Cecconello I
Published: September 2020

Diverticula of the thoracic esophagus are uncommon disorders and its most appropriate treatment continues unclear. The majority of these diverticula are results of underlying esophageal motility disorders, but some cases are results of periesophageal inflammation. The patients can be asymptomatic, or present dysphagia, regurgitation, aspirated pneumonia, retrosternal pain and weight loss. The barium esophagogram is considered the best study to show and evaluate these cases. Esophageal manometry allow study the esophageal motility abnormality.

Methods

Patients with small and asymptomatic diverticula could not require any treatment. Patients with symptomatic or big diverticula should be submitted a diverticulectomy and often with an esophageal myotomy. However the necessity, the esophageal extension and local of the myotomy are still unclear. We describe a case of a 70 yo woman with a intrathoracic esophageal diverticulum. She presented progressive dysphagia to solids in the last two years, associated to regurgitation, retrosternal pain, nausea and weight loss of 10 kilograms. She has no history of aspirated pneumonia.

Results

The upper GI endoscopy showed the diverticulum in middle esophagus (25 cm from superior dental arch) and the size in barium esophagogram was 6,5 x 4,8 cm. The high resolution esophageal manometry was normal and the patient had no tuberculosis history. She was submitted a thoracoscopic diverticulectomy with extend myotomy (intrathoracic and abdominal) and Dor’s fundoplication. She was able to resume a liquid diet by day 3, after a normal barium esophagogram, and was discharged at the 4 post-operative day. After 9 months the patient remains asymptomatic.

Conclusion

In our experience, the diverticulectomy associated with an extend myotomy bring excellent results at the esophageal function, allowing an adequate emptying of the esophagus, avoiding severe complications as mediastinitis or esophageal leakage even in patients without severe motility disorder.

References

1. Altorki N K, Sunagawa M, Skinner D B. Thoracic esophageal diverticula. Why is operation necessary? J Thorac Cardiovasc Surg 1993 Feb; 105(2): 260–4.

2. Rice T W, Baker M E. Midthoracic esophageal diverticula. Semin Thorac Cardiovasc Surg 1999 Oct; 11(4): 352–7.
363 MANAGEMENT OF COMPLEX ADVERSE EVENTS AFTER PARAESOPHAGEAL HERNIA REPAIR: EXPERIENCE OF A HIGH-VOLUME REFERRAL CENTRE
Authors: Antoun A , Karam A , Trépanier M , Cools-Lartigue J , Ferri L , Mueller C
Published: September 2020

Adverse events after paraesophageal hernia repair (PEHR), including persistent dysphagia, acute and delayed recurrence, and gastroesophageal perforation, can present complex management challenges. Medical, endoscopic and surgical treatments may be used, but descriptions of when to employ these options and how to choose a surgical approach (e.g. open vs laparoscopic, transabdominal vs transthoracic), are limited. We sought to review the treatment and outcome for complex adverse events after PEHR.

Methods

All patients undergoing primary (elective or emergency) and revisional repair of PEH at a high volume specialized referral center were identified. Demographic data, operative details and outcomes were verified by chart review. Extracted data included patient characteristics, incidence of adverse events, and diagnostic and management strategies. Details of endoscopic and surgical interventions for complex recurrences were tabulated.

Results

369 patients with PEHR were identified from 2012-19. Most (345:94%) underwent the index PEHR at our centre, with 24(6%) referred from other institutions for management of adverse events. Post-operative dysphagia requiring invasive intervention occurred in 27(7.3%), and 23(6.2%) required re-operation (19 laparoscopically). Gastric or esophageal perforations diagnosed post-operatively occurred in 11(3.0%), of which 8(72.7%) required emergency reoperation (1 laparoscopic, 2 laparotomy, 2 thoracotomy and 3 by combined abdominal/thoracic approach). Of 69 recurrences, 11 presented with incarceration requiring emergency surgery (8 repaired laparoscopically, 2 converted to laparotomy, and 2 required combined laparotomy/thoracotomy). One perioperative death occurred in this series.

Conclusion

Complex adverse events after PEH repair comprise a unique challenge given the wide variety of management options. When faced with these challenges, one should consider utilizing a customized surgical approach that varies with patient condition, anatomical characteristics of the complication and surgeon preference.
366 CLINICAL NOMOGRAM MODEL FOR RECURRENT LARYNGEAL NERVE LYMPH NODE METASTASIS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A RETROSPECTIVE MULTICENTER STUDY
Authors: Tian D , He X , Yang Y , Chen L
Published: September 2020

Recurrent laryngeal nerve lymph node metastasis (RLN LNM) is not rare in patients with esophageal cancer. We aimed to explore the risk factors for RLN LNM and to develop a nomogram predicting the likelihood of RLN LNM in esophageal squamous cell carcinoma (ESCC) patients.

Methods

We retrospectively reviewed patients with ESCC who underwent esophagectomy as well as recurrent laryngeal nerve lymph node dissection between May 2015 and February 2019 at two different institutions. The patients were divided into negative and positive groups according to the presence of RLN LNM. Risk factors for RLN LNM were evaluated by univariate and multivariate analyses. A nomogram was constructed for presentation of the final model.

Results

A total of 390 patients with ESCC were included in this study. The differences in tumor location, tumor differentiation, T stage, tumor size and carcinoembryonic antigen (CEA) between the negative (N = 270) and positive groups (N = 120) RLN LNM were significant (P < 0.05). Multivariate analysis indicated that the tumor location (OR = 0.520, 95% CI: 0.361–0.749, P < 0.001), tumor differentiation (OR = 2.279, 95% CI: 1.586–3.276, P < 0.001), T stage (OR = 1.436, 95% CI: 1.029–2.003, P = 0.033), tumor size (OR = 1.781, 95% CI: 1.021–3.106, P = 0.042) and CEA (OR = 1.206, 95% CI: 1.003–1.450, P = 0.046) were independent risk factors for RLN LNM. A nomogram with these variables had good predictive accuracy (c-index: 0.716).

Conclusion

Tumor location, tumor differentiation, T stage, tumor size and CEA may predict the risk of RLN LNM. We created a nomogram predicting the likelihood of RLN LNM in patients with ESCC.