bluuebunny/crossref_metadata_2025 huggingface dataset:
317. A NOVEL TECHNIQUE OF ‘SUPERCHARGED ELONGATED GASTRIC TUBE’ FOR THE MANAGEMENT OF CORROSIVE PHARYNGEAL STRICTURE
Authors: Dolma Tenzin
Published: August 2023

Oesophageal reconstruction using various visceral conduits is the preferred treatment for the management of dysphagia secondary to corrosive oesophageal strictures. In patients with isolated oesophageal stricture colon and stomach are the most commonly used visceral conduits. However, management of patients with long oesophageal strictures with proximal extent at the hypopharynx is even more complicated. A long replacement conduit is required and most are managed by colopharyngoplasty. The options in patients who lack an available functional colon for esophageal replacement are very limited and may include a combination of gastric pullup with interposition free jejuna or myocutaneous flaps. These operations are complex and often require a two-stage approach. We herein describe a novel single stage approach of using ‘supercharged elongated gastric tube’ for esophageal replacement in a patient with unavailable colon.
325. CAMRELIZUMAB IN COMBINATION WITH CHEMOTHERAPY VERSUS CHEMORADIOTHERAPY FOR THE CONVERSION OF UNRESECTABLE ESOPHAGEAL CARCINOMA: A PROSPECTIVE CLINICAL STUDY PROTOCOL
Authors: Chen Maohui , Zheng Bin , Huang Yizhou , Zhang Shuliang , Zeng Taidui , Ning Chenhui , Chen Chun
Published: August 2023

Background

Neoadjuvant chemoradiotherapy followed by esophagectomy is the standard of care for locally advanced esophageal squamous cell carcinoma (ESCC). However, approximately 30% of patients still develop distant metastases and have a high incidence of treatment-related adverse events. Immunotherapy, as a new modality for anti-cancer treatment, has shown promising clinical benefits for patients with ESCC. The synergistic effects of immunotherapy and radiotherapy make their combination promising as neoadjuvant treatment for locally advanced ESCC.

Methods

All participants who meet the inclusion criteria will be enrolled after signing the informed consent form. Patients with thoracic segment esophageal cancer with clinical stage T2–3 N0 M0 or T2–3 N+ M0 will be included. They will be treated with radical surgery within 4–8 weeks after the completion of two cycles of neoadjuvant radiotherapy in combination with camrelizumab according to the study schedule. The primary endpoint is the major pathological remission rate of all per-protocol patients. The secondary endpoints are the R0 resection rate, pathological complete remission rate, and adverse events. The interim analysis will be conducted after half of the planned number of patients have been enrolled. The trials will be terminated when more than two treatment-related deaths occur or fewer than five patients have major pathological remission.

Discussion

We designed this prospective single-arm phase II clinical study to evaluate the combination of camrelizumab and standard radiotherapy as preoperative neoadjuvant therapy for patients with resectable ESCC as part of the quest for better treatment options for patients with locally advanced ESCC.

Trial registration: This trial protocol has been registered on NIH Clinical Trials database (www.clinicaltrials.gov/, NCT05176002). The posted information will be updated as needed to reflect protocol amendments and study progress.
327. ANALYSING THE ROLE OF PET-CT IN ESOPHAGEAL CANCER: A SINGLE CENTRE COHORT STUDY
Authors: O'Neill Susan , Elliott Jessie , Fahey Niall , Mohan Helen , Carroll Paul , Muldoon Cian , Johnston Ciarán , Donohoe Claire , Ravi Narayanasamy , Reynolds John
Published: August 2023

Background

While PET-CT is considered the gold standard imaging investigation in diagnosing esophageal cancer, its role in determining management is controversial. It demonstrates increased sensitivity for detection of occult M1 disease in comparison with endosonography or CT alone, however its accuracy in assessment of histopathologic response to neoadjuvant therapy is unclear. The aim of this study was to evaluate the clinical utility of PET-CT in staging, response evaluation and prognostication in esophageal squamous cell carcinoma (SCC) and adenocarcinoma (AC).

Methods

Patients with esophageal cancer undergoing treatment with curative intent were studied prospectively. Baseline imaging (PET1) was carried out at diagnosis. Repeat scanning (PET2) was performed at 4 weeks post-completion of neoadjuvant chemotherapy (nCT) or chemoradiation (nCRT). Pathological complete response (pCR) was defined as TRG1, ypN0. Major pathologic response was defined as TRG1–2, ypN0. Metabolic complete response (mCR) was defined as absence of abnormal FDG uptake at the primary site, nodal sites or suspected metastatic sites. The association between 18F-FDG-uptake (SUVmax) and PET-predicted nodal status, histopathologic parameters and survival were determined using univariable and multivariable regression models.

Results

730 patients were studied. PET identified CT-occult M1 disease in 2.9% and synchronous neoplasms in 1.4%. The relative reduction in SUVmax was greater among patients treated with nCRT compared with nCT (P = 0.021). SUVmax correlated with pT stage among patients treated with primary surgery (P < 0.001), however 32.3% with AC and 15.8% with SCC who were predicted node negative were pN+. Post neoadjuvant therapy, PET parameters showed modest associations with mCR, but no parameter accurately predicted pCR. Among patients with mCR, 90.9% with AC post-nCT, 84.1% with AC post-nCRT and 54.8% with SCC post-nCRT had residual disease. Lower preoperative SUVmax was independently associated with improved survival in AC, but not SCC.

Conclusion

PET-CT identifies CT-occult M1 disease or synchronous neoplasms in 4.3% at initial staging. PET-CT poorly predicts ypN status, particularly in AC. After neoadjuvant therapy, PET-CT is poorly predictive of histopathologic response—the majority of patients with an mCR have residual disease. Nonetheless, improvements in SUVmax may reflect a greater chance of achieving major pathologic response and more favourable long-term outcomes in AC.
328. ENDOSCOPIC SUBMUCOSAL DISSECTION FOR SUPERFICIAL ESOPHAGEAL CARCINOMA INVOLVING THE ENTIRE ESOPHAGUS: SHORT-TERM RESULTS
Authors: Toshiro Iizuka , Noma Eriko , Moriguchi Yoshiaki
Published: August 2023

Background

The treatment of superficial esophageal carcinoma involving the entire esophagus remains challenging due to the difficulty in accurate preoperative diagnosis and the complexity of the Endoscopic Submucosal Dissection (ESD) technique. The management of esophageal stricture following ESD also remains controversial. In this study, we analyzed the advantages and disadvantages of ESD for superficial whole circumferential esophageal carcinoma in our hospital, based on short-term results.

Methods

We retrospectively analyzed 10 patients diagnosed with superficial esophageal carcinoma involving the entire circumference and treated with ESD from January 2021 to the present. We evaluated the accuracy of preoperative diagnosis, treatment-related complications of ESD, post-ESD stenosis, and adverse events associated with stenosis prophylaxis.

Treatment Course: The primary treatment consisted of circumferential resection under general anesthesia followed by local injection of 120–320 mg of steroids into the ulcer after resection. Patients were started on a diet 2–3 days after surgery and initiated oral steroid therapy starting with 30 mg with PPI and Sulfamethoxazole Trimethoprim. The dose of steroids was gradually reduced by 5 mg every 3 weeks for a total of 18 weeks.

Results

The study included 7 males and 3 females with a mean age of 72.9 years. The lesions were located in Upper 1, Middle 5, and Lower 4. The average dissection time was 89.1 minutes, the mean length of endoscopic longitudinal mucosal defects was 70 mm, and the en bloc resection rate was 100%. The histological depth was EP/LPM 5, MM/SM 13, and SM2 or deeper 2. The accuracy of preoperative diagnosis was 80%, but all SM2 lesions were underdiagnosed as SM1. No ESD-related adverse events were observed in any case. Two patients with SM2 after ESD underwent additional surgery. Stenosis occurred in 25% of cases. Steroid-related events included drug-induced liver dysfunction in 4 cases, esophageal candida in 2 cases, pulmonary tuberculosis in 1 case, and delayed perforation in 1 case.

Conclusion

ESD for superficial esophageal carcinoma involving the entire esophagus can be safely and effectively performed. Steroid administration may be useful for preventing post-ESD stenosis, but its management requires attention as it may cause adverse events.
330. PRE-EMPTIVE ENDOLUMINAL VACUUM THERAPY WITH A SURGICAL DRAIN FOR REDUCTION OF ANASTOMOTIC LEAK RATE FOLLOWING MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: Sivarajan Sri , Kulasegaran Suheelan , Penney Nicholas , Ari Kaso , Kumar Bhaskar , Sreedharan Loveena
Published: August 2023

Background

Endoluminal vacuum therapy (EVT) is an effective treatment for anastomotic leak (AL) following esophagectomy. A novel application of EVT is to utilise its effect to improve microcirculation and granulation at the anastomosis pre-emptively to reduce the risk of AL. We describe a unique method of positioning a fenestrated surgical drain with applied vacuum suction at the level of the anastomosis following minimally invasive esophagectomy (MIE), with the aim of reducing AL rate and postoperative morbidity.

Methods

A retrospective cohort comparison was performed on consecutive MIEs from 2019 to 2023. All operations were performed by experienced esophagogastric surgeons at a tertiary centre in the UK. Included patients were all adults undergoing MIE for esophageal cancer. Patients who underwent pre-emptive EVT (pEVT) with surgical drain following MIE were compared with a control group who underwent MIE alone. All patients followed the same enhanced recovery protocol with pEVT removed two to five days post-operatively. The primary outcome assessed was AL, secondary outcomes included: length of stay (LOS), readmission to Intensive care, complications (Clavien-Dindo) and 90-day mortality with minimum 90-days follow-up.

Results

72 patients were included, 25 patients underwent MIE with pEVT compared with 47 in the control. The AL rate in the pEVT group was 8% compared with 21.3% in the control (RRR 62%, p = 0.13). All ALs following pEVT were managed successfully with EVT alone. There was a reduced risk of aspiration pneumonia (RR:0.37, p = 0.22) and readmission to ICU (RR:0.24, p = 0.049) following pEVT. There was 0%, 90-day mortality in both groups and no significant difference in median LOS (7 vs 9 days, p = 0.72 (pEVT vs Control)). However, a higher risk of stricturing following pEVT was noted (RR:3.76, p = 0.04).

Conclusion

Our data suggests pEVT with a surgical drain may be a safe and effective method of reducing AL rate following MIE. Additionally, it confers the benefit of being an effective treatment for AL should this complication arise. There was significant increase in benign stricturing requiring dilatation following pEVT, however, this may be attributable to other operative factors. Our results support the need for further prospective studies such as a randomised controlled trial.
341. THE PREDICTION STRATEGY OF SUBMUCOSAL INVASION IN SUPERFICIAL BARRETT’S ADENOCARCINOMA BY THE COMBINATION OF HISTOLOGY IN BIOPSY AND MAGNIFYING ENDOSCOPY
Authors: Namikawa Ken , Fujisaki Junko , Kawachi Hiroshi
Published: August 2023

Background

Endoscopically predicting the depth of invasion of superficial Barrett’s esophageal adenocarcinoma (s-BEA) is important for choosing an appropriate treatment. This study aimed to evaluate the endoscopic and histopathological characteristics to diagnose s-BEA with submucosal invasion.

Methods

We retrospectively reviewed 105 tumors from 97 patients endoscopically and pathologically diagnosed with s-BEA in short-segment Barrett’s esophagus (SSBE) (60 lesions in 60 patients) and long-segment Barrett’s esophagus (LSBE) (45 lesions in 37 patients). One hundred five s-BEA lesions were classified into 60 intramucosal (pT1a) tumors and 45 submucosal (pT1b) tumors. Clinicopathological and endoscopic characteristics, including the histology in the biopsy specimens, were analyzed with comparison in pT1a vs pT1b tumors. The histology in the biopsy specimens was classified into two types such as the presence or absence of poorly differentiated component (PDC). Risk factors for submucosal invasion identified using univariate analysis were entered into a multivariate logistic regression analysis. Subsequently, the findings of magnifying endoscopy with narrow-band imaging (ME-NBI) were assessed to determine whether the poorly differentiated component (PDC) in the resected specimens can be identified or not.

Results

pT1b tumors showed significantly higher frequency than pT1a tumors in the following features: PDC in the biopsy specimens (21/45, 46.7%; vs 1/60, 1.7%; OR = 24.8), complex macroscopic type (33/45, 73.3%; vs 15/60, 25.0%; OR = 4.47), and tumor diameter > 20 mm (31/45, 68.9%; vs 13/60, 21.7%; OR = 4.40). In 87 tumors which were able to be evaluated for endoscopic findings with ME-NBI, 9 out of 11 tumors with corkscrew pattern or wavy micro-vessels showed PDC in the resected specimens. The sensitivity, specificity, and positive predicted value of these irregular vessels for predicting PDC in the resected specimens were 40.9%, 96.9%, and 81.8%, respectively.

Conclusion

PDC in the biopsy specimens, tumor diameter > 20 mm, and complex macroscopic type were independent predictors for submucosal invasion of BEA. The presence of PDC in the biopsy specimens was an especially useful predictor of T1b cancer with the highest odds. Further, ME-NBI can be useful to diagnose the presence of PDC in BEA.
350. FUNCTIONAL RESPONSES OF SWINE ESOPHAGUS TO FOCAL CRYOTHERAPY
Authors: Upchurch Weston , Iaizzo Paul
Published: August 2023

Barrett’s esophagus is a premalignant condition where the squamous epithelium of the distal esophagus is replaced by columnar epithelium. Treatment involves endoscopic resection followed by ablation for complete eradication. Various ablative techniques exist including cryotherapy which utilizes a cryogen spray or balloon catheter. While efficacious, complications such as dysphagia have been reported. To better understand the underlying mechanism of how cryotherapy might damage the muscularis, isolated muscle strips were ablated and their function studied.

Isolated muscle strips with the mucosa layers removed were prepared from freshly isolated swine esophagus and placed in tissue baths where they were electrically stimulated, and contractile forces were recorded. Contractile responses were allowed to stabilize before a given muscle strip was removed for focal ablation. Cryoablation was performed with a focal cardiac ablation catheter (Freezor, Medtronic). Following ablation, the given muscle strip was returned to the tissue baths. Regression analyses were performed using temperature data from a thermocouple integrated into the tip of the ablation catheter and contractile forces after the esophageal muscle strips had recovered for 3 hours.

Ablations lasting less than 60 seconds were applied to 135 esophageal muscle strips: with an average mass of 94 mg. From the experimental data, a multiple linear regression model was generated: 71.93 + 0.4770x—0.5530y = z, where x is the minimum temperature (C), y is the time below 0 C, and z is the contractile force (normalized to preablative force, %). Our model has an adjusted R-squared value of 0.508. As expected, lower minimum temperatures and longer treatment times were associated with greater losses in stimulated muscle forces.

We were able to reproducible ablate isolated swine esophageal strips that elicited contractile responses in vitro. Lower temperatures and longer treatment times were associated with greater losses in stimulated muscle forces. Yet, the adjusted R-squared value indicates that temperature and time only partially explain the response. Future studies could be improved by accounting for variabilities in sample sizes and additionally, regression diagnostics need to be performed to check for outliers and validate model assumptions.
358. CIRCULAR STAPLER METHOD FOR AVOIDING STRICTURE OF CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS, ‘NON-TENSIONING METHOD’
Authors: Shiraishi Osamu , Terada Masuhiro , Koda Masashi , Nakanishi Tomoya , Hagi Takaomi , Hiraki Yoko , Kato Hiroaki , Yasda Atsushi , Shinkai Masayuki , Imano Motohiro , Yasuda Takushi
Published: August 2023

Background

The weakness for the circular stapler technique of esophagogastric anastomosis for esophageal cancer is anastomotic stricture. This study was performed to verify the superiority of a new ‘non-tensioning method’ for avoiding stricture of the cervical esophagogastric anastomosis by circular stapling compared with the conventional method.

Methods

In 461 patients who underwent McKeown esophagectomy with gastric conduit (GC) reconstruction were reviewed. A GC was pulled up at the cervical site through the retrosternal route. The esophagogastrostomy site of the GC was planned as far caudally as possible on the greater curvature side. In the conventional method, the stapler was fired while pulling the GC to avoid tissue slack. In the new method, the stapler was fired through the natural thickness of the stomach wall. The blind end length was changed from 4 to 2 cm. Anastomotic stricture was compared between the two techniques, and adjustment was performed using propensity score matching.

Results

The conventional group comprised 315 patients, and the non-tensioning group comprised 146 patients. Anastomotic leakage occurred in 22 (7%) and 6 (4%) patients, respectively (P = 0.211) [and in 9 (3%) and 3 (2%) patients, respectively, if leakage at the blind end was excluded]. Anastomotic stricture occurred in 92 (29%) and 7 (5%) patients, respectively (P < 0.001). The propensity score-matching analysis including 134 pairs of patients confirmed a lower stricture rate in the non-tensioning than conventional group (4% vs. 27%, P < 0.001).

Conclusions

The non-tensioning technique, the natural thickness of the stomach wall was fired with the stapler, significantly reduced the incidence of anastomotic stricture compared with the conventional technique.
359. NFE2L2 MUTATIONS ARE PREDICTIVE AND PROGNOSTIC OF TREATMENT OUTCOME IN RESECTABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA PATIENTS
Authors: Ko Josephine , Guo Chen , Lo Anthony Wing-Ip , Tao Lihua , Law Simon , Lam Ka-On , Kwong Dora Lai-Wan , Wong Ian Yu-Hong , Wong Claudia Lai-Yin , Chan Siu-Yin , Chan Kwan-Kit , Law Tsz-Ting , Leung Alvin Ka-Kiu , Wong Carissa Wing-Yan , Dai Wei , Lung Maria Li
Published: August 2023

Background

The poor prognosis of resectable esophageal squamous cell carcinoma (ESCC) poses an unmet need to identify genomic early predictive and prognostic biomarkers to improve treatment outcome and risk stratification.

Methods

Retrospective targeted sequencing was performed on 80 ESCC formalin-fixed, paraffin-embedded (FFPE) tumor specimens from 37 good responders and 43 poor responders receiving neoadjuvant treatment. Somatic mutations and copy number variations (CNVs) were detected in 130 cancer druggable genes with TOMA Os-seq. Kaplan Meier curve and COX regression analysis were used to estimate the risk of relapse and survival.

Results

Twelve patients (12/80, 15%) with hot spot NFE2L2 mutations occurred with significantly higher frequency in poor responders (p = 0.0003) and in patients with non-complete pathological response (p = 0.007) in resectable ESCC treated by chemo-radiotherapy (CRT). These patients also had poorer prognosis with higher risk of death (HR = 1.942, p = 0.039) and relapse (HR = 1.817, p = 0.063) by COX analysis. The independent prognostic role of hot spot NFE2L2 mutations was validated by the presence of recurrent plasma cell-free (ct)-DNA NFE2L2 mutations in an independent prospective cohort of resectable ESCC patients.

Conclusions

In summary, our study now demonstrates the clinical usefulness of hot spot NFE2L2 mutations, as a potential predictive and prognostic biomarker associated with pre-surgery CRT responses, and provides novel insights for future therapeutic options targeting the NRF signaling in resectable ESCC treated by neoadjuvant CRT. The novel prognostic role of hot spot NFE2L2 mutations may be useful markers to guide clinicians for treatment decisions in resectable ESCC patients following pre-surgery treatment.
366. SARCOPENIA DECIDED FROM LOWER PSOAS MUSCLE INDEX IS STRONGLY POOR PROGNOSTIC FACTOR FOR ELDERLY ESOPHAGEAL CANCER PATIENTS
Authors: Ozawa Yohei , Taniyama Yusuke , Sato Chiaki , Okamoto Hiroshi , Ishida Hirotaka , Koseki Ken , Kanabuchi Sawa , Muranami Yuto , Fusegawa Kazuki , Kamei Takashi
Published: August 2023

Background

Elderly esophageal cancer patients undergoing esophagectomy are increasing. Although esophageal cancer patients suffering sarcopenia are already well known to have poor prognosis, the impact of sarcopenia for each age group may differ, since older patients have a higher frequency of primary sarcopenia than younger patients.

Methods

To clarify the relationship between sarcopenia and surgical outcomes in elderly esophageal cancer patients, we measured the psoas muscle index (PMI) in 103 elderly esophageal cancer patients aged 75 years or older who underwent radical esophagectomy from 2007 to 2021. The patients were then classified into two groups, sarcopenia group and non-sarcopenia group, using the 25th percentile of PMI as a cut-off value, and the relationship with outcomes of surgery and neoadjuvant chemotherapy (NAC) was examined.

Results

The 103 patients included 83 males and 20 females. The sarcopenia group had significantly lower BMI, but there was no correlation with oncological factors such as tumor depth or lymph node metastasis. NAC (FP) was performed in 39 patients and there was no clear correlation between completion, efficacy, or adverse events and sarcopenia. Thoracoscopic esophagectomy was performed in 93 patients, and there was no clear correlation between short-term surgical outcomes and sarcopenia. However, the 5-year overall survival and 5-year disease free survival were significantly lower in the sarcopenia group, resulted sarcopenia was an independent poor prognostic factor.

Conclusion

In elderly esophageal cancer patients over 75-year-old who underwent radical esophagectomy, sarcopenia does not significantly affect short-term surgical outcomes, and NAC is possibly able to administer as in the non-sarcopenia group. However, the indication of surgery to sarcopenic patients should be carefully decided because they have worse long-term prognosis than non-sarcopenic patients.
387. VARIATIONS IN THORACIC DUCT ANATOMY HIGHLIGHTED BY FLUORESCENCE IMAGING
Authors: Thammineedi Subramanyeshwar Rao , Patnaik Sujit Chayau , Syed Nusrath , Shukla Srijan
Published: August 2023

Chyle leaks are seen even after preserving or electively clipping the thoracic duct during esophagectomy. One of the reasons for this is the variations in the course, calibre and anatomy of thoracic duct. ICG Fluorescence navigation can highlight these variations and aid in enhancing the safety of esophageal surgery. This video demonstrates some variations of thoracic duct seen by ICG Fluorescence. Google drive link of the same copied below.

https://drive.google.com/file/d/1J5d2CoBb6HkvH9iaPQWnZvJGjXPm4bQ8/view?usp=share_link.
389. DEVELOPING A PROGNOSTICALLY SIGNIFICANT MORPHOLOGICAL CLASSIFICATION SYSTEM FOR ESOPHAGEAL ADENOCARCINOMA
Authors: Cotton James , Zyla Roman , Allison Frances , Bach Yvonne , Allen Jonathan , Darling Gail , Elimova Elena , Wilson Gavin , Yeung Jonathan , Kalimuthu Sangeetha
Published: August 2023

Background

Histologically, esophageal adenocarcinoma is broadly divided into two morphological subtypes: intestinal and diffuse types, with the latter conferring a worse prognosis. However, the present classification system does not account for morphological heterogeneity and the clinical and prognostic implications of this heterogeneity remains uncertain. This study focuses on elucidating the clinical and prognostic significance of the various EAC morphological patterns.

Methods

We identified surgical resection cases conducted at a single center from 2008 to the present date. All tumour-containing slides were analyzed, and the percentages of each morphological pattern was calculated. The overall percentage of each morphology was determined by summing across all tumour slides per case. Cases were stratified by neoadjuvant treatment status.

Results

This study reviewed 106 surgical resection cases. Seventy cases (58 male, 12 female, 59.26 +/− 11.12 years) received neoadjuvant treatment prior to surgery, while 36 cases (29 male, 7 female, 66.36 +/− 11.85 years) did not. A similar average slide number was obtained from treated versus untreated cases (10.13 +/− 7.43 slides vs 9.14 +/− 8.57, p = 0.5391). Morphological heterogeneity (i.e., 3+ morphologies occupying >10% of the tumor) was not different between treated and untreated cases (33% versus 24.2%, p = 0.35). Subgroup analysis revealed a significant increase in tumor morphological heterogeneity with poorer neoadjuvant treatment response (score 3) (p < 0.05).

Conclusions

To our knowledge, this is the first study investigating the clinical and prognostic implications of the heterogeneous morphological patterns observed in EAC. Our results suggest that tumours with poor response to neoadjuvant therapy are more likely to exhibit significant morphological heterogeneity. We are currently exploring whether specific morphological patterns are linked to adverse prognosis and poor response to neoadjuvant therapy. These findings have the potential to guide clinical decision-making in EAC.
398. THE HYBRID INTRA-THORACIC OESOPHAGO-GASTRIC ANASTOMOSIS—CONTEMPORARY PERFORMANCE WITH LOW BENIGN ANASTOMOTIC STRICTURE FORMATION
Authors: Joglekar Shantanu , Huynh An , Zhou Warren , Chong Lynn , Sayed-Hassen Akhtar , Hii Michael , Cade Richard
Published: August 2023

Background

The intra-thoracic linear stapled semi-mechanical anastomosis is associated with reduced rates of benign anastomotic stricture when compared with circular stapled and end-to-end hand-sewn methods.

The hybrid anastomosis is a modification of this. The hand-sewn posterior wall, extended with a stapler firing provides the theoretical advantage of increased luminal patency. It has been published as a single surgeon experience from our institutions (1993–2011), with low leak rate and stricture rate of ten percent. These patients largely underwent upfront surgery.

Methods

We assessed the performance of this hybrid anastomotic technique amongst multiple surgeons, in a contemporary setting with high use of neoadjuvant therapy, compared with the end-to-end hand-sewn anastomosis.

Patients undergoing open Ivor Lewis oesophagectomy over a 6 year period were identified using the prospective oesophagectomy database across two public hospitals. Chart review was used to compile data on anastomotic technique, reflux symptoms, PPI use and endoscopic dilatations.

Results

There were 80 patients, with minimum 12 month and mean 24 months follow up. 60 patients underwent hybrid anastomosis and 20 hand-sewn. Four surgeons oversaw more than 10 anastomoses. 70% of patients received neoadjuvant treatment. Four anastomotic leaks required intervention (5%).

Benign stricture formation requiring endoscopic dilatation was more common in the hand-sewn group (35%) compared with the hybrid group (12%) (p = 0.0061). All strictures were identified within 12 months. On multi-variate analysis, anastomotic leak, neoadjuvant therapy, smoking, diabetes and vascular comorbidities did not predict stricture formation.

Symptomatic reflux approached 50% in both groups, despite 89% long term PPI adherence.

Conclusion

We demonstrate that the hybrid anastomosis continues to achieve low rates of benign anastomotic stricture amongst multiple surgeons, even in the era of neoadjuvant therapy. Symptomatic reflux remains common after oesophagectomy, so PPI should be used long-term. Outcomes for both anastomoses compare to published standards. These results are relevant to consider when modifying techniques for minimally invasive anastomosis.
400. CONSTRUCTION OF A MODULAR SYSTEM OF ‘INFLATABLE SINGLE-INCISION MEDIASTINOSCOPY ESOPHAGECTOMY’ BASED ON FASCIA ANATOMY
Authors: Liangzhan Lv , Xiangfeng Gan , Qingdong Cao
Published: August 2023

Background

We improved Inflatable Single-Incision Mediastinoscopy esophagectomy to implement the simultaneous laparoscopic esophagectomy with inflatablesingle-Incision mediastinoscope and lymphadenectomy along bilateral recurrent laryngeal nerves under mediastinoscopy through a single left-neck incision and formed the concept of modular treatment of inflatable mediastinoscopic esophagectomy based on fascial anatomy which we can achieve standardized add programmed esophageal dissociation, greatly shorten the learning curve, make it easier to popularize and promote, and help us to control the operation time and complications.

Methods

According to anatomy of the periesophageal fascia we summarized six surgical modules, respectively is: To make the neck incision, dissociate posterior and left esophagus, dissociate anterior and right esophagus, lymphadenectomy along left recurrent laryngeal nerves, lymphadenectomy along right recurrent laryngeal nerves, dissect the Subcarinal lymph nodes. The clinical data of patients undergoing esophagectomy with inflatable single-pore mediastinoscope from February 2020 to February 2021 in our hospital were summarized and analyzed, and compared with the data of minimally invasive thoracic esophagectomy, in order to verify the clinical application effect of this modular system.

Results

In the validation study of modularization in this subject, no perioperative death was found in the 44 patients and the R0 resection rate was 100% confirmed by postoperative pathology. The average operation time was 204.9 ± 45.4 minutes, mean intraoperative blood loss was 64.6 ± 45.5 mL, average number of lymph nodes removed was 19.5 ± 9.1, average length of hospital stay was 27.0 ± 18.17 days, postoperative anastomotic fistula (2.27%), anastomotic stenosis (13.64%), chylous leakage (0%), pleural effusion (4.55%), and pulmonary infection (9.09%), better than the control group. The incidence of postoperative hoarseness (18.19%) which needed to be improved.

Conclusion

This standardized and modular surgical procedure description based on fascia anatomy is proposed for the first time for the esophagectomy under inflatable mediastinoscope, and is an exploration of the construction of a modular system for this surgical procedure. This modular system enables us to achieve standardized, programmed and rapid esophageal dissociation, which has good clinical application value.
402. LYMPH NODE METASTASIS MAPPING IN T1–2 ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Tian Dong , Nan Jin-Zhu , Jiang Kai-Yuan , Zheng Xiang-Yun , Chen Long-Qi
Published: August 2023

Background

Lymph node metastasis (LNM) is a crucial factor in predicting the prognosis of patients with T1–2 esophageal squamous cell carcinoma (ESCC), but the extent of lymph node (LN) dissection remains controversial. This study aims to investigate the optimal extent of LN dissection for T1–2 ESCC by analyzing the metastasis rate, evaluating the prognostic value at each LN station, and identifying risk factors for the LN stations with high LNM rate.

Methods

Patients with pathological T1–2 ESCC who underwent esophagectomy with LN dissection were enrolled between January 2014 and December 2019. Kaplan–Meier and Cox proportional hazards model were used to analyze the influence of LN with different metastasis rates on prognosis, respectively. The logistic regression analysis was performed to identify risk factors for the LN stations with high LNM rate.

Results

In total, 386 patients with T1–2 ESCC were included with a median LN dissection number of 18.5 (range: 12–48). The LN stations with LNM rate over 5% were the station 8 (11.9%), 2 (10.9%), 17 (8.0%), 16 (7.3%), and 7 (5.2%), and patients with metastasis of these stations showed significantly worse OS (P < 0.001). Moreover, the BMI (OR 0.45, 95%CI: 0.27–0.75, P < 0.01), tumor differentiation (OR 1.66, 95%CI: 1.14–2.42, P < 0.01), and T stage (OR 2.05, 95%CI: 1.21–3.47, P < 0.01) were independent risk factors of the metastasis of stations with LNM rate over 5%.

Conclusions

The poor prognosis of the metastasis of LN stations with LNM rate over 5% (station 8, 2, 17, 16, and 7) in T1–2 ESCC suggests the necessity of dissection, especially for patients with lower BMI, poor tumor differentiation, and deeper infiltration.
403. END-STAGE ACHALASIA: FEASIBILITY OF CARDIOMYOTOMY WITH ANTERIOR 90-DEGREE FUNDOPLICATION AS TREATMENT
Authors: Basu Pallavi , Ng Annalisa , Wong Andrew
Published: August 2023

Achalasia is a primary motor disorder of the oesophagus. End-stage achalasia is characterised by a grossly dilated sigmoid-shaped oesophagus with food stasis leading to chronic inflammation. Despite treatment, approximately 5% of patients progress to this late stage, needing oesophagectomy. Current guidelines recommend oesophagectomy as the last resort after failure of first-line endoscopic treatment or cardiomyotomy. We review a case of a 70 years old female with end-stage achalasia who successfully underwent cardiomyotomy but required a looser wrap for oesophageal emptying.

Patient first presented in her 50s with dysphagia and Oesophago-Gastro-Duodenoscopy (OGD) showed a dilated oesophagus with food stasis and no contractions. Barium swallow confirmed the diagnosis of achalasia. She underwent pneumatic dilatations with minimal symptom improvement and eventually defaulted follow-up. Several years later she presented with haematemesis due to severe oesophagitis and Eckardt score of 7. Both OGD and CT scans showed a grossly dilated megaoesophagus. High-resolution manometry confirmed Type I achalasia with IRP (integrated relaxation pressure) 25.8 and complete absence of peristalsis. She was initiated on nasogastric feeding and was also diagnosed with pulmonary embolism (PE).

In view of PE and patient’s comorbidities, she was not fit for oesophagectomy. Peroral endoscopic myotomy (POEM) was also deemed challenging in the presence of severe, chronic oesophagitis and patient’s need for anticoagulation with potential difficulty in endoscopic haemostasis. She underwent laparoscopic cardiomyotomy with anterior 180-degree fundoplication. However, post-operation contrast swallow showed hold up of contrast despite intraoperative OGD showing smooth passage of scope through LES. Decision was made for revision of fundoplication to anterior 90-degree to further promote oesophageal emptying. Post-operation contrast swallow showed satisfactory drainage into stomach and patient tolerated post-fundoplication diet regime.

This case illustrates the role of cardiomyotomy as first-line in patients with end-stage achalasia who are not fit for oesophagectomy. However, an anterior 180-degree fundoplication may not allow adequate drainage from a megaoesophagus and a less tight wrap should be considered in such cases. Post-operation, reported Eckardt score of our patient was 1 with no reflux symptoms, indicating marked alleviation of symptoms. Thus, cardiomyotomy with a lesser 90-degree fundoplication is feasible as first-line treatment in end-stage achalasia.
413. MANAGEMENT OF AORTO-ESOPHAGEAL FIFISTULA SECONDARY AFTER THORACIC ENDOVASCULAR AORTIC REPAIR
Authors: Tang Shoujun , Zhou Haining , Zhong Chuan
Published: August 2023

Background

Aorto-esophageal fifistula (AEF) is rare with highly fatal conditions and occurs most frequently secondary as a result of oesophageal malignancies, aortic aneurysms, thoracic trauma, and other thoracic surgerys. We evaluated the incidence of AEF after thoracic endovascular aortic repair (TEVAR), and investigated their clinical features, determinants, therapeutic options and results. Raising awareness and vigilance of AEF and developing individualized diagnosis and treatment measures are the key to improve the prognosis.

Methods

We conducted a voluntary survey in three centres with a thoracic endovascular programme.

Results

Of the patients who underwent TEVAR between 2010 and 2020,11/423 developed AEF. Aortic pseudoaneurysm was associated with the development of AEF among indications to TEVAR (P < 0.05). Besides, emergent and complicated procedures resulted in increased risk of AEF (P < 0.05). Five patients were treated conservatively, all of whom died within 30 days. Six patients underwent AEF surgical treatment, with a perioperative mortality of 33% (2/6). At a mean follow-up of 18.7 + 13.6 months, overall survival was 33% (2/6).

Conclusion

The incidence of AEF after TEVAR is not negligible and long-term follow-up is required especially for patients submitted to emergent and complicated procedures. Both surgical and endovascular treatment of AEF are associated with high mortality. However, once AEF develops, conservative treatment does not appear to be an optimal management. Timely operation has positive correlation with increase of long-term survival rate of patients.
419. PROGNOSTIC RELEVANCE OF METABOLIC RESPONSE TO NEOADJUVANT CHEMOTHERAPY FOR ADENOCARCINOMA OF THE ESOPHAGUS AND ESOPHAGOGASTRIC JUNCTION
Authors: Harustiak Tomas , Zemanova Milada , Fencl Pavel , Lischke Robert
Published: August 2023

Background

The prognostic value of the metabolic response to neoadjuvant therapy in patients with adenocarcinoma of the esophagus and esophagogastric junction (EAC) remains controversial. The aim of our single-center prospective trial was to evaluate the association of metabolic tumor and nodal response, as measured by 18F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT), with disease-free survival (DFS) in patient with EAC treated with neoadjuvant chemotherapy (NAC) followed by surgery.

Methods

Following the PET response criteria in solid tumors (PERCIST 1.0), PET/CT was performed before and after the third cycle of triplet NAC (epirubicine, cisplatina and 5-fluorouracil or capecitabine). The relative changes of the maximum, peak and mean standardized uptake value (ΔSULmax, ΔSULpeak, ΔSULmean), metabolic tumor volume (ΔMTV) and total leasion glycolysis (ΔTLG) in the primary tumor and ΔSULmax in the regional lymph nodes were analyzed in terms of prediction of DFS using Cox regression analysis.

Results

Some 94 patients with surgical resection were included between 2009 and 2015. Of the tumor metabolic response parameters, only ΔTLG and ΔMTV were associated with survival. Stepwise cutoff analysis found ΔTLG≥45% best predicted DFS (HR 0.25, p = 0.0018). Persistens of FDG-avidity of lymph nodes after NAC was associated with worse DFS (HR 2.63, p < 0.001). Multivariable analysis of preoperative variables (baseline characteristics and metabolic response) showed that only tumor ΔTLG≥45% and post-NAC nodal FDG-avidity were predictors of DFS. In the final multivariable model including postoperative variables, pN-stage and post-NAC nodal FDG-avidity remained the only independent variables associated with DFS.

Conclusion

ΔTLG is the most optimal metabolic parameter reflecting the response to NAC in the primary tumor, however it did not independently predict DFS after surgery. The complete metabolic response in the lymph nodes after NAC independently predicted the prognosis.
421. UNVEILING THE COMPLEXITY—DISSECTION OF 106 LYMPH NODES IN ESOPHAGEAL CANCER
Authors: Fonseca Filipa , Cabral Francisco , Ramos Paulo , Monteiro Cecília , Abecasis Nuno , Casaca Rui
Published: August 2023

https://drive.google.com/file/d/1mKXEdCEEyOmzHo0bWJoRs4qAUDpr3LAk/view

Background

Surgical resection with thoracic lymphadenectomy is currently the sole curative option for treating non-cervical esophageal cancer. While a minimally invasive approach can achieve an efficient lymphadenectomy with reduced morbidity, its intricate and complex technical nature has limited its routine utilization in many centers. We aim to present a step-by-step approach to thoracoscopic thoracic lymphadenectomy.

Methods

Our upper gastrointestinal unit has developed multiple training protocols to create an optimal learning environment that aims to enhance surgical comprehension. Video coaching is a fundamental component of this learning environment, effectively demonstrating and deconstructing intricate surgical procedures. In recognition of the importance of minimally invasive thoracic lymphadenectomy, we have developed a video that is now incorporated into our existing curriculum. The video coaching and debriefing process enables us to continuously refine and optimize our training protocols, ultimately reducing the learning curve.

Results

We present a video showcasing a systematic and minimally invasive approach to total thoracic lymphadenectomy. This video offers a comprehensive overview of the key anatomical landmarks that require identification during the procedure, the sequential steps involved, and the critical pitfalls. Additionally, it provides valuable insights into the recognition of these landmarks and emphasizes the significance of 3D visualization of the ganglionic station for a better understanding of this procedure. Furthermore, the long-form video presentation will include additional correlation with the patient’s CT scans for a more in-depth comprehension of the procedure.

Conclusion

In high-volume centers that utilize a standardized technique, thoracoscopic total thoracic lymphadenectomy for esophageal cancer can be performed in a safe and reproducible manner with minimal morbidity. The use of a minimally invasive approach not only provides optimal anatomical visualization but also facilitates video revision and debriefing of the surgeries, ultimately improving the understanding of this complex surgical procedure.
422. LAPAROSCOPIC TOUPET FUNDOPLICATION EVALUATION FOR GASTROESOPHAGEAL REFLUX DISEASE SHORT AND LONG-THERM FOLLOW-UP: A COHORT STUDY
Authors: Lisboa Fernando Freire , Oliveira Cruz Gabriel Carvalho , Souza Cordeiro Emerson Renê
Published: August 2023

Background

Gastroesophageal Reflux Disease (GERD) is one of the most important disorders of the gastrointestinal system, affecting 20% to 40% of the population of the United States of America. There are several surgical techniques for treating this disease, including the Toupet Fundoplication technique, which reduce the postoperative complications, like dysphagia, Gas Bloating Syndrome and incapacity to belch.

Methods

Prospective cohort study with 138 patients in two hospitals, one public and the other private, in the city of Natal, Brazil. All patients were evaluated postoperative as the following: 1) first week after the surgery were interviewed by the master surgeon; 2) fifty days after surgery were submitted to a Barium Swallow; 3) three months after the surgery the endoscopy was performed. The follow-up was carried out in relation to the symptom of postoperative dysphagia, ability to belch, feeling of fullness and gastroesophageal reflux.

Results

A total of 140 patients were observed, who were admitted for the Toupet Fundoplication procedure. Of this total, 74 patients were followed-up. 68 patients had improvement of symptoms related to esophageal disease and are clinically satisfied. 6 patients had recurrence of reflux symptoms. One patient still doesn’t belch. One patient had Gas Bloating Syndrome.

Conclusion

Toupet Fundoplication was a standard procedure in the study and achieved good results in 91,89% of the cases followed during follow-up of GERD control and relief symptoms with a minimal rate of adverse effects in the postoperative period.
430. MAPPING OF LYMPH NODE METASTASIS FROM ESCC AFTER NEOADJUVANT TREATMENT: A PROSPECTIVE ANALYSIS FROM A HIGH-VOLUME INSTITUTION IN CHINA
Authors: Zhang Hanlu , Chen Long-Qi , Wang Yun
Published: August 2023

Objective

The aim of the study was to describe the prevalence of lymph node metastases per lymph node station for esophageal squamous cell carcinoma (ESCC) after neoadjuvant treatment.

Methods

Clinicopathological variables of ESCC patients were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. Two-field lymphadenectomy was routinely performed and an extensive three-field lymphadenectomy was performed if cervical lymph nodes metastasis were suspected. Lymph node stations according to AJCC 8 were separately investigated. Percentage of patients with lymph node metastases was defined as number of patients with metastatic lymph nodes/number of patients with lymph node dissection of this station. Data is also separately analyzed according to pathological response of the primary tumor, pretreatment tumor length and tumor location.

Results

Between January 2019 and March 2023, 623 patients who underwent neoadjuvant therapy followed by transthoracic esophagectomy were enrolled (Table 1–1). Lymph node metastases were found in 215 patients (34.5%) and most frequently seen in lymph nodes along the right recurrent nerve (10.1%, 58/575), paracardial station (11.4%, 67/587) and lymph nodes along the left gastric artery (10.9%, 65/597). For patients with pretreatment tumor length > 4 cm and non-PCR of primary tumor, the metastatic rate of right lower cervical paratracheal lymph nodes is 10.9% (10/92) and 10.6% (11/104), respectively (Table 1–2). For patients with an upper thoracic tumor, metastatic lymph nodes were most frequently seen along the right recurrent nerve (14.2%, 8/56). For patients with a middle thoracic tumor, metastatic lymph nodes were most frequently seen in the right lower cervical paratracheal lymph nodes (10.3%, 8/78), paracardial lymph nodes (10.2%, 29/285) and lymph nodes along the left gastric artery (10.4%, 30/289). For patients with a lower thoracic tumor, metastatic lymph nodes were most frequently seen in paracardial station (14.2%, 35/247) and lymph nodes along the left gastric artery (13.1%, 33/252) (Table 1–3).

Conclusion

The study accurately identified the distribution of lymph node metastases from ESCC after neoadjuvant treatment, which may contribute to guide the optimal extent of lymphadenectomy in the surgical treatment of ESCC patients after neoadjuvant treatment.
433. INTRAOPERATIVE ICG-IMAGING AS A TOOL TO ASSESS PERFUSION IN THE GASTRIC CONDUIT
Authors: Niska Karoliina
Published: August 2023

Background

In curative surgery for esophageal cancer a gastric conduit is often used to replace the resected esophagus. Anastomotic leakage (AL) is a serious complication. Sufficient perfusion in the gastric conduit is critical for the anastomosis. The aim of this pilot study was to investigate the feasibility of intraoperative indocyanine green (ICG) and near-infrared fluorescent imaging as a tool to assess perfusion of the gastric conduit in order to prevent postoperative AL.

Methods

Patients undergoing esophageal resection at Umeå University Hospital were invited to participate in this prospective study during 2017–2022. The surgery performed was open Ivor-Lewis esophagectomy. ICG was administered intraoperatively and video footage of the near-infrared fluorescence was recorded. The time from injection until visualized fluorescence in the gastric conduit was measured, as well as the intensity of the fluorescence in the gastric conduit. A loop of jejunum was used as control and the quotient between the measurement in the jejunal loop and in the gastric conduit was used for objective assessment.

Results

50 individuals were included. 46 patients had received neoadjuvant chemoradiotherapy and 3 had received chemotherapy only. 32 patients had video footages that were possible to assess as described above. Of these 11 had AL. No differences were demonstrated between patients with AL and those without, neither regarding time to fluorescence (p = 0.42), nor intensity (p = 0.72).

Conclusion

AL is a serious complication to esophageal surgery with a high incidence. Perfusion assessment of the gastric conduit using ICG has emerged as a promising technique to reduce AL. In this pilot study we developed two techniques to evaluate the perfusion in an objective manner, whilst none of these seem to be able to predict postoperative AL.