bluuebunny/crossref_metadata_2025 huggingface dataset:
249. CLINICAL IMPLICATIONS OF CHYLE LEAKAGE FOLLOWING ESOPHAGECTOMY
Authors: Henckens Sofie , Schafrat Pascale , Hagens Eliza , Eshuis Wietse , Gisbertz Suzanne , Laméris Wytze , van Berge Henegouwen Mark
Published: September 2022

For esophageal malignancies, leading oncological centers advocate transthoracic esophagectomy, including routine en-bloc resection of the thoracic duct for adequate mediastinal lymphadenectomy. However, as a result of injury to the main thoracic duct or its collateral branches during resection, this can lead to chyle leakage. The short-term clinical consequences of chyle leakage following esophagectomy are underexposed. The aim of this study was to investigate the clinical implications of chyle leakage following esophagectomy.

This retrospective study of prospectively collected data included patients who underwent transthoracic esophagectomy in 2017–2020. Routinely, the thoracic duct was resected en-bloc as part of the mediastinal lymphadenectomy. Chyle leakage was defined as milky drain fluid for which specific treatment was initiated and/or a triglyceride level in drain fluid of ≥1.13 mmol/l, according to the Esophagectomy Complications Consensus Group classification. Primary endpoints were the clinical characteristics of chyle leakage (type, severity and treatment). Secondary endpoints were the impact of chyle leakage on duration of thoracic drainage and hospital stay.

Chyle leakage was present in 43/314 included patients (14%); of whom 24 (56%) were classified as severity A and 19 (44%) as severity B. All patients were successfully treated with either medium chain triglyceride diet (98%) or total parental feeding (2%). There were no re-interventions for chyle leakage during initial admission, although one patient needed additional pleural drainage during re-admission. Patients with chyle leakage had 3 days longer duration of thoracic drainage (bias corrected accelerated (BCa) 95%CI: 0.46–0.76) and 3 days longer hospital stay (BCa 95%CI: 0.07–0.36), independently of the presence of other complications.

Chyle leakage is a frequently occurring complication following esophagectomy with resection of the thoracic duct and extensive lymphadenectomy, with substantial clinical consequences. Even though non-surgical treatment was successful in all patients with chyle leakage in this series, chyle leakage impeded postoperative recovery. Future research should focus on reducing the incidence of chyle leakage after esophageal surgery.
250. PROGNOSTIC FACTORS ASSOCIATED WITH 18FDG-PET/CT IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA AFTER TRIMODALITY TREATMENT
Authors: Feng Wei-Hsiang , Chen Ying Yi , Kuo Yen Shou , Lin Kuan Hsun , Tsai Yuan Ming , Wu Ti Hui , Huang Hsu Kai , Huang Tsai Wang
Published: September 2022

Patients with locally advanced and potentially curable esophageal cancer (EC) should receive trimodality treatment, which involves neoadjuvant concurrent chemoradiotherapy (nCRT) followed by esophagectomy. The maximum standard uptake value (SUVmax) in SUV of 18FDG-PET/CT have been reported to be useful in predicting the prognosis of EC patients treated with nCRT and subsequent esophagectomy. We aimed to determine the pathological response in patients with EC after trimodality therapy and to investigate the prognostic factors associated with SUVmax.

This was a retrospective study of patients with locally advanced esophageal squamous cell carcinoma who received nCRT followed by esophagectomy between January 2011 and December 2018 at the Tri-Service General Hospital in Taipei, Taiwan. Survival analysis was performed using the Kaplan–Meier method and the Cox proportional hazards model. Univariate and multivariate analyses were used to determine the independent prognostic factors.

A total of 79 patients with esophageal cancer underwent esophagectomy, and 50 of them were enrolled in the study. Among the 50 patients enrolled, 18 had a pCR. A post-nCRT maximum standard uptake value (SUVmax) ≥ 3 was a poor prognostic factor associated with OS (hazard ratio [HR]: 3.665, P = 0.013) and PFS (HR: 3.417, P = 0.011). Poor prognosis was found in patients with pCR and a post-nCRT SUVmax ≥3 as compared with those with pathological partial response and a post-nCRT SUVmax <3.

SUVmax ≥3 is a poor prognostic factor in ESCC after trimodality treatment, even in patients with pCR.
256. LOCAL CONTROL OF HEPATIC/PULMONARY OLIGOMETASTASIS IS EFFECTIVE IN EGJ ADENOCARCINOMA
Authors: Imamura Yu , Kanie Yasukazu , Maruyama Suguru , Sakamoto Kei , Kuriyama Kengo , Okamura Akihiko , Kanamori Jun , Watanabe Masayuki
Published: September 2022

This study investigated the clinicopathological features of distant metastasis of esophagogastric junction (EGJ) adenocarcinoma. Survival benefit of local management was also examined in the patients with hepatic or pulmonary oligometastasis.

Among a total of 449 cases of Siewert type I-II surgically resected EGJ adenocarcinoma (2005–2020), 166 cases with distant metastasis were eligible.

Examining 22 cases with liver metastasis alone who treated in our hospital, liver-resected cases (N = 13) experienced better outcomes (mOS; 48 M for resection, vs. 8.1 M for those without resection, P = 0.0002). More favorable outcome was observed in the patients with 1–3 nodules (N = 11, P = 0.0023). Regarding lung metastasis alone, systemic chemotherapy was applied to bilateral multiple nodules, otherwise, local control including resection or stereotactic irradiation was selected. The mOS in the patients who underwent local control was significantly longer than that of chemotherapy (44 M for resection vs. 17 M for chemotherapy, P = 0.035).

Tumor location or histological type of the primary tumor was associated with organ sites of distant metastasis. Local management conferred survival benefit in the patients with oligometastasis in liver or lung alone.
258. OUR PROCEDURE OF RECONSTRUCTION DURING ESOPHAGEAL SURGERY
Authors: Tanaka Yoshihiro , Sato Yuta , Ohno Shinya , Asai Ryuichi , Endo Masahide
Published: September 2022

The incidence of anastomotic leakage in esophagectomy and reconstruction surgery is reported over 10%. We have used subtotal stomach (SS) for reconstruction.

We retrospectively examined the results of SS reconstruction, postoperative weight changes, and quality of life. We have used SNS to deal with postoperative dietary problems. We also have devised a method for combined oral nutritional supplementation by the conceot of ‘Taking a ONS along with the meal by knowing appetite: Tanaka Method.

400 cases. Anastomotic leakage was found in 2 cases (0.50%). Many cases of early feeling of fullness were observed at 3 months. The patients’ body weights, median [interquartile range], were as follows: pretreatment, 54.1 [48.9,59.9] Kg: 12 months postoperatively, 52.75[47.5–59.15] Kg: 36 months postoperatively, 52.55[47.35–59.2] Kg: 60 months postoperatively, 51.2 [46.25,58.45] Kg.

SS reconstruction seems to be feasible.
261. MALNUTRITION DEFINED BY GLIM CRITERIA ASSOCIATES WITH INCREASED RISK OF ADVERSE OUTCOME AFTER OESOPHAGO-GASTRIC CANCER SURGERY
Authors: Murnane Lisa , Adrienne Forsyth , Koukounaras Jim , Kalai Shaw , Wendy Brown , Audrey Tierney , Burton Paul
Published: September 2022

Low muscle mass is associated with postoperative complications after oesophago-gastric (OG) cancer surgery, but data demonstrating a negative impact on long-term survival is limited. Clinical tools to accurately stratify risk based on nutritional status would be of considerable value. The Global Leadership Initiative on Malnutrition (GLIM) is a consensus framework for diagnosing malnutrition. We aimed to assess the prevalence of malnutrition defined by GLIM and the impact on postoperative outcomes after OG cancer surgery.

Patients who underwent radical OG cancer surgery with preoperative abdominal computed tomography (CT) imaging were included. Retrospective collection of preoperative data identified malnutrition using the GLIM definition. The phenotypic criterion includes body mass index (BMI), unintentional weight loss, and muscle mass. All patients had a malignant disease and met the aetiologic criterion of an inflammatory condition. Nutrition status was categorised as no malnutrition, mild–moderate, and severe. Malnutrition diagnosis was assessed against oncological, surgical, and survival data. Low skeletal muscle index (cm2/m2) measured by CT was determined using predefined cut-points.1 Cox regression analysis determined predictors of overall survival.

One-hundred and eight patients were included. Malnutrition using GLIM criteria was present in 72% of patients (n = 78), including mild–moderate (n = 45) and severe malnutrition (n = 33). The predominant phenotypic criterion for GLIM malnutrition was low muscle mass (n = 66, 61%), followed by preoperative weight loss (n = 46, 43%) and low BMI (n = 11, 10%). Malnutrition was associated with postoperative pneumonia (26.9% vs 6.7% well-nourished, p = 0.010). Severe malnutrition was associated with poorer 5-year overall survival (p = 0.022) (Figure 1) and, along with stage 4 disease, higher age, and severe postoperative complications, remained an independent predictor of survival after multivariate analysis (OR 2.51, 95% CI 1.20–5.24, p = 0.014).

Malnutrition defined by GLIM is highly prevalent and is associated with postoperative pneumonia. Severe malnutrition is an independent predictor of poorer overall survival. Muscle mass is a key phenotypic GLIM criterion, and the GLIM diagnostic framework is potentially a practical and valuable component of preoperative risk stratification in OG cancer surgery.
265. SIGNIFICANCE OF AGR2 IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Konishi Hirotaka , Takabatake Kazuya , Kataoka Satoshi , Shibamoto Jun , Furuke Hirotaka , Shiozaki Atsushi , Fujiwara Hitoshi , Otsuji Eigo
Published: September 2022

Anterior gradient 2 (AGR2) promotes tumor growth and make a worse prognosis in several cancers, especially in adenocarcinoma. However, comprehensive functional analysis of AGR2 in esophageal squamous cell carcinoma (ESCC) has not been reported.

In the present study, the functional analysis and clinical significance of AGR2 were examined using ESCC cell lines and clinical samples.

AGR2 was upregulated in ESCC cell lines and ESCC tissue sample. The downregulation of AGR2 suppressed cell proliferation and increased the proportion of G2/M-phase cells. Furthermore, phosphorylation of p53 in TP53-wild-type ESCC and osteosarcoma cells was also promoted. However, these changes were not observed in TP53-mutant ESCC cells. Immunohistochemistry results showed that high AGR2 and low p53 expression in ESCC tissue was correlated with a worse prognosis. These results suggest that although AGR2 enhances cell proliferation by inhibiting p53 phosphorylation in TP53-wild-type ESCC, the same mechanism does not regulate cell functions in TP53-mutant ESCC due to suppression of TP-53 function.

In conclusion, AGR2 plays an important role in ESCC progression and might be a useful prognostic marker in patients with TP53-wild-type ESCC.
266. EXTENSION OF FDG-PET-BASED RADIOMIC MODELS ON IDENTIFICATION OF PATIENTS WITH RESIDUAL ESOPHAGEAL CANCER AFTER NEOADJUVANT CHEMORADIOTHERAPY
Authors: Valkema Maria Joanna , Beukinga Roelof , Chatterjee Avishek , Woodruff Henry , van Klaveren David , Noordzij Walter , Valkema Roelf , Bennink Roel , Roef Mark , Schreurs Wendy , Doukas Michail , Lagarde Sjoerd , Wijnhoven Bas , Lambin Philippe , Plukker John , van Lanschot Jan
Published: September 2022

For esophageal cancer patients, detection of residual tumor after neoadjuvant chemoradiotherapy (nCRT) is important for guiding treatment decisions regarding standard esophagectomy or active surveillance. Prediction models incorporating clinical variables and FDG-PET quantitative radiomic features have been previously developed in a single-center setting (‘development cohort’, Beukinga et al. 2018) to identify patients with residual tumor after nCRT. The aim was to improve generalizability by redeveloping the models (i.e. ‘model extension’) using a multicenter prospectively acquired cohort.

The development cohort was combined with a patient cohort collected from a prospective multicenter study in four Dutch institutes. Patients underwent nCRT according to the CROSS regimen followed by esophagectomy 6–14 weeks after nCRT between 2013–2019. Outcome was tumor regression grade (TRG) 1–2 (0–10% tumor) vs TRG 3–4 (>10% tumor). FDG-PET/CT was performed 6–12 weeks after nCRT. Post-treatment FDG-PET-radiomic features were calculated from gross tumor volumes. Features were standardized per scanner. A bootstrapped least absolute shrinkage and selection (LASSO) model using clinical variables and radiomic features was developed and a model incorporating clinical variables was developed for reference.

Some 262 patients were included. Median age was 65 years (IQR 60–70), 158 of 262 were male (82%) and outcomes were 129/262 TRG 1–2 (49%) and 133/262 TRG 3–4 (51%). The extended LASSO model included seven radiomic features and the clinical variables cT stage and histology (internally validated AUC, 0.59). At a probability threshold to obtain 90% sensitivity for detection of TRG 3–4 (benchmark with bite-on-bite biopsies + fine-needle aspiration of suspected lymph nodes), specificity was 36% and accuracy 63%. A LASSO clinical reference model (including cT, sex, histology) achieved an internally validated AUC of 0.58 (Fig. 1).

The extended internally validated LASSO model incorporating post-treatment radiomic features and clinical variables yielded moderate discriminative ability. The improvement in predictive performance with this model compared with a model using only clinical variables was marginal. The application of radiomics to post-treatment FDG-PET/CT scans is of no help in decision-making in individual patients regarding the choice for active surveillance after nCRT.
274. AUTOMATED SURGICAL STEP RECOGNITION FOR ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY USING ARTIFICIAL INTELLIGENCE
Authors: Takeuchi Masashi , Kawakubo Hirofumi , Matsuda Satoru , Kitagawa Yuko
Published: September 2022

More robot-assisted minimally invasive esophagectomy (RAMIE) procedures have been performed owing to three-dimensional field of view, image stabilization, and flexible joint function, however, both the surgeon, and surgical team require proficiency. Therefore, assessing the surgical learning curve and determining the surgical difficulty are essential for reducing complications. This study aimed to establish an artificial intelligence (AI)-based automated surgical phase recognition system for RAMIE by analyzing robotic surgical videos and evaluate the learning curve.

This study enrolled 31 patients who underwent RAMIE. We annotated the videos into the following nine surgical phases, namely preparation, lower mediastinal dissection, upper mediastinal dissection, azygos vein division, subcarinal lymph node dissection (LND), right recurrent laryngeal nerve (RLN) LND, left RLN LND, esophageal transection, and post-dissection to completion of surgery to train the AI for automated phase recognition. We divided all patients into two groups, namely early period (20 patients) and late period (11 patients), after which the relationship between the surgical phase duration and learning curve was assessed.

Frames were extracted from each video at a rate of one frame per second (fps), with an average of 14517 ± 4770 frames per video, which were used to train and test the AI model. Four-fold cross validation was applied to evaluate the performance of the present model. The AI had an accuracy of 84%. The preparation (p = 0.012), post-dissection to completion of surgery (p = 0.003), and ‘no step’ (p < 0.001) phases predicted by the AI were significant shorter in the late period than in the early period.

We established an automated surgical phase recognition system for RAMIE using deep learning. Specific phase durations were significantly associated with surgeons’ learning curve, and similar tendencies were observed on phase durations predicated by the AI. Our AI-based system can be useful for not only education or OR efficiency but also evaluating surgical skill.
288. ASSOCIATION BETWEEN ENDOGENOUS SUBTYPE CLASSIFICATION FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA AND OUTCOME OF CHEMORADIOTHERAPY
Authors: Yano Tomonori , Amanuma Yusuke , Minashi Keiko , Komatsu Masayuki , Nagashima Kengo , Shimizu Juko , Ishihara Ryu , Watanabe Akinori , Yamatsuji Tomoki , Matsushima Kayoko , Doyama Hisashi , Ando Takayuki , Nishimura Yasumasa , Sasaki Hiroki , Muto Manabu
Published: September 2022

Chemoradiotherapy (CRT) is a treatment option for esophageal squamous cell carcinoma (ESCC) and prognosis of patients achieved complete response is good. However, we cannot predict the outcome of the CRT before treatment. In previous single center study, RNA expression analysis using biopsy samples of 274 ESCC patients before CRT identified endogenous subtype classification. E type (high expression of squamous epithelial markers) showed good prognosis and M2 type (high expression of mesenchymal markers) did poor prognosis.

We conducted a prospective multicenter study to confirm the association between molecular subtyping and outcome of CRT. From January 2015 to July 2016, we prospectively recruited 226 patients from 10 hospitals in Japan.

This study was approved by the institutional review board at each hospital, and we obtained written informed consent from all patients (UMIN000016141). Biopsy samples were obtained before treatment, and molecular subtyping was performed. Treatment was selected by each physician. Clinical outcome of the patients treated by CRT was investigated according to the molecular subtype.

Among 226 patients, two patients withdrew the content. We could identify the subtype classification in all 224 patients. Fifty-seven patients (25.4%) were classified to E type and 56 (25.0%) to M2 type. In 224 patients, 97 received treatment include CRT (77: CRT alone, 16: induction chemotherapy followed by CRT, 4: CRT followed by surgery). The proportion of patients alive at 5 years was 48.8% (95% CI 28.0-66.7%) in E type, and 29.8% (95% CI 12.4-49.6%) in M2 type. The patients in E type showed better prognosis although it was not significant statistically (HR 0.5; 95% CI 0.23-1.09; p = 0.08).

This prospective multicenter study could show the usefulness of molecular subtyping of ESCC to predict the outcome of CRT.
289. PRIMARY MONOPHASIC SYNOVIAL SARCOMA OF THE CERVICAL ESOPHAGUS CONFIRMED BY DETECTION OF THE SS18-SSX2 FUSION TRANSCRIPTS
Authors: Tada Nobuhiro , Sasaki Ken , Tsuruda Yusuke , Shimonosono Masataka , Noda Masahiro , Uchikado Yasuto , Okumura Hiroshi , Omoto Itaru , Natsugoe Shoji
Published: September 2022

Synovial sarcoma (SS) of the esophagus is extremely rare. Because of the microscopic features of SS, the monophasic type can easily be misdiagnosed as other spindle cell tumors. Here, we present the first case of a primary SS of the esophagus in the presence of SS18-SSX2 fusion transcripts.

A 47-year-old Japanese woman was initially diagnosed with thyroid papillary carcinoma in the left lobe and leiomyoma of the cervical esophagus and subsequently underwent left thyroid lobectomy and enucleation of the esophageal tumor. Four years after the first surgery, the esophageal tumor recurred. Endoscopic biopsy of the tumor revealed atypical cell proliferation with spindle cell features and mitoses. Immunohistochemistry showed focal positivity for bcl-2 and HHF35. Furthermore, the presence of SS18-SSX2 fusion transcripts was confirmed by reverse transcription-polymerase chain reaction analysis, using a paraffin-embedded tumor specimen. Therefore, the tumor was diagnosed as monophasic SS of the cervical esophagus.

We re evaluated the surgical specimen enucleated 3 years previously, which was initially diagnosed as leiomyoma, and the diagnosis of SS was confirmed. The patient underwent cervical esophagectomy with isolated jejunal interposition reconstruction. Three years after the second surgery, SS recurred in the distal anastomotic site between the jejunum and the esophagus, and the patient underwent thoracoscopic esophagectomy with gastric conduit reconstruction. The pathological grade of the lesion worsened with every recurrence.

Monophasic SS can be difficult to discriminate from other spindle cell tumors based on microscopy alone, and molecular analysis could be useful for confirming the precise diagnosis of monophasic SS.
290. ANALYTIC MORPHOMIC INDEX AND QUANTITATIVE GASTRIC PERFUSION ASSESSMENT FOR RISK STRATIFICATION OF ANASTOMOTIC LEAKS FOLLOWING ESOPHAGECTOMY
Authors: Ishikawa Yoshitaka , Hider Ahmad , Zhang Peng , Askar Brandon , Haveric Arman , Brandser Andrew , Lagisetty Kiran , Wakeam Elliot , Lynch William , Enchakalody Binu , Sullivan June , Orringer Mark , Chang Andrew , Wang Stewart , Reddy Rishindra , Lin Jules
Published: September 2022

Sarcopenia, a reduction in muscle mass, has been considered a preoperative risk factor for complications after esophagectomy while impaired perfusion of the gastric conduit has been associated with anastomotic leaks. The aim of this study was to stratify patients by their risk of anastomotic leak following esophagectomy using morphomic factors and quantitative assessment of gastric conduit perfusion.

Patients who underwent an esophagectomy with a cervical anastomosis and gastric conduit from 2015–2021 were included. Preoperative CT scans were processed using semiautomated algorithms (MATLAB; MathWorks, MA). Indocyanine green perfusion was assessed intraoperatively (SPY elite; Stryker, MI). Sarcopenia was defined using skeletal muscle area (Martin’s criteria). Decreased subcutaneous fat, decreased bone mineral density, and impaired conduit perfusion were defined as below the cutoff value from the ROC curve. The morphomic index was determined using the number of decreased morphomic factors present (0–3). The Fisher exact test, the Mann–Whitney U test, and multivariable logistic regression were used to make statistical comparisons.

140 patients with both perfusion and morphomic data were evaluated (Leak n = 27; No leak n = 113). Decreased subcutaneous fat, decreased bone mineral density, and impaired gastric conduit perfusion were associated with an anastomotic leak (p = 0.041, 0.017, and 0.010). Neoadjuvant chemoradiation was significantly more common in the leak group (p = 0.048). On multivariable analysis, a higher morphomic Index and impaired gastric perfusion were risk factors for anastomotic leak. The incidence of anastomotic leaks with a high morphomic index (2 or 3) and impaired gastric perfusion was 40.6% compared to 9.4% with a low morphomic index and without impaired gastric perfusion (p = 0.006).

Impaired gastric conduit perfusion and decreased preoperative subcutaneous fat area, bone mineral density, and skeletal muscle area, likely surrogates for increased frailty and poor nutritional status, were associated with an increased risk of anastomotic leaks especially when multiple morphomic factors were simultaneously decreased. These findings may be useful in risk stratification and intraoperative decision making in patients undergoing esophagectomy.
295. BILATERAL VOCAL CORD PARALYSIS AFTER HYPOPHARYNGEAL CERVICAL ESOPHAGEAL ESD—AN UNRECOGNISED RARE COMPLICATION
Authors: Yip Hon Chi , Chiu Philip Wai Yan , Chan Jason Ying Kuen
Published: September 2022

This is a video showing ESD performed for recurrent early cervical esophageal squamous cell carcinoma in close proximity to the pharynx. The procedure was completed smoothly with en-bloc resection. However, patient developed vocal cord paralysis requiring temporary tracheostomy. It is postulated that vocal cord paralysis was caused by posterior cricoarytenoid muscle injury. This important muscle is the only laryngeal muscle that opens the vocal folds, and will lead to potential airway compromise if injured. There hasn’t been any report of vocal cord paralysis after cervical esophageal ESD, and this case illustrates that this potentially lethal complication should not be overlooked.
297. ESOPHAGECTOMY IN ELDERLY PATIENTS WITH ESOPHAGEAL CANCER: A FIVE-YEAR EXPERIENCE FROM A CANCER CENTRE IN NORTH-EAST INDIA
Authors: Das Gaurav , Talukdar Abhijit
Published: September 2022

North-East India has a high incidence of esophageal cancer. An elderly patient with esophageal cancer often has multiple comorbidities and compromised general condition and so, esophagectomy in this population is associated with more morbidity and mortality. Our objectives were to estimate the 30-day morbidity and mortality and estimate the disease-free and overall survival and recurrence patterns.

Retrospective, observational single institute study. We included all patients with age ≥ 60 years with a proven diagnosis of esophageal cancer and who underwent an esophagectomy during the study period from 1st January 2016 to 31st December 2020. Data was collected from patient’s records and the results were presented using median values, range and percentages.

There were 35 patients; median age was 65 years (range 60 to 76 years). Neoadjuvant chemotherapy (40.0%) was used more than chemoradiation (31.4%). Procedures included trans-thoracic esophagectomy (68.6%), trans-hiatal esophagectomy (25.7%) and left thoraco-abdominal approach (5.7%). 30-day mortality rate was 8.6% (aMI, COVID pneumonia and ARDS). 30-day morbidity rate was 40%, with pulmonary (25.7%), hoarseness of voice (17.1%), anastomotic leak (14.3%), wound infection (11.4%), symptomatic cardiac arrhythmias (5.7%) and septicaemia (2.9%) being part of the spectrum. 8.5% had locoregional recurrence and 5.7% had distant recurrence (peritoneum, bones and liver). Median overall survival was 33 months (range 9 to 43 months).

Esophagectomy in elderly patients carry a high risk of 30-day morbidity and mortality, but has acceptable overall survival.
298. COMPLIANCE FOR TRIMODALITY TREATMENT OF LOCALLY ADVANCED ESOPHAGEAL CANCER: EXPERIENCE FROM A CANCER CENTRE IN NORTH-EAST INDIA
Authors: Das Gaurav , Sarma Gautam , Roy Partha
Published: September 2022

Neoadjuvant chemoradiation (NACRT) is a standard approach for treatment of locally advanced esophageal cancer. In real-world scenario, there are several challenges to the completion of such treatment. We aim to estimate the completion rates of such treatment and also estimate the treatment response.

Retrospective, observation single-institute study. Study duration was from 1st June 2018 to 30th June 2021. Data was collected from patient’s records and results were presented in median values, range and percentages.

A total of 82 patients were planned for trimodality treatment in the Joint Tumour Board during the study period. The number of patients who completed the NACRT was 55 (67.1%). Of them, 11 (13.4%) defaulted by not undergoing esophagectomy and 4 patients (4.9%) had inoperable disease at surgery. A total of 42 patients (51.2% of intention to treat population) actually completed the trimodality treatment. Trans-thoracic esophagectomy was done in 35 and transhiatal esophagectomy in 7 patients. Complete pathological response of both the primary and the nodes (pCR) was noted in 12 patients (26.1%).

The compliance for trimodality treatment approach is a key area for improvement in esophageal cancer treatment and we need to decrease ‘drop outs’ due to temporary symptom relief, remoteness of residence, financial hurdles, treatment toxicity with an efficient system of care delivery.
301. LONG TERM RESULTS OF SINGLE AND MULTI-INCISION MINIMALLY INVASIVE ESOPHAGECTOMY (MIE) FOR TREATING ESOPHAGEAL CANCER: A PROPENSITY SCORE MATCHED STUDY
Authors: Chen Yung-Hsin , Lee Jang-Ming
Published: September 2022

Minimally invasive esophagectomy (MIE) is widely accepted as the standard treatment for esophageal cancer. It provides similar oncological outcomes with less pain and morbidity compared to open surgery. We first described MIE with single-incision both in the laparoscopic and thoracoscopic phase in 2015. Compared to multi-portal approach, short-term result showed comparable perioperative outcome with significantly reduced pain after surgery. With accumulated clinical experience, we compared our long-term follow-up result for single-incision MIE versus multi-incision MIE.

Patients with esophageal cancer, receiving MIE at our institute from 2008 to 2022 were included. 337 patients underwent single-incision MIE, while 467 patients received multi-incision MIE. Matching based on propensity scores produced 290 patients in each group.

The baseline characteristics between the two groups were similar after matching. Overall survival (OS) and progression free survival (PFS) were not compromised in single-incision MIE compared to multiple-incision MIE (5-year OS: 42.9% vs. 21.2%, p < 0.001; 5-year PFS: 35.1% vs. 17.1%, p < 0.001). The operation time was shorter (505.7 min vs. 562.4 min, p < 0.001). Single-incision MIE had larger mean number of dissected lymph nodes (45.6 vs 37.4, p < 0.001). There were no significant differences between the two groups in terms of short-term complications (single vs multi: 20.3% vs 15.9%, p = 0.196) and R1/2 rate (single vs multi: 11.5% vs 9.0%, p = 0.340).

Single-incision MIE is safe, feasible and effective for patients with esophageal cancer. Its long-term oncological outcomes are not compromised when compared to multiple-incision MIE, while its short-term perioperative outcomes are comparable to multi-incision approach. Three-dimensional imaging may play a role in higher quality oncological resection with more lymphatic clearance for single-incision MIE compared to multiple-incision MIE.
305. SURVIVAL DIFFERENCES ACCORDING TO THE PATHOLOGIC STATUS AFTER NEOADJUVANT THERAPY FOLLOWED BY SURGERY IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Park Seong Yong , Jeon Yeong Jeong , Lee Junghee , Ho Jong , Choi Yong Soo , Zo Jae Il , Shim Young Mog , Kim Hong Kwan
Published: September 2022

This retrospective study was performed to investigate the survival differences according to the pathologic status after neoadjuvant concurrent chemoradiotherapy (CCRT) followed by surgery in esophageal squamous cell carcinoma (ESCC).

The data of 507 patients who received the neoadjuvant CCRT and esophagectomy for ESCC between 2003 and 2018 were retrospectively reviewed. The mean age was 62.28 ± 8.07 and 473 (93.3%) were male patients. The median follow-up period was 29.24 months (interquartile range: 16.57–49.95 months). 144 (28.4%) patients showed pathologic complete response (ypCR) and 90 (17.8%) patients showed ypCR of primary lesion with residual metastatic lymph nodes (ypT0N+). 107 (33.5%) and 103 (20.3%) patients showed ypT + N+ and ypT + N0, respectively.

In patients with residual metastatic lymph nodes, the numbers of metastatic lymph nodes were 1(112, 22.1%), 2(49, 9.7%) and more than 3(100, 19.7%). The 5-year overall survivals (OS) of each group were 71.1%(ypCR), 47.9%(ypT + N0), 51.8%(ypT0N+) and 27.1%(ypT + N+); ypCR patients showed better survival than others and there were no survival differences in 5-year OS between ypT + N0 and ypT0N+ patients (p = 0.811). ypT + N+ patients showed more common locoregional and distant metastasis. The 5-year freedom from distant metastasis were different according to pathologic status; 83.1%(ypCR), 69.4%(ypT + N0), 59.1%(ypT0N+) and 44.6%(ypT + N+). The numbers of residual metastatic lymph nodes were related to the distant metastasis (HR1.083, p < 0.001) ypCR offers long-term survival in patients without nodal metastases, but the survival significantly deteriorates with the presence of residual primary lesion and nodal metastases. Follow-up strategies and indication of additional postoperative therapy could be guided according to the pathologic status after neoadjuvant CCRT followed by surgery.
308. RIGHT TOP PULMONARY VEIN IS A VENOUS ANOMALY OF WHICH SURGEONS SHOULD BE AWARE IN SUBCARINAL DISSECTION FOR RADICAL ESOPHAGECTOMY
Authors: Sato Yuta , Tanaka Yoshihiro , Ohno Shinya , Endo Masahide , Yoshida Kazuhiro
Published: September 2022

A right top pulmonary vein (RTPV) that crosses behind the right bronchus, is a variation of the superior posterior pulmonary vein in the right upper lobe. Damage of this vessel can lead to intraoperative bleeding, congestion of the posterior segment of the right upper lobe, and cardiac tamponade. Subcarinal lymph node dissection is mandatory in radical esophagectomy for esophageal cancer, and the RTPV is an anomalous vessel of which surgeons should be aware.

A 70-year-old man underwent thoracoscopic esophagectomy for esophageal cancer (T3N1M0). An anomaly of the superior posterior pulmonary vein in the right lobe was recognized on preoperative computed tomography imaging. With simulation and intraoperative navigation using three-dimensional imaging (SYNAPSE VINCENT, Fuji Photo Film Co., Ltd, Tokyo, Japan) of the same view as that observed during the operation, radical subcarinal dissection could be performed with preservation of the RTPV.

Only 5 case reports have described the association of RTPV in esophagectomy. In review of the literature, the incidence of RTPV ranged from 0.28 to 9.3%, and its mean vascular diameter ranged from 7.0 mm to 2.2 mm, with the right superior pulmonary vein being a common inflow site. Our case in which the RTPV ran dorsal to the right main bronchus is very rare. In radical subcarinal dissection of esophagectomy in cases with RTPV, it is important to recognize the posterior pericardial plane and release the ventral fixation of these lymph nodes to free space for the back side.

Based on our review of the relevant literature, an RTPV larger than 4.5 mm should be noted in order to prevent injury and ligation should be avoided. The preoperative recognition of this abnormal vessel using 3D imaging was very useful for radical SCLN dissection during thoracoscopic esophagectomy.
316. OMISSION OF ROUTINE PYLORIC PROCEDURES IN MINIMALLY INVASIVE ESOPHAGECTOMY: WHAT IS THE IMPACT ON PERI-OPERATIVE OUTCOMES?
Authors: Bolger Jarlath , Lau Harry , Yeung Jonathan , Darling Gail
Published: September 2022

Pyloroplasty or pyloromyotomy is often undertaken during esophagectomy to improve conduit function and potentially reduce complications. Minimally invasive esophagectomy (MIE) frequently omits a pyloric procedure. The impact on peri-operative outcomes and the need for subsequent interventions on the pylorus are unclear. This study assesses the requirements for endoscopic balloon dilation of the pylorus (EPD) following MIE.

Patients undergoing MIE from 2016–2020 were reviewed. Patients undergoing hybrid or open resection, or an intraoperative pyloric procedure were excluded. Demographic, clinical, and pathological data were reviewed. Data on the need for post-operative EPD in the short- and long-term settings were recorded. Univariable and multivariable analysis were performed as appropriate.

171 patients underwent MIE. There were no differences in age (p = 0.6), stage (p = 0.10) or ASA status (p = 0.52) between those requiring and not requiring EPD. Forty-three patients (25%) required EPD. Twenty-seven patients (16%) had EPD on their index admission. Seventy-five patients (43%) had a post-operative complication. There was a correlation between complications and the requirement for EPD both on the index admission (p < 0.001) and subsequently (p < 0.001). On multivariable analysis, there was no association between EPD and overall survival (p = 0.14). Eight patients (5%) required insertion of a feeding jejunostomy. Two patients underwent surgical pyloromyotomy for delayed gastric emptying.

Although pyloroplasty or pyloromyotomy can safely be excluded during MIE, a quarter of patients will require post-operative EPD procedures, for delayed gastric emptying or as part of management of post-operative complications. The impact of excluding pyloric procedures on gastric emptying requires further study.
319. SIGNIFICATIONS OF EXPRESSION OF TOLL-LIKE RECEPTORS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA CELLS
Authors: Sato Yusuke , Motoyama Satoru , Wakita Akiyuki , Nagaki Yushi , Fujita Hiromu , Kemuriyama Kohei , Sasamori Ryohei , Hayashi Kenjiro , Nozaki Syu , Minamiya Yoshihiro
Published: September 2022

Well known risk factors of Esophageal squamous cell carcinoma (ESCC) are habit of alcoholic drinking, smoking and poor diet. Moreover, recent reports showed that poor oral health is associated with upper aerodigestive tract malignancies including ESCC. We previously reported that among 232 ESCC patients who had preoperative assessment of oral function by dentist, about 70% of patients were diagnosed with periodontitis and about half of those patients were needed dental extraction.

Toll-like receptors (TLRs), a family of pattern recognition receptors, are able to recognize pathogen-associated molecular patterns (PAMPs) associated with a wide range of viruses, bacteria, fungi and parasites and thus play key roles in innate immune responses. Among these TLRs, TLR4 recognizes LPS, which construct the cell wall of gram-negative bacteria. Based on these findings, it is supposed that continuous exposure of LPS from gram-negative periodontal bacteria induces chronic inflammation caused by inflammatory cytokines from TLR4 signals, then carcinogenesis and progression of ESCC occurs.

Among these TLRs, TLR4 recognizes LPS, which construct the cell wall of gram-negative bacteria. We reported that ESCC patients who had higher TLR4 expression status in resected main tumor specimen showed significantly poor overall survival compared to lower patients after esophagectomy. (Sato Y, et al. Esophagus 2020) On the other hand, TLR3 recognizes dsRNA released form cell invading viruses. We previously reported that ESCC patients who had higher TLR3 expression status in resected main tumor specimen showed significantly better overall survival compared to lower patients after esophagectomy. (Sato Y, et al. Am J Surg. 2018).

Though TLR3 and TLR4 are in the same TLR family, those functional mechanism and relationships to prognosis in ESCC are totally different. Because TLR4 signaling is stimulatory on proliferative ability of ESCC, it is supposed that improvement of oral health inhibits carcinogenesis and progression of ESCC. On the other hand, because TLR3 signaling is suppressive, TLR3 agonist should be a possible candidate of therapeutic agent.
331. EFFECTIVENESS OF A SPECIALIZED AMINO ACID SUPPLEMENT CONTAINING CAHMB, L-ARGININE AND L-GLUTAMINE (ABOUND®) IN ESOPHAGEAL CANCER SURGERY
Authors: Takebayashi Katsushi , Kaida Sachiko , Yamaguchi Tsuyoshi , Otake Reiko , Miyake Toru , Kojima Masatsugu , Maehira Hiromitsu , Iida Hiroya , Tani Masaji
Published: September 2022

The wound healing effect of the specialized amino acid supplement containing CaHMB, L-arginine and L-glutamine (Abound®) has been reported. In this study, we evaluated the effectiveness of Abound® in patients with thoracic esophageal cancer in the perioperative period.

One hundred twenty-one patients who underwent esophagectomy for thoracic esophageal cancer between January 2013 and September 2021 were included. Among the 103 male and 18 female patients (median age 70 years, range 38-84 years) stage I disease was found in 41 patients, stage II in 17, stage III in 56, and stage IVa in 7. Postoperative infectious complications were evaluated between those patients who received Abound® for 7 days before surgery (n = 78) and those who did not (controls, n = 43).

The baseline characteristics between two groups were balanced. The postoperative infectious complications were follows: Anastomotic leakage occurred in 5 and 8 patients (6.4% vs 18.6%; p = 0.038) pneumonia occurred in 15 and 15 patients (19.2% vs 34.8%; p = 0.056), and wound infection occurred in 1 and 3 patients (1.2% vs 6.9%; p = 0.09) in the Abound® and control groups, respectively. The rate of anastomotic leakage was significantly lower in the Abound® group than that of control group. In anastomotic leakage cases, the treatment period was shorter in the Abound® group than that of control group: 18 (7-25) vs 25 (21-56) days; p = 0.033).

Abound® has the potential to reduce the incidence of infectious complications and shorten the treatment period for anastomotic leakage. Abound® may improve outcome following esophageal cancer surgery.
335. LONG TERM RISK FOR PROGRESSION TO NEOPLASIA FOR BARRETT’S ESOPHAGUS PATIENTS WITH VALIDATED LOW-GRADE DYSPLASIA OR INDEFINITE FOR DYSPLASIA
Authors: Elbe Peter , Öst Åke , Mellblom Lennart , Thorell Anders , Lundell Lars , Klevebro Fredrik , Lindblad Mats
Published: September 2022

Barrett’s esophagus (BE) with low-grade dysplasia (LGD) confirmed by two pathologists has a high risk of progression to high-grade dysplasia and cancer why ablation or more intense surveillance is recommended. Recent studies suggest that the progression risks for indefinite for dysplasia (IND) and LGD are similar, but the management guidelines are still different. We did a retrospective analysis to calculate the long-term risk for patients with verified LGD and IND.

All patients in the Ersta hospital BE-database in Stockholm who at least on one occasion during 1998 to 2012 were diagnosed with dysplasia. The first dysplastic specimen was re-evaluated by two highly experienced GI-pathologist. Clinical data was retrieved from the database and from patient medical records. Incidence rate (IR) was calculated for developing high-grade dysplasia (HGD) or cancer and IR ratio (IRR) was used as relative risk evaluation between the non-dysplastic Barrett’s Esophagus (NDBE) group and the LGD/IND groups and presented with 95% Confidence Intervals (CI).

Of 1180 patients with BE, 455 (39%) were diagnosed with dysplasia. 32 were excluded and 3 had HGD. Of the remaining 420 patients, 266 (63%) could be downgraded to NDBE, 82 (20%) were diagnosed as LGD and 71 (17%) as IND. Total follow-up was 4592 person years. The median follow-up time was 12 years. 34 patients developed neoplasia. The yearly IR for HGD or cancer among patients downgraded to NDBE was found to be 0,3% compared to 1,8% for LGD and 1,4% for IND. There was a five-fold increased risk of HGD or cancer among LGD/IND as compared to NDBE.

Patients with confirmed IND and LGD were found to have almost similarly elevated long-term risk for progression to neoplasia. Therefore, it seems reasonable that IND patients undergo the same surveillance regimen as non-treated LGD patients. Four patients (one with NDBE, two IND and one LGD) developed cancer more than 20 years after their initial BE diagnosis and therefore, it should be considered to keep BE patients in surveillance programs for a long period of time.
340. PROGNOSIS OF DIFFUSELY INFILTRATIVE ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Tamura Masahiro , Yoshimoto Yutaro , Yamauchi Suguru , Sugahara Yuuki , Yoshino Kohei , Ozaki Asako , Fujiwara Daisuke , Nasu Motomi , Hashiguchi Tadasuke , Hashimoto Takashi , Fukunaga Tetsu , Mine Shinji
Published: September 2022

Diffusely infiltrative esophageal squamous cell carcinoma is so rare that very few studies have been reported. Therefore, it has not been clear whether the survival of patients with this disease is poor or not. In this study, we retrospectively investigated our long-term results of radical esophagectomy for patients with diffusely infiltrative esophageal squamous cell carcinoma in our institution. In addition, we tried to detect prognostic factors of this disease if possible.

Data were retrospectively collected from medical records. Eligible patients underwent esophagectomy for esophageal squamous cell carcinoma with diffuse infiltration from 2002 to 2018 in our institution. Diagnosis of this disease was done in the conference of esophageal surgical team based on the findings of endoscopy and upper gastrointestinal series. Overall survival rates were calculated by the Kaplan–Meier method, and statistical significance was determined by the log-rank. P value of<0.05 was considered statistically significant.

32 patients were selected in this study. Median age was 66 years old, cStage I/II/III/IV was 0/10/14/8 patients respectively, preoperative treatment was undergone for 11 patients. 5-year overall survival (OS) rate was 27.3% and 3-year OS rate was 37.5%.

5-year OS rate for each cStage II/III/IV was 48.0%, 14.3% 25.0%. Patients who underwent preoperative treatment seemed to have poor prognosis with statistically significant difference. Patients with clinical or pathlogical supraclavicular lymph node metastasis tended to have poor prognosis.

In this study, about 20% patients could obtain long-term survival. Therefore, surgical intervention could be one of the treatments for the patient with this disease. And also, we may take into account the postoperative treatment for the patient with poor prognostic factor.
346. CUTOFF VALUE OF THORACOABDOMINAL PRESSURE GRADIENT FOR GASTROESOPHAGEAL REFLUX DISEASE ON STARLET HIGH-RESOLUTION MANOMETRY
Authors: Masuda Takahiro , Tsuboi Kazuto , Hoshino Masato , Yamamoto SeRyung , Akimoto Shunsuke , Tanishima Yuichiro , Uno Kohei , Hara Keigo , Takahashi Keita , Sakashita Yuki , Fukushima Naoko , Takeuchi Hideyuki , Sato Kazuhide , Omura Nobuo , Yano Fumiaki , Eto Ken
Published: September 2022

Derangement of thoracoabdominal pressure gradient (TAPG) associates with gastroesophageal reflux disease (GERD). High-resolution esophageal manometry (HRM) is the gold standard to assess pathophysiology of GERD. Starlet HRM is widely used in Japan; however, TAPG values on Starlet HRM system have been unstudied. The aim of this study is to propose the cutoff value of TAPG to discriminate GERD on Starlet HRM system.

We included patients who underwent both Starlet HRM and 24-hour multichannel intraluminal impedance pH study (MII-pH) at our hospital between July 2018 and February 2022. Patients were divided into 3 groups; control group (both HRM and MII-pH were within normal limits), GERD group (acid exposure time [AET] ≥4.0% and/or DeMeester score ≥ 14.72), and non-pathological reflux group. Normal MII-pH values were defined according to our previous study using healthy Japanese volunteers (Yano, et al. Esophagus, 2017); AET <2.5%, DeMeester score < 11, and liquid reflux episodes <80.0. TAPG and adjusted TAPG were analyzed (shown in Figure).

Total 102 patients met the study criteria (mean age 53.0 ± 16.0 years, 32 females). Thirty-four patients were categorized into the control group, 31 patients were into the GERD group, and 37 patients were into the non-pathological reflux group. In the control group, 5th and 95th percentiles of TAPG were − 3.4 and 24.3 mmHg, and those of adjusted TAPG were − 50.7 and 1.6 mmHg. TAPG poorly correlated with acid exposure time (AET) (rs = 0.287, p = 0.003); however, adjusted TAPG well-correlated with AET (rs = 0.505, p < 0.001). ROC analysis showed that the estimated cutoff of adjusted TAPG was −11.1 mmHg (sensitivity 71.0%, specificity 71.8%, AUC 0.742, p < 0.001).

Adjusted TAPG is associated with antireflux competency across the esophagogastric junction. Estimated cutoff value of adjusted TAPG was −11.1 mmHg in the study cohort. Further study is warrantied.