bluuebunny/crossref_metadata_2025 huggingface dataset:
563 VARIATION IN TREATMENT PATTERNS AND OUTCOMES FOR RESECTED ESOPHAGEAL CANCER AT DESIGNATED THORACIC SURGERY CENTERS
Authors: Gupta Vaibhav , Levy Jordan , Kidane Biniam , Mahar Alyson , Ringash Jolie , Sutradhar Rinku , Darling Gail , Coburn Natalie
Published: September 2021

Ontario defined designated thoracic surgery centres to provide high-volume care for patients undergoing esophageal cancer resection. The objective of this study was to compare thoracic centres’ performance to non-thoracic centres, and to assess variation in treatment patterns and outcomes across thoracic centres.

Methods

A retrospective cohort study (2002–2014) was conducted in Ontario, Canada (population 13.6 million), examining adults with resected esophageal cancer. Case mix, use of neoadjuvant therapy, surgical outcomes (lymph node yield and positive margin rates) and survival were described across the 15 thoracic centres. Multivariable regression was used to estimate the effect of having surgery at designated thoracic centres on postoperative (in-hospital & 90-day post-discharge) mortality and overall survival, adjusting for case mix.

Results

Of 3,880 patients meeting study criteria, 2,213 had pathology data available and were included in the analysis. Average age was 64 years, 85.7% had adenocarcinoma, 50.2% were pT3, and 38.4% were pN0. Patients at thoracic centres (82.6%) received more neoadjuvant therapy, but there was no difference in positive margin rates, lymph node harvest, postoperative mortality and overall survival between thoracic and non-thoracic centres. Across thoracic centres, rates of neoadjuvant therapy varied from 16.4–81.6%, positive margin rates varied from 8.2–29.6%, median lymph node harvest varied from 7–20 nodes, postoperative mortality varied from 0–18.7%, and median survival varied from 17–26 months.

Conclusion

There was significant variability in treatment patterns, surgical outcomes, and survival among patients treated at designated thoracic centres. Feedback of patient outcomes to surgeons and hospitals, and translating best practices from high-performing hospitals to other hospitals, is the next step in improving outcomes.
616 MULTIMODAL TREATMENT OF LOCALLY ADVANCED ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A NETWORK META-ANALYSIS
Authors: Jin Zixian , Chen Dong , Chen Meng , Ren Sijia , Wang Chunguo , Zhang Bo , Zhang Jian , Zhu Hongyu , Xue Fenglai , Wu Sikai , Zhu Chengchu , Shen Jianfei
Published: September 2021

The best treatment for the esophageal squamous cell carcinoma has not been determined. To determine the most effective and safest treatment mode for locally advanced resectable esophageal squamous cell carcinoma through a network meta-analysis.

Methods

A Bayesian model was used for a network meta-analysis comparing the efficacy and safety of surgery alone, neoadjuvant therapy, and adjuvant therapy.

Results

Overall survival rate: Adjuvant chemoradiotherapy and neoadjuvant chemoradiotherapy were significantly advantageous over surgery alone [hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.57–0.93; HR 0.75, 95%CI 0.65–0.86]. Adjuvant chemotherapy may not be as effective as surgery alone [HR 1.08, 95%CI 0.84–1.39], although there was no statistical difference. There was no statistically significant difference between adjuvant chemoradiotherapy and neoadjuvant chemoradiotherapy. Disease-free survival rate: Compared with surgery alone, neoadjuvant chemoradiotherapy had significant benefits [HR 0.65, 95%CI 0.53–0.78]; adjuvant chemoradiotherapy had similar, but not significant, benefits [HR 0.7, 0.95%CI 0.45–1.06]. The difference between neoadjuvant chemoradiotherapy and adjuvant chemoradiotherapy was also not statistically significant.

Conclusion

Both neoadjuvant chemoradiotherapy and adjuvant chemoradiotherapy appear to be the best supplements to surgery for locally advanced resectable esophageal squamous cell carcinoma.
618 STUDY ON THE RELATIONSHIP BETWEEN GASTROESOPHAGEAL REFLUX SYMPTOMS AND ESOPHAGEAL MICROBIOTA
Authors: Chen Songfeng , Zhang Mengyu , Zhuang Qianjun , Xiao Yinglian
Published: September 2021

The occurrence of gastroesophageal reflux symptoms is related to the changes of esophageal mucosal sensitivity and esophageal motility. Studies have found that changes in gut microbiota can cause lower digestive tract symptoms by changing intestinal sensitivity and intestinal motility. The current study aimed to explore whether changes of esophageal microbiota can cause gastroesophageal reflux symptoms by altering esophageal sensitivity and esophageal motility.

Methods

Patients who were admitted to our hospital due to heartburn and reflux symptoms were prospectively included. Ten healthy volunteers and 10 patients with duodenal ulcer were included as controls. Both patients’ and healthy volunteers’ distal esophagus mucosal tissues and gastric fluid were collected under endoscopy for extraction of bacterial DNA. Patients and volunteers were divided into different groups according to disease situations, esophageal motility status, proton pump inhibitor (PPI) treatment efficacy. The α-diversity, β-diversity and specific composition of the microbiota among different groups were compared.

Results

A total of 12 patients with gastroesophageal reflux disease (G), 16 patients with functional esophageal disorder (F), 10 healthy volunteers (H), and 10 duodenal ulcer patients (D) were included. Esophageal mucosal microbiota analysis revealed that the microbiota composition was similar in patients with gastroesophageal reflux disease and functional esophageal disorders, which significantly different from that in healthy volunteers and patients with duodenal ulcers. Both gastroesophageal reflux disease patients and functional esophageal disorder patients had higher proportion of Pseudomonas than healthy controls and duodenal ulcer patients (G vs. F vs. H vs. D = 25.5% vs. 41.9% vs. 0.2% vs. 1.2%；P = 0.041).

Conclusion

The microbiota composition of patients with gastroesophageal reflux disease and patients with functional esophageal disorder were similar and were both significantly different from that of healthy volunteers and patients with duodenal ulcer. The increased proportion of Gram-negative bacteria such as Pseudomonas may play an important role in the occurrence of gastroesophageal reflux symptoms.
626 ENDOSCOPIC VACUUM THERAPY FOR ANASTOMOTIC LEAK IN ESOPHAGECTOMY AND TOTAL GASTRECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Tavares Guilherme , Tustumi Francisco , Tristão Luca Schiliró , Serafim Maria Carolina Andrade , Orlandini Marina Feliciano , Datrino Letícia Nogueira , Santos Clara Lucato , Bernardo Wanderley Marques
Published: September 2021

One of the main complications related to esophagogastric surgery, due to esophageal and gastric cancer, is the anastomotic leak. The placement of endoluminal stents is the most frequent endoscopic therapy in these cases. However, since its introduction, endoscopic vacuum therapy has been shown to be a promising alternative. This study primarily aims to evaluate the efficacy and safety of endoscopic vacuum therapy for the treatment of anastomotic leak in esophagectomy and total gastrectomy.

Methods

A systematic review and meta-analysis was performed. Studies that evaluated the use of endoscopic vacuum therapy for anastomotic leak in esophagectomy and total gastrectomy were included.

Results

Twenty-three articles were included. A total of 559 patients were evaluated. Endoscopic vacuum therapy showed a fistulous orifice closure rate of 81.6% (rate: 0.816; 95% CI: 0.777–0.864) and, when compared to the stent, there is a 16% difference in favor of endoscopic vacuum therapy (risk difference [RD]: 0.16; 95% CI: 0.05–0.27). The risk for mortality in the endoscopic vacuum therapy was 10% lower than in endoluminal stent therapy (RD: −0.10; 95% CI: −0.18 to −0.02).

Conclusion

Endoscopic vacuum therapy might have a higher rate of fistulous orifice closure and a lower rate of mortality, compared to intraluminal stenting.
654 PHARYNGEAL POUCH SURGERY IN OCTO- AND NONAGENARIANS IS SAFE AND EFFECTIVE: A MULTICENTER COMPARATIVE COHORT STUDY
Authors: Liu David , Afzal Mohamed , Bright Tim , Watson David , Devitt Peter , Thompson Sarah
Published: September 2021

Surgery is the only effective treatment strategy for a symptomatic pharyngeal pouch. However, octo- and nonagenarians are often denied referral to a surgeon because of perceived increased risks. Here, we examine the perioperative outcomes of pharyngeal pouch surgery in octo- and nonagenarians in comparison to patients under 80 years-of-age.

Methods

Analysis of a prospectively maintained database of 113 patients (≥80 years-of-age: 27, <80 years-of-age: 86) who underwent pharyngeal pouch surgery across seven hospitals from 1 January 2006 to 30 September 2020.

Results

Patients ≥80 years-of-age had comparable operative time, complication profile, intensive care admission, emergency reoperation, and revisional surgery as their younger counterparts. The severity of complications was not significantly different between the two age groups. No surgical mortality was recorded. Multivariate analysis demonstrated that diverticulectomy combined with cricopharyngeal myotomy independently predicted higher rates of complications (OR: 4.53, 95% CI: 1.43-14.33, p = 0.010), but also greater symptomatic improvement (OR: 4.36, 95% CI: 1.50-12.67, p = 0.007). Importantly, a greater proportion of octo- and nonagenarians experienced improved swallowing than patients <80 years-of-age (96.3% vs. 74.4%, p = 0.013). Advanced age was not predictive of complications on multivariate analysis.

Conclusion

In appropriately selected patients, pharyngeal pouch surgery can be safely offered to patients above 80 years-of-age resulting in significant improvement in their quality-of-life. These patients should not be denied surgery on the basis of advanced age alone.
666 EARLY EXTUBATION AFTER ESOPHAGECTOMY IS SAFE. A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Serafim Maria , Santos Clara , Orlandini Marina , Datrino Letícia , Tavares Guilherme , Tristão Luca , Bernardo Wanderley , Tustumi Francisco
Published: September 2021

Esophagectomy has high morbidity and mortality, mainly due to pulmonary complications. Consequently, ventilatory support is a cornerstone in postoperative management. However, there is still no consensus on the timing for extubation. There is a fear that untimely extubation would lead to a high risk for an urgent reintubation. On the other hand, there is a risk for pulmonary damage in prolonged intubation. Thus, the present study aimed to compare early and late extubation after esophagectomy.

Methods

A systematic review was carried out on PubMed, Lilacs, Cochrane Library Central, and Embase, comparing early and late extubation after esophagectomy. The primary outcome was reintubation. Secondary outcomes included mortality; complications; pulmonary complications; pneumonia; anastomotic fistula; length of hospital stay; and ICU length of stay. The inclusion criteria were: a) clinical trials and cohort studies; b) adult patients (> 18 years); and c) patients with esophageal cancer undergoing esophagectomy. The results were summarized by risk difference and mean difference. 95% confidence interval and random model were applied.

Results

Four articles were selected, comprising 490 patients. Early extubation did not increase the risk for reintubation, with a risk difference of 0.01 (95%CI -0.03; 0.04). Also, there was no difference for mortality −0.01 (95%CI -0.04; 0.03); complications −0.09 (95%CI -0.22; 0.05); pulmonary complications −0.05 (95%CI -0.13; 0.03); pneumonia −0.06 (95% CI-0.18; 0.05); anastomotic fistula −0.01 (95% CI -0.09; 0.08). In addition, there was no significant mean difference for: length of hospital stay −0.10 (95%CI -0.38; 0.1); and ICU length of stay 0.00 (95%CI -0.22; 0.22).

Conclusion

Early extubation after esophagectomy does not increase the risk for reintubation, mortality, complications, and lenght of stay.
685 THE IMPACT OF ADJUVANT THERAPY ON SURVIVAL FOR NODE-NEGATIVE ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A PROPENSITY SCORE MATCHED ANALYSIS
Authors: Leng Xue-feng , He Wenwu , Jiang Yingchun , Leng Xuefeng , Luo Qiyu , Mao Tianqin , Zheng Kai , Han Yongtao
Published: September 2021

At present, the primary treatment of esophageal cancer is surgery-based comprehensive treatment, including adjuvant therapy such as chemotherapy and/or radiotherapy. However, the role of adjuvant therapy for esophageal squamous cell carcinoma (ESCC) with pathologically node-negative (pN0) disease is controversial. This study aimed to evaluate the impact of postoperative adjuvant therapy on survival in patients with pN0 ESCC.

Methods

Patients with ESCC who underwent R0 esophagectomy in the Department of Thoracic Surgery of Sichuan Cancer Hospital from Jan. 2008 to Dec. 2013 were involved. Patients were divided into two groups: surgery alone (Group S) or surgery + adjuvant therapy (Group S + A). The primary outcomes were overall survival (OS) and disease-free survival (DFS) between the two groups, and every consecutive case was followed up to death or the last follow-up.

Results

The study involved 387 patients with pN0 ESCC. After propensity score matching, each group consisted of 150 patients. In the overall cohort, the 5-year OS (p = 0.004) and 5-year DFS (p = 0.003) rates were higher in Group S + A than in Group S. In matched samples, the same outcomes were observed (5-year OS: p = 0.026; 5-year DFS: p = 0.014). Postoperative chemotherapy was associated with longer OS (p = 0.02) and DFS (p = 0.004); T3 tumors (p = 0.004) and < 15 lymph node dissections (p = 0.002) were independent risk factors for pN0 ESCC.

Conclusion

As the study revealed, adjuvant therapy, especially chemotherapy, prolonged OS and DFS for patients with ESCC who had pN0 disease. Fewer lymph node dissections and T3 stage tumors were independent risk factors for OS and DFS.
698 ENDOLUMINAL VACUUM THERAPY (EVT) AS A TREATMENT FOR ESOPHAGEAL LEAKS; 10-YEARS’ EXPERIENCE FROM A TERTIARY UK ESPHAGOGASTRIC CENTRE
Authors: Afzal Zeeshan , Gourgiotis Stavros , Hardwick Richard , Safranek Peter , Sujendran Vijay , Bennett John , O'Neill Robert , Noorani Ayesha , Hindmarsh Andrew
Published: September 2021

Esophageal leaks present a significant management challenge, especially in patients with delayed presentation and established sepsis. Endoluminal vacuum therapy (EVT) is an emerging treatment strategy which may reduce morbidity and mortality compared to traditional treatments in this patient group. We report the outcomes for patients with esophageal leaks from a range of different causes that were treated with EVT in a tertiary UK hospital over a 10-year period.

Methods

Between April 2011 and March 2021, 45 patients with a median age of 67 years (31–92) who had an esophageal leak were treated with EVT. All patients were treated with an ad-hoc endoluminal vacuum device (EVD) constructed using V.A.C GRANUFOAMTM (KCI) and a standard nasogastric (Ryles) tube. The median Apache II score for patients at the time of leak diagnosis was 20 (6–36). The cause of the leak was anastomotic in 16 patients (36%), iatrogenic in 14 patients (31%), spontaneous in 14 patients (31%), and traumatic in 1 patient (2%). Information related to treatment and outcome was recorded prospectively.

Results

Successful resolution of the leak was achieved in 39 (87%) patients. The median number of EVD changes required to heal the leak was 6 (1–17). There were no complications related to insertion of the EVD. The median length of hospital stay was 49 days (1–108). Six (13%) patients died during treatment. Six (13%) patients had complications during treatment requiring further intervention; 2 (4%) had a significant bleed requiring angiography and aortic stent placement, 1 (2%) had a stroke, 1 (2%) had a pulmonary embolism, 1 (2%) had a myocardial infarction, and 1 (2%) contracted COVID-19.

Conclusion

EVT is a safe and effective treatment that can be used successfully to treat esophageal leaks from a disparate range of leak causes in selected critically unwell patients. Further studies are required to develop a standardized procedure and management pathway which will enable broader adoption of EVT in this group of patients.
704 OBSERVATIONAL MEDICAL TREATMENT OR SURGERY FOR GIANT PARAOESOPHAGEAL HIATAL HERNIA IN ELDERLY PATIENTS.
Authors: Braghetto Italo , Korn Owen , Lanzarini Enrique , Musleh Maher , Figueroa Manuel , Rojas Jorge
Published: September 2021

Giant paraoesophageal hernias (GPHH) occur frequently in the elderly, account for about 5–10% of all hiatal hernias. Up to now persists the controversy between expectant medical treatment versus surgical treatment, regarding which is the most appropriate option depending on the presence or absence of symptoms. The aim of this study is to assess whether an indication for surgical repair of PHH is possible in older patients adequately evaluated before surgerymptoms.

Methods

Patients and method: Prospective study including patients hospitalized from January 2015 to December 2019 with GPHH more than 70 years old, comparing 2 group of patients which were separated in: Group A including a cohort of 23 patient in whom observational and conservative was indicated by gastroenterologist and Group B includes 66 patients in whom elective laparoscopic hiatal hernia repair was indicated at the moment of its diagnosis.

Results

Charlson’s score and ASA II or III were more frequent in group A. Emergency hospitalization was exclusively seen in group A and elective surgery in Group B. Symptomatic patients were seen in both groups (86.9 and 86.4% respectively). Symptoms period before the hospitalization was more prolonged in group A (21.8 + 7.8 vs 6.2 + 3.5 years) (p = 0.001). Symptoms of acute complications were seen frequently in Group A UCI and hospital stay were significantly more prolonged in Group A due to sepsis, emergency surgery and complications. In hospital mortality occurred in 5/23 patients (21.7%) in group A vs 1/66 patients (1.5%), Group B.

Conclusion
727 EXOCRINE PANCREATIC INSUFFICIENCY AFTER ESOPHAGECTOMY: A SYSTEMATIC REVIEW OF LITERATURE
Authors: Blonk Lotte , Wierdsma N J , Jansma E P , Kazemier G , Peet D L , Straatman J
Published: September 2021

Complaints of maldigestion, malabsorption, and unintended weight loss after esophagectomy are often attributed to an impaired exocrine pancreatic function. This review systematically summarizes all literature reporting on the presence of exocrine pancreatic insufficiency (EPI) after esophagectomy and the effect of treatment with pancreatic enzymes on gastrointestinal complaints, body weight, and quality of life.

Methods

Databases of PubMed, Embase, and Wiley/Cochrane Library were searched systematically until July 2020. Studies reporting on EPI and pancreatic enzyme replacement therapy after esophagectomy were included.

Results

Four studies, including 158 patients, were selected. Exocrine pancreatic function was investigated in three studies, measured by fecal elastase-1 and 72-hour fecal fat excretion. Fecal elastase-1 levels <200 μg/g were reported in 16% of patients at 4 months, 18% at 6 months, and 31% at 18-24 months postoperatively. A decreased fecal fat absorption was noticed in 57% 1 month postoperatively. Treatment with pancreatic enzymes was reported in two studies. In patients with fecal elastase-1 levels <200 μg/g, 90% of patients reported improvement in symptoms and 70% reported improvement in weight. In patients with complaints of steatorrhea, 87% noticed settlement of symptoms.

Conclusion

Based on current literature, complaints of maldigestion, malabsorption, and unintended weight loss after esophagectomy are common and can be related to an impaired exocrine pancreatic function. High-quality studies evaluating the presence of EPI and the effect of treatment with pancreatic enzymes after esophagectomy are needed to verify this conclusion.
736 PL11.04 HEALTH-RELATED QUALITY OF LIFE OF PATIENTS WITH ESOPHAGEAL CANCER FOLLOWING ESOPHAGECTOMY TREATED WITH NEOADJUVANT CHEMORADIOTHERAPY OR CHEMOTHERAPY: EUROPEAN MULTICENTER STUDY
Authors: Schuring Nannet , Markar Sheraz , Hagens Eliza R C , Jezerskyte Egle , Sprangers Mirjam A G , Johar Asif , Gisbertz Suzanne S , Berge Henegouwen Mark I
Published: September 2021

Curative treatment for patients with esophageal cancer consists of neoadjuvant treatment and radical surgical resection. Two different strategies exist; patients can either be treated with perioperative chemotherapy (CT) or neoadjuvant chemoradiotherapy (CRT). Both strategies improve 5-year survival rates, it is however not known if these treatments affect long-term Health-Related Quality of Life (HR-QoL) differently. The aim of this study was to compare HR-QoL between patients following CT and CRT followed by esophagectomy for esophageal cancer.

Methods

The LASER study database comprises data of a multicenter European study, with focus on HR-QoL among disease-free patients at least one year following an esophagectomy for esophageal or junctional cancer. Included patients completed the LASER, EORTC-QLQ-C30 and EORTC-QLQ-OG25 questionnaires. From this database we extracted patients either treated with CT or CRT for analysis. The primary endpoint was the mean difference in all long-term HR-QoL domains and LASER key symptom scores, using univariable and multivariable logistic regression analysis. The secondary endpoint was to compare the reported HR-QoL domain scores in the study population to the reference values of the general population.

Results

Among the 565 included patients, 349 (61.8%) received CRT, and 216 (38.2%) were treated with CT. The mean age was 63.7 years (±SD 8.6), and mean time since surgery was 4.3 years (±SD 1.7). After multivariable analysis, patients treated with CT reported worse outcomes on ‘Social Functioning’ (∆means 4.56, p-value<0.05), more symptomatology on domains ‘Insomnia’ (∆means 5.65 p-value<0.05) and ‘Diarrhea’ (∆means 5.93 p-value<0.05) of the QLQ-C30 questionnaire, and more symptomatology on domains ‘Reflux’ (∆means 7.40, p-value<0.05), ‘Odynophagia’(∆means 4.66 p-value<0.05) and ‘Pain and discomfort’(∆means 4.34, p-value<0.05) of the QLQ-OG25 questionnaire. No differences were observed for the LASER key symptoms.

Conclusion

Significant differences in favor of CRT were observed in several long-term HR-QoL domains for patients following esophagectomy for cancer. However, none of the observed differences in the reported long-term HR-QoL domains between patients treated with CT or with CRT, were clinically relevant (∆means≠ ≥ 10 points). Selection of neoadjuvant therapy should therefore be based on patient characteristics.
747 IS 99MTC BONE SCINTIGRAPHY NECESSARY IN THE PREOPERATIVE WORKUP FOR PATIENTS WITH POTENTIALLY RESECTABLE ESOPHAGEAL SQUAMOUS CELL CANCER?
Authors: Wei Xiufeng , Li Yin , Qin Jianjun , Zhang Ruixiang , Chen Xiankai , Xie Hounai , Xu Lei , Yang Yafan , Kang Xiaozheng , Qi Shu , Wang Zhen
Published: September 2021

99mTc bone scintigraphy(BS) is still the most widely used method to evaluate bone metastasis in China. The aim of this study was to investigate the necessity of the 99mTc bone scintigraphy in the preoperative workup for patients with potentially resectable esophageal squamous cell cancer (ESCC,cT1-4aN0–3).

Methods

This was a prospective cross-section clinical trial (ChiCTR1800020304). There were a total of 471 patients who were diagnosed ESCC in Thoracic Surgery Clinic from October 2018 to September 2020. Of these 471 patients, 385 patients with cT1-4aN0–3 who were potentially candidates for surgical resection were consecutively enrolled into the study. BS was performed preoperatively. The treatment strategy could be changed if the bone metastasis was confirmed. The primary endpoint was the incidence rate of the treatment regimen being changed because of bone metastasis. The secondary endpoint was the rate of positive BS findings.

Results

In all 385 patients, there are only 2(0.5%) patients changed their treatment regimen because of bone metastasis proved by BS. The rate of positive BS findings is 1%. The number of patients with false positive and false negative was 2(0.5%) and 2 (0.5%), respectively. The BS diagnostic performance for bone metastasis was as follows: sensitivity, 50%; specificity, 99.5%; positive predictive value, 50%; negative predictive value, 99.5% and accuracy, 99.0%. There were no significant difference of bone metastasis among the Age, Sex, Tumor location and Clinical stage.

Conclusion

99mTc bone scintigraphy is unnecessary in the preoperative workup for patients with potentially resectable esophageal squamous cell cancer.
755 LAPAROSCOPIC REPAIR OF GIANT PARAESOPHAGEAL HERNIAS: A SINGLE CENTER EXPERIENCE AND LITERATURE REVIEW
Authors: Neo Sheue Li , Voon Kelvin , Nagalingam Premnath
Published: September 2021

Paraesophageal hernias comprise about 5–10% of all hiatal hernias. Majority of patients are asymptomatic while some may present with reflux symptoms, obstruction or bleeding. There are numerous controversies on the indications of surgery, operative approach, hernial sac excision, fundoplication and on the use of a mesh.

Methods

We present a series of 3 patients with giant paraesophgeal hernia diagnosed in year 2020 in our institution, followed by a literature review. This study aims to assess the indications and effectiveness of laparoscopic paraesophageal hernia repair with routine sac excision, primary crural repair and fundoplication in the treatment of giant paraesophageal hernia.

Results

There were 3 patients in this study. Their mean age was 49. All patients had type IV hiatal hernia and the mean hernia defect was 8 cm in diameter. Laparoscopic paraesophageal hernia repair, sac excision and anterior 180 degree fundoplication was successfully done for all patients without conversion to open surgery. There was no intraoperative or post-op complications. Mean length of stay post-op was 2 days. At one year follow-up, all patients achieved complete resolution of symptoms without new onset reflux or dysphagia.

Conclusion

Laparoscopic paraesophageal hernia repair with routine sac excision, primary crural repair and fundoplication is safe and effective in treating giant paraesophageal hernias. Tension free repair is the key to success. A 180-degree anterior partial wrap may be able to reduce the incidence of dysphagia.
766 PROPHYLAXIS OF POST-FUNDOPLICATION SIDE EFFECTS AFTER LAPAROSCOPIC NISSEN EXTRA SOFT FUNDOPLICATION.
Authors: Haidarzhi Yevhen , Nykonenko Andrii
Published: September 2021

Laparoscopic Nissen Fundoplication (LNF) is well-established surgical treatment of GERD with best long-term postoperative outcomes in controlling reflux. Usually it is associated with a high risk of dysphagia, flatulence, inability to belch, bloating, which appear due to total over-tight wrap around esophagus. Partial fundoplication can avoid these effects, but unfortunately does not have the same long-term postoperative reflux control. So, new approach to prophylaxis of post-fundoplication side effects during LNF is needed.

Methods

Modified extra-soft LNF for GERD during 2016–2020 years were proposed in 75 patients. Prior to the fundoplication wrap formation the operation was performed according to the standard procedure. The proposed surgical techniques were: performing of an extra mobilization of the stomach (mandatory fundus and more ½ part of a large curvature) by crossing the gastro-splenic ligament completely and the gastro-colonic ligament partially and formation of a short extra-soft fundoplication wrap around the esophagus less 1.5 cm in the length with no more than 3 non-absorbable sutures with obligatory fixation to the esophagus. We examined twelve months follow-up.

Results

Along with the disappearance of GERD symptoms, no post-fundoplication dysphagia, flatulence, inability to belch and bloating were marked in any patient. Routine application of the above-described techniques allowed us to perform a modified LNF in all 75 patients by the extra mobilization of the stomach and formation of an extra-soft total fundoplication wrap with obligatory fixation to the esophagus without mandatory use of a thick (56–60 Fr) gastric fundoplication tube.

Conclusion

According to our study, in comparison with standard LNF, the proposed surgical techniques is effective in the prevention of post-fundoplication complications (dysphagia, flatulence, inability to belch, bloating) and support routine use of this modified Laparoscopic Nissen Extra Soft Fundoplication in treatment of GERD.
777 IS ADJUVANT CHEMOTHERAPY FOR ESOPHAGEAL CANCER WITH RESIDUAL DISEASE AFTER TRIMODALITY THERAPY FUTILE? A NATIONWIDE MULTICENTRIC SURVEY
Authors: Lintis Alexandru , Gronnier Caroline , Eveno Clarisse , Piessen Guillaume
Published: September 2021

For patients with resectable locally advanced esophageal cancer (EC), trimodality therapy associating neoadjuvant chemoradiation and surgery is the standard of care. However, the risk of recurrence for patients with residual disease (RD) remains high and there is no established adjuvant treatment modality in this setting. Adjuvant immunotherapy recently exhibited promising results but ACT could also play a beneficial role. This study evaluated the potential benefit of ACT in RD after trimodality therapy for EC.

Methods

A multicenter database for the surgical treatment of EC collected data from 30 university hospitals (2000–2010). Patients with RD in completely resected EC after trimodality therapy where included and separated in an ACT group and a non-ACT group. Demographics, tumor and treatment characteristics, morbidity, overall and recurrence-free survival (OS and RFS) where compared. Uni and multivariate analysis were performed to identify factors associated with OS. Survival analysis of patients treated with and without ACT was performed in a propensity score matched study.

Results

From 2944 patients included, 484 had RD after trimodality therapy, and 9.3% (n = 45) were treated with ACT. There were no major differences in demographics, preoperative tumor and treatment characteristics between groups. Major complications where higher in the non-ACT group (31 vs 20%, p = 0.018). ACT group had more nodal involvement (78 vs 45%, p < 0.001). OS and RFS were significantly worse in the ACT group (median: 36.0 vs 46.7mo, p < 0.001 and 25.5 vs 47.9mo, p = 0.029 respectively). After multivariate analysis, ACT was independently associated with worse OS (HR = 3.69, p < 0.001). In the propensity matched study, OS and RFS remained worse in ACT group.

Conclusion

This study supports current recommendations concerning ACT abstention in EC with RD after trimodality therapy. In light of the promising results of the BMS Checkmate 577 study, adjuvant immunotherapy in this setting should therefore be considered as the first choice of treatment.
783 C-REACTIVE PROTEIN VERSUS DRAIN AMYLASE; THEIR RELIABILITY IN RULING OUT ANASTOMOTIC LEAKAGE AFTER MINIMALLY INVASIVE IVOR-LEWIS ESOPHAGECTOMY
Authors: Stuart S , Kuypers T , Martijnse I , Heisterkamp J , Matthijsen R
Published: September 2021

One of the most feared complications of the esophagectomy for esophageal cancer is anastomotic leakage (AL). Early diagnosis is vital for timely initiation of therapeutic interventions as well as prompting early feeding in the absence of AL. The aim of this study is to investigate the role of serum C-reactive protein (CRP) and drain amylase levels in the early detection of AL.

Methods

All 109 patients who underwent a minimally invasive Ivor-Lewis procedure in our hospital between January 2018 and October 2020 were retrospectively included in this study. Data on CRP and drain amylase levels were collected during the first 5 postoperative days (POD) and were available for analyses. Mean CRP and median drain amylase levels between patients with and without AL were compared and ROC curves on POD 3, 4 and 5 were plotted to calculate cut-off values for CRP.

Results

In 13 of 109 patients (12%) AL was diagnosed with a median time to diagnosis of 8 days. Mean CRP was significantly higher in patients with AL on POD 3, 4 and 5. Cut-off values of 48, 113 and 90 mg/L had a high sensitivity of 100%, 92% and 92% on POD 3, 4 and 5. No difference in median drain amylase levels was observed.

Conclusion

CRP levels with a cut-off point of 113 mg/L on POD 4 do not improve earlier detection of AL, but has a high sensitivity for excluding AL while the value of drain amylase in the first 5 days after surgery is limited.
791 RECURRENT HIATAL HERNIA A HIGH PREDICTOR OF PATHOLOGIC REFLUX AND NEED FOR REINTERVENTION
Authors: Greenberg Jacques , Reyes Fernando Valle , Christianson Blake , Margolis Daniel , Thiesmeyer Jessica , Edelmuth Rodrigo , Egan Caitlin , Finnerty Brendan , Fahey Thomas J , Zarnegar Rasa
Published: September 2021

Anti-reflux surgery (ARS) has been postulated to have high failure rates, which may approach 50% depending upon hiatal hernia size. Most failures are thought to be related to wrap disruption or hiatal hernia recurrence. Recently, diaphragmatic mesh augmentation has been shown to reduce hiatal hernia recurrence. We aimed to determine factors that influence recurrence based on vigilant imaging and diagnostic pH studies, and the need for surgical reintervention.

Methods

A prospectively maintained database of all patients undergoing index robotic ARS (including Hill, Nissen, Toupet, and Linx procedures) with Phasix ST ® mesh was queried. Between December 2016 and July 2020, 134 patients were identified of which 92 met inclusion criteria for post-operative barium esophagram performed at routine intervals (6, 12, or 24-months) or for recurrent symptoms. Median follow-up time was 11.4 months. Clinical characteristics, manometry, pH studies, as well as surgical approach was evaluated. Radiographic recurrences were then associated with endoscopic confirmation and rates of surgical re-intervention.

Results

Radiographic recurrence >2 cm was noted in 9 (9.8%) patients, of which 44% were symptomatic, compared to 36% of those without radiographic recurrence (p = 0.620). Endoscopy confirmed recurrence in 67% of patients with radiographic recurrence versus 0% without (p = 0.001). When all radiographic recurrences, including those <2 cm, were evaluated, 17 (18%) were identified, of which 53% of patients were symptomatic. Endoscopic and pH studies confirmed recurrences in 75% and 71% of these patients, respectively. Overall reintervention rates were 23% in the setting of any radiographic recurrence versus 1.3% without (p = 0.001).

Conclusion

Recurrence rates following robotic ARS and hiatal hernia repair with mesh augmentation appear low with nearly 1-year follow-up. Prior to surgical reintervention, endoscopic and pH studies are warranted to confirm symptomatic recurrence. Recurrent hiatal hernias, including those <2 cm, can lead to abnormal pH studies that merit reintervention at rates higher than those without evidence of recurrence. Longer term follow-up is required to optimally delineate true recurrence patterns.
850 OBJECTIVE IDENTIFICATION OF OESOPHAGEAL ADENOCARCINOMA USING MASS SPECTROMETRY IMAGING
Authors: Antonowicz Stefan , Nima Abbassi-Ghadi , McKenzie James , Kumar Sacheen , Huang Juzheng , Jones Emrys , Strittmatter Nicole , Pitts Gemma , Kudo Hiromi , Goldin Rob , Hoare Jonathan , Veselkov Kirill , Takats Zoltan , Hanna George
Published: September 2021

Outcomes for oesophageal adenocarcinoma continue to be poor, as patients are often diagnosed too late for curative treatment. New tools to assist early and rapid diagnosis are needed. Tissue phospholipids quantified by mass spectrometry imaging (MSI) can objectively diagnose non-oesophageal cancers from control tissue in minutes. However, whether MSI can objectively identify oesophageal adenocarcinoma is unknown and represents a significant challenge, as this microenvironment is complex with phenotypically similar tissue-types.

Methods

Desorption electrospray ionisation mass spectrometry imaging (DESI-MSI) and bespoke chemometrics were used to assess the phospholipidomes of oesophageal adenocarcinoma and relevant control tissues, in surgical (discovery) and endoscopic (validation) cohorts. Structural annotations verified by tandem MS fragmentation patterns were performed to understand the characteristics of the key differential phospholipids. Bioinformatics, quantitative polymerase chain reaction, and immunohistochemistry were performed to describe the reprogramming of phospholipogenesis in oesophageal adenocarcinoma. Finally, genetic silencing experiments were performed to understand whether this genetic reprogramming impacts the oesophageal adenocarcinoma phospholipid signature.

Results

Multivariable models based on tissue phospholipids from 117 patients were highly discriminant for oesophageal adenocarcinoma both in discovery (area-under-curve = 0.97) and validation cohorts (AUC = 1). Cancer samples were enriched for polyunsaturated phosphatidylglycerols with longer acyl chains, with stepwise enrichment in pre-malignant tissues. Expression of fatty acid and glycerophospholipid synthesis genes was significantly upregulated, and characteristics of fatty acid acyls matched phospholipid acyls. Mechanistically, reducing ACLY expression in oesophageal adenocarcinoma cells shortened GPL chains, therefore linking de novo lipogenesis to the oesophageal adenocarcinoma phospholipidome.

Conclusion

DESI-MSI (i) objectively identified invasive oesophageal adenocarcinoma from a number of pre-malignant tissues (ii) described the characteristics of cancer phospholipids, which have unknown function (iii) unveiled a new mechanism of phospholipidomic reprogramming. These results call for accelerated diagnosis studies using DESI-MSI in the upper gastrointestinal endoscopy suite, as well as functional studies to determine how polyunsaturated phosphatidylglycerols are generated, and how they contribute to oesophageal carcinogenesis.
856 NODAL METASTASES AFTER NEOADJUVANT CHEMORADIATION AND R0 RESECTION IN ESOPHAGEAL ADENOCARCINOMA: PATTERNS AND PROGNOSIS
Authors: Harrington Caitlin , Carr Rebecca , Sihag Smita , Adusumilli Prasad , Bains Manjit , Bott Matthew , Isbell James , Park Bernard , Rocco Gaetano , Rusch Valerie , Jones David , Molena Daniela
Published: September 2021

Although the pattern of nodal metastasis and the prognosis of number and location of positive nodes have been well described with esophageal cancer undergoing upfront surgery, little is known about nodal metastasis after neoadjuvant treatment. The aim of this study is to assess the pattern of nodal metastases in esophageal adenocarcinoma treated with neoadjuvant chemoradiation and surgery and evaluate its effect on prognosis.

Methods

All patients with esophageal adenocarcinoma who had undergone neoadjuvant chemoradiation and an R0 esophagectomy between 2010 and 2018 at our institution were included (n = 577). Pathology reports were reviewed for sites of lymph node metastases. Patients were excluded if nodal stations were not listed separately (n = 40). Age, sex, race, tumor location, TRG, pT stage, number of positive lymph nodes, number of positive nodal stations, and specific nodal stations were analyzed for risk of recurrence using univariable Cox regression, and significant covariates were included in multivariable Cox regression model.

Results

Of 537 patients, 193(36%) had pathologic nodal metastases. 153 patients(28%) had single-station disease: 135(88%) at the paraesophageal station, 16(10%) at the left gastric, 1 at the subcarinal and 1 at the paratracheal station(0.65% each). 32 patients(6.0%) had two-station and 8(1.5%) had three-station disease. The majority of patients with multiple positive nodal stations had positive nodes in the paraesophageal(90%) and/or left gastric artery stations(60%). On multivariable analysis, the number of positive nodal stations (HR 1.59, CI 1.35–1.84, p < 0.001), subcarinal (HR 2.78, CI 1.54–5.03, p < 0.001), and paraesophageal stations (HR 2.0, CI 1.58–2.54, p < 0.001) were associated with increased risk of recurrence.

Conclusion

Patients who have undergone neoadjuvant and R0 esophagectomy for adenocarcinoma often have lymph node metastases at time of surgery, most commonly at the paraesophageal station. The number of nodal stations, along with subcarinal and paraesophageal metastases, were associated with increased risk of recurrence.
Understanding the use of heart failure online health forums: a qualitative study
Authors: Farnood Annabel , Johnston Bridget , Mair Frances S
Published: September 2021

Aims

Heart failure is a major public health challenge and is described as an epidemic. Many people resort to the internet as a source of health information and online health forums have become an increasingly common way to obtain information and support regarding health-related issues. This study aims to explore what information people concerned about heart failure seek from online health forums, and how this shapes decision-making, trust, and interactions with healthcare professionals.

Methods and results

Widely available internet search engines (Google, Yahoo, and Bing) were used to identify online health forums, accessed by people seeking information on heart failure. Comments posted between 2016 and 2019 were screened, downloaded, and analysed thematically. Normalization Process Theory provided the underlying conceptual lens to inform analysis. Ten online health forums were identified, and 204 individual posts analysed. Three themes were identified [(information and support needs; online diagnosis; and relationship with healthcare professionals (HCPs)]. The most common purpose for using online health forums was to plug information/knowledge gaps surrounding diagnosis or treatments (e.g. discussion of results, medication/health insurance queries). They were used as a tool to aid decision-making regarding, (i) whether to seek further medical attention and (ii) lifestyle choices, medications, and other advice surrounding concerns. Negative experiences with HCPs were discussed, and sometimes online health forums appeared to promote distrust with HCPs.

Conclusion

Online health forums offer a supportive platform and help fill key informational gaps. However, online forums may amplify distrust with HCPs.
Divergent assembly processes? A comparison of the plant and soil microbiome with plant communities in a glacier forefield
Authors: Junker Robert R , He Xie , Otto Jan-Christoph , Ruiz-Hernández Victoria , Hanusch Maximilian
Published: September 2021

Community assembly is a result of dispersal, abiotic and biotic characteristics of the habitat as well as stochasticity. A direct comparison between the assembly of microbial and ‘macrobial’ organisms is hampered by the sampling of these communities in different studies, at different sites or on different scales. In a glacier forefield in the Austrian Alps, we recorded the soil and plant microbiome (bacteria and fungi) and plants that occurred in the same landscape and in close proximity in the same plots. We tested five predictions deduced from assembly processes and revealed deviating patterns of assembly in these community types. In short, microbes appeared to be less dispersal limited than plants and soil microbes, and plants strongly responded to abiotic factors whereas the leaf microbiome was plant species specific and well buffered from environmental conditions. The observed differences in community assembly processes may be attributed to the organisms’ dispersal abilities, the exposure of the habitats to airborne propagules and habitat characteristics. The finding that assembly is conditional to the characteristics of the organisms, the habitat and the spatial scale under consideration is thus central for our understanding about the establishment and the maintenance of biodiversity.
Observations noise and stability of geodetic variable slip fault models
Authors: Leivadas-Stathakopoulos Ioannis , Biliani Irene , Stiros Stathis C
Published: September 2021

Variable slip models of seismic faults represent ill-posed (or underdetermined) problems with infinity of solutions; a single solution is typically obtained using constraints imposed by the L-curve theory, through an experimentally derived coefficient which optimizes the trade-off between fault roughness (smoothness, mean slip gradient) and mean misfit of observations to the fault model. However, in some cases, diverse variable slip fault models (VSFM) have been presented, even using the same data sets. In this paper, we investigate the problem of stability (sensitivity) of VSFM to input geodetic (GNSS/GPS, INSAR) ground slip measurements, based on statistics of synthetic data: statistically similar sets of synthetic ground displacements were the only degree of freedom in an analysis leading to comparable VSFM, regarded as images of slip amplitude and of rake. Differences of synthetic models from the reference fault model for different levels of noise, both for filtered and for PCA-filtered were examined, and results were summarized in images depicting the differences and the variability (standard deviation) of each fault slip patch, both for slip and rake. From this ‘truth’-based approach, it was found that an increase in observations noise is reflected in increase of variability (instability) of fault models, especially away from the fault centre, higher for slip than in rake. Analysis with a different virtual observations system indicates that stations above the fault tend to show spurious stress concentration areas on the fault surface, in agreement with previous studies. Analysis with synthetic data appears as a promising strategy to validate a VSFM based on geodetic data.
Conflict and cooperation in the age of COVID-19: the Israeli–Palestinian case
Authors: Lehrs Lior
Published: September 2021

How do disasters influence conflict and diplomacy in conflict areas? The scholarship shows that while they can provide opportunities for cooperation and ‘disaster diplomacy’ between parties to a conflict, they can also intensify tension and hostility. This article uses the Israeli–Palestinian conflict during the COVID-19 pandemic as a case study, exploring the impact of the crisis on relations between the rival parties and examining the conditions under which an ongoing pandemic might lead to either conflict or cooperation in a conflict area. The research is based on within-case analysis, comparing three conflict arenas: Israel–Palestinian Authority relations in the West Bank; relations between Israel and the Palestinian community in East Jerusalem; and Israel–Hamas government relations in the Gaza strip. The article outlines the possibilities and limitations of ‘disaster diplomacy’ in intractable conflicts and contributes to the literature by identifying how different contexts, relations and actors in each conflict arena affect the development of patterns of conflict and cooperation with regard to the pandemic. The study analyses the factors that shape how the pandemic affects the conflict, and the COVID-19-related diplomacy, in each sub-case, with attention to three main variables: the structure of the conflict arena, domestic politics and the developments in the pandemic. The analysis addresses the unique conditions of an ongoing global pandemic, as opposed to an isolated disaster event, and traces the changing impact of the pandemic on the conflict and on disaster-related cooperation at various stages.
A new sign of the slipping rib syndrome?
Authors: Romano Rosalia , Gavezzoli Diego , Gallazzi Maria Sole , Benvenuti Mauro Roberto
Published: September 2021

The slipping rib syndrome is characterized by burning pain in the lower thorax and upper abdomen, often disabling, caused by hypermobility of the costal cartilage with entrapment of the intercostal nerve. The syndrome is often underdiagnosed. The diagnosis is clinical and the definitive treatment is surgical, with an excellent result for pain relief. Based on the observation of 4 cases undergoing rib resection for SRS, we noticed a new possible sign of the disease. Our patients showed less thickness of the ipsilateral rectus abdominis muscle on ultrasound of the abdomen. The aim of this study is to demonstrate this sign in the diagnosis of SRS, to make this disease more recognizable and treatable.