bluuebunny/crossref_metadata_2025 huggingface dataset:
425. PARACONDUIT HIATAL HERNIA FOLLOWING ESOPHAGECTOMY IN A PORTUGUESE TERTIARY CENTER
Authors: Ávila Leonor , Gonçalves Beatriz , Chumbinho Beatriz , Girão Carmo , Cabral Francisco , Ramos Paulo , Monteiro Cecília , Casaca Rui , Abecasis Nuno
Published: September 2024

Background

Esophageal Cancer is the seventh most common cancer worldwide with poor overall survival. As minimally invasive esophagectomy is becoming the new standard of care, an increased incidence of para-conduit hiatal hernias has been reported. Possible risk factors, other than those related to the operative approach have been suggested, such as location of the tumor. Histological type may also account for the increased incidence of hiatal hernias due to shift from esophageal squamous cell carcinomas to adenocarcinomas of the gastro-esophageal junction in Western world. We reviewed our center’s experience to determine whether the adoption of minimally invasive esophagectomy was associated with an increased incidence of para-conduit hernia.

Methods

A single-center, prospective database was used to retrospectively analyze consecutive patient who underwent esophagectomy between January 2007 and December 2023.

Results

Between January 2007 and December 2023, 497 patients were submitted to esophagectomy (Ivor-Lewis, McKeown or transhiatal) due to cancer (242 squamous cell carcinomas and 255 adenocarcinomas); 163 proximal esophageal cancers and 323 distal esophageal cancers.

An hiatal hernia was diagnosed in 11 (2.21%) of 497 included patients submitted to esophagectomy; 5 (3.25%) after 154 totally minimally invasive esophagectomies, 3 (11.11%) after 27 hybrid esophagectomies and 3 (0.95%) after 316 open esophagectomies. The median days to diagnosis of hiatal hernia was 199 (6-3881) days. Surgical treatment consisted of cruroplasty in 1 patient, crurorrhaphy in 6 patients, reduction of herniated contents in 4 patients. The tumor was located proximally in 1 patient whereas the remaining 10 were at distal esophagus or at gastro-esophageal junction. Regarding pathologic evaluation, 2 were squamous cell carcinomas (0.82%) and 9 adenocarcinomas (3.53%).

Conclusion

In our experience, the adoption of minimally invasive esophagectomy has been associated with an increase of symptomatic para-conduit hernia, in line with the reports of recent meta-analyses. The prevalence of paraconduit hiatal hernia was also increased in adenocarcinomas, revealing the shift in the histological type in Western world.

The true rate of herniation may be much higher, as our patients are not routinely submitted imaging diagnostic tests as part of their follow-up.
426. TAILORED MANAGEMENT OF ANASTOMOTIC LEAK AFTER ESOPHAGECTOMY IN A SPECIALISED UNIT IN THE ERA OF HYBRID AND ENDOSCOPIC NOVELTIES
Authors: Triantafyllou Alexandra , Theodoropoulos Charalampos , Varsos Panagiotis , Kitsou Eleni , Saliaris Konstantinos , Matthaiou Georgia , Katsila Sofia , Kakounis Konstantinos , Xiromeritou Vasiliki , Triantafyllou Tania , Theodorou Dimitrios
Published: September 2024

Tailored management of anastomotic leak after esophagectomy in a specialised unit in the era of hybrid and endoscopic novelties.

Triantafyllou Alexandra1, Theodoropoulos Charalampos2, Eleni Kitsou1, Saliaris Konstantinos1, Karikis Ioannis1, Pachos Nikolaos1, Katsila Sofia3, Kakounis Konstantinos3, Triantafyllou Tania1, Xiromeritou Vasiliki3, Theodorou Dimitrios1

1. 1st Propaedeutic Surgical Department, Hippocratio General Hospital of Athens, University of Athens, Greece

2. Surgical Department, Tzaneio Hospital, Greece

3. Department of Gastroenterology, Hippocratio General Hospital of Athens, Greece

Background

Anastomotic leak following esophagectomy remains one of the most dreadful complications with high rates of morbidity and mortality. This study aims to delineate the incidence, therapeutic strategies, and associated outcomes of esophagogastric anastomotic leak in our unit.

Methods

We retrospectively analyzed prospectively collected data of patients diagnosed with anastomotic leak following esophagectomy. The treatment modalities and the patient outcomes are presented.

Results

199 patients underwent esophagectomy between 2019 and 2023. Among them, 21 patients (10.6%) were diagnosed with anastomotic leakage. 17 out of these 21 patients (81.0%) were male, and the mean age was 58.6 years. 14 out of the 21 patients had cervical anastomosis (leak rate: 8.6%) and 7 patients intrathoracic anastomosis (leak rate: 18.9%). Significant reduction of the intrathoracic anastomotic leak rate was recorded within 2013 (0%) following revision of the anastomotic technique. No deaths were observed, and the average time to healing was 29.1 days. Endoscopic stenting was employed in 12 patients (57.1%), reoperation in 5 (23.8%), bedside wound exploration in 7 (4.8%) and one patient was treated conservatively. Besides stenting, 4 patients (19.0%) underwent percutaneous drainage procedures under radiological guidance.

Conclusions

Managing esophageal anastomotic leakage presents significant challenges. Optimal outcomes for anastomotic healing and patient survival are achieved through a multidisciplinary and individualised approach encompassing interventional radiology or endoscopy and/or reoperation in selected patients.
428. MIDDLE MEDIASTINAL LYMPHADENECTOMY IN MEDIASTINOSCOPIC ESOPHAGECTOMY FOR ESCC
Authors: Konishi Hirotaka , Fujiwara Hitoshi , Shiozaki Atsushi , Nishibeppu Keiji , Ohashi Takuma , Kubota Takeshi , Otsuji Eigo
Published: September 2024

(Introduction) In mediastinoscopic esophagectomy, it is necessary to secure a view of the deep middle mediastinum. Although tracheal carina lymph nodes can be stably dissected using a cervical approach, but they are dissected using a hiatal approach when it is difficult to secure the field of view. (Middle mediastinum dissection) It is important to at least peel off the tracheal membrane or azygos vein in order to reduce the risk of secondary injury in the hiatal approach, even if cervical approach is difficult. In that case, the attachment between the esophagus and subcarinal tissue should be maintained for the en-block dissection. In the hiatal approach, the dissection along the pericardial and aortic surface is continuous with the dissection layer in the cervical approach and left and right tracheal cartilage are exposed enough. In the left side, the dissection along the inferior pulmonary vein is connected to the dissection of No.109L lymph node. Then, in the right side, similarly dissect the subcarinal lymph nodes along the right bronchus (No.109R lymph node). At this time, it is important to carefully check the position of azygos vein to avoid injury. Finally, the lymph nodes at the apex of the tracheal carina are sufficiently cauterized and dissected. (Conclusion) When it is difficult to reach the subcarinal tissue in cervical approach due to body type or tumor factor, the hiatal approach is necessary for sufficient lymphadenectomy of the middle mediastinum. At that case, prior detachment of the tracheal membrane and azygos vein will be important to reduce the risk of secondary injuries. Maintaining the continuity between the esophagus and dissected tissue is also important for the stable field of view.
441. EXTENT AND BOUNDARIES OF LYMPH NODE STATIONS DURING MINIMALLY INVASIVE ESOPHAGECTOMY: A SURVEY AMONG DUTCH ESOPHAGEAL SURGEONS
Authors: van der Aa Dillen , Ketel Mirte , Henckens Sofie , van Berge Henegouwen Mark , Rosman Camiel , Klarenbeek Bastiaan , Gisbertz Suzanne
Published: September 2024

Background

The optimal extent of lymph node dissection (LND), and the anatomical boundaries per lymph node station (LNS) during minimally invasive esophagectomy (MIE) for esophageal cancer remains a topic of debate. This study investigated the opinion of Dutch esophageal cancer surgeons on their routine LND extent and anatomical boundaries per LNS, during MIE.

Methods

In April 2023, an English web-based cross-sectional survey was conducted. Within all 15 Dutch hospitals performing MIE, two MIE surgeons were asked to participate. The routine LND extent (quantity, specific LNS) for distal esophageal adenocarcinoma, (dis)agreement with the TIGER definition, and anatomical boundaries for each LNS in six directions were inquired.

Results

Twenty-four Dutch MIE surgeons completed the survey (80% response rate). Consensus on the routine LND extent (85% or more of the participating surgeons) included the left and right paracardial, left gastric artery, celiac trunk, proximal splenic artery, common hepatic artery, subcarinal middle mediastinal paraoesophageal, lower mediastinal paraoesophageal, pulmonary ligament and upper mediastinal paraoesophageal LNSs. Other LNS were not widely considered routine. Although, certain anatomical boundaries were consistent among surgeons, the majority varied, even when agreeing on the TIGER definition.

Conclusion

Significant variations in surgical practice among Dutch esophageal surgeons, regarding their routine extent of LND and anatomical boundaries of LNSs during MIE were demonstrated. Variation may impact clinical outcomes, hampers uniform treatment strategies, and hinders comparison of performance assessments. This study highlights the need for an international follow-up study towards one uniform defined LND during MIE for esophageal cancer.
449. CAN LARGE ANASTOMOTIC LEAKAGE AFTER ESOPHAGEAL SURGERY BE TREATED BY ENDOLUMINAL VACUUM-ASSISTED CLOSURE (EVAC THERAPY)?: A CASE REPORT
Authors: Momblan Dra Dulce , Farguell Jordi , Sendino Oriol , Turrado Victor , Cardin Dra Verena , Ibarzabal Dra Ainitze , Curell Dra Anna , Pera Miguel
Published: September 2024

Background

Anastomotic leakage after esophageal surgery is a deadly complication which approach is still under debate. The high morbimortality of the surgical approach has led to debate whether there are any alternative treatments. The appropriate strategy is based on many factors that include patient’s general conditions, size of anastomotic leakage and diagnosis delay. EVAC (Endoscopic vacuum assisted wound closure) is an emerging technique to treat these patients that can be placed either into the cavity or in the lumen under endoscopic guidance. It is then connected to a negative continuous pressure of 75-125mmhg and then reviewed after 3-4 days.

Methods

A 62-year-old man with esophageal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy, followed by a minimally invasive Mckeown esophagectomy. On the fourth postoperative day, inflammatory indexes increased, and a CT scan showed an anastomotic leakage. It was decided to perform an endoscopy that showed that the leakage was about 70% of the anastomosis opening to a wound cavity of 5cm with necrotic tissue and fibrosis. Due to the clinical stability of the patient, it was decided to treat the anastomotic leakage conservatively by EVAC therapy.

Results

To start the EVAC therapy a polyurethane sponge was placed in the cavity via an overtube during the first endoscopy. The patient underwent a total of 14 EVAC sessions over 85 days. As we performed the sessions, healthy granulation tissue appeared leading the leakage and the cavity size to progressively improve. After the 13th session, the endoscopic evaluation showed a healed anastomosis. A CT scan with oral contrast was performed showing leak resolution. The patient started oral intake and was discharged after four days.

Conclusions

Treatment of anastomotic leakage after esophagectomy is still challenging and presenting high morbidity. The appropriate strategy needs to be individualized. Although surgical reintervention was the classical approach for these patients, new strategies have appeared like the EVAC. It is a promising option to improve the outcome of patients with transmural leakages who would otherwise require surgery. It has demonstrated that it is a reliable, safe and effective treatment.
451. PREDICTIVE FACTORS FOR PNEUMONIA AND ANASTOMOTIC LEAK AFTER TRANSTHORACIC ESOPHAGECTOMY FOR CANCER AND FAILURE TO RESCUE ANALYSIS ON 1355 PATIENTS
Authors: Kemeter Melissa , Kemeter Melissa , Thumfart Lucas , Huettner Felix , Heger Patrick , Koch Oliver , Grechenig Michael , Emmanuel Klaus , Capovilla Giovanni , Riccio Federica , Salvador Renato , Valmasoni Michele , Latorre-Rodriguez Andres R , Mittal Sumeet , Hitzl Wolfgang , Diener Markus K , Dubecz Attila
Published: September 2024

Background

Pneumonia (PN) and anastomotic leak (AL) represent the most feared complications after transthoracic esophagectomy for cancer, the former more commonly observed after open and the latter after minimally-invasive (MI) procedures. Studies comparing these two complications with focus on predictive risk factors and procedure-related failure-to-rescue (FTR) are sparse. Aim of the study was to explore such aspects with a large multicentric dataset.

Methods

All patients who underwent an Ivor Lewis transthoracic esophagectomy for cancer between 2008 and 2022 in four tertiary centers were queried. Predictive risk factors for pneumonia, anastomotic leak and in-hospital mortality were analyzed with univariable models. FTR was defined as in-hospital death following a major complication. Patients were then classified and compared according to the type of operation [open, hybrid-laparoscopic, hybrid-robotic, standard minimally-invasive (MIE) or robotic minimally-invasive (RAMIE)]. Pneumonia and anastomotic leak associated FTR was calculated and compared across the groups. Machine-learning models (neuronal nets, support vector machines and random forests classifier) were applied to predict complications and FTR.

Results

In total, 1,355 patients were included. Significant (p<0.05) predictors for PN (n=211, 15.6%) were ASA=4, preexisting cardiac and pulmonary conditions, conversion (thoracotomy), neoadjuvant therapy and age. Those for AL (n=160, 11.8%) were preexisting cardiac condition, conversion (thoracotomy) and operation time. Overall FTR-rate was 3.6%. Age>65y, preexisting cardiac and pulmonary condition, AL, PN, postoperative bleeding, sepsis, pulmonary embolism, myocardial infarction, arrhythmia and need for blood transfusion were the risk factors significantly associated with in-hospital mortality. PN- and AL- associated FTR rates did not significantly differ among the different operation types (Figure 1). Machine-learning models were unable to predict complications or FTR properly.

Conclusions

Our study showed that there is a greater number of factors associated with pneumonia rather than anastomotic leak, probably making the prevention of this complication more challenging to achieve. However, pneumonia- and leak-associated FTR-rates did not significantly differ among the groups, demonstrating that the implementation of minimally-invasive procedures can be safely carried out, if experience is provided.
454. QUALITY OF LIFE AFTER ESOPHAGECTOMY WITH INTRATHORACIC VS CERVICAL ANASTOMOSIS: A NATIONWIDE COHORT STUDY
Authors: Matthée Eric , Ubels Sander , Verstegen Moniek , Hannink Gerjon , Klarenbeek Bastiaan , van Workum Frans , Rosman Camiel , Grutters Janneke PC
Published: September 2024

Background

Transthoracic esophagectomy with either intrathoracic or cervical anastomosis is considered standard of care in patients with mid to distal esophageal or gastroesophageal junction (GEJ) cancer. Patients after esophagectomy will experience a deterioration in health-related quality of life (HR-QoL) after esophageal cancer surgery. Whilst some reports describe long-lasting deterioration, other reports show recovery of HR-QoL comparable with the general population after 2 years. The aim of this study was to investigate the difference in HR-QoL in patients after a transthoracic esophagectomy with either intrathoracic- or cervical anastomosis in a nationwide database.

Methods

A nationwide cohort study was performed combining data from two registries: Netherlands Cancer Registry (NCR) and Prospective Observational Cohort Study of Esophageal-Gastric Cancer Patients (POCOP). All patients after esophagectomy for mid/distal esophageal or GEJ cancer between 2015 and 2022 were included. HR-QoL was measured at baseline, 3, 6, 9, 12, 18, and 24 months postoperatively using EORTC QLQ-C30 and OG-25 questionnaires.

Linear mixed models were used to assess the mean score difference between patients with intrathoracic and cervical anastomosis. A difference of 10 points or more was considered clinically relevant. Adjustments were made for potential confounders (age, gender, ASA classification).

Results

Of the 4269 registered patients in the NCR, in 1274 patients at least one questionnaire was available. Of these patients 346 underwent an esophagectomy with cervical - and 928 with intrathoracic anastomosis. Patients after esophagectomy with cervical anastomosis reported statistically significant more problems in the following categories: dysphagia, couching, trouble eating with others and swallowing saliva during the first 3 months, choked when swallowing and trouble talking during the first 12 months postoperatively. In all other categories no significant difference was found. Only trouble talking at the 3-month time point was considered as a clinically relevant difference.

Conclusion

Although the intrathoracic anastomosis is associated with significantly better HR-QoL in several categories, only trouble talking at 3 months postoperatively was considered clinically relevant. Overall HR-QoL was comparable for esophageal cancer patients after an esophagectomy with either a cervical or intrathoracic anastomosis.
465. INNOVATION TO STANDARDIZATION OF THORACOLAPAROSCOPIC ESOPHAGECTOMY: CULMINATION OF THREE DECADES OF EXPERIENCE
Authors: Palanivelu C , Parthasarathi R , Ramesh N
Published: September 2024

Minimally invasive esophagectomy has seen a great deal of evolution over the last three decades. As one of the earliest adopters of minimally invasive approach for esophagectomy, we present our experience and the lessons we have learnt in over 1300 cases. We adopted the prone position and later modified to mid prone position for the thoracic phase of esophagectomy. This position has several advantages of better exposure due to gravity aided retraction of the lungs, clear operating field as blood trickles away as well as feasibility of rapid conversion to open thoracotomy in emergencies. A major transformation in our surgery was the technical modifications and the extent of mediastinal lymphadenectomy. With refinements in technique and greater understanding of the lymphatic spread, we evolved from standard to extended and even total mediastinal lymphadenectomy improving the oncological outcomes without increasing the operative morbidity. The mean total lymph node yield is over 35. Recurrent laryngeal nerve injury was noted in 7% of cases. The technique of anastomosis was also extensively modified from hand sewn to circular stapler to semi mechanical and finally fully mechanical side to side anastomosis using triangulation technique. The triangulation technique has led to significant reduction in leak rates to less than 5% and stricture formation (<1%). Finally, our innovative railroading technique for specimen extraction through the neck is oncologically safe that avoids large incisions in the chest or abdomen. The 30 day mortality rate is less than 1%
468. CALCULATING THE MINIMAL CLINICALLY IMPORTANT DIFFERENCE FOR THE FACT-E FROM ESOPHAGECTOMY TO RECOVERY USING DISTRIBUTION-BASED METHODS
Authors: Crump Trafford , Dehghani Mehrnoush , Mueller Carmen , Ferri Lorenzo
Published: September 2024

Background

The Functional Assessment of Cancer Therapy-Esophageal (FACT-E) is a validated patient-reported outcome instrument that measures four subscales of general cancer health and one subscale specific to esophageal cancer. To make the instrument more clinically useful, therapeutic thresholds known as minimal clinically important differences (MCID) are needed. The purpose of this study was to calculate the MCID for the FACT-E and its subscales for patients undergoing an esophagectomy.

Methods

The study was based on a retrospective analysis of a registry maintained by a high volume North American tertiary care referral centre, which includes the FACT-E collected between August 2004 and September 2023. The FACT-E was administered at nine time points over the course of a patient’s care, ranging from the time of first presentation to 5 years post-esophagectomy. This study used two distribution-based approaches – the standard error (SE) and the standard deviation (SD) – to calculate the MCID for the FACT-E’s total score and its five subscales. Nonparametric bootstrapping was used to generate 95% confidence intervals for each MCID.

Results

There were 731 participants included in this study but not all of those completed each subscale at each time point. The MCID for physical well-being ranged from 2.2-3.1 using SE and 2.3-3.4 using SD, from 2.1-3.6 using SE and 2.2-3.6 using SD for social well-being, 1.2-1.7 using SE and from 1.4-2.0 using SD for emotional well-being, 2.1-2.4 using SE and 3.2-3.6 using SD for functional well-being, and from 3.2-4.3 using SE and from 4.3-6.4 using SD for the esophagus cancer subscale. The MCID for the total score ranged from 6.7-8.3 using SE and from 8.9-11.2 using SD.

Conclusion

The MCID thresholds for the FACT-E subscales vary depending on when they are collected and how they are measured. In general, smaller thresholds of change are needed in the social and emotional well-being subscales, while larger ones are needed for the esophagus cancer subscale. Overall, the MCID for the FACT-E total score ranged from 6 to 11. Clinicians should consider these MCID if using the FACT-E to assess changes in patients’ symptom severity before and after esophagectomy.
482. REFLUXSTOP PROCEDURE IN THE LAPAROSCOPIC REPAIR OF HIATAL HERNIA
Authors: Zehetner Joerg
Published: September 2024

The video demonstrates laparoscopic anti-reflux surgery with the RefluxStop procedure, first introduced in 2016 and now offered in multiple centers across Europe. As this tertiary level hospital was among the first to offer this treatment to patients in clinical practice, this video provides unique insight to the lessons learned from the early experience of this surgery, with regard to optimizing effectiveness and safety. In light of the promising clinical outcomes that are emerging as follow-up data become available, the number of surgeons performing this this technique is likely to continue to increase.

The RefluxStop procedure addresses all 3 components of the anti-reflux barrier as follows: 1) laparoscopic hiatal hernia repair, 2) high mediastinal dissection to achieve 4-6 cm intraabdominal length of esophagus, allowing the LES to be brought into an optimal intraabdominal position, and 3) recreation of the flap valve at the angle of His though creation of a 90-degree esophago-gastric plication. The 22mm round silicone RefluxStop device is then positioned high-up and close to the esophagus in a fundic pocket, to maintain the correct position of the repair.

https://drive.google.com/file/d/1hlXXRUUMkDPmheW_mgPM_g1wWCu2R_Y3/view
491. STEP BY STEP INTRATHORACIC HAND-SEWN ESOPHAGOGASTRIC ANASTOMOSIS DURING TOTALLY ROBOTIC MINIMALLY INVASIVE TWO-STAGE ESOPHAGECTOMY
Authors: Farguell Jordi , Turrado Victor , Nuñez Hemberly Dereck , Gil Ignacio , Cardin Dra Verena , Curell Dra Anna , Ibarzabal Dra Ainitze , Pera Miguel , Momblan Dra Dulce
Published: September 2024

Background

In every esophagectomy, regardless of the approach, the creation of the anastomosis is a critical step. In minimally invasive esophagectomy, to avoid challenges of thoracoscopic suturing in the upper mediastinum most surgeons use stapling devices or even decide to do a cervical anastomosis. However, in robot-assisted minimally invasive esophagectomy, the surgeon benefits from increased dexterity that facilitates to perform a hand-sewn intrathoracic anastomosis.

Methods

A 67-year-old man with esophageal adenocarcinoma, staged as a T3N1 underwent neoadjuvant chemotherapy, followed by a fully robotic minimally invasive Ivor-Lewis esophagectomy (robotic surgery during both the abdominal and thoracic phase). For the thoracic phase, the patient was placed in left sided semi-prone position. An 8 mm robotic trocar is inserted in the 6th intercostal space for the camera. Two other 8mm robotic trocars were inserted in the 4th, 8th and a 12mm 10th intercostal space. The anastomosis was constructed at the level, just above the azygos vein.

Results

The esophagogastric anastomosis was performed with an end-to-end construction. A barbed 3.0 suture was used to close the posterior wall by a single-layer running hand-sewn technique. The esophagostomy and the gastrostomy were performed using vascular scissors. A 36Fr Faucher was placed to expose de inner layer during the esophagostomy. A second posterior continuous full-thickness layer was performed using barbed 3.0 suture. Finally, an anterior wall full-thickness layer was performed using the same suture. To protect the anastomosis an omental wrap was applied.

Conclusions

Totally robotic minimally invasive esophagectomy for the treatment of esophageal cancer is on the rise. It offers all the advances of minimally invasive techniques, like reduced rates of pulmonary and cardiac complications associated with open thoracotomy and shorter length of stay. Intrathoracic esophagogastric anastomosis still remains challenging and it is considered as the most difficult step of the procedure. Robotic transthoracic manual anastomosis has appeared to overcome this difficulties.

https://www.dropbox.com/scl/fi/km4oo66hhnb00k45e7ecq/Stepbystepmanual.mp4?rlkey=eb074cf3sj796byijqza0zoq6&dl=0
495. LAPAROSCOPIC FUNDOPLICATION IMPROVES ESOPHAGEAL MOTILITY IN PATIENTS WITH GERD A HIGH VOLUME SINGLE CENTER CONTROLLED STUDY IN HIGH-RESOLUTION MANOMETRY ERA
Authors: Santangelo Matteo , Vittori Arianna , Capovilla Giovanni , Provenzano Luca , Nicoletti Loredana , Costantini Andrea , Pittacolo Matteo , Forattini Francesca , Moletta Lucia , Valmasoni Michele , Savarino Edoardo V , Salvador Renato
Published: September 2024

Background

Pathophysiology of GERD is complex and esophageal motility disorders are frequently contributing to the disease. Most of the existing literature demonstrates that Laparoscopic Fundoplication (LF) is safe in the setting of ineffective or weak peristalsis, however the effect of the wrap on esophageal motility is still debated. This study aimed to assess how a functioning and effective fundoplication could impact the esophageal motility in patients with GERD.

Methods

We analyzed prospectively collected data on patients who underwent laparoscopic Nissen (LN) or Toupet (LT) fundoplication for GERD between 2010-2022. We selected patients who have been treated with LF according to the GERD international guidelines. The exclusion criteria were: patients with a giant hiatal hernia and patients with a proof of a too-tight LF.

Patients were evaluated with the GerdQ questionnaire, barium-swallow, endoscopy and HRM and 24-hour pH-Impedance before and after surgery. The HRM were reviewed by 2 experts (Chicago Classification v4.0). LF failure was recorded in case of an abnormal postoperative pH-MII using the Lyon 2.0 criteria.

Results

We recruited 124 patients (M:F=89:35). Fifty-eight LN and 66 LT were recorded. A good outcome at the 24-hour pH-Impedance was registered in 103 patients (GLF) and a failure in 21 patients (FLF).

As shown in Figure 1, in GLF patients, 29 had a preoperative motility disorder (24 IEM and 5 DES), and postoperatively 22 (76%) of these patients had a normalization of the esophageal motility. Ten FLF patients had a preoperative motility disorder (9 IEM and one DES); 4 (40%) of them showed normal motility after LF. There was a significant association between GLF and normalization of esophageal motility (p<0.05).

Conclusion

This study demonstrates that LF is an effective and functioning treatment in patients with GERD associated with an esophageal motility disorder. Moreover, our results indicate that LF could determine a normalization of the disordered esophageal motor function in patients with GERD.
496. OESOPHAGEAL STENTING IN BOERHAAVE SYNDROME: OUR EXPERIENCE
Authors: Vos Gigi , Martijnse Ingrid , Heisterkamp Joos , Laheij Robert , Matthijsen Robert
Published: September 2024

Introduction

Boerhaave syndrome is the spontaneous rupture of the oesophagus. This rare condition is associated with a high mortality. Its treatment remains controversial, with an aggressive surgical approach being most described.

In striving for the safest and most minimally invasive treatment for our patients, we opt for a multidisciplinary intervention: prompt endoscopic stenting of the esophageal defect in combination with optimal drainage of the pleural cavities. We reviewed our recent experience.

Methods

In our referral hospital, between October 2018 and October 2023, we treated nine patients with Boerhaave syndrome by prompt endoscopic stenting of the esophageal defect combined with drainage of either one or both pleural cavities, preferentially by thoracoscopy.

Retrospectively the data from these patients was analysed to provide an overview of our experience with this multidisciplinary approach.

Results

In total we have treated six men and three women with a median age of 61 years (53-82years). All patients received an endoscopy and pleural catheter drainage at presentation, combined with stenting of the 1-4cm esophageal defect.

In six patients (67%) the minimally invasive treatment was successful, with a median hospitalisation period of 33 days (17-77days) and median stent removal after 47 days (40-73days). All these patients reported a good oral intake.

Thoracoscopic debridement of the pleural cavity was performed in seven patients. In one patient endoscopic stenting failed with the need for an oesophagostomy. Two patients have deceased, resulting in 22% overall mortality.

Conclusion

Boerhaave syndrome is known to be a surgical emergency. From our experience we conclude that prompt endoscopic stenting of the oesophageal defect in combination with drainage of the pleural cavities is a safe and minimal invasive approach, even for cases with larger defects and extensive contamination of the thorax. Due to the rarity of the condition, data is limited. We advocate for a registration study to obtain the current golden standard.
507. LONG BARRETT´S ESOPHAGUS IN MONOZYGOTIC TWINS WITH ADENOCARCINOMA DEVELOPMENT
Authors: De Tomas Jorge , Tudela Ms Maria , Monturiol Jose Maria
Published: September 2024

Background

Familial aggregation of Barrett's esophagus (BE) and esophageal adenocarcinoma (EA) suggests a genetic pattern in fewer than 10% of patients with the former diseases. In 1983, BE was described in identical twins, underlining the hereditary influence on the development of mucosal dysplasia in some patients with this epithelial alteration. At present, some studies have attempted to identify chromosomal alterations among patients with familial aggregation of BE or EA, but there is not a clear pattern.

Methods

Description of the case report of a male patient who underwent esophagectomy due to EA on a long BE, who had a monozygotic twin without gastroesophageal reflux symptoms and no upper GI endoscopies before.

Results

A 53-year-old man was diagnosed with EA and a long BE (8 cm length) in 2017. He underwent CROSS neoadjuvant treatment and minimally invasive Ivor-Lewis esophagectomy. The pathological report indicated a GI T3N1M0 adenocarcinoma. Unfortunately, the patient developed lung metastases and passed away in 2019. Before that, the patient recalled that he had an identical twin brother with no gastroesophageal reflux symptoms, but we decided to scope him in 2017. The gastroscopy report revealed a 2 cm hiatal hernia with a long BE (C4M6 Prague Classification) but with no dysplasia. Nowadays, the twin patient is under close follow-up with proton pump inhibitors (PPI) and has not developed dysplasia.

Conclusion

Monozygotic twins provide a perfect model to study the possible influence of genetic predisposition to develop BE and EA. The development of EA in a patient guided us to diagnose and treat a long BE in his asymptomatic identical twin. More studies should be done to find the possible genetic alterations linked to familial aggregation of BE and EA.
510. INNOVATIVE ROBOTIC-ASSISTED ESOPHAGECTOMY WITH THREE-FIELD LYMPHADENECTOMY: A NOVEL APPROACH TO ESOPHAGEAL CANCER SURGERY
Authors: Patraithikul Premkamol , Swangsri Jirawat , Suwatthanarak Tharathorn , Nampoolsuksan Chawisa
Published: September 2024

Background

Esophageal squamous cell carcinoma, the predominant form of esophageal cancer in Thailand, often presents at advanced stages (III - IV), necessitating surgical intervention. Radical esophagectomy, including three-field lymphadenectomy, stands as one of the most invasive gastrointestinal surgeries. However, in the era of minimally invasive surgery (MIS), robotic systems have emerged as a formidable approach to achieve radical treatment goals while minimizing surgical invasiveness. This video showcases a novel surgical technique and its challenges.

Methods

A case of mid-thoracic esophageal squamous cell carcinoma, clinically staged III, treated via robotic-assisted esophagectomy and three-field lymphadenectomy using the Da Vinci Xi system. The operation encompassed three phases: Initially, the thoracic phase with patient in semi-prone position with three robotic and one assistant trocars for complete esophageal mobilization and mediastinal lymph node retrieval. The abdominal phase, followed by the cervical phase, utilized four robotic trocars and one assistant trocar in supine position with hyperextended neck, facilitating perigastric lymph node retrieval, gastric tube reconstruction via the posterior mediastinal route, and cervical esophago-gastric tube anastomosis using a circular stapler.

Results

The patient experienced an uneventful recovery. Postoperative esophagogastroduodenoscopy on day 1 revealed the integrity of the anastomosis and normal vocal cord function. Imaging conducted on day 7 confirmed that the anastomosis was patent without any leakage. Surgical outcomes included an operative time of 615 minutes, estimated blood loss of 150 ml, a 14-day hospital stay, and recovery without complications. This video highlights the intricacies of the procedure and the robotic system's ability to access anatomically challenging spaces, thereby minimizing surgical invasiveness and enhancing recovery.

Conclusion

The robotic system is capable of performing radical procedures in anatomically challenging areas, such as narrow spaces and areas requiring precise maneuverability among vital structures. It enables a comprehensive approach spanning from the upper to the lower thoracic regions and diversity of surgery in thoracic and abdominal cavity. Additionally, this presentation highlights unique surgical tips and techniques that enhance the safety and feasibility of robotic-assisted esophagectomy. By significantly reducing surgical errors and optimizing outcomes for both oncologic and minimally invasive surgeries, it thereby marks a significant leap forward in the field of esophageal surgery.

https://drive.google.com/file/d/1vrmu2D8TGoetnplcREPWQocXJle4PrOX/view?usp=share_link
511. IS IT SAFE TO USE NONABSORBABLE MESH IMPLANTATION FOR HIATAL REINFORCEMENT DURING PRIMARY ANTIREFLUX PROCEDURES?
Authors: Haidarzhi Yevhen
Published: September 2024

Background

Laparoscopic Fundoplication (LF) is highly effective in surgical treatment of GERD and the prevention of disease progression. Currently it is the gold standard of treatment and allows to achieve good and excellent postoperative results in majority patients. However, despite the gained experience, failures of primary LF and hiatus repair like hiatal hernia recurrence demonstrate that current surgical techniques are not optimal. One of the decisions is mesh implantation for hiatal reinforcement in GERD. However, due to the different types of complications (mesh erosion, scarring, dysphagia) safety use of mesh are still controversial.

Method

Laparoscopic Total Fundoplication (LTF) with nonabsorbable and composite light mesh implantation for hiatal reinforcement during 2022 – 2023 years were performed in 71 patients. We use macroporous nonabsorbable polypropylene or composite (polypropylene/monocryl) light mesh repair routinely by own proposed surgical technique. Our decision did not depend on size of hiatal hernia and hiatal surface area. We use U-shaped mesh posteriorly on the approximated crura by previous interrupted suturing not around the esophagus (Fig. 1). The mesh fixes with staples to the muscular and ligamentous structures of crura. We compared our results with the group of LTF without mesh implantation.

Result

All patients underwent completed validated questionnaires, esophagogasroduodenoscopy, contrast video esophagram, 24-hour impedance-pH monitoring after surgery. Some patients underwent computed tomography. Along with the disappearance of GERD symptoms, no mesh erosion and long (>3 month) postoperative follow-up dysphagia were marked in any patient with mesh repair. There are no significant difference in comparison with these results of LTF without mesh implantation. During the early postoperative period (< 12 months) no recurrence of hiatal hernia was diagnosed in the group with mesh implantation.

Conclusion

According to our study, in comparison with no-mesh repair, the proposed surgical technique is safe. Nonabsorbable and composite light mesh implantation for hiatal enforcement during primary antireflux procedures may be used routinely to prevent hiatal hernia recurrence effectively. Further, longer-term follow-up will be continued to confirm this position.
515. LAPAROSCOPIC PHARYNGO-COLOPLASTY WITH RIGHT COLON FOR A CASE OF COROSSIVE INJURY
Authors: Vijaya Kumar K , Ramesh N , Parthasarathi Ramakrishnan , Chinnusamy Palanivelu
Published: September 2024

Introduction

Corrosive stricture of esophagus and stomach is more common in Acid poisoning. Management these cases requires good surgical planning, technical expertise in doing these complex procedures

Case report

A34 year gentleman consumed small quantity of sulphuric acid. Feeding jejunostomy was done for improving the nutrition. After 9 months of initial insult Upper GI scopy and CT NECK, CHEST, ABDOMEN was done which confirmed complete esophageal stricture from cricopharyx, thickened entire stomach.

We Did LAPAROSCOPIC PHARYNGO-COLOPLASTY WITH RIGHT COLON. Intraoperatively thickened stomach, total gastrectomy done, Right colon used for Coloplasty.Post procedure patient recovered well, Drins removed on 4th post op day, patient was discharged on 6 th day.

https://drive.google.com/file/d/15OkPYKjsoQ-NVceBUzUArFAqMzcnA02S/view?usp=drive_web
516. HELLER MYOTOMY FOR SYMPTOMATIC ACHALASIA: TRADITIONAL LAPAROSCOPY OR ROBOTICS? A SYSTEMATIC REVIEW WITH META-ANALYSIS
Authors: Cuce Federica , Sacco Michele , Bencivenga Maria , Zenzaro Matteo , de Manzoni Giovanni , Giacopuzzi Simone
Published: September 2024

Background

Laparoscopic Heller myotomy (LH) has been established as the gold standard for symptomatic achalasia; robotic-assisted laparoscopic myotomy (RH) has shown promising outcomes regarding safety and effectiveness. We aim to meta-analyse data comparing LH and RH surgical outcomes and complications.

Methods

A systematic search was conducted in February 2024 without restrictions according to PRISMA guidelines in PubMed, Web of Science, Scopus, and Cochrane Register. Studies comparing laparoscopic and robotic approach for Heller myotomy in adults with symptomatic achalasia were included for systematic review. Meta-analysis was performed trough generalized linear mixed model in R 4.3.2.

Results

16 observational studies, out of 273, were included; reporting on 15076 patients. No statistically differences in preop characteristics were noted.

RH had significantly fewer intraoperative esophageal perforations (OR=7.29, p< 0.0001, 95%), fewer subsequent myotomies and endoscopic treatments for recurrence (OR= 3.64, p=0.01 and OR= 3.38, p=0.03) and better symptom score improvement (OR=0.507, p=0.04). Although not clinically significant, RH had shorter hospital stays (MD=0.45 days, p= 0.005,) and reduced intraoperative blood loss (MD=10.46 ml, p=0.0002).

Although not statistically significant, RH had fewer bleeding episodes, lower conversion, reintervention and mortality rates, comparable morbidity and postoperative GERD and higher operative time.

Conclusion

This updated meta-analysis suggests that RH is associated with lower regarding perforations, recurrence rates and symptom improvement compared to LH, with negligible lengthening of operative times.

RH for symptomatic achalasia represents a feasible treatment for symptomatic achalasia, with a satisfying safety and effectiveness profile.

RCTs on the topic and about cost-effectiveness evaluations are necessary to support the reported data.
518. ARTIFICIAL INTELLIGENCE MODELS VS CLINICIAN PERSPECTIVES OF IMPORTANT FACTORS IN OESOPHAGEAL CANCER DECISION-MAKING
Authors: Webb Catherine , Thavanesan Nav , Dewar-Haggart Rachel Dewar-Haggart Rachel , Naiseh Mohammed , Underwood Timothy , Vigneswaran Ganesh
Published: September 2024

Background

Decision-making for oesophageal cancer (OC) management remains multifaceted and nuanced in the face of a traditionally complex patient demographic. The evolving movement of artificial intelligence (AI) offers the potential of an imminent paradigm shift in traditional multidisciplinary team (MDT) workflow with Machine Learning models proving capable of encapsulating much of that decision-making framework. Clinician buy-in however stems from trust that such models accurately represent the perceptions and considerations of the MDT in its current form.

Methods

A mixed methodology study combining a national survey of United Kingdom OC MDT clinicians (sent to the British Society of Gastroenterologists, Association of Upper Gastrointestinal Surgery and UK& Ireland Oesophagogastric Cancer group) was conducted and compared with a Machine Learning (ML) based Random Forests model of treatment-decisions from a leading UK tertiary referral centre. The factors influencing OC treatment decisions from a human perspective were contrasted with variable importance from the AI approach. Human perceptions of barriers and attractions of AI-driven support tools were also explored to understand how human-AI collaboration could be facilitated in future.

Results

The National Survey which generated 67 responses found age and gender to play a more significant role in the ML model than they did in the clinicians' conscious decision-making process. Additionally, thematic analysis identified a variety of important factors, including molecular tests, symptoms, social circumstances, and nutritional status. The prospect of utilising AI-based decision support in the future received generally positive feedback, although opinions varied widely. Challenges to its adoption include perceptions of clinician superiority, the uniqueness of patient cases, the need for transparency and safeguards in the model, the requirements for data input, and the demand for proven effectiveness.

Conclusions

Comparison with the model highlighted demographic factors which appear to heavily influence treatment but were consciously deemed less important by clinicians. While overall, the response was positive towards an ML tool, some respondents felt very unwilling to use one. This could limit its adoption by MDTs unless decision-tools are developed to address such concerns around the barriers identified.
522. MULTI-SLICE, VOLUMETRIC COMPUTED TOMOGRAPHY BODY COMPOSITION ANALYSIS IN PATIENTS WITH OESOPHAGOGASTRIC CANCER
Authors: Brown Leo , Soupashi Maria , Yule Michael , Laird Barry , Wigmore Stephen , Skipworth Richard
Published: September 2024

Background

Single-slice computed tomography (CT) body composition has been studied extensively for prognostication in patients with cancer. New software packages can also provide multi-slice volumetric measurements, but the clinical utility of these remains under explored. This study aimed to evaluate the concordance between single- and multi-slice body composition analyses in patients with oesophagogastric cancer, and to explore the association between these measures and overall survival.

Methods

Consecutive patients with newly diagnosed oesophagogastric cancer were identified through the prospectively maintained regional database of the South-East Scotland Cancer Network across a 2-year study period. CT body composition analyses were undertaken using scans collected during routine clinical care. Single-slice (cross-sectional area at mid L3) and multi-slice (volume between T12-L4) measurements were obtained for skeletal muscle (SKM), subcutaneous adipose (SAT), visceral adipose (VAT) and intermuscular adipose (IMAT). Agreement between sex-stratified z-scores was quantified using Pearson correlation coefficients and Bland–Altman analyses. Cox proportional hazard modelling was used to estimate the effect of these measures on overall survival.

Results

Overall, 504 patients (67.9% male, median 72 years) were newly diagnosed with oesophagogastric cancer during the study period. Treatment was commenced with curative intent for 131 patients (26.0%). Single-slice area and multi-slice measurements were highly correlated for SKM (R: 0.97, p<0.001), SAT (R: 0.98, p<0.001) and VAT (R: 0.97, p<0.001), SKM radiodensity (R: 0.93, p<0.001) and IMAT (R: 0.88, p<0.001). Bias on Bland-Altman analysis was 0.00 for all tissue measurements. Limits of agreement (LoA) were narrowest for SAT (± 0.43), VAT (± 0.46) and SKM (± 0.48), but slightly wider for SKM radiodensity (± 0.73) and IMAT (± 0.96). Adipose tissue ‘outliers’ (those where agreement between single- and multi-slice z-scores was outside the LoA) had a higher median weight and body mass index (BMI), suggestive of poorer agreement in patients with obesity. Sensitivity analysis, excluding those with BMI >30, narrowed the LoA for SKM, VAT, SAT and IMAT. Direction and magnitudes of observed effect sizes for overall survival were all highly comparable, with hazard ratios for each tissue type varying by ≤0.04 between single- and multi-slice adjusted estimates.

Conclusions

Single-slice and multi-slice assessments of CT body composition provide highly correlated measurements for skeletal muscle, subcutaneous fat, visceral fat, and intra-muscular fat amongst patients with OG cancer. However, agreement between measurements is poorer in patients with obesity. The associations between these tissues measurements and overall survival are comparable across both types of body composition analysis.