bluuebunny/crossref_metadata_2025 huggingface dataset:
PS01.196: SHORT-TERM AND MEDIUM-TERM OUTCOMES IN PATIENTS OVER 70 DIAGNOSED WITH OESOPHAGEAL CANCER
Authors: Madhavan Anantha , Wyatt Nicola , Boreham Charlotte , Phillips Alexander , Michael Griffin S
Published: September 2018

Background

Oesophageal cancer incidence has increased over the last decade in the UK, particularly in older patients. Surgery, with or without perioperative chemotherapy, remains the gold standard treatment for patients with potentially curable disease. Currently, 41% of new cases of oesophageal cancer are in patients aged over 70. However, only 10% underwent surgery compared to 25% of those aged under 70. Concerns exist that advanced age may prejudice treatment decisions. The aim of our review is to evaluate the impact of age on outcomes in those undergoing planned curative treatment for oesophageal cancer.

Methods

A retrospective review of patients undergoing oesophagectomy for carcinoma between 2006 to 2016 at a single institution was performed. Patients were divided into two cohorts based on age at the time of diagnosis; under 70 years (Group A) and over 70 (Group B). Patients underwent a standardised staging protocol and treatment was decided by a multi-disciplinary team. Oesophagectomy was performed using a transthoracic approach with two field lymphadenectomy and perioperative chemo (radio) therapy used in those patients with locally advanced disease who were fit enough.

Results

There were 555 patients in Group A and 241 in Group B. Adenocarcinoma was the prevalent histological subtype in both cohorts: 76% (423) in Group A and 68% (165) in Group B. Median age at the time of diagnosis was 62 in Group A versus 74 in Group B. In Group A, 12% (18/343) did not receive neo-adjuvant treatment for locally advanced cancer versus 47% (101/212) in Group B (P < 0.001). Median hospital stay was longer in Group B (18 v 15 days P = 0.02). There was no significant difference in hospital mortality (Group A 1% vs Group B 2.4% P = 0.37) and major complication rate (Group A 14% vs Group B 20% P = 0.31). Two-year survival was 66% (adenocarcinoma) and 78% (SCC) in Group A compared to 60% (adenocarcinoma) and 64% (SCC) in Group B.

Conclusion

These results demonstrate that patients over 70 can be treated successfully with minimal additional risk to morbidity and mortality. However, these patients are more likely to be denied neoadjuvant treatment which may compromise their long-term outcomes.

Disclosure

All authors have declared no conflicts of interest.
PS01.202: MANAGEMENT OF RESECTABLE ESOPHAGEAL AND GASTRIC (MIXED ADENO)NEUROENDOCRINE CARCINOMA: A NATIONWIDE COHORT STUDY
Authors: Van Der Veen A , Seesing Mfj , Wijnhoven Bas P L , Steur Wo , Van Berge Henegouwen Mark I , Rosman Camiel , Van Sandick Johanna , Mook Stella , Haj Mohammad Nadia , Hillegersberg Richard , Ruurda Jelle , Brosens Lodewijk
Published: September 2018

Background

Esophageal and gastric neuroendocrine- and mixed adenoneuroendocrine carcinomas (NEC, MANEC) are very rare. Optimal treatment strategies, the role of surgery and outcomes remain unclear. The aim of this study is to provide insight in accuracy of diagnosing, current treatment and survival in patients with resectable esophageal and gastric (MA)NEC.

Methods

All patients with esophageal or gastric (MA)NEC, who underwent surgical resection between 2006–2016, were identified from the Dutch national registry for histo- and cytopathology (PALGA). Patients with a neuroendocrine tumor lower than grade 3 were excluded. Data on patients, treatment and outcomes were retrieved from the patients record. Diagnosis by endoscopic biopsy was compared with diagnosis by resection specimen. Kaplan Meier survival analysis was performed.

Results

A total of 49 patients were identified in 25 hospitals, including 21 patients with esophageal (MA)NEC and 26 patients with gastric (MA)NEC on resection specimen. Biopsy diagnosis of (MA)NEC was correct in 23/27 patients. However, 20/47 patients with definitive diagnosis of (MA)NEC, were misdiagnosed on biopsy. Neoadjuvant therapy was administered in 13 (62%) esophageal (MA)NECs and 12 (46%) gastric (MA)NECs. Survival curves were similar with and without neoadjuvant therapy. One (4.8%) esophageal (MA)NEC and 4 (15%) gastric (MA)NECs died within 90 days postoperatively. For esophageal (MA)NEC the median overall survival (OS) after surgery was 37 months and 1-, 3- and 5-year OS were 71%, 50% and 35%, respectively. For gastric (MA)NEC, the median OS was 23 months and 1-, 3- and 5-year OS were 62%, 50% and 39%, respectively.

Conclusion

Localized esophageal and gastric (MA)NEC are often misdiagnosed on endoscopic biopsies. After resection, long-term survival was achieved in respectively 35% and 39% of patients.

Disclosure

All authors have declared no conflicts of interest.
PS01.206: ASSESSMENT OF THE GASTRIC CONDUIT RECONSTRUCTION USING INDOCYANINE GREEN FLUORESCENT IMAGING DURING ESOPHAGECTOMY
Authors: Yamabuki Takumi , Ohara Masanori , Kaneko Tsukasa , Fujiwara Aki , Takahashi Ryou , Komuro Kazuteru , Iwashiro Nozomu
Published: September 2018

Background

Recently, indocyanine green (ICG) fluorescent imaging has been applied as a real-time navigation tool in various surgical fields. We used ICG fluorescent imaging for gastric conduit reconstruction during esophagectomy.

Methods

A total of 92 consecutive patients with esophageal cancer who received gastric conduit reconstruction during esophagectomy from February 2011 to December 2017 were enrolled in the present study. We made gastric conduit with hand-assisted laparoscopic surgery (HALS) following esophagectomy. A gastric conduit with a width of 3cm was usually fashioned. After evaluation of the blood flow to the gastric conduit using ICG fluorescent imaging, anastomosis was done by circular stapler.

Results

The study group was comprised of 73 males and 19 females and the median age was 70 years (range 54–85 years). Nineteen patients received preoperative chemotherapy and eleven patients received preoperative chemo-radiotherapy. Forty-eight patients underwent thoracoscopic esophagectomy, nineteen patients underwent thoracotomy and twenty-five patients underwent laparoscope assisted transhiatal esophagectomy. In eighty-five patients, reconstruction was done via the posterior mediastinal route, while six patients ware treated by the retrosternal route, and the subcutaneous route was used in one patient. Cervical anastomosis was done in 84 patients and intrathoracic anastomosis was done in eight patients. The complications of the gastric conduit reconstruction were anastomotic leakage in one (1.1%) patient and stricture of the anastomosis site requiring esophageal dilatation in 26 (28.3%) patients. Periodic esophageal dilatation was done in 13 (14.1%) patients. There was one case of stricture of the gastric conduit, one case of bleeding of the gastric conduit and one case of fistula between the gastric conduit and the lung.

Conclusion

The gastric conduit reconstruction using ICG fluorescent imaging during esophagectomy may contribute to a reduction in the incidence of anastomotic leakage. However, further advancement of the relevant skills is required to improve the incidence of stricture of the anastomosis site.

Disclosure

All authors have declared no conflicts of interest.
PS01.211: IMPLEMENTATION OF A TOTALLY MINIMALLY INVASIVE OESOPHAGECTOMY PROGRAMME IN A UK SPECIALIST CENTRE: INITIAL EXPERIENCE AND OUTCOMES
Authors: Akitikori Temisanren , Lorenzi Bruno , Shanmuganathan Kanatheepan , Soile Oluwasunmisola , Hussain Aadil , Farhangmehr Neda , Sdralis Elias , Venkatesh Jayanthi Naga , Charalabopoulos Alexandros
Published: September 2018

Background

Totally minimally invasive oesophagectomy although challenging to perform has garnered popularity in the surgical treatment of oesophageal cancer. Advanced laparoscopic surgical skills are needed with the construction of the intra-thoracic anastomosis in the case of a 2-stage procedure being the rate-limiting step. We aim to report our initial experience and short-term outcomes of totally minimally invasive 3-stage and 2-stage oesophagectomies for cancer.

Methods

From January 2016 when the minimally invasive oesophagectomy programme was implemented in our Unit, to December 2017, 65 consecutive cases underwent either a 2-stage or a 3-stage oesophagectomy for cancer. In all cases a radical 2-field lymph node dissection was performed. All were performed in a prone position and in the 3-stage oesophagectomies, superior mediastinal lympadenectomy was additionally performed. In the 2-stage cases an end-to-side esophago-gastric anastomosis was constructed in two layers with barbed knotless suture (V-LocTM).

Results

Male: female was 4:1 with a mean age of 66.44 years (IQR, 43–82). n = 53 were 2-stage and 12 were 3-stage oesophagectomies. Thirty five (53.8%) had neoadjuvant chemotherapy and 30(46.2%) went straight to surgery. There were no open conversions. No feeding jejunostomies were placed routinely. Complete resection (R0) rate was 61.54% (40/65) with a mean lymph node harvest of 28 (IQR, 11–68). Five (7.6%) anastomotic leaks were diagnosed (4 in 2-stage and 1 in 3-stage oesophagectomies), with 1(1.5%) of them (in the 2-stage group) being subclinical requiring no intervention. Furthermore, 1(1.5%) chyle leak and 1(1.5%) gastric staple line leak were also observed. Pulmonary complications were reported in 13.8% of cases and cardiac complications arose in 1.5%. Seven (10.8%) anastomotic strictures were also noted that were treated with endoscopic balloon dilatation. Mean hospital stay was 13 days and 30-day mortality rate was 4.62%.

Conclusion

Implementation of a minimally invasive oesophagectomy program in our high-volume tertiary centre is yielding good initial results. Vast previous experience in the field is of paramount importance. Hand-sewn intrathoracic anastomosis during 2-stage procedures is feasible and with repetitively good outcomes.

Disclosure

All authors have declared no conflicts of interest.
PS01.216: INTRODUCING MINIMAL INVASIVE OESOPHAGECTOMY AT A DEPARTMENT
Authors: Ainsworth Alan , Larsen Michael , Fristrup Claus
Published: September 2018

Background

Minimal invasive oesophagectomy has gained increasing popularity. This study reports the results of the first two years after introducing the technique at our department.

Methods

All procedures have been prospectively registered in a database. All patients were followed until death, 2 years after surgery, or end of the inclusion period.

Results

140 procedures were performed (23 November 2015 to 1 February 2018). There were 19 women and 121 men. Median age was 67 years (range 16–83 years). Pathologic T-and N-stage is shown in table 1. Patients were divided into the first 70 patients and the last 70 patients. The mean procedure time was 352 minutes for the ‘first patients’ and 331 minutes for the ‘last patients’ (P < 0.001). The risk for conversion to open surgery in the abdominal procedure was 6% for the ‘first patients’ and 9% for the ‘last patients’ (NS). For the thoracic procedure the corresponding figures were 11% and 6% (NS), respectively. Median length of postoperative stay was 9 days for both groups. The risk of anastomotic leakage was 16% (‘first patients’) and 11% (‘last patients’) (NS). However, in only 4% and 7%, respectively, endoscopic or surgical treatment was required. For all 140 patients, pulmonary complications were observed in 26 cases (18%) and cardiac complications were registered in 15 cases (11%).The 30 day mortality rate was 3% (131 patients) and the 1 year survival rate was 83% (53 patients). Table 1: Pathologic T-and N-stage

Conclusion

Minimal invasive oesophagectomy can be introduced at a department with acceptable short time morbidity.

Disclosure

All authors have declared no conflicts of interest.
PS01.222: HAS A MEDIASTINOSCOPE-ASSISTED ESOPHAGECTOMY CONTRIBUTE TO CURABILITY AND MINIMAL INVASIVE SURGERY?
Authors: Uchikado Yasuto , Omoto Itaru , Sasaki Ken , Okumura Hiroshi , Kita Yoshiaki , Owaki Tetsuhiro , Osako Yusaku , Arigami Takaaki , Yanagita Shigehiro , Ishigami Sumiya , Natsugoe Shoji
Published: September 2018

Background

In a mediastinoscope-assisted esophagectomy, it is unknown whether it contributes to minimally invasive surgery or curability. We examined the outcome of treatment of a mediastinoscope-assisted esophagectomy performed in our hospital.

Methods

From June 2014 to October 2017, 31 patients underwent a mediastinoscope-assisted esophagectomy. The examined items were clinicopathological factors, preoperative complications, preoperative treatment, bleeding volume, operation time, postoperative complications, and recurrence.

Results

There were 29 males, 2 females, and the average age 66 years. As preoperative treatment, 12 nontreatment, 4 chemotherapies, and 15 chemoradiotherapy (CRT) were performed. Preoperative complications were found in 27 cases, among which 13 cases were respiratory complications. The percentage of double cancers was also high, 8 cases with synchronous cancer, and 6 cases with metachronous cancer. Gastric cancer accounted for half in synchronous cancer, and in metachronous lung cancer was 4 cases. The reconstructed organs were 29 cases of stomach tube and 2 cases of colon. The reconstruction route was 17 cases in front of the chest wall and the chest wall anterior route was selected for the case of preoperative CRT significantly. The average bleeding volume was 316 ml, and the average operation time was 560 minutes. Pathological tumor depth T0/1a/1b/2/3 were each 2/11/6/7/4 cases. In the postoperative complications, 12 cases of temporary recurrent nephropathy, 5 cases of anastomotic suture failure, 3 cases of pulmonary complications. There were 6 cases (19.3%) of recurrence. Postoperative recurrence was associated with significant pathological tumor depth.

Conclusion

A mediastinoscope-assisted esophagectomy decreased postoperative pulmonary complications and there were not many recurrences after surgery. It seemed to contribute to minimally invasive surgery and curability.

Disclosure

All authors have declared no conflicts of interest.
PS01.224: MODIFIED INTRATHORACIC ESOPHAGOGASTROSTOMY AT MINIMALLY INVASIVE ROBOT-ASSISTED IVOR-LEWIS ESOPHAGECTOMY FOR CANCER
Authors: Wang Wen-Ping , Chen Long-Qi , Zhang Han-Lu , Yang Yu-Shang , He Song-Lin , Wang Yun
Published: September 2018

Background

The intrathoracic esophagogastrostomy played important role in minimally invasive Ivor-Lewis esophagectomy for cancer. The methods of intrathoracic esophagogastric anastomosis at robot-assisted Ivor-Lewis esophagectomy mostly included hand-sewn, and circular stapler (anvil placement via OrVil system or transthoracically), which were still technically challenging. In this study, we modified the techniques of intrathoracic esophagogastric anastomosis at robot-assisted Ivor-Lewis esophagectomy for cancer, in order to seek to simplify this complicated intrathoracic procedure. Then retrospective comparison between robotic and thoracoscopic cohorts was conducted.

Methods

We modified techniques focused on the ‘side-insertion’ anvil placement and purse string suture of intrathoracic robot-assisted esophagogastric anastomosis. The consecutive records of patients who underwent minimally invasive Ivor-Lewis esophagectomy for cancer via robot-assistant and thoracoscopic procedures in our department between January 2015 and November 2017 were retrospectively analyzed.

Results

Totally 47 patients were enrolled including 20 patients (male: 17, female: 3) in robot-assisted group and 27 patients (male: 21, female: 6) in thoracoscopic group. There was no conversion to open thoracotomy in both two groups. Mean operation duration of robotic group was 412.5 ± 63.5 min, significantly higher than 363.0 ± 53.3 min in thoracoscopic group (P = 0.006). Estimated blood loss in robotic group was less than that in thoracoscopic group (107.5 ± 63.5ml vs. 188.9 ± 94.3ml, respectively, P = 0.002). One patient (5.0%) in robotic group and two patients(7.4%) in thoracoscopic group had anastomotic leak. No postoperative reoperation or mortality (in-hospital or within 30 days after surgery) occurred in both groups.

Conclusion

Robot-assisted Ivor-Lewis esophagectomy was safe and feasible. Our modified procedure highlighting the ‘side-insertion’ method could simplify the process of intrathoracic anvil placement and purse string suture for the robot-assisted esophagogastric anastomosis. Robot-assisted Ivor-Lewis esophagectomy was nearly equivalent to thoracoscopic Ivor-Lewis esophagectomy at short-term outcomes, except higher operation time and less blood loss.

Disclosure

All authors have declared no conflicts of interest.
PS01.230: THE THREE-DIMENSIONAL ANIMATION ILLUSTRATING THE UPPER MEDIASTINAL ANATOMY FOR VIDEO-ASSISTED TRANSCERVICAL APPROACH IN ESOPHAGEAL CANCER SURGERY
Authors: Shinohara Hisashi , Kurahashi Yasunori , Ozawa Rie , Nakanishi Yasutaka , Niwa Hirotaka , Ishida Yoshinori
Published: September 2018

Description

Video-assisted transcervical approach may be promising for the upper mediastinal lymphadenectomy in patients with esophageal cancer. However, it is difficult to recognize positioning of landmark organs, such as the bronchus, recurrent nerves, and major vessels, since the operating field is unfamiliar for most surgeons and any anatomical charts have failed to show. Using a technique of the computer graphics, we have created three-dimensional animation illustrating the upper mediastinal anatomy which includes stepwise positional change of such landmark organs depending on progress of the dissection of the esophagus. This animation clip will become a useful tool for education for surgeons who introduce transcervical approach in upper mediastinal lymphadenectomy in video-assisted esophageal cancer surgery.

Disclosure

All authors have declared no conflicts of interest.
PS01.232: SHORT-TERM OUTCOMES OF ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: He Haiqi , Fu Junke , Zhang Guangjian
Published: September 2018

Background

Surgical resection with radical lymphadenectomy is a pivotal component in the multidisciplinary therapy of esophageal cancer. Minimally invasive esophagectomy was shown to be effective in reducing the morbidity and was adopted increasingly. As a novel minimally invasive technique, robot-assisted esophagectomy remains in the initial stage ofapplication. This study describes the single-institution experience of robotic esophagectomy.

Methods

Between March 2016 and October 2017, 20 consecutive patients underwent robot assisted esophagectomy at our institute. The thoracic and abdominal mobilization were all performed with the assistance of the robot. We retrospectively collected the operative data and postoperative outcomes.

Results

The majority of patients were male (80%), and the median age was 62 years. The average operative time was 342 minutes (range 280–440). The average blood loss was 112 ml (range 50–400). No patient experienced conversion to a thoracotomy or laparotomy. R0 resection was achieved in all patients, the mean number of dissected lymph nodes was 19 (range 8–32). No 90-day operative mortality was observed, and postoperative complications were present in 8 of 20 patients (40.0%). Pulmonary complications were the most common event and were observed in 3 patients. Two patients experienced an anastomotic leak.

Conclusion

Our study demonstrated that robot-assisted esophagectomy is a safe and technically feasible alternative to conventional thoraco-laparoscopic esophagectomy.

Disclosure

All authors have declared no conflicts of interest.
PS01.235: THE METHOD AND THE SHORT OUTCOME OF MEDIASTINAL LYMPH NODES DISSECTION FOR ESOPHAGEAL CANCER USING A TRANS-BICERVICAL AND TRANSHIATAL APPROACH UNDER THE PNEUMOMEDIASTINUM
Authors: Tokairin Yutaka , Nakajima Yasuaki , Kawada Kenro , Hoshino Akihiro , Okada Takuya , Ryotokuji Tairo , Okuda Masafumi , Kume Yuichiro , Kawamura Yudai , Yamaguchi Kazuya , Nagai Kagami , Akiata Keiichi , Kinugasa Yusuke
Published: September 2018

Background

We previously reported the performance of mediastinoscopic esophagectomy with lymph node dissection (MELD) under pneumomediastinum using a transcervical and transhiatal approach as a method of radical esophagectomy. For more complete lymph node dissection, it is necessary to dissect via not only left cervical but also right cervical approach in pneumomediastinum. We herein report the dissection method for upper mediastinum using a cervico-pneumomediastinal approach including right cervical approach in pneumomediastinum and the short surgical outcome.

Methods

This method was applied to nine cases for esophageal cancer. The right recurrent nerve was first identified using an open approach. Pneumomediastinum was then initiated to allow for the 105 and 106recR lymph nodes to be completely dissected along the right mediastinal pleura, the right vagus nerve, the proximal portion of the azygos vein and the right bronchial artery. The left recurrent nerve (106recL) lymph nodes and 106tbL lymph nodes were dissected using a cross-over technique, as described previously.

Results

This operation using bilateral cervical approach in pneumomediastinum were performed for nine cases. The median operation time and bleeding is 606 minutes and 506 ml, respectively. The median post-operative stay is 15 days.

Conclusion

MELD is therefore considered to be a more minimally invasive and useful modality for radical esophagectomy than the thoracic approach, although the field of view is different from that of the thoracic approach.

Disclosure

All authors have declared no conflicts of interest.
PS01.237: SAFETY OF RECURRENT LARYNGEAL NERVE NODAL DISSECTION IN PATIENTS WITH ESOPHAGEAL CANCER WHO HAD UNDERGONE CHEMORADIOTHERAPY
Authors: Chao Yin-Kai , De Leon Ayala Ivan
Published: September 2018

Background

Lymph node dissection (LND) along the recurrent laryngeal nerve (RLN) is a challenging surgical procedure that carries a high risk of morbidity, especially in patients who had undergone chemoradiotherapy (CRT). Here, we retrospectively examined the feasibility and safety of thoracoscopic RLN LND in patients with esophageal cancer who had been previously treated with CRT.

Methods

Patients with esophageal cancer who had undergone thoracoscopic esophagectomy with RLN LND were divided into two groups according to prior treatment with CRT or not (CRT group versus upfront surgery [US] group, respectively). Intergroup comparisons were made in terms of 1) number of dissected nodes, 2) rates of RLN palsy, and 3) rates of perioperative complications. The learning curve for the RLN LND procedure was investigated with the cumulative sum (CUSUM) method.

Results

A total of 103 patients with esophageal cancer were included in the study (CRT group: n = 65; US group: n = 38). No conversion to open thoracotomy was required in either group. Moreover, intraoperative blood loss and the need for blood transfusions were similar. The technical challenges of RLN LND after CRT were more evident when performed in the left side. Accordingly, complete skeletonization of the left RLN was achieved only for 66.2% of patients in the CRT group, a percentage significantly lower than that obtained in the US group (86.8%; P = 0.022). Similarly, the rate of postoperative RLN palsy in the left side was significantly higher in the CRT group than in the US group (32.6% vs. 9.1%, respectively, P = 0.015), albeit not resulting in higher pneumonia rates. CUSUM analysis revealed a steep learning curve for left RLN LND performed in patients who had undergone CRT. Significant fluctuations in RLN palsy rates were observed over time, suggesting that proficiency did not improve linearly with increasing surgical experience.

Conclusion

To our knowledge, this is the first study to specifically investigate the feasibility and safety of thoracoscopic RLN LND in patients with esophageal cancer who had undergone CRT. Our data indicate that RLN LND is feasible even after CRT, although the technical challenges to be faced are greater than in CRT-naïve patients.

Disclosure

All authors have declared no conflicts of interest.
PS01.238: MESENTERY-ORIENTED LYMPH NODES DISSECTION AND INTRA-OPERATIVE NEURAL MONITORING TO REDUCE THE POSTOPERATIVE RECURRENT LARYNGEAL NERVE PARALYSIS IN ESOPHAGECTOMY
Authors: Kobayashi Hiroyuki , Mizumoto Motoko , Kondo Masato , Kita Ryosuke , Masui Hideyuki , Kitano Shoichi , Kumata Yukiko , Matsubara Takaaki , Shiokawa Keiichi , Kaihara Satoshi , Hosotani Ryo
Published: September 2018

Description

Background: As the thoracic esophageal carcinoma has a high metastatic rate of upper mediastinal lymph nodes, especially along the recurrent laryngeal nerve (RLN), it is crucial to perform complete lymph nodes dissection along the RLN without complications. Although Intraoperative neural monitoring (IONM) during thyroid and parathyroid surgery has gained widespread acceptance as the useful tool of visual nerve identification, the utilization of IONM during esophageal surgery has not become common. Here, we describe our procedures focusing on a lymphadenectomy along the RLN utilizing the IONM. Methods and Procedures: We first dissect ventral and dorsal side of the esophagus preserving the membranous structure (mesoesophagus), which contains tracheoesophageal artery, RLN and lymph nodes. We next identify the location of the RLN which runs in the mesoesophagus using IONM before visual contact. After that, we perform lymphadenectomy around the RLN preserving the nerve. To evaluate the efficacy of this method, we compared short term surgical outcome of our 36 consecutive cases (neural monitoring group; Nm) of esophagectomy in prone positioning with 56 of our historical cases (conventional method group; Cm). Results: In all 36 cases of Nm group, we could obtain the location information of the RLN before the visual contact. Although the operation time of thoracic part was significantly longer in Nm group compared to Cm group (281 min vs. 254 min each, P = 0.005), postoperative RLN paralysis according to postoperative laryngoscopy was seen in 3 cases (8.3%) after surgical operation in Nm group, which was significantly lower than that in the Cm group (18/56, 32.1%, P = 0.005). As a result, median postoperative hospital stay was significantly shorter in Nm group than Cm group (22 days vs. 39 days each, P = 0.0003). Conclusion: Mesentery-oriented lymph nodes dissection using IONM has substantial advantages to perform accurate and safe thoracoscopic esophagectomy. It could decrease the RLN paralysis and postoperative hospital stay after esophagectomy.

Disclosure

All authors have declared no conflicts of interest.
PS01.239: MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER IN PATIENTS WITH AIDS: AN ENTITY ON THE RISE
Authors: Lorenzi Bruno , Farhangmehr Neda , Akitikori Temisanren , Shanmuganathan Kanatheepan , Soile Oluwasunmisola , Hussain Aadil , Sdralis Elias , Charalabopoulos Alexandros
Published: September 2018

Background

Recently it was reported by World Health Organization that over 36 million people are living with HIV globally; for the first time ever life expectancy in people with HIV exceeds the average. This is mainly due to the development of highly active antiretroviral medication that have turned AIDS from a life threatening disease to a chronic condition. HIV patients are as prone as the general population to developing esophageal cancer. We aim to describe our experience and factors for consideration whilst treating HIV patients with esophageal cancer.

Methods

In 2017, 77 cases were surgically treated for esophageal and gastroesophageal junction cancer in our tertiary referral centre. n = 2 (2.5%) were HIV positive. Their disease, demographic and surgical characteristics were analyzed and the outcomes are presented.

Results

A 62 and 65-year-old HIV male patients had 2-stage esophagectomy for gastro-esophageal junction adenocarcinoma. They both had similarities with locally advanced tumours and late presentation with dysphagia and > 10% total body weight loss. Clinical staging revealed T3N2M0 tumours in both cases. Viral load was low (< 40 copies/mL) and both had neoadjuvant chemotherapy as first line of treatment. Both had a 2-stage esophagectomy; one had laparoscopic-assisted and the other had totally minimally invasive. Histological staging was ypT3N1 and ypT3N3 respectively. Antiretroviral medications were in both started enterally on day 1; in the first case via a triple-lumen nasojejunal feeding tube and in the second via a single-lumen nasogastric tube. No feeding jejunostomies were placed. No immediate post-operative complications were noted. Length of stay was 14 and 8 days respectively.

Conclusion

AIDS patients with esophageal cancer can present late, with advanced tumors, as dysphagia is common due to fungal esophagitis and tends to be underestimated. Where indicated, this cohort of patients should receive full multimodality treatment, like the general population, as results are no different. Multidisciplinary approach with involvement of an HIV specialist doctor from the beginning of treatment planning is of paramount importance as optimization prior to surgery is commonly necessary. Antiretroviral medications are needed immediately post-operatively in all cases and a clear plan for enteral route administration should be in place.

Disclosure

All authors have declared no conflicts of interest.
PS01.240: ROBOTIC ESOPHAGECTOMY USING THE DA VINCI XI: INITIAL EXPERIENCE FROM A TERTIARY CANCER CENTRE
Authors: Jiwnani Sabita , Tantravahi Umasankar , Ingle Parag , Patil Vijayraj , Karimundackal George , S Pramesh C
Published: September 2018

Background

Esophagectomy is a daunting procedure with a steep learning curve. Minimally invasive esophagectomy is associated with reduced perioperative complications. However, most studies so far have evaluated thoracoscopic or laparoscopic approaches. We describe our initial experience with robotic esophagectomy using the da Vinci Xi system.

Methods

We performed a retrospective analysis of a prospectively maintained database of patients operated with radical intent for esophageal cancer between November 2014 and November 2017.

Results

Thirty-four of the 483 curative esophagectomies were performed robotically. We performed the thoracic part in the semi-prone position and the abdominal part in a supine position. The thoracic component of the procedure was completed robotically in all 34 patients. For the abdominal approach, 19(55.9%) patients underwent gastric mobilization by the robotic approach, 9(26.5%) by the laparoscopic approach, and 6(17.6%) by laporotomy. The median age was 51 years and 76.5% of the patients were male. 73.5% of the patients had T3 tumours and 52.9% of the patients did not have significant nodes (N0) on preoperative imaging by PET-CT. 70.6% of the patients received neoadjuvant chemotherapy and 2.9% of the patients received neoadjuvant chemoradiotherapy. Standard two field (infracarinal and abdominal) lymphadenectomy was performed in 88.2% and three field lymphadenectomy in 11.8%. The median blood loss was 275 ml, with 85% of patients having blood loss below 400ml. The total surgical time (including docking and changing patient position) was 390 min. No patient needed intra or post-operative blood transfusion. Median ICU and hospital stay were 0.6 days and 10 days respectively. Major morbidity (Clavin-Dindo score > 3A) occurred in 17.6% with one post-operative mortality (2.9%). Pulmonary complications were seen in 8.8% and anastomotic leak in 11.8%. The median lymph nodes retrieved were 18. At a median of 24-months follow-up, the disease free survival was 58%, and the overall survival was 70%.

Conclusion

Transthoracic total esophagectomy is safe and feasible through the robotic approach. Larger studies with longer follow-up are needed to establish robotic esophagectomy as a standard surgical option for patients with esophageal cancer.

Disclosure

All authors have declared no conflicts of interest.
PS01.243: THORACOSCOPIC IVOR LEWIS MIE WITH END-TO-SIDE INTRATHORACIC ESOPHAGOGASTROSTOMY BY USE OF CIRCULAR STAPLER: INITIAL EXPERIENCE AND COMPARISION WITH MCKEOWN MIE
Authors: Ziccarelli Antonio , Vecchiato Massimo , Concina Serena , Petri Roberto , Martino Antonio
Published: September 2018

Background

Minimally invasive esophagectomy (MIE) has been met with increased interest for the surgical treatment of esophageal cancer. One critical obstacle for the implementation of MIE has been the intrathoracic anastomosis. In this study, we describe a technique of Ivor Lewis MIE in prone position and we present the short-term outcomes of this procedure compared to the McKeown MIE.

Methods

A total of 53 consecutive patients with with an Adenocacinoma of the gastroesophageal junction (GEJ) or the distal esophagus esophageal who had undergone MIE were included in the analysis. The clinical outcomes were analized and compared between the 24 patients treated with thoracoscopic two field Ivor Lewis (IL) MIE with intrathoracic stapled End-to-side anastomosis and 29 patients treated with thoracoscopic three field McKeown (McK) MIE with cervical stapled End-to-side anastomosis. The main outcome was postoperative respiratory complications. The secondary outcomes included the length of the operation, blood transfusion, number of dissected lymph nodes, postoperative morbidities and mortality.

Results

No statistical difference was found between postoperative respiratory complications (p: 0, 475), operative time (p: 0395), Lymph node retrieved (p: 0864), blood transfusion (p: 0951), ICU stay (p: 0131), oral intake in days (p: 0592), post operative stay (p:0830), anastomotic leakage (p: 0669), overall morbidity (p:0400), mortality (p: 0267). Anastomotic stenosis were more frequent in the McKeown group (p: 0062).

Conclusion

The intrathoracic stapled end-to-side anastomosis technique seems to be feasible, safe, and easy to perform, associated with a limited postsurgical complication rate and a good functional outcome.

Disclosure

All authors have declared no conflicts of interest.
PS01.244: MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER WITH THE PATIENT IN PRONE POSITION: EXPERIENCE OF 156 CONSECUTIVE CASES IN A SINGLE CENTER
Authors: Ziccarelli Antonio , Vecchiato Massimo , Lirusso Chiara , Rosignoli Alessandro , Silvestro Roberto , Innocente Roberto , Petri Roberto , Martino Antonio
Published: September 2018

Background

Minimally invasive esophagectomy is performed with increasing frequency and proves to be a safe and effective surgical alternative to the open technique. Minimally invasive esophagectomy using thoracoscopic esophageal mobilization with the patient in prone position seems to offer some advantages with regard to surgeon ergonomics and clinical outcome.

Methods

Between July 2005 and December 2017, 156 patients underwent minimally invasive esophagectomy in the prone position at the authors' institutionin. Was performed 132 three field McKeown MIE (84,6%) with circular stapled cervical anastomosis and 24 two field Ivor Lewis MIE (15,4%) with circular stapled intrathoracic anastomosis; For four patients (2,6%) the colon was used for cervical anastomosis, and two patients (1,3%) had previously undergone left pneumonectomy because of lung cancer. The preoperative indication was squamous cell carcinoma for 100 patients (64,1%) and adenocarcinoma for 53 patients (33,9%). In three cases (1,9%), the histology of the specimen showed a squamous cell carcinoma with neuroendocrine differentiation. Neoadjuvant treatment was administered to 79 patients (50,6%)

Results

In 152 patients (97,4%) was performed esophagectomy using minimally invasive thoracic mobilization of the esophagus with the patient in prone position. In four cases (2,6%) an early thoracotomic conversion was necessary due to the presence of lung adhesions such that made it impossible to establish the pneumothorax. The mean operative time was 255 min (range: 130–420 min). The median intensive care unit stay was 2 days (range: 0–77 day), and the median postoperative hospital stay was 15 days (range: 8–79 day). The mean number of procured lymph nodes was 16 (range: 0–56 Ln). The perioperative pulmonary morbidity rate was 22,4%, and the perioperative mortality rate was 2.6%. An anastomotic leakage occurred in 13 patients (8,3%).

Conclusion

Minimally invasive esophagectomy is safe and technically feasible. It entails a lower mortality rate and a shorter hospital stay than those reported in most open series. Thoracoscopy with the patient in prone position offers results comparable with those obtained using other minimally invasive techniques.This technique shows considerable advantages such as improved surgeon ergonomics, increased operative field exposure, and satisfactory respiratory results.

Disclosure

All authors have declared no conflicts of interest.
PS01.246: ESOPHAGECTOMY-SPECIFIC OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILL (E-OSATS): CONSENSUS ON ESSENTIAL STEPS THROUGH DELPHI METHODOLOGY
Authors: Eddahchouri Yassin , Gisbertz Suzanne , Van Berge Henegouwen Mark I , Klarenbeek Bastiaan , Rosman Camiel
Published: September 2018

Background

Minimally invasive esophagectomy (MIE) is a technically demanding procedure, but without consensus regarding essential steps and assessment of surgical technique. The objective of this study was to determine expert consensus on essential steps in MIE as a first step in the development of an ‘esophagectomy-specific objective structured assessment of technical skills’ tool (E-OSATS).

Methods

Essential steps were defined for both MIE with intrathoracic- and cervical anastomosis, based on local expert opinion, peer-reviewed literature and surgical textbooks. In round table discussion disparities between experts were resolved, and an online Delphi questionnaire was sent to an international expert panel of minimally invasive upper GI surgeons. Based on replies and comments steps were adjusted and resent in iterative fashion.

Results

A total of 137 and 138 essential steps were identified for the MIE with intrathoracic- and cervical anastomosis respectively. After the first Delphi round 24 out of 36 (67%) invited international experts replied, and consensus was reached in 99 out of 137 (72%) and 95 out of 138 steps for both procedures respectively.

Conclusion

A Delphi method seems feasible in determining essential steps as a first step in the development of an E-OSATS for both MIE with intrathoracic- and cervical anastomosis. The second Delphi round is currently pending.

Disclosure

All authors have declared no conflicts of interest.
PS02.001: IMPLICATIONS OF JEJEUNOSTOMY OMISSION IN COMBINATION WITH EARLY FEEDING IN A MINIMALLY INVASIVE ESOPHAGECTOMY COHORT
Authors: Carroll Paul , Allison Frances , Yeung Jonathan , Darling Gail
Published: September 2018

Background

Early oral feeding in esophagectomy is recognised as safe in esophagectomy. Typically, enteral feeding has been used in combination to avoid weight loss in the recovery period post surgery. Recently, avoidance of jejeunal feeding has been shown to be efficacious with respect to nutritional safety over one year post surgery. In Toronto, jejeunostomy insertion is routinely omitted in our minimally invasive esophagectomy practice.

Methods

This study sought to determine the nutritional impact this practice has by determining the examining a retrospective cohort before and after the practice change in 2016. Only patients with complete weight measurement follow up to 1 year were incorporated. Data displayed as median and interquartile range (IQR).

Results

The initial results analysis consists of a total of 63 patients (n = 38 with feeding Jej (FJ) and n = 25 without (NFJ). Median BMI at surgery was 26 kg/m2 (23.1–30.5) with no differences between the groups identified: FJ BMI 25.9 (23–29.4) vs NFJ 26.8(23.9–32.2). Length of stay was 10 days in both groups. At one year, BMI was 23.4 (20.6–26.0) with no difference between the groups, FJ 22.4 (20.6–25.9) vs 23.4 (20.9- 27.7), P = 0.798. Median weight loss at 1 year was 11.2kg (9.1%). More weight loss was identified in the NFJ group in the 1st month, 4kg (1.9–5.1) vs 7kg (4.5–10.4) (P = 0.035) but subsequent intervals demonstrated no significant difference. Readmissions within one year were higher in the FJ group (n = 10, of which 2 needed operative intervention for jejeunostomy site issues), as compared to a single admission in the NFJ group for a para-conduit hernia repair.

Conclusion

Early commencement of oral nutrition in combination with the omission of feeding jejeunostomy insertion has no prolonged nutritional impact after the 1st month. Overall, Body mass index is reduced in esophagectomy patients over the first year irrespective of feeding approach.

Disclosure

All authors have declared no conflicts of interest.
PS02.008: MINIMAL INVASIVE OSEOPHAGECTOMY FOR CARCINOMA OESOPHAGUS BY USING WITH AN INNOVATIVE TECNIQUE: OUR EXPERIENCE
Authors: Pawar Suraj
Published: September 2018

Background

Minimally invasive esophagectomy(MIE) is associated with lower morbidity and mortality compared to open procedures. In order to retain the benefits and overcome disadvantages of the left lateral decubitious and fully prone positions, a modified semiprone position was developed at our centre.We aim to describe our growing experience of operating patients of esophageal carcinoma with MIE in a semiprone position.

Methods

A retrospective review of hospital records of all patients who underwent MIE for esophageal carcinoma at our oncological surgical centre from January 2007 till December 2017 was done. A modified semi-prone position (dorsolateral) was developed i.e. left lateral position with an inclination of 45 degrees with the horizontal. All surgeries were performed under general + Epiduralanesthesia with a double lumen endotracheal tube. Esophageal mobilization was done by thoracoscopic approach in a semiprone position andthoracoscopic 2 field lymhadenectomy was done and end-to-end cervical anastomosis was done in the neck. From the records, we obtained intraoperative parameters and post-operative complications. A multidisciplinary follow-up was established for all patients for a period of 2 `to 5 years.

Results

Retrospective data of 214 patients was included in this study. Mean length of hospital stay was 15.46 ± 4.48 days (range from 3 to 33 days) and mean number of lymph nodes dissected were 15.64 ± 5.98 (range 0 to 32). The mean blood loss was 282.92 ± 197.22 ml. Operative time for the total surgical procedure and 211.29 ± 54.62 minutes. Only 7% of the patients had intra-operative complications like arrhythmia, azygous vein bleeding, cardiac arrhythmia, hypotension, splenic bleeding, and others. Most common immediate post-operative complications were pulmonary related (22.7%) and wound infections (8.7%). Approximately 6% of the patients died in the early and delayed post operative period

Conclusion

MIE with mediastinal lymphadenectomy in the semiprone position is a feasible, convenient and safe option which can combine the benefits of the two conventional left lateral and prone approaches. Further large scale studies are required to support our findings.

Disclosure

All authors have declared no conflicts of interest.
PS02.015: EXPERIENCES OF COMPLETE LAPARO-THORACOSCOPIC MINIMALLY INVASIVE ESOPHAGECTOMY WITH SIDE-TO-SIDE ESOPHAGOGASTROSTOMY
Authors: Kamiya Satoshi , Rouvelas Ioannis , Klevebro Fredrik , Lindblad Mats , Nilsson Magnus
Published: September 2018

Background

Recently minimally invasive esophagectomy (MIE) has become more common over the world. Since 2014 we applied the laparo-thoracoscopic minimally invasive esophagectomy with intrathoracic side-to-side esophagogastrostomy. In this study, we present our experiences of minimally invasive Ivor-Lewis (IL) technique.

Methods

In succession to laparoscopic abdominal operation with upper abdominal lymphadenectomy and formation of the gastric tube conduit, patients were turned to prone position. After middle and lower mediastinal lymphadenectomy, the gastric conduits were pulled up to the chest through the hiatus and the specimens were removed. The side-to-side anastomoses were done using linear triple stapler and the defects were closed with thoracoscopic suturing. The outcomes of minimally invasive IL during 2014–2018 have been compared with those of open IL for esophageal adenocarcinoma.

Results

Among 279 patients with esophagectomy a minimally invasive IL was done in 118 3 cases (2.5%) were converted to open technique due to technical or oncological reasons. There were no significant differences in age, sex, BMI and ASA score at baseline. In the MIE group the peroperative blood loss and operation time was reduced 100 ml vs 550 ml (P < 0.01), and 395 min vs 420 min (P < 0.01). The numbers of harvested lymph nodes were superior in MIE group: 33 vs 23 (P < 0.01). Although there were no significant differences in the incidence of postoperative complication rate (36% vs 38%) and leakage rate (20% vs 16%), 1-year and 3-year overall survival rate were significantly better in MIE group (0.76 and 0.63, respectively (P = 0.01) as compared to open procedure (0.73 and 0.42, respectively) (P = 0.01). MIE was proven to be an independent factor for better prognosis in a Cox regression analysis.

Conclusion

Our minimally invasive Ivor-Lewis esophagectomy technique is feasible and might achieve better prognosis. Future research has to provide further evidence whether the method can minimize the risk and severity of postoperative complications including anastomotic leakages and improve survival.

Disclosure

All authors have declared no conflicts of interest.
PS02.020: ADENOCARCINOMA OF THE ESOPHAGOGASTRIC JUNCTION (SIEWERT I AND II): DOES TRANSHIATAL APPROACH SUFFICIENT FOR A STANDAND LYMPHADENECTOMY? A MULTIVARIABLE STUDY ANALYSIS
Authors: Takeda Flavio , Sallum Rubens , Ribeiro Jr Ulysses , Mariano Rocha Julio , Duarte Andre , Cecconello Ivan
Published: September 2018

Background

The surgical treatment of adenocarcinoma of the esophagogastric junction surgical treatment (AGEJ) is still controversial, particularly concerning to survival and postoperative complications. To compare thoracoscopic esophagectomy (group A) with transhiatal esophagectomy (group B) in patients with AGEJ in relation to the occurrence of complications and mortality; number of ressected lymph nodes, the positive and the ratio between the ressected and positive; overall and disease free survival; and survival after relapse.

Methods

There was a selection of 147 patients from 2000 to 2017. Epidemiological data were analyzed and compared between the groups. Postoperative complications were evaluated. The anatomopathological staging was evaluated, analyzing the resected lymph nodes. Analysis of overall survival, disease free survival and survival after relapse were made, besides multivariate analysis of survival related factors.

Results

In relation to the complications, group A presented greater occurrence of hoarseness and surgical infections. In relation to mortality, group A presented 2 cases (3.7%) and group B presented 4 (4.3%), without statistical difference. In group A, the average number of ressected lymph nodes was 31.88 and in group B was 20.73 (P < 0.001), however the average number of affected lymph nodes was 3.96 in group A and 4.25 in group B. The general overall survival was 42.3%, in group A was 38.9% and in group B was 47.6% (P = 0.298). In the multivariate analysis of overall survival only lymphatic invasion (P = 0.005), diabetes mellitus (P = 0.038) and surgical infection (p-0.001) were significant. However, in tumors with stage until 2B, group A overall survival was 80.4% and group B was 38.5% (P = 0.001).

Conclusion

Both methods are safe with similar morbidity and mortality rates. Transthoracic thoracoscopic esophagectomy allows a larger ressection in the number of lymph nodes. Overall survival and disease free survival are similar, however until stage 2B thoracoscopic esophagectomy improves overall survival. Diabetes and lymphatic invasion interfere in overall and disease free survival.

Disclosure

All authors have declared no conflicts of interest.