bluuebunny/crossref_metadata_2025 huggingface dataset:
196. MINIMALLY INVASIVE ESOPHAGECTOMY WITH AWARENESS OF THE THIN MEMBRANOUS DENSE CONNECTIVE TISSUES AROUND THE ESOPHAGUS
Authors: Tokairin Yutaka , Fukuda Akira , Iida Satoshi , Imai Kenichiro , Ganno Hideaki , Amagasa Hidetoshi , Shiobara Hiroyuki , Kawaguchi Machiko , Nagai Kagami , Kinugasa Yusuke
Published: August 2023

Background

We have clinically introduced the ‘mediastinoscopic esophagectomy with lymph node dissection’ (MELD) to esophagectomy for thoracic esophageal cancer, performed under pneumomediastinum via trans-bicervical and transhiatal approach since 2014. In parallel with this, we have been conducting histological studies of the thin membranous dense connective tissue (TMDCT) around the esophagus and utilizing the results during these surgeries to ensure a rational esophagectomy. Here, we describe the differences in the visibility of TMDCT between the two approaches for esophagectomy.

Methods

We retrospectively examined the visibility of TMDCT in surgical videos of trans-mediastinnal and trans-right thoracic approaches after 2015 to determine the characteristics of each approaches.

Results

The trans-mediastinal approach reaches the visceral sheath by entering just dorsal to the esophagus in the right neck, and the TMDCT is seen in a bubbled appearance. Unlike the right thoracic approach, the visceral sheath can be easily reached without a pleural incision. The adipose tissue including lymph nodes around the left recurrent laryngeal nerve (RLN) showed a clear dissection layer between the left subclavian artery, but the boundary between the lymph nodes around the left RLN and the aorta was unclear near the aortic arch, which was thought to be due to the lack of visceral sheath around No.106tbL. On the other hand, the trans-right thoracic approach showed a slightly shiny visceral sheath covering the surface of the thoracic duct on the dorsal side of the esophagus. In the left superior mediastinum, the left RLN and RLN lymph nodes were located on the organ side of the visceral sheath covering the esophagus and trachea. In right and left sides, the visceral sheath was obscured near the branch of the RLN from the vagus nerve, but the RLNs ran cranially on the medial side of the visceral sheaths.

Conclusion

We reported how the TMDCT is visualized with each surgical approach. The visceral sheath was visualized as a bubbly structure in the trans- mediastinal approach and as a slightly shiny areal structure in the trans-right thoracic approach. Recognition of the TMDCT around the esophagus was useful for safe and rational lymph nodes dissection regardless of the surgical approach.
198. MODELING CANCER CACHEXIA USING PATIENT TUMOR ORGANOID-DERIVED XENOGRAFTS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Lung Bryan Chee-chad , Yu Valen Zhuoyou , Wong Ian Yu-hong , Wong Claudia Lai-yin , Chan Desmond Kwan-kit , Chan Fion Siu-yin , Law Betty Tsz-ting , Lam Ka-on , Kwong Dora Lai-wan , Lo Anthony Wing-ip , Law Simon , Lung Maria Li
Published: August 2023

Background

Cancer cachexia is a metabolic and functional multifactorial body wasting syndrome and is one of the major causes of death in late-stage patients. Esophageal squamous cell carcinoma (ESCC) presents one of the highest morbidity and mortality rates due to cancer cachexia. However, there is limited effective and approved targeted treatment. Cancer cachexia animal models are highly limited, with few cancer types available as a pre-clinical drug testing platform and with none related to esophageal carcinoma.

Methods

We have developed a panel of ESCC patient-derived organoid xenograft (PDOX) mouse models based on our latest patient-derived organoid cultures from Hong Kong patients.

Results

Our PDOX mouse model displays cachexic phenotypes that traditional cell line-derived xenografts lack, including body wasting and functional signs. The slow-proliferating characteristic of the ESCC PDOX on mice allows development of cachexic conditions before the humane endpoint. Our comprehensive panel of PDOX lines allowed us to identify full spectrum and differential cachexia severities across mice bearing different PDOXs, indicating a heterogenous nature and allowing faithful mimicking of various patient conditions. Molecular analysis showed that several classic cachexia-related gene expressions were up-regulated in the isolated liver and inguinal adipose tissues of cachexic mice, along with elevated circulating Il-6 levels.

Conclusion

Our ESCC PDOX model potentially serves as a useful pre-clinical cachexia-targeted drug testing platform, providing more treatment options for ESCC patients for better disease management.

Acknowledgments

We acknowledge the Research Grants Council (Theme-based Research Scheme T12–701/17-R to MLL) and the Food and Health Bureau (Health and Medical Research Fund 06171566 to VZY) of the Hong Kong Special Administrative Region for funding support. We acknowledge DSMZ (German Collection of Microorganisms and Cell Culture) for the KYSE cell lines. We acknowledge the University of Hong Kong LKS Faculty of Medicine Centre for PanorOmic Sciences for providing imaging facilities.
210. BIORESORBABLE SYNTHETIC MESHES IN LARGE PARAESOPHAGEAL HERNIAS. TECHNIQUE OF APLICATION AND EARLY RESULTS
Authors: Brandalise Andre , Aranha Nilton Cesar , Lorenzetti Claudia , Brandalise Nelson Ary
Published: August 2023

Background

Large paraesophageal hernias (LPEH) are still a challenge faced by foregut surgeons. Surgical options are highly debated among specialists; esophageal lengthening procedures, diaphragmatic relaxing incisions, gastropexy and—mesh reinforcement. Severe complications related to synthetic meshes has led many surgeons to avoid this type of reinforcement.

However, newly developed synthetic bioresorbable meshes have been used as an alternative for hiatal reinforcement, lowering the rates of recurrence without the drawbacks of synthetic materials.

Methods

From April 2018 to February 2023, 65 patients underwent LPEH repair with hiatal augmentation with an inverted C-shape bioresorbable mesh. All surgeries were performed by two surgeons (AB and NCA). The meshes (Bio-A®—Gore® and Phasix ST®—BARD) were applied over crurorrhaphy, covering the anterior and posterior aspects of the hiatus and secured in place with sutures and cyanoacrylate. The choice of mesh was determined by the surgeon’s preference. Follow up visits were at 1, 6 and 12 months and yearly after that.

Results

There were 34 patients where Bio-A was used and 31 with Phasix. Median age (55,5 vs 54,8 years) didn’t differ between groups. LPEH were primary (PS) in 39 patients and recurrence from prior interventions (RS) in 26. Median age was higher in PS (58,6 vs 49,6 years). There were no intraoperative complications related to the use of mesh. The patients were discharged after 24–48 hours.

The average follow-up period was similar between PS and RS (10,1 vs 9,6 months).

There were three recurrences (2 Bio-A, 1 Phasix) in PS (7,6%) and seven (26,9%) in RS (2 Bio-A, 5 Phasix).

There weren’t complaints of prolonged dysphagia or need for dilatation.

Nine out of 10 recurrences are small. One large recurrence, required reintervention for acute volvulus after 1 year (RS group with Phasix).

Conclusion

bioresorbable meshes are safe to use as a reinforcement of hiatoplasty in LPEH. They can reduce recurrence and reoperation rates in PS at a short term follow-up. Large recurrent hiatal hernias still present as a major challenge and adjuvant techniques should be employed to further reduce recurrences.
225. PREDICTORS OF ANASTOMOTIC LEAK AMONG PATIENTS UNDERGOING ESOPHAGECTOMY: A RETROSPECTIVE COHORT OF 6669 PATIENTS
Authors: Jogiat Uzair , Verhoeff Kevin , Mocanu Valentin , Turner Simon , Bédard Eric
Published: August 2023

Background

Despite advances in operative techniques, anastomotic leak (AL) after esophagectomy remains a dreaded complication associated with a relatively high morbidity and mortality. Identification of patient and surgical factors associated with AL are useful for risk stratification to improve patient and procedure selection. Furthermore, an adequately powered analysis for the incidence of AL after minimally invasive esophagectomy is lacking.

Methods

The ACS-NSQIP database was used to extract patients who underwent esophagectomy between 2016 and 2021. Categorical variables were analyzed using chi-squared tests and continuous variables were evaluated using ANOVA tests. Using a hypothesis driven purposeful selection methodology, a multivariable logistic regression model was created with the primary outcome of interest being the odds of AL. Statistical analysis was completed with StataSE 17 (STATACorp, LP, College Station, TX). The primary outcome of interest was the effect of minimally invasive surgery on AL. Secondary outcomes were the effect of patient characteristics and surgeon specialty on AL.

Results

Of the 6669 esophagectomies, the leak rates were 14.6% (open; 360/2451), 13.4% (MIS-abdominal; 64/478), 21.1% (MIS-chest; 69/326), 14.3% (MIS-total; 369/2590), and 20.1% (Robotic; 166/824), respectively. On multivariate analysis, positive margin (OR 1.37, 95% CI 1.01–1.85, p = 0.043), MIS-chest (OR 1.40, 95% CI 1.01–1.96, p = 0.047), MIS-total (OR 0.95, 95% CI 0.78–1.15, p = 0.595), MIS-robotic (OR 1.37, 95% CI 1.07–1.77, p = 0.014), transhiatal esophagectomy (OR 1.28, 95% CI 1.01–1.62, p = 0.040), and three-hole esophagectomy (OR 1.38, 95% CI 1.12–1.77, p = 0.014) were surgical factors associated with increased odds of AL (Table 1).

Conclusion

Anastomoses that were performed by certain types of minimally invasive surgery and those performed in the cervical region were associated with increased odds of AL. Consideration of this increased risk needs to be weighed against the established benefits of minimally invasive surgery when selecting the appropriate procedure for each patient. Identifying patients who are high-risk for an AL pre-operatively may prevent delay in the diagnosis and treatment of ALs in this patient population.
227. RELATIONSHIP BETWEEN 90-DAY PROGNOSIS NUTRITIONAL INDEX AND INFLAMMATORY RESPONSE MARKERS AND LONG-TERM SURVIVAL IN ESOPHAGEAL CANCER
Authors: Xie Qin , Miao Yan
Published: August 2023

Background

The incidence rate of esophageal cancer in Asia is mainly squamous cell carcinoma, which is characterized by high mortality and poor prognosis. The prognosis of tumors is not only related to the biological characteristics of tumor cells, but also closely related to the nutritional status and inflammatory response of patients. The aim of this study is to investigate the relationship between nutritional index (PNI) and inflammatory response markers (NLR, LMR) at 90 days after surgery and long-term survival in patients with esophageal squamous cell carcinoma. To provide reference for accurately assessing the condition, identifying survival risks, and improving long-term prognosis.

Methods

The data of ESCC patients who underwent radical resection for esophageal cancer from April 2018 to November 2018 were extracted (n = 66). Calculate the prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR) and other indicators of patients at 90 days after operation. ROC was used to calculate the cut-off values of PNI, NLR, and LMR. KaplanMeier survival curve was used to analyze the relationship between different PNI, NLR, LMR levels and long-term survival of patients. All patients were followed up regularly after surgery, and the last follow-up time was April 2023.

Results

The best cut-off values of PNI, NLR, and LMR were 42.8, 3.27, and 4.76, respectively. Kaplan Meier survival analysis showed a correlation between postoperative PNI, NLR, LMR at 90 days and overall survival and disease-free survival. At 90 days after surgery, the OS (P = 0.007) and DFS (P = 0.038) of patients in the high PNI group (PNI ≥ 42.8) were better than those in the low PNI group; The OS (P = 0.002) and DFS (P = 0.048) of patients in the low NLR group (NLR < 3.27) were better than those in the high NLR group; The OS (P = 0.001) and DFS (P = 0.039) of patients in the high LMR group (LMR ≥ 4.76) were better than those in the low LMR group.

Conclusions

PNI, NLR, and LMR are important predictors of OS and DFS in patients with esophageal squamous cell carcinoma after radical resection of esophagus. Patients with PNI ≥ 42.8, NLR<3.27, and LMR ≥ 4.76 at 90 days after surgery have better OS and DFS.
237. PRE-NEOADJUVANT CHEMOTHERAPY SARCOPENIA IS PREDICTIVE OF MORTALITY IN ESOPHAGOGASTRIC ADENOCARCINOMA PATIENTS
Authors: Convill James , Samake Maurice , Sellars Hannah , Chmelo Jakub , Brown Joshua , Petrides George , Phillips Alexander
Published: August 2023

Background

Sarcopenia is defined as a loss of skeletal muscle mass and function. Preoperative sarcopenia amongst patients with esophageal cancer has been linked to mortality, various postoperative complications and the severity of these complications. The majority of this evidence comes from populations with squamous cell carcinoma or where neoadjuvant chemoradiotherapy was used. Whether sarcopenia is associated with neoadjuvant chemotherapy (NAC) for esophagogastric adenocarcinoma (EGA) and any link to mortality is not fully understood.

Methods

Patients diagnosed with EGA between January 2017 and December 2021 and undergoing NAC followed by esophagectomy from a single high-volume center had their pre-NAC CT scans assessed for radiological sarcopenia. Skeletal muscle index (SMI) was calculated from muscle area measured on CT scans at the level of third lumbar vertebra. Previously published SMI cut off values for radiologically defined sarcopenia were used (52.4 cm2 for men and 38.5 cm2 for women). A cox-regression model was used to investigate mortality between those with sarcopenia and those without.

Results

There were 191 patients included in the analysis. Pre-NAC sarcopenia was associated with increased mortality (Hazard ratio 1.59, 1.00–2.54 p = 0.046). 5-year survival for sarcopenic and non-sarcopenic patients was 27.8% (17.1%, 45.2%) and 35.6% (21.3%, 59.5%), respectively. Median survival was 2.72 and 4.09 years, respectively.

Conclusion

EGA patients with sarcopenia pre-NAC have a significantly higher chance of mortality in the 5-years following their surgery. Strategies to treat sarcopenia and prevent its further development should be investigated with the aim to increase survival in this cohort.
238. ESOPHAGOGASTRIC ADENOCARCINOMA PATIENTS WITH SARCOPENIA BEFORE OR AFTER NEOADJUVANT CHEMOTHERAPY ARE MORE LIKELY TO HAVE LONGER POST-OPERATIVE INPATIENT STAYS
Authors: Convill James , Samake Maurice , Sellars Hannah , Chmelo Jakub , Brown Joshua , Petrides George , Phillips Alexander
Published: August 2023

Background

Sarcopenia is defined as a loss of skeletal muscle mass and function. It is prevalent amongst patients with esophagogastric adenocarcinoma (EGA) and associated with adverse treatment outcomes. The majority of this evidence comes from populations with squamous cell carcinoma or where neoadjuvant chemoradiotherapy was used. Protracted inpatient stays are directly associated with adverse events such as healthcare-associated infections and patient deconditioning and increase the economic burden on healthcare institutions.

Methods

Patients diagnosed with EGA between January 2017 and December 2021 and undergoing neoadjuvant chemotherapy (NAC) followed by esophagectomy from a single tertiary center in the UK had their pre- and post-NAC CT scans assessed for radiological sarcopenia. Skeletal muscle index (SMI) was calculated from muscle area measured on CT scans at the level of third lumbar vertebra. Previously published SMI cut off values for radiologically defined sarcopenia were used (52.4 cm2 for men and 38.5 cm2 for women). Wilcoxon signed-rank test for non-parametric data was used to determine significance.

Results

191 patients were included in the analysis. The number of patients with sarcopenia increased from 96 to 123 following NAC. Sarcopenia before (p = 0.047) or after (p = 0.007) NAC was significantly associated with longer inpatient stays post-operatively. The median stay for patients with sarcopenia before or after NAC was 12 days compared to 9 for those without sarcopenia before or after NAC.

Conclusion

Radiological sarcopenia is highly prevalent in this cohort of patients and increases following NAC. This study demonstrates that sarcopenia before or after NAC in patients with EGA undergoing esophagectomy are likely to have longer inpatient stays following surgery. Peri-operative treatment to treat and reduce the incidence of sarcopenia should be trialed with the aim of improving post-operative outcomes in this cohort.
243. COMPARISON BETWEEN THE THERAPEUTIC AND PROPHYLACTIC LYMPHADENECTOMY OF THE SUPRACLAVICULAR AREA FOR PATIENTS WITH ESOPHAGEAL CANCER
Authors: Mine Shinji , Hashimoto Takashi , Orita Hajime , Nasu Motomi , Hashiguchi Tadasuke , Kaji Sanae , Fujiwara Daisuke , Yube Yukinori , Ozaki Asako , Yoshino Kohei , Sugahara Yuki , Kubota Akira , Egawa Hiroki , Fukunaga Tetsu
Published: August 2023

Backgrounds

Lymphadenectomy of the supraclavicular area (SCA) for patients with esophageal cancer has still remained controversial. Some previous studies showed that it could not improve survival. In this study, we retrospectively investigated the results of therapeutic and prophylactic lymphadenectomy around SCA for patient with esophageal cancer.

Methods

From 2010 to 2015, the patients who underwent esophagectomy with 3-fields lymphadenectomy were enrolled in this study. Patients with cervical esophageal cancer and with pN3 were excluded. Clinical nodal metastasis was decided on CT findings. Efficiency of index for lymphadenectomy (EI) was calculated with nodal incidence multiplied by 3-year relapse free survival (3yRFS).

Results

A total of 514 patients was enrolled in this study. Therapeutic lymphadenectomy was performed in 47 patients, and prophylactic lymphadenectomy was performed in 467 patients. In the therapeutic lymphadenectomy group, nodal metastasis was found in 17 patients (36.2%) and 3yRFS of these patients was 34.3%, and EI was 12.4. Meanwhile, in the prophylactic group, nodal metastasis was found in 14 (3.0%) and 3yRFS of these patients was 35.7%, and EI was 1.1. Of 514 patients, 138 received neo-adjuvant treatments. In the neo-adjuvant group, EI of the therapeutic lymphadenectomy was 21.5, and that of the prophylactic lymphadenectomy was 2.7. In the upfront surgery group, EI of the therapeutic lymphadenectomy was 0, and that of the prophylactic lymphadenectomy was 0.6.

Conclusion

The 3yRFS of the patients with pathological nodal metastasis in the SCA was relatively good. However, EI in the prophylactic group was very low due to very low incidence of the pathological nodal metastasis in the SCA. Clinical significance of prophylactic lymphadenectomy of SCA is not clear based on our data.
245. CONVERSION SURGERY AFTER DEINITIVE CHEMORADIOTHERAPY FOR THORACIC ESOPHAGEAL CANCER
Authors: Sato Hiroshi , Miyawaki Yutaka , Lee Seigi , Sakuramoto Shinichi
Published: August 2023

Background

Definitive chemoradiotherapy (dCRT) is an important treatment option for cStage III/IVa esophageal cancer. In our hospital, dCRT is the treatment of choice for cT4b. In this study, we investigated the technique, prognosis, and postoperative complications of salvage surgery after dCRT, with the aim of gaining knowledge to achieve both cure and safety.

Methods

The study included 36 patients who underwent conversion surgery after dCRT for thoracic esophageal cancer with suspected invasion of other organs between April 2012 and June 2021. The median age was 68 years (38–80 years). cT4b invasive organs were trachea and left main bronchus in 21 cases, aorta in 11 cases, and other organs in 4 cases. Thoracoscopic esophagectomy was performed in 13 patients. Reconstruction of the gastrointestinal tract via the posterior sternal route was the basic procedure.

Resluts

There was one case of death in hospital (3%). Postoperative complications (Clavien-Dindo Grade II or higher) were observed in 17 patients (47%), including pneumonia in 9 patients (25%) and suture failure in 5 patients (14%). The median postoperative hospital stay was 17 days. The incidence of postoperative pneumonia was lower in patients with higher preoperative serum Alb and preoperative PNI. The median recurrence-free survival was 14 months. Histopathologically, 7 patients (19%) showed cancerous remnants, and the prognosis was poor in patients with remnant disease, aortic invasion, or preoperative lymph node metastasis.

Conclusion

Perioperative outcomes were considered acceptable. Down staging is likely to be achieved after dCRT, but preoperative nutritional status should be improved. The prognosis is poor in patients with aortic invasion or lymph node metastasis, and the indication for chemoradiation should be carefully considered. Postoperative adjuvant therapy is an issue for the future.
247. TARGETING HAUS7/GAMMA-TUBULIN INTERACTION WITH HTIP1 SUPPRESSES TUMORIGENESIS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Cai Ziqing , Lee Pui Yue Nikki , Wong Yu Hong Ian , Law Ying Kit Simon
Published: August 2023

Background

Uncontrolled cell division is a hallmark of cancer, making targeting deregulated cell cycle molecules with prognostic significance a promising approach to combat tumorigenesis. Our research focuses on HAUS7, a molecule highly relevant to esophageal squamous cell carcinoma (ESCC), and its interaction with gamma-tubulin. We designed a novel peptide, HTIP1, to target this interaction and suppress tumorigenesis.

Methods

We investigated the clinical relevance of HAUS7 upregulation in ESCC cohorts, studied its physiological microtubule-regulating and tumorigenic functions in vitro and/or in vivo, and employed a multidisciplinary approach to decode the mechanism underlying HAUS7 suppression. HTIP1 was designed by structure modelling and docking simulation. Its properties, cancer selectivity, anti-tumor efficacy, off-target effect and mechanisms of action were comprehensively evaluated. Patient-derived tumor xenograft models were used to provide additional preclinical evidence.

Results

Our results show that HAUS7 is the most essential HAUS member for regulating microtubule dynamics in ESCC, and its overexpression is correlated with aggressive tumor phenotypes and poor prognosis. Mechanistically, HAUS7 suppression releases gamma-tubulin, which upon phosphorylation, seizes LMAN1 and together they re-localize to the nucleus. The removal of LMAN1 from its innate location triggers endoplasmic reticulum stress and apoptosis. We designed HTIP1 to perturb HAUS7/gamma-tubulin interaction, which demonstrated anti-tumor effects similar to HAUS7 suppression, with high tumor specificity, negligible off-target effects, and more potency than relevant compounds.

Conclusions

Our findings provide a new strategy to counter tumorigenesis and pave the way for the development of a new drug targeting the HAUS7/gamma-tubulin interaction.
250. ASSOCIATION OF SLING-FIBER PRESERVATION POEM AND POST-POEM GERD SYMPTOMS: A NORTH AMERICAN SINGLE-CENTER RETROSPECTIVE STUDY
Authors: Fujiyoshi Yusuke , Fujiyoshi Mary Raina Angeli , Khalaf Kareem , Gimpaya Nikko , Pawlak Katarzyna , Seleq Samir , Lamba Mehul , Li Suqing , Grover Samir , Mosko Jeffrey , May Gary , Teshima Christopher
Published: August 2023

Background

Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been a limiting factor with this procedure. Preservation of the sling fiber during POEM was reported to reduce post-POEM GERD in Japan, but there are no reports of this technique in a western population. As such, we investigated the association of sling-fiber preservation during POEM and post-POEM GERD symptoms at our institution, which is a large therapeutic endoscopy referral center in Canada.

Methods

This is a retrospective, single-center study of patients who underwent POEM from October 2017 to January 2023 at our center. The initial cohort of patients were treated by conventional POEM until June 2021, after which a second cohort underwent POEM with sling-fiber preservation, as the techniques advanced. The primary outcome was the rate of positive GERD symptoms after POEM. The secondary outcomes were procedure time, gastric myotomy length, clinical success rate (Eckard score of less than 3), adverse events rate and use of PPI at follow-up.

Results

148 POEM cases (52.5 ± 15.6 y/o, female: 61(43%)) were included in this study. There was no significant difference in patient characteristics between the groups. The mean procedure time (108.6 ± 34.5 vs 109.1 ± 45.7 min, P = 0.93) and rate of adverse events (21% vs 14%, P = 0.36) were similar between the traditional and modified groups. In the sling fiber preservation group, gastric myotomy length was significantly longer (2.2 ± 0.7 vs 1.6 ± 0.8 cm, P < 0.05) yet the GERD symptom rate at follow-up was significantly lower (22% vs 41%, P < 0.05), although PPI use was similar (57% vs 50%, P = 0.47). Finally, the clinical success rate was similar between groups (88% vs 84%, P = 0.6).

Conclusions

Sling fiber preservation during POEM is safe and reduces post-POEM GERD symptoms, despite the longer gastric myotomy length. As such, sling fiber preservation may be a useful solution to reduce post-POEM GERD in western populations.
274. ROBOTIC-ASSISTED THORACOSCOPIC ESOPHAGECTOMY WITH MEDIASTINAL LYMPH NODE DISSECTION: DOES IT FEASIBLE FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA SURGERY?
Authors: Swangsri Jirawat , Patraithikul Premkamol , Parakonthun Thammawat , Methasate Asada
Published: August 2023

Background

Esophageal cancer is sixth leading cause of cancer-related mortality globally in 2020. Esophageal squamous cell carcinoma is one of most aggressive and need extensive operative treatment for radical and oncologic purpose. Conventional thoracotomy is highly invasive, conventional video-assisted is quite technical difficulty related with deep and narrow angle of exposure. Robotic-assisted procedure is new challenging to beat this limitation. This is descriptive report of initial robotic-assisted experiences regard to feasibility, safety and oncologic outcome.

Methods

We conducted a retrospective analysis of a single-center database from March 2012 to February 2023, including patients aged 45–85 years with resectable lesions of the esophageal squamous cell carcinoma who underwent robotic-assisted thoracoscopic esophagectomy using the Da Vinci Robotic surgery system. Patient data, surgical procedures, interventions, and early outcomes (within 30 days postoperation) were collected and analyzed to assess postoperative variables and adequacy of cancer clearance. The study included 12 patients, and the primary outcome was the incidence of pulmonary complications during the hospital stay.

Results

The overall incidence of postoperative pulmonary complications was 4cases (33.3%), with mild pulmonary infection occurring in 2cases (16.7%) without 30-day mortality in robotic-assisted thoracoscopic esophagectomy. The median admission period were 2 days and 15 days for ICU and hospital stay, respectively. The median time for the thoracic phase of operation was 210 minutes (150-445 minutes), and the median blood loss volume was 55 mL (20–300 mL). Pathological results showed that overall proximal and distal margins were uninvolved by tumor, and the median number of lymph nodes retrieval in the thoracic region was 22.5lymph nodes (14-73lymph nodes). 41.7% of patients were classified in pathological stage I.

Conclusion

Robotic-assisted thoracoscopic esophagectomy has shown promising early postoperative outcomes, low blood loss volume, short ICU and hospital stay, a low rate of pulmonary complications and including adequate lymph node retrieval and pathological results. These findings support the feasibility and safety of robotic-assisted thoracoscopic esophagectomy, which enhance postoperative recovery and improve surgical outcomes for the treatment of esophageal squamous cell carcinoma.
292. SPECIFIC METHYLATION MARKERS ASSOCIATED WITH CHANGES IN GENE EXPRESSION DISTINGUISH EAC AND SUB-TYPES OF BE PATIENTS
Authors: Dehkordi Nastaran Riahi , Higareda-Almaraz Juan Carlos , Kunej Urban , Chersicola Marko , Kruusmaa Kristi
Published: August 2023

Background

Esophageal adenocarcinoma (EAC) is one of the most deadly tumors in the world, owing to its aggressive nature and late detection. Barrett’s esophagus (BE), a premalignant condition, is the only known precursor of EAC. We focused on finding epigenetic changes such as differentially methylated regions within EAC and BE patients to demonstrate their biological significance in relation to patient stratification and early detection.

Methods

A differential methylation analysis pipeline was used to identify significant CpGs between 23 EAC, 62 BE, 49 normal squamous (SQ) and 7 fundus samples (GSE81334). These CpGs of interest were validated in the second dataset from an independent cohort (GSE104707) and the TCGA ESCA project dataset. RNASeq and methylation datasets from TCGA were integrated to find overlapping biomarkers that may reveal biological control of methylation. We further performed GO and pathway analysis of differentially methylated CpGs and cnetplot, correlating the obtained CpGs with affected genes and Gene Ontologies and pathways.

Results

We identified and validated 505 differentially methylated CpGs. Using the obtained markers, we were able to separate the normal samples from the EAC samples. BE samples were divided into 2 distinct sub-classes clustering either with normal or EAC, indicating potential for early patient stratification. With the integrated analysis of differentially methylated probes and gene expression, 108 regions were identified to be correlated, indicating epigenetic control of the regions. GO enrichment analysis revealed these regions to belong to biological processes related to cancer development. Further integration of mutation signatures revealed this signal to be independent of known alterations.

Conclusion(s): Methylation based clustering reveals markers showing distinct biological signals in BE and EAC patients and provides methylation status of distinct BE and EAC subtypes. Identified biomarkers show their relevance in early cancer detection and may exhibit strong potential in BE prognosis and better patients’ stratification. Characterization of these subtypes could aid in choosing more appropriate management strategies and better outcomes and improved survival of the patients.
302. IMPACT OF ERAS BENCHMARK ACHIEVEMENTS AND HYBRID ROBOTIC ASSISTED ESOPHAGECTOMY ON RECOVERY AND READMISSION IN AN ERAS CENTER OVER TIME
Authors: Stiles Erik , Harrison Madison , Qaraqe Taha , Sternbach Joel , Low Donald , Hubka Michal
Published: August 2023

Background

Early recovery after surgery (ERAS) guidelines have provided an effective recovery approach for esophagectomy. Adherence to ERAS benchmarks leads to improvements in accelerated recovery over time. We evaluated differences in ERAS clinical benchmark achievements in patients undergoing hybrid robotic assisted esophagectomy (hRAMIE) and the impact on length of hospital stay (LOS). We also examined the overall performance of our ERAS program and impact of operative technique on recovery and readmissions over time.

Methods

A single-center prospective database of esophageal cancer patients was retrospectively analyzed between January 2020 and December 2022. All consecutive patients underwent hRAMIE within a standardized ERAS pathway. Impact of individual ERAS benchmark achievements on postoperative outcomes were evaluated according to LOS groups: accelerated (≤6 days, AR), targeted (7–8 days, TR), and delayed recovery (≥9 days, DR). Ability to achieve AR and readmission rates were compared with previous esophagectomy patient cohorts and institutional published data. Data were tested for normality with Shapiro–Wilk testing. Continuous variables were compared via ANOVA or Kruskal-Wallis testing. Categorical variables were compared via Fisher testing.

Results

Sixty-four patients underwent hRAMIE with a median LOS 5.5 days. AR, TR, and DR was achieved by 75.0%, 18.8%, and 6.3% patients, respectively. AR outperformed the other groups in ICU stay (p = 0.0046), transition to PO medications (p < 0.0001), and chest tube removal (p = 0.0002). Complications (48.4%) were more frequent among the TR and DR groups (p = 0.0051). 30-day readmission rate of 9.4% did not differ among the recovery groups (AR 6.2%, TR 25.0%, DR 0%, p = 0.114). 90-day mortality was 4.7% and disproportionately impacted the DR group (p = 0.0203). AR increased overtime without impacting readmission rate compared to previous cohorts in our ERAS center (Figure 1).

Conclusion

Within a common ERAS pathway at a single center, adherence to recovery benchmarks in patients undergoing hRAMIE multiplies the impact of ERAS and evolving operative technique on accelerated recovery across time. Improvements in AR can be achieved without affecting readmission rates. Routine audit of achievements of ERAS benchmarks is necessary to maintain post-esophagectomy outcomes in a time of changing health care resources.
315. LAPAROSCOPIC GASTRIC PULL-UP WITH GASTROJEJUNOSTOMY AS AN ALTERNATIVE TO COLON-TRANSPOSITION FOR CORROSIVE STRICTURE INVOLVING OESOPHAGUS AND ANTROPYLORIC REGION OF STOMACH
Authors: Dolma Tenzin
Published: August 2023

Background

Various gastrointestinal segments are used for replacement of the scarred oesophagus following corrosive ingestion. Colon is preferred if scarring involves both the oesophagus and the stomach, however, in some patients only the antral part of the stomach maybe involved (in addition to the oesophagus), and a gastric pull-up with a roux en Y gastrojejunostomy may also be feasible.

Methods

Retrospective analysis of corrosive strictures managed surgically between 2020–2023. The short and long-term outcomes of laparoscopic gastric pull-up with roux en Y gastrojejunostomy (LGPU-GJ) were compared with colonic pull-up.

Results

During the study period, 45 patients underwent surgical management for corrosive injury to the oesophagus and stomach. Of these, 7 patients underwent a LGPU-GJ (group A) and 20 patients underwent a colonic pull-up (Group B) and formed the study group. The mean operative time and blood loss was (195.7 ± 55 and 322 ± 63 min, p = 0.001; 48.5 ± 24 and 108 ± 30.8 mL p < 0.001) in Group A and B respectively. One patient in Group A had a gastric staple line leak which was managed with intercostal drainage and antibiotics, 3 patients in Group B had cervical anastomotic leak which was managed conservatively. There was no mortality.

Over a median followup of 18 months, 2 patients in Group A and 7 in Group B required at least one session at endoscopic anastomotic dilatation. There were no significant reflux symptoms reported and all patients were able to tolerate a standard Indian diet.

Conclusion

In a select group of patients with concomitant oesophageal and isolated gastric antral stricture a laparoscopic gastric pull-up with roux en Y gastrojejunostomy may be a feasible alternative to the more complex colonic pull-up with shorter operative times, less blood loss and equivalent outcomes.
319. A SUCCESSFUL CASE OF VACUUM-STENT TREATMENT FOR ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY WITH COMPLICATED POST-SURGICAL COURSE
Authors: Pattynama Lisanne , Eshuis Wietse J , Pouw Roos
Published: August 2023

Background

Anastomotic leakage after esophagectomy is associated with severe morbidity. Endoscopic vacuum therapy (EVT) has gained a greater role in endoscopic treatment of these defects and is most often applied using endoscopically placed vacuum-sponges. Recently, the vacuum-stent was introduced as a new device to apply EVT, combining the benefits of negative pressure wound therapy and an intraluminal stent, while allowing for oral intake of a soft diet.

Methods

This video describes a patient with anastomotic leakage after esophagectomy with complicated post-surgical course, successfully treated with a vacuum-stent, including the technical aspects of the technique. First, a guidewire was placed and the vacuum-stent was advanced over the guidewire and introduced into the esophagus. The vacuum-stent was placed over the defect and deployed using the distal release system. Lastly, the vacuum-stent was connected to a vacuum pump, which was set to a pressure of -125 mmHg on the day of placement and -75 mmHg from the second day on. Generally, the vacuum-stent was removed after 7 days. If the defect persisted, another vacuum-stent was placed.

Case/Results: A 65-year-old female had undergone a minimally invasive esophagectomy with gastric conduit reconstruction and intrathoracic anastomosis. Post-surgically, the patient had dysphagia due to an elongated gastric conduit, only improving after stent placement. However, this caused a stent-induced broncho-esophageal fistula and was no definite treatment. Therefore, she underwent surgery to close the fistula with a bovine patch and gastric conduit re-construction. A prophylactic vacuum-sponge was placed, but 8 days post-surgery, endoscopy showed a dislocated sponge and dehiscence of the complete anastomosis. A vacuum-stent was placed. After 3 vacuum-stents in 20 days, the defect had closed endoscopically, which was confirmed by CT-scan with oral contrast.

Conclusions

The vacuum-stent seems to be a safe and possibly organ-saving treatment option for anastomotic leakage after esophagectomy.

Link to video: https://we.tl/t-eOVEhUiwge
320. ESOPHAGEAL PULL-DOWN TECHNIQUE IMPROVES THE FINAL OUTCOME OF LAPAROSCOPIC HELLER-DOR FOR END-STAGE ACHALASIA
Authors: Nezi Giulia , Forattini Francesca , Provenzano Luca , Capovilla Giovanni , Vittori Arianna , Nicoletti Loredana , Moletta Lucia , Pierobon Elisa Sefora , Costantini Andrea , Valmasoni Michele , Costantini Mario , Salvador Renato
Published: August 2023

Background

Patients with sigmoid shape have an advanced form of the disease and are considered the most difficult to treat. A modified technique (pull-down) has been proposed to straighten the esophageal axis, but there is a limited amount of data available in literature. In this study, we aimed to compare the final outcome of the pull-down technique (PDLHD) with the results of classical myotomy (CLHD) in patients with end-stage achalasia.

Methods

From 1995–2022, patients with a radiological diagnosis of end-stage achalasia undergoing laparoscopic myotomy were enrolled in the study.

Symptoms were quantified using the Eckardt score. Barium-swallow, endoscopy and manometry were performed before and after the treatment. Treatment failure was defined as the persistence or reoccurrence of an Eckardt score > 3, or the need for retreatment.

Results

Of the 94 patients with end-stage achalasia (M:F = 52:42), 60 patients were treated with CLHD, and 34 patients with PDLHD.

The surgical procedures were completed laparoscopically in all patients. During follow-up, two patients (2.1%) developed squamous cell carcinoma (SCC), both in the CLHD group.

All patients in both groups had an improvement in their Eckardt score after surgery, and the failure rates were 27.6% (16/58) after CLHD and 5.9% (2/34) after PDLHD (p < 0.01).

Amongst the patients who underwent complete post-operative follow-up, an abnormal acid exposure was detected in 2 patients after PDLH, and in 6 after CLHD (p = n.s.).

Conclusions

Taken into account the intrinsic limitations of the study (different time window, and different follow-up), the results of this study indicate that performing the pull-down technique during Laparoscopic Heller-Dor improves the final outcome in end-stage achalasia patients.
355. DEVELOPMENT OF A CUSTOM RELATIONAL DATABASE FOR INTEGRATING CLINICAL AND RESEARCH DATA FOR THE STUDY FOR ESOPHAGEAL ADENOCARCINOMA
Authors: Allen Jonathan , Allison Frances , Ghany Rasheed , Akhter Akhi , Rispoli Thaiane , Aiyar Niharikaa , Shathasivam Premalatha , Darling Gail , Wilson Gavin , Yeung Jonathan
Published: August 2023

Background

With the advent of next-generation sequencing, digital pathology, and other high-dimensional data sources used in modern research, improved data management is required to maintain organization and relationship to the corresponding patient and their outcomes. The complexity of the data often limits interpretation by clinicians not highly versed in its analysis. Conversely, data scientists may not be able to interpret the data in the correct clinical context. We describe here a relational database and custom tools which coordinates clinical, organoid, and genomic data in the study of esophageal adenocarcinoma.

Methods

Database architecture was designed with pillars of clinical data and outcome, organoid culture data, and next-generation sequencing data. Data dictionaries were composed for all tables in the database architecture. Oracle Database was utilized and populated with datasets formatted to adhere to data dictionaries. Application Express was used to develop web applications for users to enter, query, and analyze data. Automatic nightly backups, robust login security, and tiers of access protect confidential data against system failures, human error, and data theft. Custom tools with graphical user interfaces were developed for survival curve generation and organoid drug-screening results, to facilitate clinician use.

Results

This database now encompasses over 21 data tables comprising clinical, surgical, recurrence, treatment response, tissue sample storage, organoid research, and genomic data. Data scientists can link omic data directly to patient clinical data and clinician researchers can rapidly obtain patient and organoid survival data for covariates of choice using a graphical user interface.

Conclusion

Proper data management requires a substantial initial investment in designing of database architecture, deployment of software and servers, formatting of data, and the creation of front-end user applications. The investment is well worth the cost, however, as a centralized database allows for rapid querying of data that would otherwise be scattered or require individualized analysis for each project. This also facilitates the interactions between data scientists and clinician researchers.
367. SPATIAL ORGANIZATION OF TUMOR-INFILTRATING LYMPHOCYTES PREDICTS PROGNOSIS OF PATIENTS WITH ESOPHAGEAL CANCER RECEIVING IMMUNOTHERAPY—A DEEP-LEARNING APPROACH
Authors: Huang Shujie , Wu Hansheng , Hong Liangli , Qiao Guibin
Published: August 2023

Background

Neoadjuvant immunotherapy plus chemotherapy has shown satisfying efficacy and manageable safety in locally advanced esophageal squamous cell carcinoma (ESCC) patients. Tumor-infiltrating lymphocytes (TILs) have been shown to be associated with the prognosis of various cancer types. It is unknown whether these TILs-associated characteristics can be adopted as a reliable prognostic biomarker for immunotherapy-based regimen. The current study aimed to assess the prognostic power of spatial organization of TILs in patients with advanced ESCC treated with immunochemotherapy.

Methods

In this retrospective, multicenter cohort study, pathologically confirmed locally advanced ESCC that was potentially resectable after neoadjuvant immunochemotherapy were included. Image segmentation was performed using UNet++ algorithm and H&E-stained nuclei were segmented using the StarDist deep-learning image segmentation. For the nuclei classification task, we choose to train and validate the classic convolutional neural network (CNN) Resnet50. We calculated tumor density and TiLs density in the tumor region (T_TiLs), TILs in the peritumoral region (P_TiLs) as well as TiLs density in the stromal region (S_TiLs). Based on the relative position relationship of tumor cells and lymphocytes, we subclassified the TILs spatial patterns into TILs-dominant, TILs-infiltrating, and TILs-circulating.

Results

Among the enrolled 86 patients, the male to female ratio approached 4:1. In this study, the mean IoU (mIoU) for nuclei segmentation is 0.9369 and the mean Dice coefficient is 0.9209. The areas under curve (AUC) for lymphocyte, tumor cell, and stromal cells classification are 0.92, 0.90 and 0.86, respectively. Through univariate analysis, TILs in tumor region (HR = 1.285, 95% CI: 1.042–1.586, p = 0.019), and TILs spatial organization (HR = 3.652, 95% CI: 1.216–10.967, p = 0.021) were identified as significant prognostic factors for OS. Multivariate analysis further revealed TILs in tumor region as the independent prognostic factor (HR = 1.248, 95% CI: 1.006–1.547, p = 0.044).

Discussion

The present study indicates that spatial organization and T_TILs are significant prognostic factors for ESCC patients receiving neoadjuvant immunochemotherapy. Future prospective studies with large sample size are needed to further validate the prognostic role of interaction between TILs spatial characteristic and distribution density in predicting overall survival.
372. INVESTIGATION OF RISK FACTORS OF POSTOPERATIVE PNEUMONIA IN MEDIASTINOSCOPIC ESOPHAGECTOMY
Authors: Konishi Hirotaka , Fujiwara Hitoshi , Shiozaki Atsushi , Nishibeppu Keiji , Ohashi Takuma , Kubota Takeshi , Otsuji Eigo
Published: August 2023

Background

Pneumonia is a usual complication in esophagectomy. Although frequency of pneumonia in mediastinoscopic esophagectomy is low, risk factors for pneumonia are unclear. The risk factors are investigated.

Methods

Two hundred and forty-four patients with mediastinoscopic esphagectomy and gastric tube reconstruction for esophageal cancer from 2016 to 2021 in our hospital were retrospectively considered in the present study. Postoperative pneumonia was diagnosed as Clavien-Dindo grade 2 or higher. Patients were divided into two groups with (n = 21) and without (n = 223) pneumonia, and background, surgical factors, or histopathological factors were investigated.

Results

Post-operative pneumonia was observed in 21 patients (8.6%), and pre-operative albumin, PNI (< 45), PLR (> 122), and operative bleeding (>134) were significantly related with post-operative pneumonia in the univariate analysis (p < 0.05). Age and previous respiratory disease were also tended to be related with post-operative pneumonia, but not significant. Low PNI was an independent risk factor of post-operative pneumonia in the multivariate analysis (p = 0.047, OR = 2.74). Post-operative pneumonia was not related to the complications, such as anastomosis leakage or recurrent nerve paralysis. No correlation with postoperative pneumonia was observed even in patients with preoperative respiratory dysfunction.

Discussion

PNI has been reported to be useful as a predictor of postoperative complications. In the present study, it was also a predictor factor of postoperative pneumonia. Early nutritional intervention for undernourished esophageal cancer patients may prevent postoperative pneumonia.

Conclusion

Low PNI can be a predictive factor of postoperative pneumonia in the mediastinoscopic esophagectomy.