bluuebunny/crossref_metadata_2025 huggingface dataset:
P160 miR-24-3p REGULATES CDX2 DURING THE PROCESS OF INTESTINALIZATION OF THE CARDIAC-TYPE EPITHELIUM IN A HUMAN MODEL OF BARRETT´S ESOPHAGUS
Authors: Manuel Pera , Marta Garrido , Gabriel Gil , Matteo Fassan , Marta Climent , Miriam Aylagas , Lara Nonell , Roger Anglada , Mar Iglesias , Vicenza Guzzardo , Luis Grande , Carme de Bolós
Published: November 2019

Aim

The aim of this study was to identify miRNAs differentially expressed between CDX2 positive and negative glands of Barrett’s esophagus and, based on this, to examine the function of specific miRNAs on the regulation of CDX2.

Background & Methods

Cardiac-type epithelium has been proposed as an intermediate stage between normal squamous epithelium and intestinal metaplasia (IM) in the development of Barrett´s esophagus. Deregulation of certain miRNAs and their effects on CDX2 expression might contribute to the intestinalization process of cardiac-type epithelium.

miRNA expression profiling using OpenArray technology in microdissected cardiac-type glands with and without fully CDX2 expression was performed in biopsies from patients who developed cardiac-type epithelium in the remnant esophagus after esophagectomy. Data were validated using real-time PCR in esophageal adenocarcinoma cell lines and in situ miRNA/CDX2 co-expression analysis in cardiac-type mucosa samples. The effect of miR-24-3p precursor transfection on CDX2 expression was assessed in the esophageal adenocarcinoma cell lines FLO-1 and KYAE-1.

Results

CDX2 positive glands were characterized by an unique miRNA profile with a significant downregulation of miR-24-3p, miR-520e-3p, miR-548a-1, miR-597-5p, miR-133a-3p, miR-30a-5p, miR-638, miR-625-3p, miR-1255b-1, miR-1260a and upregulation of miR-590 (Figure A). miRNA-24-3p was identified as potential regulator of CDX2 gene expression in three bioinformatics algorithms, and this was confirmed in esophageal adenocarcinoma cell lines (Figure C). Furthermore, miR-24-3p expression negatively correlates with CDX2 in cardiac-type mucosa samples with different stages of mucosal intestinalization (Figure B).

Conclusion

These results imply that miRNA-24-3p directly targets CDX2, and downregulation of miRNA-24-3p is associated with the acquisition of an intestinal phenotype in cardiac-type epithelium.

Figure: (A) OpenArray results showing downregulation of 10 miRNAs in CDX2 positive glands and upregulation of one miRNA (miR-590). (B) miR-24-3p in situ hybridization: intestinal metaplastic glands were characterized by a positive staining for CDX2 (red) and faint to negative miR-24-39. Adjacent non-intestinalized CDX2-negative glands showed a moderate miR-24-3p expression. (C) Transfection of KYAE-1 cells with miR-24-3p and miR-24-39 inhibitor. A significant CDX2 decrease was observed.
O161 LASTING SYMPTOMS AFTER ESOPHAGEAL RESECTION (LASER) – EUROPEAN MULTI-CENTER CROSS-SECTIONAL STUDY
Authors: Markar S , Zaninotto G , Castoro C , Johar A , Lagergren P , Elliott J , Gisbertz S , Mariette C , Alferi R , Huddy J , Sounderajah V , Pinto E , Scarpa M , Klevebro F , Sunde B , Murphy C , Greene C , Ravi N , Piessen G , Brenkman H , Ruurda J , Van Hillegersberg R , Lagarde S , Wijnhoven B , Pera M , Roigg J , Castro S , Matthijsen R , Findlay J , Antonowicz S , Maynard N , McCormack O , Ariyarathenam A , Sanders G , Cheong E , Jaunoo S , Allum W , Van Lanschot J , Nilsson M , Reynolds J , van Berge Henegouwen M , Hanna G
Published: November 2019

Aim

Long-term functional outcomes and the associations to health-related quality of life (HRQOL) after esophagectomy is largely unknown. LASER is a multi-center European study aimed to identify the most prevalent symptoms, and those with the greatest impact upon HRQOL among patients surviving more than one-year after esophagectomy for cancer, and to develop a clinically relevant symptom-based tool to measure HRQOL.

Background & Methods

Between 2010 and 2016, patients from 20 European Centers who underwent esophagectomy for esophageal cancer, and were disease-free at least one year postoperatively were invited to complete the LASER questionnaire, EORTC-QLQ30 and OG25. Specific symptom questionnaire items that were associated with a poor HRQOL as identified by EORTC-QLQC30 and OG25 were identified by multivariable linear and logistic regression analysis and combined to form a tool, which was tested using receiver operating characteristics curve analysis.

Results

A total of 876 of 1081 invited patients responded to the questionnaire, giving a response rate of 81%. Of these, 66.9% stated in the last 6 months they had had symptoms associated with their esophagectomy and 52.4% of patients had sought medical treatment for their symptoms. Ongoing weight loss was reported by 10.4% of patients while 32.4% were struggling to maintain their body weight, and 18.8% of patients required supplemental oral nutrition. Only 13.8% of patients had returned to work with the same activities as before.

Three LASER symptoms in multivariate analysis were correlated with poor HRQOL; pain on scars on chest (Odds ratio (OR) 1.27; 95% CI 0.97-1.65), low mood (OR 1.42; 95% CI 1.15-1.77) and reduced energy or activity tolerance (OR 1.37; 95% CI 1.18-1.59). The areas under the curves for the development and validation datasets were 0.81±0.02 and 0.82±0.09 respectively.

Conclusions

Two-thirds of patients experience symptoms related to their esophagectomy more than one year after surgery. The three key symptoms associated with poor HRQOL identified in this study should be further validated, and could be used in clinical practice to identify patients who require increased long-term term support.
P162 ENHANCED RECOVERY PROTOCOL COMPLIANCE AND CLINICAL OUTCOMES IN ESOPHAGECTOMY FOR CANCER: DESIGN OF A MEASURING INSTRUMENT
Authors: Moons J , Lerut T , Van Achterberg T , Depypere L , Nafteux P
Published: November 2019

Objectives

Success of an enhanced recovery program (ERP) is not easily measured/quantified. Can a newly developed measuring instrument help to determine compliance and thus success of an ERP?

Methods

From the introduction of our ERP (May 2017), 200 consecutive potential curative esophagectomies for cancer were reviewed. A newly developed instrument with 12 prospectively recorded benchmarks was used to measure compliance. Each patient was scored for all benchmarks, reflecting how well the protocol-timeline was followed. A mean score of ≥70% of all benchmarks in a patient is considered compliant with the ERP-protocol.

Results

Sixty-three percent (125/200) of the patients were compliant (Fig1A). Compliance to the ERP showed significant beneficial effects on clinical outcomes: the comprehensive complications index was significantly lower in the compliant group compared to the not-compliant group: 22.6 versus 43.3; p<0.0001. This resulted in a significant lower median (IQR) length of stay between both groups: 9 (8-10) days versus 14 (11-22) days; p<0.0001. Some of the benchmarks showed a direct relation to individual complications, e.g. the percentage of pneumonias is correlated to the benchmark ‘active mobilization on postoperative day1’ (Fig1B)

Conclusion

Higher compliance to the ERP protocol helps to reduce postoperative complications and thus shortens the postoperative hospital stay.
P163 OUTCOMES OF DISTAL PANCREATECTOMY AND SPLENECTOMY DURING 2-STAGE ESOPHAGECTOMY FOR CANCER
Authors: Syllaios Athanasios , Mpaili Eustratia , Mpoura Maria , Meropouli Antonia , Davakis Spyridon , Schizas Dimitrios , Karavokyros Ioannis , Charalabopoulos Alexandros , Liakakos Theodore
Published: November 2019

Aim

The aim of the study was to assess safety, feasibility and outcomes of esophagectomy with distal pancreatectomy and splenectomy for T4a esophageal and esophagogastric junction adenocarcinoma.

Background & Methods

From 01/10/2018 to 01/03/2019, three patients were operated in our Unit for adenocarcinoma of the distal esophagus or esophagogastric junction with 2-stage esophagectomy combined with distal pancreatectomy and splenectomy. Records were reviewed and clinicopathological outcomes presented.

Results

All patients were males with a mean age of 55 years (Range: 44-64). Two out of three had undergone neoadjuvant chemotherapy. Mean operative time was 420 min. (Range: 360- 480 min.). Mean blood loss was 180 ml (Range: 150-230ml). Mean ICU stay was 2.33 days (Range:1-3 days). Mean length of stay was 20 days (Range: 15-25 days). Postoperative complications observed was pneumonia in n=1. R0 resection was achieved in all patients while positive lymph node ratio was 0.3 (Range: 0- 0.73). Adjuvant chemotherapy was administered in all patients.

Conclusion

Two-stage esophagectomy for cancer along with distal pancreatectomy and splenectomy may be safely performed in specialized Upper GI Units offering adequate postoperative clinical and oncological outcomes. Further studies with larger sample size are needed to reach reproducible results.
P164 Esophageal perforations. Fighting between time, severity and individualization: a collective interhospital Upper GI Unit experience.
Authors: Mpaili Eustratia , Syllaios Athanasios , Mpoura Maria , Davakis Spyridon , Vailas Michail , Zografos Konstantinos , Tsimpoukelis Antonios , Alexandrou Andreas , Schizas Dimitrios , Charalabopoulos Alexandros
Published: November 2019

Aim

Esophageal perforation is a serious injury associated with high morbidity and mortality. The management ranges from observation to operative treatment. The aim of this study was to evaluate safety and efficacy of different treatment strategies in patients with esophageal perforation depending on the severity and time from diagnosis to treatment.

Background & Methods

We performed a retrospective review of a prospective esophageal perforation database from two Upper GI Units between 01/01/2014 and 31/12/2018. Patients admitted for esophageal perforation were identified and reason of perforation, perforation site, time of diagnosis, management, length of stay (LOS) and outcomes were recorded.

Results

Sixteen patients were identified. Reason of perforation was Boerhaave's syndrome in n=9 (56.2%), iatrogenic in n=4 (25%) and foreign body in n=2 (12.5%) patients. Perforation site was distal esophagus in n=11 (68.7%) mid- esophagus in n=3 (18.7%) and Upper esophagus in n=2 (12.5%) patients. Time from perforation to diagnosis was 24h in n=12 (75%) and 48h in n=4 (25%) patients. Treatment in patients diagnosed the first 24h was esophagectomy in n=5 (41.6%), primary closure in n=2 (16.6%) and feeding tube along with thoracotomy and washout in n=2 (16.6%). Conservative management was offered in n=2 (16.6%). Patients diagnosed after 24h were managed with chest drains (50%) and stent insertion (50%). Mean LOS in patients that required surgical intervention was 18.2 days (Range: 6-60), while mean LOS in those who did not required was 11.1 days (Range: 1-37) Eleven (68.7%) patients were discharged in good clinical condition.

Consclusion

Esophageal perforations should be treated in specialized Upper GI Units due to the severity of the injury. Treatment plan should be individualized.
P166 SPONTANEOUS ESOPHAGEAL RUPTURE – BOERHAAVE SYNDROME
Authors: Movchan B  , Usenko O , Zgonnyk A , Vynogradov R
Published: November 2019

Aim

To study the most effective method of treatment in patients with spontaneous rupture of the esophagus.

Background

The timely diagnosis of Boerhaave syndrome presents great difficulties due to its rarity, a variety of clinical manifestations, often simulating different pathologies from other organs and are difficult to treat.

Methods

From 2003 to 2019 9 patients with Bourhave's syndrome were treated at the clinic, primary care was provided to 6 patients in the community. All patients were admitted to the clinic with external left-sided esophageal-pleural fistula, 1 patient had a spontaneous rupture of the esophagus in the cliniс, the defect of the esophagus wall defect was completed, which led to successful results.

Results

Treatment in the remaining patients was started with adequate enteral nutrition and effective drainage of the pleural cavity. As a result of the use of pleural double-lumen drainage with active sanation with antiseptics and subsequent aspiration, with the exception of feeding through the mouth in four patients, it was possible to eliminate the esophageal-pleural fistula, profuse bleeding and death of the patient.

Against the background of ongoing conservative therapy in two patients, it was not possible to eliminate the esophago-pleural fistula. A left-sided thoracotomy was performed with excision of the fistula with the decortication of the lung and the extirpation of the esophagus with the formation of an esophagostomy.

Subsequently, these patients underwent retrosternal colic esophagoplasty. Two patients underwent Lewis surgery with drainage of the pleural cavity.

Conclusion

Boerhaave syndrome has a very high mortality rate, however, with a timely diagnosis and adequate surgical tactics, it develops into the formation of an esophageal-pleural fistula. In this case, the most effective treatment is excision of the fistulous course with extirpation of the esophagus and subsequent esophagoplasty. The use of esophageal stents is possible in extremely depleted patients or in elderly patients, due to the frequent occurrence of hypergranular esophagitis. Esophageal stents should be removed as soon as possible when confidence in the elimination of the esophageal-pleural fistula occurs.
O17 A PROPENSITY SCORE-MATCHED CASE-CONTROL STUDY TO COMPARE POEM AND LAPAROSCOPIC HELLER MYOTOMY IN THE TREATMENT OF ESOPHAGEAL ACHALASIA
Authors: Andrea Costantini , Pietro Familiari , Mario Costantini , Renato Salvador , Michele Valmasoni , Giovanni Capovilla , Rosario Landi , Francesca Mangiola , Luca Provenzano , Stefano Merigliano , Guido Costamagna
Published: November 2019

Background

We designed this study with the aim of comparing POEM and laparoscopic Heller myotomy+Dor fundoplication (LHD) by matching 2 groups of consecutive patients, treated in 2 high-volume Centers, with the propensity score (PS).

Methods

Patients undergoing treatment for achalasia from 2014 to 2017 were selected: by applying the PS, 140 patients in both centers were matched. LHD and POEM were performed following established techniques. Patients were followed with clinical, endoscopic and pH-manometry evaluations.

Results

POEM required a shorter operation time (47 min [35-57]) and postoperative stay (2 days [2-2]) compared to LHD (95 min [85-105] and 3 days [3-3], respectively, p<0.001). No mortality was recorded in either group. Seven complications were recorded in the POEM group (5 mucosal perforations) and 3 in the LHD group (3 mucosal perforations)(p=0.33). At a median follow up of 24 mos. [15-30] for POEM and 31 mos. [15-41] for LHD (p<0.05), the median Eckardt score did not differ: moreover, 99.3% of the POEM patients and 97.7% of the LHD patients showed an Eckardt score ≤ 3 (p <0.12). Four years after the treatment, the probability to be symptom free was > 90% for both groups (98.2% for POEM and 93.9% for LHD, p=0.2, Log-rank test). HR-Manometry showed a similar reduction in the LES pressure and 4sIRP; however, 24-h pH-monitoring showed an abnormal exposure to acid in 38.4% of POEM patients, as compared to 17.1% of LHD patients (p<0.01) and esophagitis was found in 37.4% of the POEM and 15.2% of LHD patients (p<0.05). Finally, the need for PPI therapy was higher in the POEM group (38.8%) compared to the LHD group (15.1%), p<0.001.
P171 LAPAROSCOPIC REPAIR OF A GIANT MORGAGNI’S HERNIA PRESENTING WITH RESPIRATORY DISTRESS
Authors: Davakis Spyridon , Syllaios Athanasios , Karydakis Lysandros , Hasemaki Natasha , Skotsimara Antonia , Mylonas Konstantinos , Tsiboukelis Antonios , Papalampros Alexandros , Charalabopoulos Alexandros
Published: November 2019

Background

Morgagni hernias are a rare entity among diaphragmatic hernias, representing 2% of all cases. Although uncommon, it can be fatal if the diagnosis is missed. Foramen of Morgagni is a triangular space located between the muscular fibers of the xiphisternum and the costal margin fibers that insert on the central tendon of the hemidiaphragm. They usually present in childhood with respiratory symptomatology, and a majority of cases in adults are detected incidentally on chest radiographs.

Aims/Scope

To present an extremely rare case of acute dyspnea caused by a giant congenital Morgagni’s hernia, together with review the diagnostic algorithm and the role of surgical treatment.

Results

A 48-year-old caucasian male, previously healthy, was referred to our department with acute onset dyspnea and vague right-sided chest pain for the past 4 months. No history of chest or abdominal trauma was mentioned. Chest examination revealed bowel sounds and decreased air-entry in the right chest. The patient was offered a laparoscopic repair; at operation, jejunum, ileum, appendix, ascending and transverse colon to its distal two thirds with the associated omentum were found within the hernia sac. Hernia’s neck was bridged with a dynamesh IPOM mesh in a tension free manner. The patient is well and symptoms free at 1 year follow up.

Conclusion

Majority of Morgagni hernias are diagnosed late because patients are either asymptomatic or present with nonspecific gastrointestinal or respiratory symptoms. Controversy exists regarding operative approaches via either transabdominal route or transthoracic route. In our case, laparoscopic repair was offered with favorable outcome.
P173 HIGH-RESOLUTION MANOMETRIC FINDINGS AFTER MAGNETIC SPHINCTER AUGMENTATION
Authors: Riva Carlo Galdino , Siboni Stefano , Lazzari Veronica , Sozzi Marco , Asti Emanuele , Bonavina Luigi
Published: November 2019

Aim

The aim of this study was to evaluate esophageal motility before and after Magnetic Sphincter Augmentation (MSA) for medically refractory Gastro-Esophageal Reflux Disease (GERD).

Background and Methods

MSA (LINX® Reflux Management System) is intended for patients with chronic GERD with incomplete symptom relief from proton-pump inhibitors (PPI) and abnormal acid exposure. A prospectively collected database of patients who underwent MSA between 2007 and 2019 was queried. All patients who completed pre- and post-operative high-resolution manometry (HRM) were included in the study. Additional investigations included Health-Related Quality of Life (GERD-HRQL) questionnaire, Functional Outcome Swallowing Scale (FOSS), upper gastrointestinal endoscopy, barium swallow, and 24-96 hours pH-study. Data were analyzed using Wilcoxon signed rank test and McNemar test.

Results

Forty-five patients met the inclusion criteria. The median follow-up was 10 months (IQR 6). Compared to baseline, there was a statistically significant reduction in PPI use (p=0.000), rate of heartburn (p=0.000), regurgitation (p=0.008), and extra-esophageal symptoms (p=0.000). Only three (6.7%) patients required dietary changes. The GERD-HRQL score significantly improved (p=0.000). There was a significant increase in the Lower Esophageal Sphincter (LES) competency, including LES length (p=0.004) and Esophago-gastric Contractile Integral ((EGJ-CI) (p=0.000). A significant increase in integrated relaxation pressure (IRP) (p=0.000), mean Distal Contractile Integral (DCI) (p=0.008) and intrabolus pressure (p=0.000) was also found. Thirteen (28.9%) patients presented pre-operative Ineffective Esophageal Motility (IEM) and five of them resolved postoperatively. Two patients (4.4%) developed IEM after surgery: both had IRP and DCI values within normal limits, and one of them complained of dysphagia. However, the GERD-HRQL score recovered in both patients.

Conclusion

MSA was clinically effective in relieving both typical and atypical GERD symptoms. LES competency increased after MSA. EGJ outflow obstruction was uncommon and not associated with symptoms. Finally, ineffective esophageal motility may reverse to normal after MSA.
P176 MICRONUTRIENT DEFICIENCIES FOLLOWING MINIMAL INVASIVE ESOPHAGECTOMY FOR CANCER
Authors: Thijs H J B Janssen , Laura F C Fransen , Jeroen E H Ponten , Grard A P Nieuwenhuijzen , Misha D P Luyer
Published: November 2019

Aim

To investigate the role of micronutrient deficiencies in patients undergoing an esophagectomy for cancer.

Background & Methods

Over the past decades survival rates for patients with resectable esophageal cancer have improved significantly. Consequently, the sequelae of having a gastric conduit such as development of micronutrient deficiencies become increasingly important. For this study, a systematic search of the literature was conducted, and postoperative hematological and nutritional parameters in the follow-up of patients that participated in the NUTRIENT II trial between October 2015 and May 2018 at the Catharina Hospital were investigated. Patients were included if they had at least one postoperative value for either iron, ferritin, vitamins B1, B6, B12, D, folic acid or methylmalonic acid.

Results

Data was available in 83 of 95 patients. Of these, 78.3% (65/83) had at least one and 37.3% (31/83) had more than one micronutrient deficiency at a median of 6.1 months (interquartile range 5.4-7.5) after surgery. Similar to the results found in previous studies, deficiencies included iron (including ferritin) in 42.2% (27/64), vitamin B12 (including methylmalonic acid) in 18.3% (15/82) and vitamin D in 50.6% (41/81) of patients, respectively. Moreover, folic acid deficiency was present in 28.8% (23/80) of patients. Anemia was present in 32% (16/50) of patients. At 24.8 months (interquartile range 19.4-33.1) after surgery, most micronutrient deficiencies normalized following supplementation.

Conclusion

Micronutrient deficiencies are common in patients as early as six months following an esophagectomy. Therefore, these patients should be routinely checked and supplementation provided when needed.
P178 SYNCHRONOUS TRIPLE CANCER OF THE ESOPHAGUS, GASTRIC CARDIA AND GIST OF THE STOMACH: A CASE REPORT AND REVIEW OF THE LITERATURE
Authors: Czubba M , Riepl R L , Theisen J
Published: November 2019

Background

A 82-year old man was admitted to our hospital in February 2019 for a thorough investigation to determine an incidential finding of a tumor of the stomach in a CT-Scan. He had no history of previous abdominal surgery or of serious illness. The initial symptoms were slight dysphagia, deterioriation in general condition and weight loss in the last months.

Endoscopy of the stomach confirmed a poorly differentiated adenocarcinoma of the gastric cardia (intestinal type, Siewert Type II AEG) with the suspicion of paragastric lymph node metastasis.

The consensus of our Comprehensive Cancer Center was a neoadjuvant FLOT-chemotherapy followed by radical resection.

The Patient presented again during chemotherapy in April 2019 complaining of discomfort and epigastric pain. Endoscopy showed a partial regress of the primary tumor and on CT scan a progress of the potential lymph node metastases. Due to the symptoms and findings early resection was recommended.

On surgery extensive tumor masses were found around the lesser curve and around the peritoneal cavity not like lymph node metastases. An radical resection with intrathoracic anastomoses with gastric pull up was performed. The patient was discharged 4 weeks postoperatively.

The histopathological findings showed 2 other synchronous cancers besides the adenocarcinoma of the gastric cardia (ypT1b, L0;V1,G3,R0, HER2-negative, no microsatellite instability). It showed an early stage of squamous cell carcinoma of the esophagus (pT1a (m3-Type), Gn0 (0/21), L0, V0, G1, R0) and the potential paragastric lymphnode metastasis revealed to be a rare high-risk wild-type GIST of the stomach which showed a high mitotic index (> 120 mitoses/15 high-power fields).

The patient was readmitted to our hospital because of severe epigastric pain. A CT-Scan showed a massive progress and local recurrence of the GIST with a diameter of 7cm and infiltration into the portal vein and ascites with suspicion on peritoneal carcinomatosis. Despite the attempt of a sunitinib therapy the patient died in the beginning of May 2019 in a palliative setting .

Conclusion

There have only been few reports in the literature of synchronous triple cancer of gastric GIST, esophageal squamous cell carcinoma, and gastric adenocarcinoma.

In our case we considered the gastric adenocarcinoma to be a middle stage cancer and the squamous cell carcinoma an early stage esophageal cancer. The incidental finding of the high-grade gastric GIST with a high mitotic index and unfavorable histopathological features as the wild-type confirmation was probably the cause of death of the patient.
P180 OPTIMIZING UPPER MEDIASTINAL LYMPHADENECTOMY DURING MINIMALLY INVASIVE OESOPHAGECTOMY IN PRONE POSITION: FROM 2D THORACOSCOPY AND DOUBLE LUMEN (DL) ENDOTRACHEAL TUBE VENTILATION TO 3D THORACOSCOPY AND SINGLE LUMEN (SL) TUBE VENTILATION
Authors: Bruno Lorenzi , David O’Hara , Gabriele Corsi , Parameswaran Pragatheswaran , Thusyanthan Vinayagamoorthi , Daniela Zanotti , Alexandros Charalabopoulos
Published: November 2019

Aim

Upper mediastinal lymphadenectomy is a fundamental step of a radical oesophagectomy. Nodal dissection around the recurrent laryngeal nerves may be difficult and different approaches have been described in minimally invasive surgery. We describe our experience including recent technological advancements leading to improved outcomes.

Background & Methods

A retrospective analysis was performed among patients who underwent minimally invasive oesophageal resection for cancer including upper mediastinal lymphadenectomy between January 2016 and October 2018 at our Regional Centre for Oesophago-gastric Surgery (Broomfield Hospital, Chelmsford). A comparison between the initial cases performed using 2D thoracoscopy and DL endotracheal tube ventilation vs the more recent ones adopting 3D technology and SL tube ventilation was carried out.

Length of operative time for this part of the operation, number of nodes removed and related peri-operative complications were among the data collected.

Results

A total of 14 patients were included in the study. 2D thoracoscopy and DL endotracheal tube ventilation was used in 10 patients whilst 3D technology and SL tube ventilation was adopted in 4 cases. Operative time was reduced in the 3D group. Complications related to upper mediastinal lymphadenectomy were noted in 5 patients (all of the 2D group) and included 5 recurrent laryngeal nerve palsies and 2 temporary tracheostomies for glottis oedema. There was no significant difference in the number of nodes retrieved.

Conclusion

Lymphadenectomy of the upper mediastinal nodes can be challenging and is associated with significant morbidity. In our experience, the use of SL tube ventilation facilitates the retraction of the trachea and the exposure of the area, and 3D thoracoscopy gives optimal magnified visualization of the recurrent nerves reducing the risk of damage.
P182 3D TECHNOLOGY IN MINIMALLY INVASIVE UPPER GI SURGERY: COMPARISON BETWEEN DIFFERENT SYSTEMS
Authors: Bruno Lorenzi , Ali Kordzadeh , Krashna Patel , Attila Jonas , Priyantha Siriwardana , Naga Venkatesh Jayanthi , Cheuk-Bong Tang , Sritharan Kadirkamanathan , Daniela Zanotti , Alexandros Charalabopoulos
Published: November 2019

Aim

Three-dimensional laparoscopy improves the depth of perception during minimally invasive surgery, leading to better visibility and more precise dissection, and providing better clinical and surgical outcomes in complex surgical procedures. The aim of this study was to compare the pros and cons of the 3D technological systems available in our Unit for UGI surgery.

Background & Methods

In our Unit, we have two different 3D systems for abdominal and thoracic surgery. B Braun has the EinsteinVision 3D system with 0 and 30 degree fixed camera. Olympus produces an Endoeye Flex with an articulating tip 0 degree 3D camera as well as an Endoeye 3D 0 and 30 degree rotating camera. Advantages and disadvantages of the different 3D systems were evaluated on the basis of the experience of our senior surgeons performing routinely 3D operations.

Results

All surgeons agreed of the superiority of 3D vision compared to conventional 2D laparoscopy or thoracoscopy. The B Braun system is not available in an integrated operating theatre system and does not allow image rotation, but provides a full HD sharp resolution and has the advantage of a reusable camera with single use warming cover which could be used for unlimited procedures every day. The Olympus Endoeye Flex does not provide HD resolution and can be more difficult to manoeuvre, but has the advantage of the articulating tip. The Olympus Endoeye 30 degree rotating camera has a better HD resolution and the advantage of image rotation while maintaining the horizon.

Conclusion

Technology beyond 3D laparoscopic system has been evolving rapidly. Different products have their own strengths and weaknesses, and surgeons should be familiar with the system used.
P183 NEW METHOD OF ESOPHAGO-GASTRO ANASTOMOSIS WITHIN MINIMALLY INVASIVE HYBRID IVOR LEWIS PROCEDURE
Authors: Oleksandr Usenko , Andrii Sydiuk , Andrii Klimas , Olena Sydiuk , Savenko Georgii
Published: November 2019

Aim

Improve the results of surgical treatment of esophageal cancer by developing and implementing a new method for the formation of invagination mechanical esophagogastoanastomosis.

Material and methods

Reconstruction after esophagectomy together with the reliability of the esophagus-gastric anastomosis (EGA) constitute some of the most important problems in the surgery of the esophagus, because anastomosis leakage is one of the main reasons of lethal surgery.

The research included 60 patients who anderwent the minimally invasive hybrid Ivor Lewis procedure for malignant tumors of esophagus in Shalimov National Institute of Surgery and Transplantation (1 group comprised 30 patients with mechanical EGA end-to-side; 2 group comprised 30 patients with invaginated mechanical EGA).

The objects for estimation included post-operative mortality as well as the number of post-operative anastomosis complications: the number of EGA leakages in the early post-operative period and the number of post operative strictures in the EGA area three, six and twelve months after the surgery.

All patients underwent a course of neoadjuvant chemo/RT in accordance with NCCN guidelines.

Data processing was done by means of Statistic - licensed application programs for Windows.

Results and discussion

Patients belonging to both groups were comparable according to their age, sex, weight, height and surgery duration.

Research group did not register a single case of EGA leakage while 2 patients in control group (р<0,05). had the leakage which was stopped by means of “Endovac” system. There were 2 cases of esophagus post-operative strictures which developed 3 months after the surgery in the research group which was less than in the control group which saw 6 cases of strictures of EGA (р<0,05). 6 months after surgery, the number of post-operative strictures increased in both groups, but was lower in the research group and amounted to 4 cases in the research group and 11 cases in the control group (р<0,05). There were 5 cases of esophagus post-operative strictures which developed 12 months after the surgery in the research group which was less than in the control group which saw 13 cases of strictures of EGA (р<0,05). Neither of the groups had any cases of post-operative mortality.

Conclusion

The study found that invaginated mechanical EGA within minimally invasive hybrid Ivor Lewis procedure reduces EGA leakages as well as EGA benign strictures.
P186 CAROTID-GASTROPLASTY FISTULA: AN UNCOMMON CAUSE OF HEMATEMESIS IN THE DELAYED POSTOPERATIVE PERIOD AFTER ESOPHAGECTOMY
Authors: Hurtado-Pardo L , Mingol Navarro F , Menéndez Jiménez de Zadava Lissón M , Pérez Alonso C , Bruna Esteban M , Álvarez Sarrado E , Vaqué Urbaneja J , García-Granero Ximénez E
Published: November 2019

Aim

To describe a case report of a carotid-gastroplasty fistula post esophagectomy with a successful result.

Background & Methods

Upper gastrointestinal bleeding due to a fistula between esophagus or gastroplasty and carotid vessels is infrequent. It is usually due to malignant tumors, penetrating trauma, foreign bodies or radiotherapy.

Results

A 55-year-old man, with background of laryngeal squamous cell carcinoma that was treated with total laryngectomy and tracheostomy followed by radiotherapy, and posterior recurrence of squamous cell carcinoma at the upper esophagus required total esophagectomy with pharynguectomy and lymphadenectomy, and reconstruction with gastroplasty with anastomosis to the floor of the mouth and pectoralis muscle flap. During this second postoperative period, patient developed a left hemiplegia secondary to thrombosis of the right common carotid artery.

After recovery, the patient had repeated episodes of hematemesis that required hospital admission and blood transfusion. After several episodes with conservative management, upper endoscopy revealed blood oozing close to the anastomosis with no other findings. Once again, the patient returned to the emergency department with massive hematemesis, being visualized by endoscopy a high-flow arterial bleeding close to the anastomosis of the floor of the mouth. Arteriography showed the already known thrombosis of the right common carotid artery and the origin of the bleeding distal to that occlusion, where it was repermeabilized by a branch of the right vertebral artery. Given the inability of selective embolization by interventional radiology, urgent surgical approach was decided, performing a right lateral cervicotomy and identifying a fistula that communicated the common carotid artery with gastroplasty. It proceeded to close the fistulous orifice of the arteria and the gastroplasty with a continuous suture. A partial sternocleidomastoid muscle flap was interposed between the two sutures.

The postoperative evolution was satisfactory. Patient was discharged 16 days after surgery and being currently stable without signs of hemorrhagic neither oncological recurrence.

Conclusion

Carotid-gastroplasty fistula is a rare complication with high mortality rate due to its more frequent presentation: the massive hematemesis. Gastrointestinal endoscopy and angiography allow us to diagnose and treat this complication, however in massive and uncontrollable bleeding, surgical approach is indicated. Prognosis will depend on the early diagnosis and a therapeutic individualization is required.
P188 QUALITY ASSURANCE OF SURGICAL INTERVENTION WITHIN RANDOMIZED CONTROLLED TRIALS FOR GASTRO-ESOPHAGEAL REFLUX DISEASE
Authors: Sheraz R Markar , Sara Jamel* , Tom Wiggins , George B Hanna
Published: November 2019

Aim

Randomized controlled trials provide level 1 evidence for surgical intervention in the treatment of gastro-esophageal reflux disease (GERD). This systematic review aimed to investigate the practice of surgical quality assurance in RCTs concerning surgical interventions in GERD.

Background & Methods

A systematic literature search for articles was performed in Medline, Embase, Web of Science and Cochrane library for randomized controlled trials (RCT) evaluating surgical intervention in the management of GERD. Each RCT was assesses for surgical quality assurance (SQA) using an eight-point checklist in three main areas and given a SQA score out of 8. Clinical outcomes from each trial including reoperation rates were then compared against the SQA score.

Results

Thirty-one publications were included compromising 5803 patients.

The assurance of surgical quality was poor with the randomized controlled trials included, ranging from 3% to 68% for the factors examined:

Credentialing surgeon experience before entry into the trial by;

1. Case volume – 26% (8/31)

2. Operative reports – 6% (2/31)

3. Video assessment – 6% (2/31)

4. Live operating room evaluation – 3% (1/31)

Pre-trial standardization by;

5. Education of surgeons – 13% (13%)

6. Consensus for standardization – 68% (21/31)

Monitoring surgical performance during the trial by;

7. Video assessment – 10% (3/31)

8. Monitoring of data – 3% (1/31)

RCTs with a high SQA score had a reduced average rate of reoperation (SQA score 4 to 8 vs. 0 to 3; 0% vs. 3.19%; P<0.05). Credentialing surgeons by case volume before entry into the trial was also associated with a reduced rate of reoperation (0.04% vs. 3%; P<0.05).

Conclusion

Surgical quality assurance has been largely lacking in randomized controlled trials for GERD previously. High surgical quality assurance was associated with reduced reoperation rates within RCTs, highlighting the need for good SQA within these types of trials. Future RCTs in benign UGI conditions with surgical interventions should ensure SQA in three main areas:

(i) Credentialing surgeon experience before trial; to ensure they are past learning curve.

(ii) Standardizing the surgical technique; to ensure less heterogeneity in operative performance.

(iii) Monitoring performance during trial; to ensure standard of surgical quality is maintained within the trial.
O190 THE EPIDEMIOLOGY OF ANTI-REFLUX SURGERY IN DENMARK 2000-2017: A NATIONWIDE REGISTRY-BASED POPULATION STUDY
Authors: Ljungdalh Jonas Sanberg , Durup Jesper , Houlind Kim Christian
Published: November 2019

Aim

The primary aim of this register-based study was to describe the utilization and development of anti-reflux surgery compared to use of proton-pump inhibitors from 2000-2017 in a nationwide population-based cohort.

Background & Methods

Treatment of GERD consists of anti-secretory drugs, mainly proton pump inhibitors (PPI), or anti-reflux surgery. Laparoscopic anti-reflux surgery is considered standard of care in surgical treatment of gastro-esophageal reflux disease1 and with careful patient selection based on thorough preoperative workup2 symptom control and patient satisfaction are high compared to medical therapy3–5.

In American studies, the rate of anti-reflux surgery peaked at 16.7 per 100.000 inhabitants in 2000 and then decreased to 6.1 per 100.000 inhabitants by 20106, 7. The only Danish study on the epidemiology of anti-reflux surgery, describes a reoperation rate of 5%, but only includes data from 1997-2005 and describes no rate of surgery compared to population size8. It is therefore unclear how the use of anti-reflux surgery has developed.

This register-based cohort study includes all patients who have undergone anti-reflux surgery in Denmark from 2000-2017. Data was retrieved from The National Danish Patient Registry and linked at an individual level using the unique civil registration number issued to all Danes. For the entire study period, rate of anti-reflux surgery, including primary and reoperative procedures, Charlson comorbidity index (CCI), 30- and 90-days perioperative mortality, use of laparoscopic technique and length of stay was calculated. Population-based rates of surgery was compared to rates of PPI-use.

Results

Rate of surgery peaked between 2000-2005 with >5.0 procedures per 100.000 inhabitants, but declined consistenly in the rest of the study period. Reoperations were an increasing percentage of the prodecures with up to 20% increasing from 7%. CCI increased during the study period with >25% having a CCI>0 at the end of the study. In the entire period, >98% of procedures were performed laparoscopically, mortality <1% and length of stay declined to median 1 day.

Conclusion

Anti-reflux surgery was utilized less, but mortality, conversion rates and length of hospital stay were consistently low, despite an increased burden of comorbidity and reoperations.
P192 CROSS REGIMEN FOR ADENOCARCINOMA OF THE ESOPHAGUS AND CARDIA: DOES PATHOLOGICAL RESPONSE INFLUENCE OVERALL AND DISEASE FREE SURVIVAL? MULTICENTER RETROSPECTIVE ANALYSIS
Authors: Stefano de Pascale , Paolo Parise , Michele Valmasoni , Jacopo Weindelmayer , Fabrizia Terraneo , Chiara Alessandra Cella , Simone Giacopuzzi , Andrea Cossu , Stefano Merigliano , Uberto Fumagalli Romario , Riccardo Rosati
Published: November 2019

Aim

Primary aim is to evaluate the relationship between pathological response after CROSS regimen for locally advanced esophageal adenocarcinomas and overall and disease-free survival. Secondary endpoint is to analyze the principal sites of relapse after surgery in this group of patients.

Background & Methods

The CROSS trial showed an improvement of overall survival after neoadjuvant chemoradiation and subsequent surgical resection compared to surgery alone for patients with esophageal cancer, representing the benchmark [1].

Patients submitted to CROSS regimen for adenocarcinoma of the esophagus and cardia followed by esophagectomy with a transthoracic extended lymphadenectomy were analyzed. The patients were treated in 4 centers part of Italian Group for the Study of Esophageal Diseases (SISME). Actuarial Overall survival (OS) and actuarial disease-free survival (DFS) were analyzed and stratified according to yp Stage (1 – stage I and II; 2 – stage IIIA and IIIB and 3 - stage IVA) as described in the 8th edition of TNM.

Kaplan-Meier method was used to estimate overall and progression-free survival, with the log-rank test to ascertain significance (p<0.05). Median and range were used. Statistical analysis was done with SPSS version 21.0.

Results

132 patients, from January 2014 to February 2019, were analyzed. Median age was 63 years (range 42-82). The site of the neoplasm was the distal esoghagus-EGJ in 127 cases and the middle esophagus in 5. Ivor Lewis was the procedure adopted. Fifty-month OS and DFS were respectively 42% and 6.7% respectively. No difference emerged when overall survival was analyzed according to yp Stages. Time to relapse is significantly longer for ypStage I and II. Recurrence occurred in 48 cases (36.3%) with 9 months as median time to relapse. Local and distal relapse were 10 (paratracheal nodes) and 38 respectively (7.5% and 28.7%, p<0.001).

Conclusion

Pathological response after CROSS regimen doesn’t relate to OS and DFS. Time to recurrence is significantly longer for yp Stage 1 e 2 rather than other ypStages. Chemoradiotherapy in a neoadjuvant setting may influence the site of relapse.
O193 ROLE OF MALNUTRITION IN 0ESOPHAGEAL SURGERY FOR CANCER
Authors: Alfieri R , Nardi M , Moretto V , Pinto E , Briarava M , Pomba L , Scarpa M , Pilati P L , Castoro C
Published: November 2019

Aim

To investigate whether preoperative malnutrition is associated with long term outcome and survival in patients undergoing radical oesophagectomy for oesophageal or oesophagogastric junction cancer.

Background & Methods

Dysphagia, weight loss, chemo-radiationtherapy frequently lead to malnutrition in patients with oesophageal or oesophagogastric junction cancer. Severe malnutrition is associated with higher risk of postoperative complications but little is known on the correlation with long term survival. We conducted a single center retrospective study on a prospectively collected database of patients undergoing oesophagectomy from 2008 and 2012 in order to evaluate the impact of preoperative malnutrition with postoperative outcome and long term survival. Preoperative malnutrition was classified as: prealbumin level less than 220 mg/dL (PL), MUST index (Malnutrition Universal Screeening Tool) >2 and weight loss >10%.

Results

177 consecutive patients were considered: due to incomplete data 60 were excluded from the analysis that was performed on 117 patients. PL was reported in 52 (44%) patients, MUST index was recorded in 62 (53%), 58 (49%) patients presented more than 10% weight loss at the preoperative evaluation. PL was associated with more postoperative Clavien-Dindo 1-2 complications (p=0.048, OR 2.35 95%IC 1.001-5.50), no differences were observed in mortality, anastomotic leak, major pulmonary complications. MUST index was not correlated with postoperative complications nor mortality but resulted worse in patients treated with chemo-radiotherapy (p=0.046, OR 1.92 95%CI 1.011-3.64). Weight loss >10% was not associated with postoperative complications or mortality. Overall 7 years survival rate was 69%. and DFS was 68%. Malnourished patients did not differ from non-malnourished regarding age, sex, tumor site, tumor stage and histology. No significant difference in 7 years survival rates was observed in patients with PL <220 mg/dL ( 55 % vs 67%), neither in patients with MUST score>2 (58% vs 72%), nor in patients with weight loss >10% (53% vs 70%).

Conclusions

Malnutrition is more common in patients treated with chemoradiation therapy and it is associated with postoperative complications. However, both long term and disease free survival are not affected by preoperative nutritional status. Larger patient population and data on long term postoperative nutritional status will be analyzed in further studies.
P198 SUPERIOR POLAR GASTRECTOMY ASSOCIATED WITH ANTI-REFLUX TECHNIQUE: CASE REPORT
Authors: Navío Seller A , Jiménez-Rosellón R , Bruna Esteban M , Vaqué Urbaneja J , Mingol Navarro F
Published: November 2019

Aim

To present a case report where Kamikawa’s technique1 was used, as well as the patient’s postoperative evolution and results.

Background and Methods

Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence.

This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer.

Results

A 55 year-old female with no relevant medical history, diagnosed with diffuse signet ring cell gastric adenocarcinoma. The tumor was 3 cm long, extending from the esophago-gastric junction to the subcardial region (cT3 N1 M0). After presentation in a Multidisciplinary Group, the patient underwent perioperative chemotherapy according to the FLOT-4 protocol, presenting partial clinical response.

The surgical intervention took place 6 weeks after finishing chemotherapy, and a laparoscopic superior polar gastrectomy was performed, associating extended resection including 3-4 cm of distal esophagus and D1+ lymphadenectomy with periesophageal lymph node regions 110 and 111. Once the resection was finalized, an assistance laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of the cranial part of the gastric pouch and afterwards, two seromuscular flaps were dissected. Then, the gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis made with 2 running sutures of V-lock 3/0. Finally, the previously prepared seromuscular flaps were sewn overlapping the esophagus and the esophago-gastric anastomosis in order to prevent reflux.

The patient presented a benign postoperative course, reintroducing oral intake and developing no heartburn, no dysphagia, nor vomiting and was discharged on the 9th postoperative day.

The postoperative barium swallow radiography showed no leak of contrast nor any regurgitation. The pathology report showed pT3N1 (2/17) and confirmed tumor free resection margins.

Conclusion

The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.