bluuebunny/crossref_metadata_2025 huggingface dataset:
438 THE IMPACT OF ROUTE OF RECONSTRUCTION FOLLOWING THREE PHASE ESOPHAGECTOMY: AN UPDATED PERSPECTIVE
Authors: Wong C , Luk Y , Chan D , Wong I , Chan F , Law B , Law S
Published: September 2020

The retrosternal space (RS) and posterior mediastinum (PM) are the two common routes for reconstruction after three-phase esophagectomy. It remains controversial if the choice of route impacts on post-operative outcome. This study aims to compare the two routes in the era of increased application of multimodal therapy.

Methods

In a single tertiary center, patients who had squamous cell carcinoma of the esophagus and underwent three-phase esophagectomy with gastric conduit reconstruction via either the RS or PM routes between 2002 and 2017 were studied. Patient demographics, surgical outcomes and survival were analyzed from a prospectively managed database.

Results

345 patients were included (271 men); RS 73 and PM group 272. Demographics were not different. Between RS and PM, proportion of neoadjuvant therapy (59%vs.63%, p = 0.536) and thoracoscopic resection (61.6% vs.72%, p = 0.116) were comparable. More advanced disease was found in RS, with fewer R0 resections (36.9% vs.90%, p < 0.001) and more advanced pT&pN stages (p = 0.000&0.008).

Operative results were presented in Table 1. In the RS group, there was more blood loss (p = 0.015) and anastomotic leaks (p = 0.03). Cardiopulmonary complications, 30-and 90-day mortality were comparable. On multivariate analysis for 90-day mortality R-category was the only independent factor (p = 0.014). Overall survival was worse for RS (p = 0.000), but not different when only R0 resections were selected.

Conclusion

The RS route was more often the choice for reconstruction in loco-regionally advanced disease. Compared with PM route, more anastomotic leaks were found. Survival was not different between RS and PM routes when resection was curative.
453 LAPAROSCOPIC RESECTION OF A GIANT EPIPHRENIC DIVERTICULUM
Authors: Ramos D , Priego P , Blazquez L , Cuadrado M , Sanchez S , Galindo J
Published: September 2020

Epiphrenic diverticula are acquired mucosal out-pouchings of the distal third of the oesophagus; vastly undiagnosed due to their usual asymptomatic status, with limited number in all published series, and a still ongoing debate both in their surgical indication and technique. This video shows all steps we think that are necessary when operating an epiphrenic diverticulum, in order to illustrate them all and to show the feasibility of performing such operation with minimally invasive procedures.

Methods

A 52-year-old male was diagnosed of a symptomatic giant epiphrenic diverticulum after previous complaints of dysphagia and regurgitation of undigested food. Preoperative barium-swallow and upper endoscopy confirmed the diagnosis, excluding any other secondary aetiology, and conventional oesophageal manometry did not show any relevant findings.

Results

Surgery was indicated for symptomatic disease, and a laparoscopic procedure was performed, with pneumoperitoneum created through a Veress needle and trocars placed similar to those used for a hiatal hernia repair. After opening the hiatus, access was granted to the mediastinum and the diverticulum was identified and dissected, and when its neck was completely exposed, diverticulectomy was performed using endostapler loads reinforced with Peri-strips Dry®. Aferwards, both an oesphageal myotomy (from the oesophago-gastric junction to the distal point of the diveticulum’s neck) and a partial Dor fundoplication (despite the absence of relevant findings in the conventional manometry) were performed.

Conclusion

Surgical management of epiphrenic diverticula should entail both resection of the pouch (diverticulectomy, to avoid postoperative persistent symptoms) and treatment of the underlying motility disorder that has been demonstrated in other studies in nearly 100% of the patients using high-resolution manometry (myotomy and fundoplication, both to avoid recurrences and leakages of the staple line). The laparoscopic approach is feasible without video-assisted thoracoscopy in diverticula with their neck up to 10 cm from the oesophagogastric junction.

Video

https://www.dropbox.com/s/hugbemgi6wl55kp/EpiphrenicDiverticulumx2.mp4?dl=0
462 DEFINING IMPACT OF PRE-OPERATIVE ANAEMIA ON SURVIVAL IN OESOPHAGOGASTRIC CANCER: A MULTI-INSTITUTIONAL ANALYSIS
Authors: Kamarajah S , Khaw R , Chmelo J , Navidi M , Phillips A
Published: September 2020

Growing interest surrounding pre-operative anaemia in patiens undergoing major surgery. However, no current evidence surrounding role of pre-operative anaemia on the post-operative outcomes and long-term survival following esophagectomy for esophageal cancers. This study aimed to evaluate morbidity and mortality according to pre-operative in patients undergoing esophagectomy for esophageal cancer.

Methods

Consecutive patients undergoing esophagectomy for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between January 2000 and December 2018 at the Northern Oesophagogastric Unit were included from a prospectively maintained database. The main explanatory variable is pre-operative anaemia. Primary outcome was overall survival. Secondary outcomes include overall complications, anastomotic leaks and pulmonary complications.

Results

During the study period, 1148 patients underwent esophagectomy for cancer. Of these 7% (n = 78) had pre-operative anaemia. Median survival of patients with anaemia were similar to those without pre-operative anaemia (median: 67 vs 45, p = 0.1). On Cox multivariable regression analysis, pre-operative anaemia had no impact on long-term survival, even when stratified for oesophageal adenocarcinoma and squamous cell carcinoma. Rates of overall complications (71% vs 66%), anastomotic leaks (4% vs 8%) and pulmonary complications (19% vs 14%) were similar between the groups.

Conclusion

Contrary to published evidence in cardiothoracic and vascular surgery, pre-operative anaemia had no impact on long-term survival and post-operative outcomes for esophagectomy.
76 WHOLE-EXOME SEQUENCING EXPLORES DIFFERENTIAL GENES EXPRESSION OF METASTASIS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA: A PROPENSITY-SCORE MATCHING STUDY
Authors: Zeng Y , Liu M , Xiang C , Yu J , Han Y , Li Z , Fu X , Cai X
Published: September 2020

Metastasis is the most popular failure pattern for esophageal squamous cell carcinoma (ESCC) patients. There were rare ESCC patients with stage T1-3N0M0 metastasized within 1 year after surgery or stage T1bN3M0, while many ESCC patients with stage T1-3N0M0 didn’t metastasize within 2 years after surgery or stage T1bN0M0. This study is to analyze paired ESCC patients with or without early distant metastasis or multiple lymph nodes, and identify potential biomarkers for early metastasis of ESCC.

Methods

1942 ESCC patients who underwent surgery in our institution were retrospectively reviewed from January 2013 to December 2017. One group of patients with stage T1-3N0 who developed metastasis within one year and without recurrence within two years after surgery (M group), and another group of patients with stage T1bN0 and T1bN3 (N group) were screened. We matched patients with the critically clinicopathological factors by propensity-score matching (PSM) method. Whole-exome sequencing (WES) was performed on the formalin-fixed paraffin embedded samples of the included patients. Statistical analysis was performed by SPSS version 22.0.

Results

From 1942 patients screened, there were only 6 T1-3N0 patients with early distant metastases and 4 T1bN3 patients. We paired 6 T1-3N0 patients without recurrence within two years and 4 T1bN0 patients by PSM. The median overall survival (mOS) of patients in M1 was 21 months, while M0 did not reached. The mOS of patients in N3 and N0 were 10 months and 48 months, respectively. The WES result showed that the FRG1, HLA-DRB1 and MUC6 expressed differentially in these patients. However, only the HLA-DRB1 expression was associated with the survival of patients in N group by univariate analysis (p = 0.013).

Conclusion

Regardless of the small sample size, the study identified several genes correlated with the early metastasis of ESCC. ESCC patients with T1bN3M0 had significantly higher expression of HLA-DRB1 gene than patients with T1bN0M0 (p = 0.013). It seemed that HLA-DRB1 gene was correlate with early multiple lymph nodes metastases, which needs further research and may be helpful in new drug discovery.
485 MINIMALLY INVASIVE EN-BLOC OESOPHAGECTOMY: ANALYSIS OF THE OUTCOMES ALONG A LEARNING CURVE
Authors: Di Maggio F , Lee A , Vrakopoulou Z , Deere H , Botha A
Published: September 2020

Minimally invasive oesophagectomy is technically demanding but benefits perioperative morbidity and intra-hospital mortality. We previously described open total adventitial resection of the cardia (TARC) as an optimal anatomical resection technique for lower oesophageal and gastro-esophageal junction cancers. We wanted to investigate whether the peri-operative benefits of minimally invasive techniques, along with en-bloc resection of the primary tumour, translate into long term survival benefit in a specialized high volume center along a surgeon learning curve.

Methods

Data from 198 consecutive patients undergoing oesophagectomy by a single surgeon was collected prospectively. Patient stratification was made to chronologically reflect four main stages of our learning curve: open surgery, Laparoscopic Ivor Lewis, laparoscopy/thoracoscopy with mini-thoracotomy and laparoscopic TARC. Primary outcomes included five-year survival rate, operating time, hospital stay, specimen lymphnodes. Peri-operative complications and mortality are also described. 45 patients had open surgery; laparoscopy (n = 50) was initiated after two years, and thoracoscopy (n = 56) introduced after case 94. MIO was performed for the last 47 patients.

Patients in all groups had similar demographics, histological diagnosis, preoperative and pathological staging.

Results

158 patients were male (79.8%); age was 63 +/− 10 years. Overall five-year survival rate was 45%; perioperative mortality rate was 1.5% (n = 3); 13 patients were returned to theatre. Hospital stay was 22+/−23 days. Specimen lymph nodes were 21+/− 8. Resection margins were negative (ACP) in 193 cases (97.4%).

Five-year survival rates during the 4 phases were 38.6%, 44.9%, 42.8% and 59% respectively, showing a benefit trend towards the end of the learning curve (p = 0.03).

Specimen lymph nodes were: open = 20.5+/−9.5; Lap = 19.5+/− 7; mini-tho = 19.9+/− 7; MIO = 25+/− 10 (p = 0.027). Resection margins were > 1 mm in 68.1%(open), 67.3%(lap), 64.2%(mini-tho) and 79.5(MIO).

Conclusion

Laparoscopic en-bloc resection of cancers of the OGJ requires a long learning curve. Proficiency gains along this learning curve affects oncological quality of oesophageal resectional surgery and benefits patients survival after minimally invasive oesophagectomy.
489 A COMPREHENSIVE ANALYSIS OF ANASTOMOTIC COMPLICATIONS FOLLOWING ESOPHAGECTOMY
Authors: Katz A , Bendayan S , Hilzenrat R , L Ramirez-GarciaLuna J , Kammili A , Al Lawati Y , Abureida F , Nevo Y , Cools-Lartigue J , Spicer J , Mueller C , Ferri L
Published: September 2020

Post-esophagectomy anastomotic complications can result in high morbidity/mortality. Those with necrosis and sepsis have traditionally resulted in conduit loss and cervical esophagostomy. We sought to examine our management and outcomes of anastomotic complications, with a focus on an approach that stresses conduit salvage.

Methods

Conduit complications were identified from a prospectively collected esophagectomy database (2006–17) at a high-volume referral center. Patient/tumor/treatment details and surgical outcomes were collected. Conduit complications were defined as Leak/Conduit Necrosis/Tracheoesophageal Fistula (TEF) and graded according to the Clavien-Dindo classification. Successful treatment was defined when sepsis/leak control was achieved and no further intervention was required. Statistical analysis was done using Cox regression, logistic regression, ANOVA or Chi-square tests, *p < 0.05.

Results

Of 647 esophagectomies, conduit complications occurred in 103 (16%) [Leak:73 (11%); Necrosis:24 (4%), (TEF):6(1%)]. Antibiotics (C-D = 2) was successful in 28 (38%) of Leaks. Endoscopic stent alone (C-D = 3A) was successful in 20 (27%) Leak, 7(29%) Necrosis, and 1(17%) TEF cases. Early conduit revision+re-anastomosis (C-D = 3B/4) was successfully performed in 22 (30%) Leak, 13 (54%) Necrosis, and 5(83%) TEF cases. Only 6 patients [2(3%) Leak, 4(16%) Necrosis] had conduit loss+cervical esophagostomy. 90-day mortality was: Minor (C-D = 2-3A) Leak = 3%, Major (C-D = 3B-4) Leak = 8%, and Necrosis = 21%*. Necrosis, but not Leak or TEF, was associated with lower 3-year survival compared to patients who did not have conduit complication (30% vs 55%, p < 0.008).

Conclusion

The vast majority of conduit complications, including conduit necrosis, can be managed successfully with conduit salvage with endoscopic treatment or early surgical re-anastomosis. Cervical esophagostomy is rarely required.
494 LONG-TERM SYMPTOM CONTROL FOLLOWING LAPAROSCOPIC HELLER MYOTOMY AND DOR FUNDOPLICATION FOR ACHALASIA
Authors: Doubova M , Gowing S , Robaidi H , Gilbert S , Maziak D , Shamji F , Sundaresan S , Villeneuve P , Seely A
Published: September 2020

Achalasia is a primary esophageal motility disorder in which there is incomplete relaxation of the lower esophageal sphincter and absence of peristalsis in the lower two-thirds of the esophagus. A favored treatment is with laparoscopic modified Heller myotomy with Dor fundoplication (LHMDor) with over 90% beneficial effect. The short-term outcomes of LHMDor are well documented, but stability and durability of post-operative symptom control over time is less understood.

Methods

Between 2004–2016, 54 patients with achalasia underwent LHMDor (single center). Using validated questionnaires, patients rated their symptoms in five domains: pain, gastroesophageal reflux disease (GERD), dysphagia, regurgitation and quality of life (QOL), rating their symptoms preoperatively, 4-weeks post-operatively, 6-months post-operatively and yearly following the operation.

Results

As expected, patients reported marked improvement in dysphagia, odynophagia, regurgitation, GERD and quality of life after the operation (p < 0.001). From then on, the symptom control remained durable with respect to absence of pain, regurgitation and odynophagia; however, we observed a recurrence of GERD symptoms beginning 3–5 years postoperatively (p = 0.001, p = 0.04, respectively), with associated increased antacid use. Following initial LHMDor, 5 patients required endoscopic dilatation an average of 1.5 years post-operatively and no patient required reoperation. Patients reported preserved improved quality of life up to 11 years following the operation (p = 0.001).

Conclusion

These results demonstrate the durability of LHMDor in the definitive management of achalasia offering consistent symptomatic relief and significant improvement to QOL over the decade following surgery, despite some increase in GERD symptoms and antacid use.
560 CORRELATION ANALYSIS OF TYPES AND NUMBER OF GASTROESOPHAGEAL REFLUXES WITH NUTRIENTS CONSUMPTION IN CHILDREN
Authors: Morozov S , Borodina G , Nikityuk D
Published: September 2020

Little is known about association of types and number of gastroesophageal refluxes with nutrients consumption in children. However this may be important for planning further research and from the practical point of view.

The aim of the study was to perform a correlation analysis between the number and type of gastroesophageal refluxes (GER) with nutrients consumption in children and adolescents.

Methods

The data of the examination of 219 children served as the source for the study. The complex examination included the analysis of nutrients consumption (Validated language-specific food frequency questionnaire), esophageal pH-impedance recordings (Ohmega, MMS, the Netherlands) esophagogastroscopy (Olympus Excera II, Olympus, Japan). Spearman rank correlation analysis between types and number of gastroesophageal refluxes and level of nutrients consumption was performed with the use of Statistica 10 software (StatSoft Inc, USA). To analyze the data on actual nutrition of children of different age groups, the obtained direct values of were converted into a percentage deviation from the recommended daily allowance rates.

Results

Significant (P < 0.05) inverse correlation was found between AET and consumption of PUFAs (Spearman rank R = -0.33), ω-3 PUFA (R = -0.33), ω-6 PUFA (R = -0.3), vitamin A (R = -0.34), niacin (R = -0.28) and ascorbic acid (R = -0.37).

The number of acid refluxes, was associated with energy values of the rations (R = 0.269), amount of protein (R = 0.279), total fat (R = 0.272), total carbohydrates (R = 0.152), and added sugar (R = 0.157) consumption.

There was no correlation between number of weak-acid refluxes and diet.

Nr of non-acid refluxes was associated with the amount of PUFAs (R = 0.19), ω-6 (R = 0.151), ω-3 (R = 0.19), sodium (R = 0.158), phosphorus (R = 0.166), vitamin B1 (R = 0.17), niacin (R = 0.19), and ascorbic acid (0.23) consumed.

Conclusion

We found that esophageal acid exposure time and number of different types of refluxes (but not weak-acid) may be associated with the consumption of some of the nutrients in children. This information may be of use for the diet correction as a component of treatment of children with GERD.
573 PER-ORAL ENDOSCOPIC MYOTOMY FOR RECURRENT KILLIAN-JAMESON DIVERTICULUM
Authors: Boucher Z , Ducoin C , Velanovich V
Published: September 2020

Killian-Jameson Diverticulum (KGD) is similar to Zenker's diverticulum(ZD) in respect to underlying pathology of protrusion of esophageal mucosa and vague foregut symptoms including dysphagia. However, KGD is distinctly different from ZD due to location of diverticulum, incidence, and preferred surgical approach.

Methods

We present a case of a patient who had previously undergone a transcervical diverticulectomy for JKD. He initially had symptomatic relief but eight months later developed a recurrence of his diverticulum with dysphagia. A per-oral endoscopic myotomy (POEM) was then performed. A video of this endoscopic intervention can be seen in this submission, along with appropriate commentary.

Results

The patient had resolution of his dysphagia and he recovered without complication.

Conclusion

This novel approach to recurrent Killian-Jameson Diverticulum after the more standard open transcervical approach should be considered for this challenging clinical scenario. The basic principles of an endoscopic myotomy can be applied similarly to such a diverticulum.

Video

https://www.dropbox.com/s/dlne8d08tp3rskb/KJ%20Diverticula%203%20min%20Edit%20%28edited%20-%20WeVideo%29.mp4?dl=0
576 P40, P63-NEGATIVE NON-SQUAMOUS CELL CARCINOMA OF ESOPHAGUS EXCEPT FOR ADENOCARCINOMA OF ESOPHAGOGASTRIC JUNCTION, REPORT OF TWO CASES
Authors: Fujishima F , Taniyama Y , Yamauchi T , Akaishi R , Kamei T , Sasano H
Published: September 2020

Esophageal cancer is the eighth most common human malignancy and the sixth most common cause of death from cancer worldwide. In Europe and the United States, the proportion of adenocarcinoma has increased due to the increase of Barrett's adenocarcinoma. On the other hands, in Japan most cases are squamous cell carcinoma and adenocarcinoma except esophagogstric junction including Barrett's adenocarcinoma is extremely rare.

Methods

We experienced two cases of tumors with morphologically no distinct squamous or glandular differentiation and confirmed not to be Barrett’s adenocarcinoma. No clear positive findings for p40 and p63 by immunohistochemistry.

Case 1 is 69-year-old man. Esophagectomy was performed after neoadjuvant chemotherapy. Macroscopic findings of the resected specimen showed 59 × 43 mm of tumor (type 2) at upper to middle thoracic esophagus.

Case 2 is 53-year-old man. Esophagectomy was performed without neoadjuvant chemotherapy. Macroscopic findings of the resected specimen showed 68 × 46 mm of tumor (type 1) at middle thoracic esophagus.

Results

Pathological examination revealed that the cancer cells showed mainly solid proliferation and no clear keratinization and gland formation was observed. The relationship with the duct of esophageal gland proper was not observed.

Immunohistochemistry, tumor cells showed no neuroendocrine differentiation(ChromograninA-, synaptophysin-)and negative for p40, p63 and CK14, on the other hands tumor cells were positive for CK18.

Conclusion

By the WHO classification, in addition to adenocarcinoma of the esophagogastric junction, squamous cell carcinoma, neuroendocrine tumor, and salivary gland type tumor, there is an item of undifferentiated carcinoma. However, tumor cells of our cases had not such strong atypia, and immunohistochemical study showed glandular differentiation. Although we could not clarify the origin of tumor, it was suggested that there may be carcinoma other than adenocarcinoma of the esophagogastric junction, which may have glandular elements.
584 MULTIPLE OBSERVER DETERMINATION OF GASTRO-ESOPHAGEAL JUNCTION CHARACTERISTICS ON VIDEO-FLUOROSCOPY RELATING TO TROUBLESOME DYSPHAGIA POST-FUNDOPLICATION
Authors: Gan S , Lee N , Tan S , Edwards S , Kiroff G , Myers J
Published: September 2020

Dysphagia is a common adverse effect of fundoplication and in some patients, there is no clear identifiable cause despite extensive investigation. Subtle anatomical features of anti-reflux surgery may relate to dysphagia. In this study multiple observers examine gastro-esophageal junction (GEJ) anatomy using objective measures of video-fluoroscopy swallow study (VFSS) to explore possible correlates with post-fundoplication dysphagia.

Methods

Thirty-one patients underwent structured VFSS 6–12 months after laparoscopic total (TotLF) or partial anterior (PAntLF) fundoplication recording: standing AP, 2x standing oblique (SOb), 2x prone oblique (POb), and prone oblique with continuous drinking (PObCont). Post-operative dysphagia was evaluated (Dakkak & Bennett Score: range 0–45; troublesome ≥12). Three observers (Obs1–3) independently measured: GEJ displacement anteriorly; degree of axis deviation of esophagus & GEJ (E-GEJ); posterior distal esophageal angle (PDEA); and GEJ opening diameter cf. maximal distal esophageal diameter (ME-GEJ). Correlations between measurements and dysphagia by operation type were assessed using linear regression analysis and linear mixed-effects models.

Results

Post-operatively, 5/18 TotLF and 4/13 PAntLF patients reported troublesome dysphagia. Three observers independently found: patients with troublesome dysphagia after TotLF had greater anterior displacement of the GEJ (SOb, range 0.61 cm–1.18 cm, Obs1 p = 0.04), and larger axis deviation of E-GEJ (POb, range 3.28°-13.07°, Obs2 p = 0.03) compared to patients with no/mild dysphagia. There was a trend for greater PDEA in patients with troublesome dysphagia after TotLF (POb, range 0.46°-2.12° and PObCont, range 3.37°-13.4°), but this trend did not reach statistical significance. Following PAntLF, all observers recorded a reduction in ME-GEJ for each unit of worsening dysphagia (PObCont, range 0.03 cm–0.04 cm, Obs1 p = 0.02, Obs2 p = 0.02).

Conclusion

Multiple observers concur that anterior GEJ displacement, the angle between the esophagus axis—GEJ axis, and posterior distal esophageal angulation are anatomical factors associated with troublesome dysphagia after total fundoplication. After partial anterior fundoplication, a small reduction in GEJ opening diameter relative to the distal esophagus related to worsening dysphagia. To reduce post-fundoplication dysphagia, attention to operative techniques affecting angulation and luminal diameter at the GEJ by fundoplication and hiatal repair is warranted.
588 THE INFLUENCE OF CHANGE OF DIET COMPOSITION ON ESOPHAGEAL MOTILITY PATTERNS IN PATIENTS WITH NON-EROSIVE GERD
Authors: Morozov S , Isakov V
Published: September 2020

The aim of the study was to evaluate the influence of change in diet composition on high-resolution esophageal manometry (HRM) patterns.

Methods

The data of 43 NERD patients with low (<20 g/day) dietary fibre intake served as a source data. These patients were examined with the use of standard food frequency questionnaire and HRM. Thirty of them received psyllium 5.0 G TID 10 days additionally to their usual diet (NCT01882088). Control group was formed by the database search for patients who had repeated HRM examinations and dietary assessments at the same time point and if no significant change in diet composition was revealed. HRM assessment was in accordance to Chicago-3.0. Non-parametric statistics were used to assess the change in HRM metrics.

Results

Minimal LES resting pressure at rest and after 10 water swallows increased in study group: 5.41 ± 10.1 vs 11.3 ± 9.4 mmHg, P = 0.023 and 14.1 ± 8.0 vs 14.9 ± 6.4 mmHg, P = 0.008. No difference was found in those whose diet composition was stable. Ineffective esophageal motility initially was found in 46.7% patients of the study group and 53.8% in the control group (P = 0.7). IEM resolved in 71.4% of the study group, and in 14.3% of controls (P = 0.0135). IEM not changed in 28.6% of the study group and in 85.7% of controls, P = 0.014. New IEM revealed in 12.5% of the study group and 16.7% among the controls (P = 0.13).

Conclusion

Change of diet composition by additional quantity of dietary fibre (psyllium) to the standard rations may result in the improvement of esophageal motility.
83 10-YEAR CHANGES IN DIETARY HABITS AND MEDICAL KNOWLEDGE OF ESOPHAGEAL CANCER IN A HIGH-INCIDENCE AREA: A POPULATION-BASED STUDY
Authors: Tian D , Huang H , Jiang K , Wen H , Fu M
Published: September 2020

Yanting was reported as a high-incidence area of EC with an unclear etiology. Many preventative measures and control policies have been performed during recent years in Yanting County, but no study has examined the changes in dietary habits and medical knowledge of EC during this decade. This study aimed to compare the differences in dietary habits, food group intake and medical knowledge of EC among residents of Yanting between 2007 and 2017.

Methods

Using a self-designed questionnaire, we investigated rural residents from Yanting county in the year 2007 and 2017. The 10-year changes of demographic features, personal dietary habits, food groups and medical knowledge of EC were compared. The results were then statistically analyzed. This study is based on a household survey of 570 and 898 rural residents aged 18+ years from Yanting County conducted in 2007 and 2017, respectively.

Results

Participants in the year 2007 were more likely to consume foods of lower toughness, have a slower speed of eating, have hotter temperature food, and have rice as a staple food less often (P < 0.05). Residents in the year 2007 ate more preserved foods but fewer fresh foods than those in the year 2017 (P < 0.05). Participants in the year 2017 improved their medical knowledge compared to those in the year 2007, which was conceptualized as a clear understanding of medical insurance for EC, common causes of EC, therapeutic measures for EC, preventive measures for EC, and government interventions (P < 0.05).

Conclusion

Although the medical knowledge of participants in year 2017 have changed a lot, most of them also never head of detail knowledge on EC. Residents in the year 2017 had healthier dietary habits and better medical knowledge of EC than those in the year 2007, while prevention and control measures in Yanting should be strengthened persistently.
91 SIMPLE, HIGHLY SENSITIVE CLINICAL PREDICTION SCORES FOR RULING OUT ESOPHAGEAL ADENOCARCINOMA IN PATIENTS WITH BARRETT’S ESOPHAGUS
Authors: Chahal D , Pi S , Sharma V , Duggan S , Donnellan F , Enns R
Published: September 2020

Barrett’s Esophagus (BE) is a risk factor for development of Esophageal Adenocarcinoma (EAC). Detection of EAC at an earlier stage is known to improve patient outcomes, but only a very small proportion of patients with BE will progress to EAC. Even in the context of established risk factors, it is difficult to rule out EAC in patients with BE prior to or during endoscopy.

Methods

We performed a retrospective chart review of all patients with non-dysplastic BE, dysplastic BE and EAC diagnosed at St. Paul’s Hospital from 2012–2016 to investigate patient characteristics that would establish a risk score to discriminate patients with EAC from those without EAC.

Results

132 patients were identified. Patients with EAC had higher rate of smoking history (52.4% vs. 20.7%, p = 0.002), higher rate of prior malignancy (33.3% vs. 8.1%, p = 0.001), older mean age (71.0 +/− 8.3 vs. 61.3 +/− 12.2, p = 0.001), greater frequency of carcinoid malignancy (9.5% vs 0.0%, p = 0.024), greater incidence of family history of breast cancer (22.2% vs. 6.2%, p = 0.027) and lung cancer (23.5% vs. 4.1%, p = 0.004) and greater rate of endoscopic mucosal irregularity (85.7% vs. 28.8%, p < 0.001). A clinical risk score to discriminate between patients with EAC from those without EAC had an AUC of 0.90 and NPV of 0.97.

Conclusion

We have devised clinical risk scores that could be used Risk scores, in combination with established factors such as degree of dysplasia, may help triage patients with BE appropriately with regards to timing of endoscopy. By ruling out EAC and in low risk patients, high risk patients might be monitored more carefully which could lead to earlier detection of EAC and improved patient outcomes.
176 SURGICAL MANAGEMENT OF CORROSIVE INJURIES OF ESOPHAGUS AND STOMACH—A 5 YEAR SINGLE CENTER EXPERIENCE
Authors: Raj A , S P , Bhoopathi S , Ahanatha Pillai S
Published: September 2020

Corrosive injuries to the upper aero-digestive tract are a frequent cause of morbidity in India. We report here our institution's last 5-year experience in surgical management of corrosive injuries of oesophagus and stomach.

Methods

The aim of this study was to analyze the circumstance, demographic features, clinical findings and complications of caustic ingestion, the various surgical procedures performed and their short and long term outcomes. The records of 20 patients who underwent surgery for corrosive injuries of the oesophagus and stomach in our institution over a 5-year period (Jan2015-Dec2019) were retrospectively analyzed.

Results

Of 20 patients 13(65%) were accidental and 7(35%) were suicidal. Median age was 31 years with 75%males & 25%females. Presenting complaints were weight-loss(95%), dysphagia(65%) & vomiting(50%). Distributions of strictures were oesophageal, gastric or combined. 70% (N = 14) underwent feeding jejunostomy(FJ) as initial procedure. Isolated oesophageal strictures were managed by dilatation followed by gastric-pull through(N = 4)/coloplasty(N = 2). Isolated gastric strictures were managed Antrectomy (N = 5), distal/total gastrectomy (N = 2). Combined strictures were managed with coloplasty with antrectomy and Billroth I (N = 3) or coloplasty with Colo-jejunal anastomosis (N = 1). One patient underwent emergency esophagogastrectomy+cervical-oesophagostomy for perforation. Mortality rate was 15%(3/20).

Conclusion

Management of corrosive strictures varied between individual patients requiring a injury based surgery. Extensive injury with perforation, peritonitis or mediastinitis needed emergency surgery but associated with high mortality. Dilatation frequently failed in long segment strictures. High pharyngeal strictures were associated with higher morbidity. Isolated gastric strictures were easiest to manage. Corrosive strictures of oesophagus and stomach are difficult to manage and surgery has to be tailored according to site and extent of oesophageal/gastric stricture.
232 HYBRID MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: FIVE-YEAR SURVIVAL RESULTS OF THE MIRO TRIAL.
Authors: Nuytens F , Dabakuyo-Yonli S , Meunier B , Pezet D , Collet D , DJourno X , Brigand C , Perniceni T , Carrère N , Mabrut J , Msika S , Peschaud F , Prudhomme M , Mariette C , Markar S , Piessen G
Published: September 2020

Multiple randomized controlled trials have demonstrated the short term benefits of (hybrid) minimally invasive esophagectomy (MIE) over open esophagectomy. Data regarding long term results are more conflicting with similar or even better results in the MIE arm. In this follow-up study of the MIRO-trial we evaluated the long-term 5-year outcomes including overall survival (OS), disease-free survival (DFS) as well as the pattern of disease recurrence, along with evaluation of potential prognostic factors affecting these outcomes.

Methods

From October 2009 till April 2012, we conducted a multicentre, open-label, prospective, randomized, controlled trial including patients who were diagnosed with thoracic esophageal cancer and eligible for curative surgical resection (Ivor-Lewis procedure). Patients were randomized between hybrid minimally invasive esophagectomy and open esophagectomy. The primary end-point of the initial MIRO trial was major intra- and postoperative complication (Clavien-Dindo ≥2) within 30 days after surgery. The primary end-points of this follow-up study were OS and DFS. Additional secondary end points were defined as site of disease recurrence and potential prognostic or mediating factors associated with DFS and OS.

Results

207 patients underwent randomization. The median follow-up was 58,2 (95% CI, 56,5– 63,8) months. The 5y OS was 59% (95% CI, 48–68) and 47% (95% CI, 37–57) in the hybrid- and open-procedure group respectively (HR, 0,71, 95% CI, 0,48-1,06). The 5y DFS was 52% (95% CI, 42–61) in the hybrid-procedure group vs. 44% (95%CI, 34–53) in the open-procedure group. (HR 0.81 (95% CI, 0,55-1,17). There was no significant difference in recurrence rate (p = 0.519) or -location (p = 0.692) between groups. In a multivariate analysis, major postoperative and pulmonary complications were identified as prognostic factors of impaired OS (p < 0.0001;p = 0.005) and DFS (p = 0.002;p = 0.006).

Conclusion

Besides a significant reduction in postoperative overall and pulmonary complication rate, minimally invasive (hybrid) esophagectomy offers long-term oncological results that are at least equivalent to open esophagectomy. Postoperative and pulmonary complications are independent prognostic factors for impaired overall- and disease-free survival, providing additional proof that minimally invasive esophagectomy could even be associated with better long-term oncological results compared to open esophagectomy mediated by a reduction in postoperative complications.
242 ABANDONING RESECTIONAL INTENT IN PATIENTS INITIALLY DEEMED SUITABLE FOR ESOPHAGECTOMY; A NATIONWIDE STUDY OF RISK FACTORS AND OUTCOMES
Authors: Edholm D , Lindblad M , Linder G
Published: September 2020

The main curative treatment for esophageal cancer is resection. In some cases, patients initially deemed suitable for resection become unsuitable, often due to signs of generalized disease or having become unfit for surgery.

The aim of the present study was to assess frequency and risk factors for patients initially deemed suitable for esophagectomy becoming ineligible for resection.

Methods

All patients in the Swedish National Quality Register for Esophageal and Gastric Cancer from 2006 to 2016 were included and risk factors associated with becoming ineligible for resection were analyzed and adjusted in multivariable logistic regression analysis calculating Odds ratios (ORs) with 95% Confidence intervals (CIs).

Results

A total of 1792 patients were planned for resection, of these 303 (17%) became ineligible for resection (114 patients were non-resectable and 189 patients never progressed to surgery). High and intermediate educational level was associated with an increased probability of resection (OR 1.80 95% CI 1.21–2.66 and OR 1.49 95% CI 1.07–2.09, respectively) while patients with clinically advanced disease were more likely to become ineligible (cT4a: OR 0.34, 95%CI 0.14–0.0.87, cN3: OR 0.26, 95%CI 0.09–0.79 respectively). Patients given neoadjuvant treatment were also more likely to become ineligible for surgery (OR 0.62 95%CI 0.46–0.86).

Conclusion

Of those planned for resection for esophageal cancer, 17% never progressed to esophagectomy. High educational level was associated with an increased chance of undergoing resection whereas clinically advanced disease and neoadjuvant treatment were independent factors associated with increased risk of abandoning resectional intent.
253 COMPARISON OF LEFT LATERAL POSITION AND PRONE POSITION IN THORACOSCOPIC ESOPHAGECTOMY
Authors: Tabuchi S , Koyanagi K , Koganezawa I , Nakagawa M , Yokozuka K , Kobayashi T , Miyoshi K , Ozawa Y , Sano T , Tomita K , Tsutsui R , Shigoka M , Chiba N , Katayanagi S , Hidaka E , Kawachi S
Published: September 2020

Thoracoscopic esophagectomy for esophageal cancer has been widely introduced and performed in many institutions. However, the position is different by institutions in left lateral position and prone position. We first started thoracoscopic esophagectomy in the left lateral position (group L), then it was changed in the prone position (group P). In the study, we assessed the differences in the surgical results and early operative complications according to the patients’ position.

Methods

A total of 20 patients underwent thoracoscopic esophagectomy. The group L included 12 patients consisted of 8 male and 4 females with median age of 72 between 2015 and 2017. The group P included 8 patients consisted of 5 male and 3 females with median age of 70 between 2017 and 2020. The surgical results and postoperative complications were compared between the two groups.

Results

The operative time was 504 minutes in the group L, 614 minutes in the group P (p = 0.043), and the blood loss was 55 mL in the group L and 65 mL in the group P (p = 0.615). Recurrent laryngeal nerve palsy was observed in 2 cases in the group L and none in the group P. And, the pneumonia was observed in 1 case of the group L. In our hospital, the operative time was longer in the prone position than in the left lateral position, but the complication tended to be little.

Conclusion

Although sample number was small in our study, the prone position might have some advantages because no pneumonia and recurrent laryngeal nerve palsy occurred in the group P. Furthermore, we experienced better ergonomics in the prone position because movement of the forceps was easier in the prone position.
255 OUTCOME OF ADDITIONAL ESOPHAGECTOMY AFTER NON-CURATIVE ENDOSCOPIC SUBMUCOSAL DISSECTION FOR C-MM-SM1ESOPHAGEAL CANCER.
Authors: Fujita H , Minamiya Y , Nagaki Y , Sato Y , Wakita A , Motoyama S
Published: September 2020

For patients diagnosed cT1(MM-SM1)N0 esophageal cancer, we perform endoscopic submucosal dissection (ESD) as a primary treatment. Furthermore, additional treatments were performed for the patients diagnosed pT1b(SM) in resected tumor by ESD. Our aim of this study is to investigate whether additional esophagectomy after non-curative ESD can be considered a valid treatment.

Methods

Forty-four patients who received esophagectomy with lymph node (LN) dissection in neck, mediastinum and upper abdomen as additional surgery after non-curative ESD between 2006 and 2019 were enrolled. Histological examination revealed that squamous cell carcinoma in 41 and adenocarcinoma in 3 patients. We examined the rate of pathological LN metastasis and outcomes of patients received esophagectomy.

Results

The cT was LPM in 9(20%), MM-SM1 in 35 (80%) patients. However, the pT was MM in 3(7%), SM1 in 14 (32%) and SM2 in 27 (61%) patients. Lymphatic invasion was positive in 32 (73%) and venous invasion was positive in 16(36%) patients. Seven patients had pathological metastatic LN (1–2 LNs/case) (total 10 metastatic LNs). The metastatic LNs existed in neck, mediastinum and upper abdomen. The recurrences were occurred in 2 patients (No.106recL LN and No. 112ao-A LN). One patient died by esophageal cancer (LN recurrence, 38 months alive). One patient died of gastric tube ulcer perforation (16 months).

Conclusion

We showed that esophagectomy with extended LN dissection is sufficient as additional treatment for the patients treated non-curative ESD. To expand the indications of ESD for pSM esophageal cancer, new methods are needed, such as the risk diagnosis of LN metastasis using genetic analysis.
256 DRAINAGE OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY: THROUGH THE FISTULA OR NOT, WHICH IS BETTER?
Authors: Dai L , Zhao X , Yang Y , Fu H , Chen K
Published: September 2020

Thoracic abscess and/or mediastinal abscess due to anastomotic leakage after esophagectomy are very serious postoperative complications, and adequate surgical drainage is of critical importance to treatment. In this study, we compared the treatment efficacies of two drainage methods (through-the-fistula or not-through-the-fistula).

Methods

We retrospectively collected the esophageal cancer patients who underwent surgery from Jan 2016 to Aug 2019 who had complications of anastomotic leakage which was above grade III according to Lerut grading system. The drainage methods of thoracic/mediastinal abscess were drainage tube through-the-fistula (TF) (with the aid of X-ray or endoscope) and not-through-the-fistula (nTF) (via thorax or neck). According to the time from drainage tube placed to stable of the fistula, the patients were divided into fast stable group (<14 days) and slow stable group (≥14 days), and the differences of clinical characteristics and drainage methods were compared.

Results

Among the 495 cases underwent surgery, 43 (8.7%) had anastomotic leakage, 20 (4.0%) of which were grade III. 8 obtained fast stable and 12 were slow stable. As to drainage efficacy, there were 87.5% and 16.7% of the cases adopted TF drainage in fast stable group and slow stable group, respectively (P = 0.002). As to safety, there were 1 case in TF group that needed repeated drainage, whereas in nTF group, there were 2 cases died of bleeding and 2 cases needed repeated drainage (P = 0.319). Furthermore, there were 2 residual cavity cases after recovery in the nTF group.

Conclusion

TF drainage is safe and reliable for the thoracic/mediastinal abscess caused by anastomotic leakage after esophagectomy, which was better compared to nTF drainage, and facilitated recovery of the anastomosis.
261 LENGTH OF HOSPITAL STAY AND THE ASSOCIATION WITH READMISSION AFTER UNCOMPLICATED ESOPHAGECTOMY. SIGNIFICANT HOSPITAL VARIATION IN THE NETHERLANDS.
Authors: Voeten D , Werf L , Sandick J , Hillegersberg R , Berge Henegouwen M
Published: September 2020

Prolonged length of hospital stay is a negative outcome of esophageal cancer surgery, not only for the patient; it also leads to increased hospital costs. Within the scope of value-based health care, this study aimed to analyze Dutch hospital performance in terms of length of hospital stay and to investigate its association with readmission rates. Since both parameters are influenced by the occurrence of complications, this study only included patients after an uncomplicated esophagectomy.

Methods

All patients registered in the Dutch Upper GI Cancer Audit (DUCA) who underwent a potentially curative esophageal cancer resection between 2015 and 2018 were considered for inclusion. Patients were excluded if they had an intraoperative and/or postoperative complication, if they were retransferred to the intensive care unit, or if they had undergone a re-intervention. Length of hospital stay was dichotomized around the national median into “short admissions” and “long admissions”. Hospital variation was evaluated using a case-mix corrected funnel plot based on multivariable logistic regression analyses. Association of length of hospital stay with readmission rates was investigated using the χ2-statistic.

Results

A total of 1,007 patients was included for analyses. National median length of hospital stay was 9 days, ranging from 6.5–12.5 days among 17 hospitals. The percentage of “short admissions” per hospital ranged from 7.7% to 93.5%. After correction for case-mix variables, 2 hospitals had significantly higher “short admission” rates and 4 hospitals had significantly lower “short admission” rates (figure 1). Overall, 6.2% (hospital variation [0.0%–13.2%]) of patients was readmitted. Hospital readmission rates were not significantly different between hospitals with a short length of hospital stay and those with a long length of hospital stay (5.5% versus 7.6%; p = 0.19).

Conclusion

Based on these nationwide audit data, length of hospital stay after an uncomplicated esophagectomy varied significantly between hospitals and ranged from 6.5 to 12.5 days among Dutch hospitals. Short length of hospital stay was not associated with a higher readmission rate. The hospital variation indicates that enhanced recovery programs are not implemented at the same level of efficacy among hospitals in the Netherlands. Nationwide improvement might lead to a substantial reduction of hospital costs.
302 IS 18F-FDG PET/CT PARAMETERS USEFUL IN PREDICTING PATHOLOGICAL RESPONSE TO NEOADJUVANT CHEMORADIOTHERAPY FOR ESOPHAGEAL CARCINOMA?
Authors: Tustumi F , Takeda F , Duarte P , Albenda D , Sallum R , Ribeiro Junior U , Buchpiguel C , Cecconello I
Published: September 2020

The 18F-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) provides an ability to functionally evaluate metabolic activity improving patient selection for surgical treatment. The value of SUVmax, MTV and TLG from FDG PET/CT of primary tumor and lymph nodes in the setting of neoadjuvant chemoradiotherapy for esophageal cancer in predicting pathological response to neoadjuvant therapy is the aim of this study.

Methods

A retrospective cohort study was performed, assessing the correlation of SUVmax and volumetric parameters (MTV and TLG) of 18F-FDG PET/CT prior and post to neoadjuvant therapy for esophageal carcinoma with the pathological response as outcomes.

Results

One hundred and seventeen patients were included. The higher AUC values in predicting pathological complete response were obtained for the primary tumor, on post neoadjuvant therapy. These variables showed high sensibility, but low specificity (SUVmax: AUC: 0.71, 95% CI: 0.55–0.87; MTV: AUC: 0.7, 95% CI: 0.54–0.86; TLG: AUC 0.71, 95% CI: 0.55–0.87).

Conclusion

PET-Scan functionally evaluates metabolic activity, and the absolute values and changes of SUVmax and volumetric variables provide important information for pathological tumor response to neoadjuvant chemoradiotherapy.
304 DOES INTRAOPERATIVE FLUID MANAGEMENT INFLUENCE THE POSTOPERATIVE HOSPITALIZATION IN PATIENTS UNDERGOING ROBOTIC-ASSISTED ESOPHAGECTOMY
Authors: Tatakuri M , Murthy H , K J
Published: September 2020

Esophageal resection is a formidable surgery which is often associated with high morbidity and mortality rate despite an improvement in postoperative care. Fluid administration has been described to be a major factor that contributes to the development of postoperative complications after esophagectomy. The aim was to study the relationship between intraoperative fluid administration and the postoperative hospitalization stay

Methods

After hospital ethical committee approval, 69 patients who underwent Robotic-assisted esophagectomy dated from January 2011 to till date were accessed from the hospital electronic databank. Single lung ventilation was used in all of the patients during the thoracic approach. 69 patients were divided into two groups with respect to patients in first group who received 4 litres and below and the second group who received 4litres and above of crystalloids. Variables studied were ASA status, demographic data, intraoperative fluids administered, ventilator mode, positioning, postoperative parameters studied were icu stay, sepsis, ionotropic support, respiratory distress, reexploration, readmission to icu.

Results

None of the variables studied except fluid administration were shown as risk factor.

Conclusion

Anesthetic regimen directed at a restrictive intraoperative fluid of less than 4 litres has reduced the postoperative morbidity rates and the duration of hospital stay in patients undergoing Robotic esophagectomy.