bluuebunny/crossref_metadata_2025 huggingface dataset:
151. INFLUENCE OF PERIOPERATIVE ANEMIA ON MORBIDITY AND MORTALITY OUTCOMES AFTER RADICAL ESOPHAGECTOMY
Authors: Guerrero-Antolino Pablo , Bruna Marcos , Vaqué Javier , García Nuria , Nieto Marta , Quevedo David , Menéndez Miriam , Navarro Fernando Mingol
Published: August 2023

Objectives

Methods

Retrospective and analytical study of patients who underwent radical esophagectomy for esophageal cancer performed in our institution from 2015 to 2021.

Several parameters related to anemia were measured: hemoglobin, ferritin, transferrin saturation and iron blood levels, as well as the need for perioperative blood transfusion. We analyzed, on the one hand, the incidence of complications in the immediate postoperative period. On the other hand, we assessed the results of overall survival and disease-free survival in relation to tumor disease.

Results

A total of 137 patients treated for esophageal neoplasia were included. The interventions performed were McKeown/Ivor-Lewis esophagectomy. Up to 106 (77,4%) patients received neoadjuvant therapy.

Patients who required transfusion in the perioperative period (35 patients; 26%) had a significantly lower mean survival (33 vs. 53 months). In addition, they presented higher rates of postoperative complications as well as a lower 5-year overall survival (Log Rank; p = 0.004). Patients with preoperative hemoglobin levels below 12 g/dL had a significantly higher recurrence rate (21% vs. 7%; p < 0.05).

The anemic status was improved after the implementation of a multimodal prehabilitation protocol (12.1 g/dL versus 13 g/dL).

Conclusions

Radical esophagectomy is associated with high morbidity and mortality. Minimally invasive surgery has improved intra and postoperative outcomes. Despite this, the risk of intraoperative bleeding is not negligible. Therefore, it is essential for the patient to be in an optimal clinical and analytical status.

Multimodal prehabilitation could improve this status and the postoperative recovery. Studies with a larger number of patients and a longer follow-up will be necessary to evaluate the impact of this strategy.
167. NATIONAL TRENDS IN TECHNIQUE UTILIZATION FOR ESOPHAGECTOMY: DOES PRIMARY SURGEON SPECIALTY MATTER?
Authors: Dyas Adam , Mungo Benedetto , Stuart Christina , Mungo Alison , Mitchell John , Randhawa Simran , David Elizabeth , Stewart Camille , Mccarter Martin , Meguid Robert
Published: August 2023

Background

Cardiothoracic surgeons (CTS) and general surgeons (GS; including surgical oncologists) perform the vast majority of esophagectomies nationwide. We hypothesize that different clinical focus and training background could lead to different distribution in the use of open and minimally invasive surgery (MIS) techniques. Furthermore, we sought to explore whether specialty driven differences in surgical approach affect outcomes.

Methods

In a retrospective review of the ACS-NSQIP esophagectomy targeted participant user file (2016–2018), patients who underwent esophagectomy were sorted into CTS and GS cohorts. Perioperative characteristics and postoperative outcomes were compared using chi-square analysis or independent t-tests. Multivariate logistic regression controlling for perioperative variables was performed to generate risk adjusted odds ratios of postoperative outcomes by specialty.

Results

Of 3247 patients included, 1792 (55.2%) underwent esophagectomy by CTS and 1455 (44.5%) by GS as primary surgeon. CTS were more likely to use traditional MIS (p = 0.0004) or open approach (p < 0.0001) and less likely to use robotic surgery (p = 0.04) or a hybrid robotic/traditional approach (p < 0.0001) (Figure). CTS performed more Ivor Lewis esophagectomies and fewer transhiatal and McKeown esophagectomies (p < 0.0001). After risk-adjustment, there were no differences in rates of post-esophagectomy complications or rate of positive margins between CTS and GS (all p > 0.05). However, CTS were more likely to treat anastomotic leaks with surgery rather than other procedural interventions.

Conclusion

CTS and GS use MIS subtypes differently within esophagectomy. However, all risk adjusted differences in postoperative complications were driven by patient and operative characteristics rather than surgical subspecialty. Esophagectomy is being performed safely by surgeons with different clinical specialties and training pathway, with no differences in perioperative and oncologic outcomes.
173. FEASIBILITY AND POTENTIAL ADVANTAGE OF ROBOT-ASSISTED ESOPHAGECTOMY FOR CT4B ESOPHAGEAL CANCER
Authors: Makino Facs Tomoki , Momose Kota , Yamashita Kotaro , Tanaka Koji , Eguchi Hidetoshi , Doki Yuichiro
Published: August 2023

Background

Advantages of robot-assisted esophagectomy (RAMIE) includes operator-led stable surgical field with stereoscopic HD surgical vision and robotic instruments with EndoWrist technology. However, feasibility and potential benefit of RAMIE for cT4b thoracic esophageal cancer remain unclear.

Patients

A total of 16 cases with cT4b esophageal cancer treated with RAMIE between Feb, 2019 and April, 2023 were reviewed. Surgical technique and peri-operative factors in addition to short term outcome were evaluated in the present study.

Results

Background parameters of all 16 cases are as follows; median age = 70.5(42–81), gender (male/female) = 10/6, histology (SCC/Adenoca) =13/3, tumor location (Ut/Mt/Lt) = 4/6/6, invaded organs (Tr/Br/Ao/other) = 7/2/2/5, cN0/1/2/3 = 1/10/4/1, cM0/1 = 11/5, cStage3/4 = 11/5, and preoperative treatment (none/chemotherapy/CRT/both) = 0/9/6/1. In terms of surgical outcomes, median operation time/console time (thoracic procedure) were 506 (403–833)/253 (194–459) min while estimated blood loss was 116 (15–2090) ml. R0 resection was achieved in all cases without conversion to open procedure. Overall postoperative morbidity (Clavien-Dindo classification≧grade3) was 31.3% and the common morbidities were palsy of recurrent laryngeal nerve (n = 2) and anastomotic leakage (n = 2), followed by chylothorax (n = 1), pneumonia (n = 1), and non-occlusive mesenteric ischemia (n = 1). No hospital death (within 90 days) was identified and median postoperative hospital stay was 21 (14–142) days. Surgical videos of cT4b cases to show in our presentation include #1; Mt cT4 (Ao, ltPV) case previously treated with definitive CRT followed by immunotherapy where combined resection of aortic adventitia layer was performed by RAMIE and #2; Ut, cT4 (Tr, ltSCA) case previously treated with definitive CRT. We also discuss potential advantages of RAMIE over conventional approach together with protective measures to be taken in cT4b cases.

Conclusion

RAMIE for cT4b esophageal cancer seems to be feasible and might have potential advantage over conventional approach.
204. CORRELATION OF CIRCULATING T LYMPHOCYTES WITH RESPONSE TO NEOADJUVANT CHEMOIMMUNOTHERAPY IN OPERABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Li Kunzhi , Huang Yixuan , Yang Mu , Wang Kangning , Wei Xing , Zhou Qiang , Han Yongtao , Miao Yan , Fang Qiang
Published: August 2023

Background

There is growing evidence indicating that neoadjuvant chemotherapy combined immune-oncology therapy (neoCTIO) with anti-PD-1 antibodies is effective in esophageal squamous cell carcinoma (ESCC). However, the precise benefits remain unclear. This study aimed to explore whether the subsets and production of effector cytokines in circulating T lymphocytes were correlated with response to neoCTIO with toripalimab in operable ESCC.

Methods

ESCC patients staged cT2N1–2 M0 or cT3–4aN0-2 M0, with ECOG PS 0–1 status randomly received two cycles of different sequences of toripalimab plus chemotherapy (paclitaxel and carboplatin) on day 1 to 2 of each 21-day cycle. Minimally invasive esophagectomy (MIE) was performed 4–8 weeks after neoCTIO. Peripheral blood was collected before and after neoCTIO. Flow cytometry was used to detect the effector cytokines and subsets of CD8+ and CD4+ T lymphocytes. The primary endpoints were the advanced change of subsets, effector cytokines in T lymphocytes, and pathological complete response (pCR). The secondary endpoints included major pathological response (MPR) (NCT05044728).

Results

96.7% (32/33) patients received MIE with R0 resection. 18.8% (6/32) patients achieved pCR and 31.3% (10/32) patients achieved MPR. In the responders, CD8+ T lymphocytes showed higher IFNγ and TNFα coexpression compared to non-responders before neoCTIO (P = 0.010). The responders had higher frequency of effector subsets (P = 0.029) and lower naive subsets (P = 0.006) of CD8+ T lymphocytes than the non-responders before neoCTIO. No difference was found in the cell frequency of CD4+ T lymphocyte subsets between the responders and non-responders. There was no correlation between the change of subsets, effector cytokines in T lymphocytes and the sequence of neoCTIO.

Conclusion

NeoCTIO with toripalimab is effective in the treatment of ESCC. The baseline frequency of effector subsets and coexpression of IFNγ and TNFα in circulating CD8+ T lymphocytes have positive predictive value while the baseline frequency of Naive subsets is a negative biomarker. CD4+ T cell subsets have no correlation with the treatment response. The change of circulating CD8+ T lymphocytes is not affected by the sequence of neoCTIO.
219. ASSOCIATION BETWEEN VIDEO-BASED SURGICAL PERFORMANCE AND PATIENT OUTCOMES IN MINIMALLY INVASIVE ESOPHAGECTOMY IN THE NETHERLANDS
Authors: Ketel Mirte , Klarenbeek Bastiaan , Abma Inger , Det Marc , Esser Stijn , Law Simon , Steur Wobbe , Sosef Meindert , Wijnhoven Bas ,   MIE-CAT NL Collaboration Group, Hannink Gerjon , Rosman Camiel , Workum Frans
Published: August 2023

Background

Increasing evidence shows substantial variation in surgical performance measured by a (video-based) competency assessment tool (CAT). Moreover, suboptimal surgical performance has been associated with less favorable patient outcomes in complex minimal invasive procedures. It is likely this also applies for minimally invasive esophagectomy (MIE). In a previous study a CAT for MIE (MIE-CAT) was developed and validated. The present study investigated the association between surgical performance and postoperative outcomes of MIE in the Netherlands.

Methods

A nationwide observational video analysis study was performed. All fifteen Dutch hospitals performing MIE voluntarily submitted all patient outcomes from the 2020–2021 Dutch Upper-GI Clinical Audit registry, and two representative surgical videos from 2022. Surgical performance was assessed by 7 blinded and independent expert MIE surgeons with the MIE-CAT. Hospitals were divided into quartiles based on their performance score. Multilevel logistic regression, with clustering of patients within hospitals, was used to study associations between surgical performance and patient outcomes. Primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery.

Results

Highest- (mean MIE-CAT 113.6, SD 5.5, n = 3) versus lowest-performance-quartile (mean 94.1, SD 5.9, n = 3) had more MIE experience (Pearson’s r = 0.74, 95%CI 0.32–0.92), larger volumes (Pearson’s r = 0.46, 95%CI -0.13-0.81) and favorable outcomes (Figure 1). Performance of highest- versus lowest-quartile was statically significantly associated with less complications (severe postoperative (RR, converted from OR, = 0.50, 95%CI 0.24–0.99), peroperative (RR = 0.21, 95%CI 0.04–0.94) and any postoperative (RR = 0.54, 95%CI 0.24–0.96)), less conversions (RR = 0.21, 95%CI 0.21–0.21) and a 11.5% absolute chance reduction of severe postoperative complications for an average patient. Increased anastomotic-phase performance was associated with less anastomotic leakage (RR = 0.14, 95%CI 0.06–0.31).

Conclusion

This Dutch nationwide study showed statistically significant and clinically relevant associations between surgical performance and outcomes of patients undergoing MIE. An average patient has a 11.5% absolute chance reduction of a severe postoperative complication when operated in a highest-performance quartile hospital, compared to a lowest-performance quartile hospital. These findings show that good surgical performance is an essential aspect for good clinical outcomes.
230. SURVIVAL OUTCOMES OF ROBOT-ASSISTED TRANS-MEDIASTIONAL ESOPHAGECTOMY IN PATIENTS WITH CT1N0 ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Yajima Shoh , Yagi Koichi , Aikou Susumu , Okumura Yasuhiro , Mitsui Takashi , Nishida Masato , Yamagata Yukinori , Yamashita Hiroharu , Nomura Sachiyo , Mori Kazuhiko , Seto Yasuyuki
Published: August 2023

Background

We have developed a robot-assisted trans-mediastinal esophagectomy (RATME) to reduce the surgical invasiveness of open trans-thoracic esophagectomy (oTTE). However, the long-term outcome of esophageal cancer patients who underwent RATME remains unclear.

Methods

Patients who underwent RATME or oTTE for clinical T1N0 esophageal squamous cell carcinoma were enrolled in this study. The clinicopathological and surgical details, overall survival (OS), disease-free survival (DFS), and cause-specific survival (CSS) were compared between the RATME and oTTE groups.

Results

Forty-three and 47 patients who underwent RATME and oTTE, respectively, were included in this analysis. The RATME group included more male patients and had a significantly lower comorbidity index. There was no significant difference in age, tumor location, preoperative ESD rates, and pathological TNM factors between the two groups. The RATME group showed a longer operation time, less blood loss, low incidence of pneumonia, and shorter hospital stays. The OS and DFS rates in the RATME tended to be higher than in the oTTE group; The 5-year OS rates were 88.4 vs 71.5%, and the 5-year DFS rates were 81.4 vs 62.8% (RATME vs oTTE group, p = 0.09 and p = 0.11). The CSS in both groups were equivalent; The 5-year CSS rates were 93.7 vs 92.4% in the RATME and oTTE groups respectively. The RATME group had significantly fewer deaths than the oTTE group (p = 0.032).

Conclusions

The RATME group tended to show better OS and DFS than the oTTE group. The OS of the RATME group was equivalent to that of the comprehensive registry data in Japan, indicating that RATME radicality is guaranteed.
236. INDOCYANINE GREEN TRACHEOBRONCHIAL FLUORESCENCE (ICG-TBF) VIA NEBULIZATION DURING MINIMALLY INVASIVE ESOPHAGECTOMY -A NOVEL TECHNIQUE
Authors: Thammineedi Subramanyeshwar Rao
Published: August 2023

Keywords

ICG, fluorescence guided surgery, esophagectomy, ICG nebulization, ICG-TBF, tracheobronchial fluorescence.

Abstract

Background

Surgical manipulation of tracheobronchial complex is a contributing factor in pulmonary morbidity of esophagectomy. Accurate dissection between membranous trachea and bronchi with esophagus is essential. This study tests the feasibility of delivering indocyanine green (ICG) in an aerosol form to achieve tracheobronchial fluorescence (ICG-TBF).

Methods

Patients with esophageal and esophagogastric carcinoma undergoing minimally invasive esophagectomy (McKeowns type) were included. ICG was aersolized by nebulisation in supine position before thoracoscopy. ICG-TBF was observed with real time fluorescence enabled camera. Intraoperative and postoperative complications related to ICG were noted.

Results

37 patients were included in the study. ICG-TBF was identified in 94.6% (35/37) of patients with mean time to fluorescence identification of 13 minutes (1–43). There were no airway resections/injuries in the study. No intraoperative or postoperative complications attributable to ICG were observed. No 90 day postoperative mortality was seen.

Conclusions

ICG delivered in aerosol form was found to be safe and effective in achieving ICG-TGF. Further studies on effect of ICG-TBF in decreasing pulmonary complications of esophagectomy are needed.
248. SYSTEMIC INFLAMMATORY MARKERS AS PROGNOSTIC FACTORS IN ESOPHAGEAL CANCER: A MEXICAN PERSPECTIVE
Authors: Takahashi Alberto Mitsuo Leon , Basave Horacio Noe Lopez , Jones Daniel , Lino-Silva Leonardo Saul , Salcedo-Hernandez Rosa Angelica , Calderillo-Ruiz German , Diaz-Romero Maria Del Consuelo , Gomez-Hernandez Maria Fernanda , Gomez Angel Herrera
Published: August 2023

Background

Esophageal cancer (EC) represents the eighth most commonly diagnosed cancer, and sixth cause of cancer-related deaths worldwide. Several studies have demonstrated an association between systemic inflammation, anti-cancer immunity, and poor oncological outcomes in patients with EC. Biomarkers including neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-lymphocyte ratio (PLR) may reflect the balance between pro-cancer inflammation and anti-cancer immune response and have prognostic implications in Mexican esophageal cancer patients.

Methods

A retrospective review of a prospectively collected database of all EC patients from 2011–2022 was performed. Baseline pre-treatment NLR, LMR and PLR was collected. The date of last follow-up or death was ascertained from medical records. ROC curves were used to calculate cut-off values for NLR and PLR, while the median-value was used for LMR. Serum albumin of <3.5 g/dL was considered malnutrition. Kaplan–Meier (univariate) and Cox regression (multivariate) were performed to evaluate survival against prognostic factors.

Results

498 patients were included during the study period, 80.1% men and 19.9% women, median age 60 (±12.2) years old. Adenocarcinoma (49.8%) was the most common histological subtype, followed by squamous cell carcinoma (31.7%). Clinical stage included: I (3%), IIA-B (11.8%), III (37.6%), IVA (2.6%), and IVB (44.2%). Neoadjuvant chemoradiotherapy was the predominant initial therapy (50.4%), followed by chemotherapy (41.7%). ROC curves revealed the following cut-off value: 2.92 for NLR, 174 for IPL, and 3.5 for LMR. In the univariate analysis, four prognostic factors were significant for overall survival (NLR, PLR, LMR, albumin) (Table 1), while in the multivariate analysis only NLR and albumin remained independent factors for survival (Table 2).

Conclusion

In our population, low NLR and high albumin can be considered independent prognostic markers in patients with esophageal cancer. These common pretreatment biomarkers can serve to identify patients with good prognostic factors, contributing to an improved consent process and therapeutic decision making. Further research should focus on more accurate cut-off values for survival prognostication.
278. MEDIASTINOSCOPIC ESOPHAGECTOMY WITH INTRAOPERATIVE NERVE MONITORING FOR ESOPHAGOGASTRIC JUNCTION ADENOCARCINOMA; A SINGLE-CENTER INITIAL EXPERIENCE
Authors: Suzuki Akihiro , Yokoi Tadao , Matsubara Taketo , Mitsuoka Koichiro , Sanbonmatsu Mariko , Miyachi Yosuke , Taketa Takashi , Shimada Gen , Kaido Toshimi
Published: August 2023

Background

In recent years, adenocarcinoma of esophagogastric junction (EGJ) has been on the increase in Japan. Although laparoscopic resection by the transhiatal approach is commonly used, patients often have difficulty with mediastinal lymph node dissection and reconstruction after resection. Since 2020, we have been performing mediastinoscopic esophagectomy for EGJ adenocarcinoma patients with esophageal invasion exceeding 3 cm in length or with a large tumor diameter. We report on the short-term results of the surgery performed.

Methods

Of 15 patients with adenocarcinoma of the esophagogastric junction who underwent radical esophagectomy at our hospital during a 36-month period from January 2020 to December 2022, 5 patients underwent mediastinoscopic esophagectomy without thoracic incisions. Surgery consisted of mediastinoscopic and laparoscopic subtotal esophagectomy, mediastinal lymph node dissection, and posterior mediastinal gastric tube reconstruction with cervical anastomosis. In all cases, continuous left recurrent nerve monitoring was performed intraoperatively. Short-term surgical outcomes were evaluated in terms of age, gender, TNM classification, stage, preoperative complications, operation time, blood loss, tumor diameter, length of esophageal invasion, postoperative complications, and postoperative hospital stay.

Results

All five patients were male, with a mean age of 67.8 years. 4 of the 5 patients had preoperative complications. Tumor localization was Siewert classification type I in 4 patients and type II in 1. The average tumor length and esophageal invasion length was 44 ± 26 mm and 38 ± 11 mm respectively. The average operation time was 395 ± 29 minutes and blood loss was 38 ± 39 mL. Lymph node metastases was revealed in three patients. No postoperative anastomotic leakage or recurrent nerve palsy was observed. One patient developed postoperative aspiration pneumonia but was cured without reintubation.

Conclusion

Mediastinoscopic esophagectomy for EGJ adenocarcinoma was performed safely. RCTs conducted in Western countries reported that esophagectomy with cervical anastmosis is associated with higher rates of recurrent nerve palsy than esophagectomy by the transhiatal approach. The use of a mediastinoscope to visualize the recurrent nerve and the use of intraoperative nerve monitoring devices might reduce the frequency of recurrent nerve palsy.
283. 18F-FDG PET/MRI FOR RESTAGING ESOPHAGEAL CANCER AFTER NEOADJUVANT CHEMORADIOTHERAPY
Authors: Valkema Maria , Sablonière Quido de Lussanet , Valkema Roelf , Thomeer Maarten , Dwarkasing Roy , Harteveld Anita , Doukas Michail , Mostert Bianca , Zijden Charlène , Sluis Pieter , Lagarde Sjoerd , Wijnhoven Bas , Verburg Frederik , Lanschot Jan
Published: August 2023

Background

The accuracy of 18F-FDG PET/CT is insufficient to detect residual locoregional esophageal cancer after neoadjuvant chemoradiotherapy (nCRT). This feasibility study aims to investigate whether post-treatment 18F-FDG PET/MRI may potentially improve tumor detection.

Methods

This was a prospective, single center feasibility study. At 6–12 weeks after nCRT, patients underwent standard 18F-FDG PET/CT followed by PET/MRI, and completed a questionnaire to evaluate burden. Two teams of readers either assessed the 18F-FDG PET/CT or the 18F-FDG PET/MRI first; the other scan was assessed one month later. SULmax and ADCmean were measured at the primary tumor location. Histopathology of the surgical resection specimen served as reference standard for diagnostic accuracy calculations. When patients with clinically complete response continued active surveillance, response evaluations until nine months after nCRT served as proxy for ypT and ypN (i.e. ‘ycT’, ‘ycN’).

Results

In the 21 included patients (median age 70 [IQR 62–75], 16 males), disease recurrence was found in the primary tumor in 14 (67%) patients (of whom one ypM+, detected on both scans), and in locoregional lymph nodes in six patients (29%). Accuracy (team 1/team 2) to detect yp/ycT+ with 18F-FDG PET/MRI vs 18F-FDG PET/CT was 38/57% vs 76/61%. For ypN+, accuracy was 63/53% vs 63/42%, resp. Neither SULmax (both scans) nor ADCmean were discriminatory for yp/ycT+. Fourteen of 21 (67%) patients were willing to undergo a similar 18F-FDG PET/MRI examination in the future.

Conclusion

18F-FDG PET/MRI currently performs comparably to 18F-FDG PET/CT. Improvements in the scanning protocol, increasing reader experience, and performing serial scans might contribute to enhance accuracy of tumor detection after nCRT using 18F-FDG PET/MRI.
286. A BIBLIOMETRIC ANALYSIS OF NEOADJUVANT THERAPY FOR ESOPHAGEAL CANCER
Authors: Huang Yizhou , Zheng Bin , Chen Maohui , Zhang Shuliang , Zeng Taidui , Chen Chun
Published: August 2023

Background

The study aims to summarize publication characteristics of neoadjuvant therapy for esophageal cancer and create scientific maps to explore hotspots and emerging trends with bibliometric methods.

Method

The publications between 2013 and 2022 were retrieved from the Web of Science Core Collection (WoSCC) on March 4, 2023. Bibliometric tools including VOSviewer and CiteSpace were used for statistical analysis. Data on the trend of the annual output, countries/regions, institutions, journals, authors, subject categories, keywords, and co-cited references were presented in this study.

Results

A total of 1713 publications written by 9222 authors of 1696 institutions, 49 countries/regions in 287 journals were included in the bibliometric study. China was the most prolific country with 414 publications, and The United States was the country that cooperated most with other countries. Doki, yuichiro, van Hagen, p, annals of surgical oncology, j clin oncol, and sun yat sen univ were the top 1 productive author, co-cited author, productive journal, co-cited journal, and prolific institution, respectively. The top 4 most present keywords were esophageal cancer, neoadjuvant chemoradiotherapy, neoadjuvant chemotherapy, and chemotherapy. Furthermore, the clinical research hotspots involved in the immunotherapy of ESCC have received the most attention in recent years.

Conclusions

This study visually analyzed the development status and scientific trend of neoadjuvant therapy for esophageal cancer over the past decade. The results could guide scientists to comprehensively understand the existing research and determine future directions.

Keywords

Web of Science (WOS); esophageal cancer; bibliometric analysis.
309. SURGICAL TREATMENT FOR THE RECURRENT SITE OF ESOPHAGEAL CANCER AFTER ESOPHAGECTOMY
Authors: Okamoto Hiroshi , Taniyama Yusuke , Sato Chiaki , Ozawa Yohei , Ishida Hirotaka , Koseki Ken , Muranami Yuto , Kamei Takashi
Published: August 2023

Background

Although the outcome of patients with recurrent esophageal cancer following radical esophagectomy is extremely poor, long-term survival can be achieved with multimodal therapy, including surgical resection of the recurrent lesion. Developing a treatment strategy is a critical issue; therefore, we examined the indications and optimal timing for surgical treatment in patients with recurrence.

Methods

A total of 184 patients with recurrent esophageal cancer after radical esophagectomy were studied between 2001 and 2015, with a focus on surgical resection.

Results

The first recurrence site was the lymph nodes (124 cases; 67%) [neck (35; 19%), mediastinum (82; 45%), abdomen (35; 19%)], lung (36; 20%), liver (32; 17%), pleura (18; 10%), bone (13; 7%), etc. Second-line treatment following recurrence was surgery (8 cases), chemoradiotherapy (89 cases), chemotherapy (64 cases), and best supportive care (23 cases). Patients with single organ or solitary recurrence and recurrence more than 8 months after surgery had better prognoses. All the surgical cases had single-site recurrence (lung-3, cervical lymph nodes-3, colon-1, and brain-1). Good prognosis was expected for the patients with lung or cervical lymph node recurrence.

Conclusion

Surgical treatment for recurrent esophageal cancer following radical esophagectomy was considered beneficial for the recurrence of cervical lymph node or lung metastasis of solitary lesions at least 8 months after esophagectomy. Immune checkpoint inhibitors have recently been indicated for esophageal cancer and expected for improving prognosis, and the role of surgery in multidisciplinary treatment for metastatic recurrence needs repeated investigation.
321. ESD AND ELPS A NOVEL MINIMALLY INVASIVE TREATMENT FOR MULTI-EPISODE SUPERFICIAL ESOPHAGEAL SCC AND 2ND PRIMARY HYPOPHARYNGEAL SCC:A CASE REPORT
Authors: Maneesoi Siwaree , Swangsri Jirawat , Sureepong Paiboon
Published: August 2023

Background

Esophageal SCC is a common cancer worldwide. Major risk factors were tobacco and alcohol use. It’s also a cause of head and neck cancers, particularly hypopharyngeal SCC. ESD was established as standard procedure for curative early esophageal SCC. However, conventional ESD for hypopharyngeal lesions is technically difficult. This report describes a patient who had superficial hypopharyngeal SCC following multiple esophageal ESD sessions. This VDO presentation shows how to perform safe ELPS and achieve oncological purposes.

Methods

A 77-year-old Thai man. He had primary cervical esophageal SCC and 1 month after complete response from definite CCRT, he began presenting four other recurrent episodes of superficial esophageal SCC in the lower, middle, and two times of cervical regions over a 3-year period. ESD and APC were applied and showed a complete response. The last endoscopic finding also revealed of superficial hypopharyngeal SCC and ELPS was decided by the following step: curve laryngoscope placement, laryngeal packing, lesion identification and marking, submucosal injection, circumferential incision, submucosal dissection, and bleeding control. The specimen was removed transorally and sent for pathological examination.

Result

The operation was successful without complications. The patient was able to start a liquid diet on day 1 and a soft meal on second day post operation. He was discharged on 3rd day without any complications. The pathological report was moderated differentiate SCC with positive deep margin, so he was planned for further RT.

Conclusion

ELPS provided good visualization, which led to a sufficient working space for resection. The procedure was safe and feasible for superficial hypopharyngeal lesions and exhibited good oncological outcomes, preserving both swallowing and phonation functions.
331. IMPACT OF SARCOPENIA ON RECURRENCE OF ESOPHAGOGASTRIC ADENOCARCINOMA IN PATIENTS THAT HAVE UNDERGONE NEOADJUVANT CHEMOTHERAPY
Authors: Convill James , Samake Maurice , Sellars Hannah , Chmelo Jakub , Brown Joshua , Petrides George , Phillips Alexander
Published: August 2023

Background

Sarcopenia is defined as a loss of skeletal muscle mass and function. Preoperative sarcopenia amongst patients with esophageal cancer is known to be associated with post-operative complications and increased mortality. Whether preoperative sarcopenia has an affect on disease recurrence has not been investigated for patients with esophageal adenocarcinoma undergoing neoadjuvant chemotherapy.

Methods

Patients diagnosed with EGA between January 2017 and December 2021 and undergoing NAC followed by esophagectomy from a single high-volume center had their post-NAC CT scans assessed for radiological sarcopenia. Skeletal muscle index (SMI) was calculated from muscle area measured on CT scans at the level of third lumbar vertebra. Previously published SMI cut off values of 52.4 cm2 for men and 38.5 cm2 for women were used. Patients that had complete resection (R0) of were included in the analysis. A cox-regression model was used to investigate recurrence between those with sarcopenia and those without.

Results

133 patients were included in the analysis. Patients with sarcopenia before or after NAC were not more likely to develop disease recurrence than those patients without sarcopenia (Hazard ratio 1.08, 95% CI 0.97–1.17; p > 0.05).

Conclusion

In this cohort of patients from a single high volume centre, sarcopenia status in EGA patients undergoing NAC and esophagectomy does not significantly impact the rate of disease recurrence.
345. ADJUVANT IMMUNOTHERAPY IN CURATIVE INTENT ESOPHAGEAL CANCER RESECTION PATIENTS
Authors: Kwak Hyunjee , Banks Kian , Hung Yun-Yi , Alcasid Nathan , Susai Cynthia , Velotta Jeffrey
Published: August 2023

Background

Despite ongoing therapeutic innovations, esophageal cancer remains a disease with one of the poorest survival rates with an overall 5 year survival of 20%. Recent clinical trials have demonstrated the role of adjuvant immunotherapy to improve patient survival. However, these therapies are often not completed in their entirety due to side effects or disease progression. We report our real world experience with immunotherapy and esophageal cancer within an integrated health care system.

Methods

All adult patients undergoing minimally invasive esophagectomy (MIE) in our large integrated health care system between September 1, 2017 and November 15, 2021 were reviewed. Patients with multiple cancers were excluded for a final patient cohort of 37 patients who received immunotherapy and 139 who did not. Patients who received immunotherapy were reviewed for the number of doses they received, if they were able to complete therapy, side effects, and disease progression. Baseline characteristics and outcomes, including 90 day and 1 year mortality, were compared between the two patient groups. Logistic regression was performed to identify factors that impacted survival.

Results

Of 37 patients who received immunotherapy, 17 received nivolumab, 17 received pembrolizumab, 11 received trastuzumab, 2 received ipilimumab, and 9 received combination. Only 5 patients successfully completed therapy. Therapy was terminated in 7 patients due to side effects, most commonly colitis. Furthermore, 18 patients stopped therapy due to disease progression, and 4 patients expired during treatment. There were no significant differences in 90 day or 1 year mortality between patients who received immunotherapy and those who did not. At a maximum of three year follow up, patients with late stage disease who received immunotherapy had a significantly worse survival.

Conclusion

Immunotherapy has been shown to have a promising impact on patient survival in esophageal cancer. However, outside of a clinical trial, there are numerous barriers to successful treatment in a real-world setting. At our regionalized center of excellence, we found that most patients are unable to complete immunotherapy treatment due to disease progression or side effects, and immunotherapy did not improve survival. Further work is required to tailor immunotherapy delivery to diverse patient populations.
382. CARDIAC REMODELING IN PATIENTS WITH ESOPHAGEAL CANCER-ASSOCIATED CACHEXIA
Authors: Cameron Miles E , Judge Sarah , Judge Andrew , Awad Ziad
Published: August 2023

Background

Cachexia is a debilitating wasting syndrome affecting 60% of patients with esophageal cancer, regardless of stage. While cachexia is usually characterized by skeletal muscle atrophy, systemic inflammation and aberrant endocrine signaling is thought to also precipitate cardiac atrophy and dysfunction. Indeed, cachectic patients often display clinical signs of heart failure. In this initial study, we sought to characterize the relationships between weight loss, body composition and parameters of cardiac structure and function.

Methods

We performed a retrospective review of patients that received esophagectomy between 2015 and 2020 at our facility. Male patients with pre-operative transthoracic echocardiogram studies and no prior history of cardiac disease were included. Body composition was measured using PET/CT scans. Patients were classified as having cachexia if having more than 8% loss in body mass in the six months before surgery. Appropriate t-tests and correlational analyses were performed after assessing normality. A p-value less than 0.05 was considered statistically significant.

Results

Mean age was 65.8 ± 7.54 years. Mean six-month weight loss was 13.2%, and 65.4% of patients were classified as having cachexia. Patients with cachexia tended to have lower left ventricular mass (135 ± 7.38 g v. 148 ± 7.53 g, p = 0.2) and significantly lower left atrial diameter (3.32 ± 0.441 cm v. 4.47 ± 0.515 cm, p = 0.0261). Curiously, pre-operative weight loss positively correlated with left ventricular internal diameter end systole (R = 0.4521, p = 0.0204) and negatively correlated with diastolic blood pressure (R = -0.4102, p = 0.0417). When compared to segmented PET/CT scans, patients with increased deposition of adipose to muscle—a sign of pathologic remodeling—also had decreased left atrial diameter (R = 0.6497, p = 0.0222).

Conclusions

Various measures of heart structure and function are altered in cachectic patients with esophageal cancer. Patients were more weight loss have reduced left atrial and increased left ventricular diameters. These findings suggest that cardiac structure may dynamically change in response to cachexia. In summary, there is a profound need to better characterize the pathology of cardiac atrophy and dysfunction in patients with cachexia.
383. DEVELOPMENT OF PERSONALIZED ‘LIQUID BIOPSY’ FOR ESOPHAGEAL ADENOCARCINOMA FROM MATCHED ORGANOID CULTURE
Authors: Rispoli Thaiane , Shathasivam Premalatha , Aiyar Niharikaa , Allen Jonathan , Allison Frances , Bach Yvonne , Darling Gail , Wilson Gavin , Yeung Jonathan
Published: August 2023

Background

Recurrent mutations are not a hallmark of esophageal adenocarcinoma (EAC). This challenges the identification of circulating tumor DNA in the plasma and can limit the development of liquid biopsy strategies. We have cultured patient-derived EAC organoids and hypothesize that these can be used as a roadmap for the identification of circulating tumor DNA in the corresponding patient’s blood.

Methods

EAC tumor tissue from patients was processed to generate patient-derived organoids (PDOs) in Matrigel domes. Established PDOs were then scaled-up in suspension culture. To isolate mononucleosomes (147 bp), chromatin from these cells was extracted and digested with micrococcal nuclease (MNase). Right size selection was used to remove DNA larger than the targeted 147 bp. Next Generation Sequencing will be performed for nucleosome mapping and to generate a personlized SNV map. Using the SNV map, a personalized PCR panel will be developed to detect circulating tumor somatic variants in patient plasma cfDNA.

Results

DNA from three different PDOs were collected and MNase digested. MNase concentration and digestion time were optimized for each sample to avoid over digestion. MNase digestion resulted in mononucleosomes at approximately 147 bp for all three samples, as well as large DNA segments between 300 to 8000 bp. Right size selection resulted in isolation of 34 to 48 ng of the mononucleosome peak. These results indicate that MNase digestion was successful in generating nucleosomes of the desired size range and the selected nucleosomes were of high quality, as confirmed by the Bioanalyzer. Samples will be subjected to next-generation sequencing.

Conclusion

This study will determine nucleosome SNVs maps in circulating cell-free DNA from EAC patients to allow for generation of optimized targeted PCR panels, prediction of recurrence based on specific variants unique to each patient, and development of more precise drug screening. These advantages have the potential to fill a void in early cancer detection and the prediction of cancer recurrence, leading to improved prognoses for individuals diagnosed with EAC.
394. USEFULNESS OF INTRAOPERATIVE RECURRENT LARYNGEAL NERVE MONITORING IN REDUCING RECURRENT LARYNGEAL NERVE PARALYSIS AFTER ROBOT-ASSISTED THORACOSCOPIC ESOPHAGECTOMY
Authors: Koyanagi Kazuo , Tajima Kohei , Kanamori Kohei , Ogimi Mika , Shoji Yoshiaki , Ninomiya Yamato , Yamamoto Miho , Kazuno Akihito , Nishi Takayuki , Nabeshima Kazuhito
Published: August 2023

Background

Robot-assisted thoracoscopic esophagectomy (RAMIE) is a precise and safe procedure with its advantages. On the other hand, RAMIE has several disadvantages. The lack of tactile function must be fully recognized, and surgical procedures must take the characteristics into account. We examined whether the findings obtained by intraoperative recurrent nerve monitoring (NIM) are useful in reducing recurrent laryngeal nerve paralysis (RLNP) after RAMIE.

Methods

Overall, 81 cases of RAMIE through February 2023 were included in the study. NIM was performed in 41 patients in the first term using a combination of continuous and intermittent methods (NIM group). In the subsequent 40 patients, NIM was not performed (non-NIM group) in order to confirm the learning effect of NIM and to shorten the operation time. RLNP was confirmed by a combination of symptoms and postoperative laryngoscopy. Clinical and oncological factors and short-term outcomes of the two groups were compared.

Results

All postoperative RLNP occurred on the left side. Six patients (14.6%) in the NIM group had Grade 1 or higher RLNP. The causes of RLNP were all found during thoracic manipulation; 4 cases of over-traction of RLN and 2 cases of crush injury by robotic forceps. There was a significant decrease in RLNP of Grade 2 or higher; 4 patients (9.7%) in the NIM group and 0 in the non-NIM group (p = 0.04). In the non-NIM group, there was a reduction in thoracic operative time, total operative time, and thoracic blood loss.

Conclusion

NIM made us aware of surgical maneuvers that cause RLNP after RAMIE. Although the proficiency of the RAMIE technique may have played a role in the reduction of RLNP in the later period, avoidance of risky surgical procedures due to the learning effect from the NIM was thought to have contributed to the decrease in RLNP.
397. LEFT PILLAR PINCHING TECHNIQUE FOR MINIMALLY INVASIVE REPAIR OF PARA-CONDUIT HERNIA
Authors: Joglekar Shantanu , Sane Saee , Liu David , Duong Cuong
Published: August 2023

Surgical repair of the para-conduit hernia provides an increasing challenge in the era of minimally invasive oesophagectomy. The key principles are preservation of the gastric conduit and its right gatro epiploic vascular arcade, and durable closure of the defect.

Of various methods, posterior crural repair is difficult without mobilising and risking and kinking the conduit, while anterior repair of a big defect requires the adjunct of a mesh which carries its own risks of infection or erosion. There is no consensus on the appropriate surgical technique.

We propose that the Left pillar of the hiatus be pinched to provide an effective repair. This is safe as dissection and suturing is well away from the conduit and arcade. We find the left pillar to be adequately mobile to allow repair, and the sutures sit in the tendinous portion of the left hemi diaphragm to provide durability.

We provide 2 videos to describe the key steps in this technique and demonstrate that this technique is effective in both small and large defects, and acute and chronic para-conduit hernia.

Link: https://1drv.ms/v/s!Anu-cyBTuGbsgbxtX8aLf2P1YEPl9g?e=fXz7Pm.

Please contact me, shantjog@gmail.com if this link does not work and I will explore an alternative method to share the video.

Many thanks.
408. COMPARISON OF THE SHORT-TERM EFFICACY OF THORACOSCOPY COMBINED WITH GASTROSCOPY AND TRADITIONAL THORACOTOMY IN THE TREATMENT OF SPONTANEOUS ESOPHAGEAL RUPTURE
Authors: Tang Shoujun , Zhou Haining , Zhong Chuan
Published: August 2023

Background

Early and thorough intrathoracic debridement，irrigation and catheter drainage are of great significance for the healing of esophageal rupture. This study aims to explore the surgical treatment of spontaneous esophageal rupture, reduce the trauma and improve the cure rate.

Methods

A total of 21 patients with spontaneous esophageal rupture were selected from June 2010 to June 2022. In the thoracoscopy combined with gastroscopy group, 12 patients were treated with thoracoscopic debridement, esophageal rupture repair, thoracic drainage with closed drainage tube, nasal drainage with gastroscope and nasal duodenal feeding tube placement. In the thoracotomy group, 9 patients performed scheduled thoracotomy.

Results

Compared with the thoracotomy group, the thoracoscopy combined with gastroscopy group had less incision pain, shorter operation time, less surgical bleeding, and lower incidence of incision infection, pulmonary infection and arrhythmia, with statistical significance (P < 0.05), while the incidence of anastomotic fistula and mortality showed no statistical significance (P > 0.05).

Conclusion

Spontaneous esophageal rupture is an emergency in thoracic surgery, and the combined operation of thoracoscopy and gastroscopy after early diagnosis has less trauma, faster recovery and good therapeutic effect.
411. SINGLE-PORT THORACOSCOPIC RESECTION FOR THE SPINDLE CELL TUMOR OF ESOPHAGUS
Authors: Zhou Haining , Tang Shoujun , Zhong Chuan
Published: August 2023

Backgroud

Single-port thoracoscopic for the huge spindle cell tumor of esophagusis is one of the most challenging surgeries. Here we reported a rare case of huge spindle cell tumor of esophagusis to explore the application of single-port thoracoscopic in esophageal resection.

Methods

A 61-year-old female was admitted due to swallow obstruction with breath tight for 1 month. The enhanced CT showed an irregular mass in the right posterior superior mediastinum close to the cephalic trunk, superior vena cava, right superior pulmonary artery and azygos vein, with tracheal and esophageal displacement. The differential diagnosis is potentially large, including lymphoma, lung cancer, bronchial cysts, esophageal tumors, etc. Ultimately we decided to use single-port thoracoscopic surgery for a biopsy or a complete resection of the tumor based on the intraoperative conditions.

Results

During the operation, we found that the tumor was located in the right posterior superior mediastinum and originated from the intrinsic muscular layer of the esophagus. The spindle cell tumor of esophagus resection by single-port thoracoscopic approach was carried out successfully. Pathological examination revealed esophageal leiomyoma.

Conclusion

The single-port thoracoscopic resection for the spindle cell tumor of esophagus is feasible and comprehensive.
438. NO ROBOT, NO PROBLEM. LAPAROSCOPIC TREATMENT OF LARGE HIATAL HERNIAS
Authors: Brandalise Andre , Aranha Nilton Cesar , Lorenzetti Claudia , Brandalise Nelson Ary
Published: August 2023

Large paraesophageal hernias are always a challenge to the surgeons. Robotic platforms add advantages to theses technically challenging surgical procedures, but it is not available in many parts of the world.

Laparoscopy is still the most common approach and we present a video of different tips and tricks and some key steps to achieve better results.

https://www.dropbox.com/s/lx6lqmzw9h6vn8b/Large%20Hernias%20ISDE.mov?dl=0.