bluuebunny/crossref_metadata_2025 huggingface dataset:
P113 ESOPHAGECTOMY-SPECIFIC OBJECTIVE STRUCTURED ASSESSMENT OF TECHNICAL SKILL (E-OSATS): CONSENSUS ON ESSENTIAL IVOR-LEWIS AND MCKEOWN STEPS TROUGH DELPHI METHODOLOGY
Authors: Eddahchouri Yassin , van Workum Frans , Klarenbeek Bastiaan , van den Wildenberg Frits , van Berge Henegouwen Mark , Polat Fatih , van Goor Harry , Pierie Jean-Pierre , Gisbertz Suzanne , Rosman Camiel
Published: November 2019

Aim

The objective of this study was to determine expert consensus on essential steps in MIE to develop an ‘Esophagectomy-specific Objective Structured Assessment of Technical Skills’ tool (E-OSATS).

Background & Methods

Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure. Studies have shown that MIE has a long learning curve which is associated with increased morbidity and mortality. To master MIE training of procedural steps is crucial. Yet, no consensus regarding the essential steps nor a structured way of assessment of MIE are available.

Essential steps were defined for both Ivor-Lewis (IL) and McKeown (MCK) approach, based on expert opinion and peer-reviewed literature. In round table discussions experts finalized the list, and an online Delphi questionnaire was sent to an international expert panel (7 European countries) of minimally invasive upper GI surgeons. Based on replies and comments steps were adjusted and rephrased and sent in iterative fashion until consensus was achieved.

Results

Two Delphi rounds were conducted, and response rates were 74% (23 out of 31 experts) for the first and 81% (27 out of 33 experts) for the second round. Consensus was achieved on 94 and 98 steps for the IL and MCK approach respectively. Cronbach’s alpha in the first round was 0,77 (IL) and 0,77 (MCK), and in the second round 0,91 (IL) and 0,87 (MCK).

Conclusion

International consensus on essential surgical steps for MIE with both intrathoracic- and cervical anastomosis was achieved. Validation of the assessment tool allows for specific and structured feedback and will potentially shorten the learning curve and decrease learning associated morbidity consequently.
P117 THE IMPACT OF ELDERLY ON SURGICAL OUTCOMES AFTER IVOR-LEWIS ESOPHAGECTOMY: REVIEW OF A SINGLE INSTITUTION EXPERIENCE
Authors: Cossu A , Parise P , Puccetti F , Palucci M , Cerchione R , Elmore U , Rosati R
Published: November 2019

Background

Esophagectomy is a surgical procedure burdened by a high morbidity rate. The effect of minimally invasive (MI) approach on elderly patients is still not clear. Aim of this study was to analyze the impact of MI approach on post-operative course according to the patient age.

Methods

A consecutive series of 692 patients underwent to elective oncological esophagectomy between 1997 and 2017. All data were entered into a prospective database. Patients submitted to 3-flield or trans-hiatal esophagectomy were excluded and only Ivor-Lewis open, hybrid or totally minimally invasive esophagectomy were evaluated. Patients were stratified according to age in 3 groups: Group A (≤ 50 years) 53 patients, Group B (> 51 and < 70 years) 269 and Group C (were ≥71 years) 126. Clinical and pathological factors influencing surgical outcome were evaluated. Complications were classified according to Clavien-Dindo (CD).

Results

As expected outcomes worsened with patients age (CD ≥ 3b: 7.5% group A, 13% group B and 21% group C. p=0.001), mortality (0% group A, 3% group B and 5.5% group C. p=0.035) and length of stay (10 days group A, 11 days group B and 13 days group C. p=0.001). A statistically significant higher incidence of anastomostic leaks was observed among patients submitted to totally MI esophagectomy in group C vs A and B that were respectively 12,5%, 0% and 7%. Major respiratory complications were not statistically different among these 3 three sub-group.

Conclusions

Old age has a significant impact on outcomes after esophagectomy. In this subset of patients a MI approach could also increase postoperative morbidity. Elderly patients should be carefully selected before to be submitted to MI esophagectomy.
P119 SURGICAL OUTCOMES AFTER ESOPHAGECTOMY IN THE ELDERLY POPULATION - A SINGLE CENTER COHORT STUDY
Authors: Henna Söderström , Ilkka Ilonen , Saana Andersson , Juha Kauppi , Jari Räsänen
Published: November 2019

Aim

To evaluate morbidity and mortality after esophagectomy among elderly patients

Background & Methods

Esophagectomy is associated with significant morbidity1, and with the aging population we are faced with an increasing number of elderly patients eligible for surgery. In this retrospective study we analyzed both minor and major postoperative complications (Clavidien-Dindo II-V), in-hospital and 90-day mortality, and overall survival in all carcinoma patients ≥75 yo undergoing esophagectomy for cancer between 2009 and 2018 at a high-volume center.

Results

47 patients underwent esophagectomy during the 10-yr. period, 95,7% either minimally invasively or with a hybrid approach. Median age was 77, and the oldest patient 85 yo. The majority were in otherwise good health, 39 had an ASA score of 1-2, and all but one was ECOG 0. 70% had adenocarcinomas, and 70% received neoadjuvant treatment.

68,1% of the patients suffered some sort of complication. 19 patients (40,4%) had a C-D III-IV complication, 9 of which were pulmonary requiring a median of 5 days in the ICU.

Only 4 patients (8,5%) had anastomotic leakage requiring an intervention, 2 were managed endoscopically, 1 early dehiscence was sutured and one required a revision and LD plasty. One patient had non-fatal gastric tube necrosis that was excised. Atrial fibrillation (34%) was the most common but easily managed issue, followed by pulmonary complications (C-D II 5pts /10,6%, C-D III-IV 10 pts / 21,3%). We had 3 re-operations for bowl herniation, and one for bleeding.

Our in-hospital and 90-day mortality were 0%, in spite of the high complication rate. 63,8% were discharged home. Mean and median survival times 68,2 mo. and 47 mo., respectively. At time of follow up, 28 patients (59,6%) were still alive.

Conclusion

Esophagectomy comes with high morbidity, but with acceptable long term results it should be considered for elderly patients otherwise fit for surgery. Our results show that in select cases age is just a number

1. Low DE, Kuppusamy MK, Alderson D, Cecconello I, Chang AC, Darling G, Davies A, D'Journo XB, Gisbertz SS, Griffin SM, Hardwick R, Hoelscher A, et al. Benchmarking Complications Associated with Esophagectomy. Ann Surg 2017;:1.
O122 INTERVAL DISTANT METASTASES DURING OR AFTER NEOADJUVANT CHEMORADIOTHERAPY FOR ESOPHAGEAL OR GASTROESOPHAGEAL JUNCTION CANCER: A NATION-WIDE POPULATION-BASED COHORT STUDY
Authors: Kroese Tiuri E , Dijksterhuis Willemieke P , van Rossum Peter S N , Verhoeven Rob H A , Mook Stella , Mohammad Nadia Haj , Ruurda Jelle P , van Laarhoven Hanneke W M , van Hillegersberg Richard
Published: November 2019

Aim

A certain proportion of esophageal or gastro-esophageal junction cancer patients develop interval distant metastases during neoadjuvant chemoradiotherapy (nCRT) or in the time interval after nCRT to planned surgery. The aims of this study were to assess the post-detection survival rates and prognostic factors affecting post-detection survival in patients with interval distant metastases.

Background & Methods

Esophageal and gastro-esophageal junction cancer patients who underwent nCRT and in whom distant metastases were detected during nCRT, after nCRT in the time interval to surgery or at the time of planned surgery, between 2010 and 2016, were included in this nation-wide population-based cohort study. The primary outcome measure was post-detection overall survival. Prognostic factors (including management) affecting the post-detection overall survival were studied using multivariable Cox proportional hazard models.

Results

A total of 150 patients were included in this study. The median post-detection overall survival was 6.1 months (95% confidence interval [CI] 5.1–7.7). Multivariable analysis identified signet ring cell carcinoma morphology (hazard ratio [HR] 2.88, 95%CI 1.35-6.13; p=0.021), poor tumor differentiation (HR 2.70, 95%CI 1.60-4.57; p<0.001), and palliative anti-tumor treatment as opposed to best supportive care (HR 0.38, 95%CI 0.23-0.61; p<0.001) as independent prognostic factors associated with post-detection survival. An observed survival advantage in a small selected group of 11 patients who received localized treatment with curative intent (metastasectomy and/or stereotactic body radiotherapy) did not reach statistical significance as compared to best supportive care (HR 0.62, 95% CI 0.26-1.43; p=0.263). Patient characteristics including WHO performance score, age, number of comorbidities, and characteristics of interval distant metastases including the location or number of affected locations were not significantly related to overall survival.

Conclusion

In this study the largest series of patients with esophageal or gastroesophageal junction cancer with interval distant metastases are reported. These patients have a poor prognosis with a median post-detection overall survival of 6.1 months. Prognostic factors independently associated with detrimental survival include poor tumor differentiation and signet ring cell carcinoma morphology. Anti-tumor treatment with palliative intent is associated with improved survival as compared to best supportive care.
P127 TRENDS IN CLINICOPATHOLOGICAL DATA OF ESOPHAGEAL CANCER IN GREECE. A SINGLE CENTER’S EXPERIENCE
Authors: Jose Duran Moreno , Anna Koumarianou , Aliki Liakea , Periklis Foukas , Eirini Kefalidi , Elli Tsagari , Katerina Kampoli , Nikoletta Koropouli , Manolis Kapetanakis , Periklis Tomos
Published: November 2019

Aim

The aim of this analysis is to describe the clinicopathological characteristics of patients (pts) with esophageal cancer diagnosed in our unit.

Background and methods

Esophageal cancer (EC) is the eighth most common malignancy. Updated data indicate that rates of adenocarcinoma are increasing while the incidence of squamous-cell carcinoma is decreasing in industrialized countries. Epidemiologic data from Greek population are scarce. We analyzed the data of pts diagnosed with EC and treated in our unit from 2009 to 2019.

Results

Thirty-one pts were diagnosed with EC in our unit, 29 males and 2 females (ratio 14.5:1). Mean age of diagnosis was 62.90±11.19 (39-82) years. Eighteen pts were diagnosed with adenocarcinoma, representing the 58.1% of the sample. Seven pts (22.6%) had squamous-cell carcinoma and 6 pts (19.4%) were classified as “other”. Lower esophagus and gastroesophageal junction were the most common location (20 pts). Four pts had tumors located in the upper esophagus and 3 pts in the medium esophagus. Eleven pts had a previous diagnosis of Barret’s esophagus, of which 7 developed adenocarcinoma, 1 squamous-cell carcinoma and 2 neuroendocrine tumors. Four pts (12.9%) presented with metastases at diagnosis. Thirteen pts were treated in peripheral hospitals after diagnosis, so treatment and follow-up data are available for 18 pts. Of them, 4 pts underwent neoadjuvant chemotherapy and 2 pts received neoadjuvant chemoradiation. Downstaging was achieved in 3 pts (2 complete responses and 1 partial response). Most common treatments applied included radical radiotherapy with chemotherapy followed by surgery in some cases. Nine pts (55.5%) presented relapse with a mean time of progression-free survival of 10.44±9.18(2-29) months. With a mean follow-up of 13.48±14.08 (1-56) months, 4 pts are alive without disease, 8 pts are alive with disease and 6 pts deceased. Mean overall survival was 15.83±11.65(4-36) months.

Conclusions

EC is a heterogeneous disease with a changing epidemiologic trend. Data from our unit are superimposable to those described worldwide and may be representative of Greek population with EC. However, prospective data at national level are needed.
O128 TGF-BETA1 AND TGF-BETA2 MEDIATED EPITHELIAL-MESENCHYMAL TRANSITION IN ESOPHAGEAL ADENOCARCINOMA CELLS
Authors: Thieme René , Chemnitzer Olga , Götzel Katharina , Mehdorn Matthias , Lyros Orestis , Gockel Ines
Published: November 2019

Aim

he esophageal adenocarcinoma (EAC) is characterized by an early lymphogenic dissemination and a poor prognosis. The tumor biology and the impact of autocrine, paracrine and endocrine mediators are involved in these mechanisms. For dissemination, the tumor cells need to escape the solid tumor and invade into new target structures. This mechanism is described as epitheliale-mesenchymal transition (EMT), which could be initiated by TGF-beta

Methods

Two proliferation and motility of the esophageal adenocarcinoma cell lines (OE33, OE19) were analyzed after TGF-beta1 and TGF-beta2 treatment. EMT marker gene expressions (e.g. vimentin) were assessed by qRT-PCR.

Results

TGF-beta2 led to a deceased proliferation rate compared to untreated and TGF-beta1 treated cells in OE33 cells. In OE19 cells both, TGF-beta1 and TGF-beta2 treatment resulted in an increased proliferation compared to untreated cells. In OE33 cells the motility was affected by TGF-beta1 only, while in OE19 cells the motility was increased by TGF-beta1 and TGF-beta2 compared to untreated cells. The vimentin mRNA-expression in OE33 cells was increased by TGF-beta1 and TGF-beta2 (14.7-fold and 25.9-fold). However TGF-beta1 and TGF-beta2 only led to a moderate increase in the vimentin mRNA-expression (4.0-fold and 1.8-fold) in OE19 cells.

Conclusion

TGF-beta1 and TGF-beta2 induce EMT and cellular motility in a cell line specific pattern. The responsible intracellular signaling cascades addressed by TGF-beta1 and TGF-beta2 and their contribution for dissemination in EAC patients need to be investigated with full details.
O129 CLASSIFICATION OF BARRETT’S CARCINOMA SPECIMENS BY HYPERSPECTRAL IMAGING (HSI)
Authors: René Thieme , Marianne Maktabi , Hannes Köhler , Claire Chalopin , Boris Jansen-Winkeln , Ines Gockel
Published: November 2019

Aim

Hyperspectral imaging (HSI) technology combines imaging with spectroscopy and can be used for the classification of malignant and non-malignant cells. Thereby HSI combined with artificial intelligent algorithms can be used to predict tumor cells in in Barrett’s carcinoma specimens.

Methods

HSI imaging records light between the visual and near-infrared light (500-1000nm). For a first feasibility study, this technique was used to discriminate between squamous epithelium and esophageal adenocarcinoma and 45 specimens from Barrett’s carcinoma patients were recorded. In 22 of the 45 investigated specimens contained also squamous epithelium. The specimens were fixed routinely after resection in paraformaldehyde, were sliced to 3μm, and were stained by haematoxylin and eosin (HE). A non-parametric supervised classification learning algorithm (K-nearest neighbours (k-NN)) was used for discrimination.

Results

Barrett’s adenocarcinoma cells were recorded by HSI in all 45 investigated cases. Squamous epithelium and Barrett’s adenocarcinoma cells displayed differences in the absorbance between the wave lengths of 500 to 700 nm. For both, the squamous epithelium and the Barrett’s adenocarcinoma cells, the intra group variances of the investigated specimens were quite low. 333,275 and 74,000 spectra could be measured from Barrett’s adenocarcinoma and from squamous epithelium, respectively. Specificity, sensitivity and precision with a k-NN (k=5) classifier were 0.74, 0.92 and 0.94 for the presence of Barrett’s adenocarcinoma cells.

Conclusions

HE-stained squamous epithelium and Barrett’s adenocarcinoma cells showed specific spectral alterations, when measured by HSI. These characteristics could be used in the future to develop a computer-assisted algorithm to discriminate semi-automated for tumor cells Barrett’s carcinoma specimens, which will help to foster decision-making support in histopathological diagnosis.
P130 HISTONE DEACETYLASES EXPRESSION AND ACTIVITY IN ESOPHAGEAL ADENOCARCINOMA CELLS IN VITRO
Authors: René Thieme , Robert Nowotny , Ronja Maly , Orestis Lyros , Finn K Hansen , Ines Gockel
Published: November 2019

Aim

The response of EAC patients to common chemotherapeutic regimens is relatively low (approx. 50%). Improving the response rate in cancer patients is challenging and novel therapeutic treatment options are needed. Histone deacetylases (HDAC), an enzyme class with promising novel features, are involved the regulation of gene expression affecting the epigenom.

Methods

The expression of Zn2+-dependent HDACs and the endogenous HDAC activity were characterized in a Berrett’s esophagus in vitro model, containing cells from squamous epithelium, Barrett’s metaplasia, dysplasia and EAC. Proliferation assays were carried out in EAC cells to determine cell response to an experimental, HDAC1-3 specific, HDAC inhibitor (HDACi) in comparison to vorinostat (pan HDACi). The HDAC activity, the p21 expression, and the histone H3 acetylation were investigated under HDACi treatment.

Results

All Zn2+-dependent HDACs were expressed by each stage of the Berrett’s esophagus in vitro model. However, the expression intensity was variable. Vorinostat showed an inhibition of proliferation in the EAC cells OE33 and OE19 (IC50 of 1.1μM and 1.8μM), while the experimental HDACi DDK137 revealed an increased anti proliferative effect (IC50 of 0.4μM and 0.6μM), a higher HDAC activity reduction, and higher increase in H3 acetylation. The p21 mRNA-expression showed a cell line, time and inhibitor specific increase. The highest increase was determined in OE33 cells (2.5fold) by DDK137 after 48h, while no increase in p21 was measured under vorinostat treatment.

Conclusion

We could show a pharmacological more potent HDACi than vorinostat in EAC cells in vitro. However, further studies are necessary to evaluate the significance of HDACi and whether HDACi are able to increase chemosensitivity in EAC patients.
P132 LARYNGOPHARYNGEAL PH MONITORING (RESTECH) MAY PREDICT A SUCCESSFUL SURGICAL OUTCOME FOR REGURGITATION AND OROPHARYNGEAL SYMPTOMS AFTER LAPAROSCOPIC ANTIREFLUX SURGERY
Authors: Müller D T , Knepper L , Schröder W , Bruns C J , Leers J M , Fuchs H F
Published: November 2019

Introduction/Aim

Laryngopharyngeal pH-monitoring (Restech) is a relatively new reflux testing device that needs more validation. It was developed to detect both liquid and acidic gas vapor, and the more consistent pharyngeal placement may lead to more reliable results, especially when laryngopharyngeal symptoms such as cough, hoarseness and globus sensation are present. Aim of this study is to determine if Restech can identify patients with a successful outcome for certain symptoms after antireflux surgery.

Background and Methods

In our esophageal center of excellence, more than 300 esophageal surgeries are performed annually. All patients are prospectively entered in our IRB approved database and undergo a routine check-up program with postoperative surveillance following surgery. All patients with suspicion for GERD received a complete diagnostic work-up for gastroesophageal reflux including symptom evaluation, endoscopy, 24-hour impedance pH-metry, high resolution manometry and Restech. Only patients with a complete dataset and oropharyngeal reflux symptoms were included in this study.

Results

A total of 155 [99 females] consecutive patients with suspected gastroesophageal reflux disease and oropharyngeal symptoms that were seen between 10/2013 and 08/2018 were included and underwent 24-h laryngopharyngeal with concomitant esophageal pH-monitoring.

A total of 24 of these patients with laryngopharyngeal symptoms underwent laparoscopic antireflux surgery from 10/2013 - 02/2018 and had a complete follow up. Restech evaluation was abnormal in 62.5% (n=15, mean RYAN Score upright 121.73 [35.1-386.05], mean RYAN Score supine 5.74 [2.17-50.62]). Two out of preoperatively 12 [16.7%] patients with a pathologic Restech test complained about regurgitation after surgery versus 4 out of preoperatively 8 [50%] patients with a normal Restech result. No patient with an abnormal Restech result out of preoperatively 11 complained about extraesophageal symptoms after the surgery versus 1 from preoperatively 4 [25%] patients with a negative Restech.

Conclusion

An abnormal Restech result better identifies a successful outcome for regurgitation and extraesophageal symptoms after antireflux surgery. All patients had a complete resolution of extraesophageal symptoms after surgery.
P133 INTRATORATHIC ANASTOMOSIS IN IVOR-LEWIS ESOFAGUECTOMY: TECHNICAL DESCRIPTION AND RESULTS
Authors: Menéndez M , Mingol F , Bruna M , Vaqué F J , Alvarez E , Hurtado L , Pérez C , García-Granero E
Published: November 2019

Aim

Description of the technique of intrathoracic anastomosis in Ivor-Lewis esophagectomy in prone position with minimally invasive approach (MIE) by manual tobacco-bag suture and anastomosis with circular stapler and its results.

Background & Methods

Retrospective descriptive analysis of the intrathoracic anastomosis technique in prone of the cases performed in our Health Care Center by thoracoscopic and laparoscopic approach in Ivor-Lewis esophagectomy between April 2017 and December 2018. Patients who required conversion to thoracotomy due to pleural adhesions were excluded

Results

The median age of the 18 patients was 59 years (54-67 years). In the 18 analyzed (17 adenocarcinomas of 1/3 lower or gastro-esophageal junction and 1 benign stenosis post-RT) 12 were performed with mechanical anastomosis CEA 25, 2 with CEA 28 and 4 with Orvyl CEA 25. No leakage occurred during the postoperative period, performing in 16 a TEGD at 4-5º DPO. Three patients underwent feeding jejunostomy. In the postoperative period, 2 patients presented with ARDS, 2 with pneumonia, 2 with pleural effusion, and 1 with AF. In the follow-up performed until May 2019 1 patient presented stenosis of the anastomosis that was treated by endoscopic dilation. No leakage of the anastomosis has been recorded. The postoperative mortality (<30 days) was 0%

Conclusion

Compared with other technical variations, even with another type of anastomosis, the circular mechanical anastomosis, making the tobacco bag around the head by manual suture and reinforcing it by Endoloop is a safe and reproducible technique with a 0% leakage rate and stenosis of 5.88%. According to the literature, the rate of anastomotic leakage in the thoracoscopic approach is between 0-20% and that of anastomotic stenosis is 0-27.5%, without finding significant differences between the different types of anastomosis.

It has been demonstrated in numerous series that the thoracoscopic approach is oncologically equal to or better than the approach by thoracotomy because it allows a better dissection with resection of a greater number of nodes and that provides benefits such as less postoperative pain, better patient ventilation, better ergonomics for the surgeon and better vision of the operative field. However, we believe that this new approach should not change the usual technique of performing the anastomosis or the indication of the Ivor-Lewis esophagectomy. Randomized studies with a larger number of cases are necessary to determine which anastomosis technique is safest and reproducible in MIE surgery of esophageal cancer.
P14 THE IMPACT OF TRANSTHORACIC AND TRANSHIATAL ESOPHAGECTOMY ON LONG-TERM QUALITY OF LIFE ACCORDING TO EORTC QLQ-C30 AND EORTC QLQ-OG25 QUESTIONNAIRES
Authors: Jezerskyte E , Saadeh L M , Hagens E R C , Sprangers M A G , Noteboom L , van Laarhoven H W M , Eshuis W J , van Berge Henegouwen M I , Gisbertz S S
Published: November 2019

Aim

The aim of this study was to evaluate long-term HR-QoL in patients undergoing transhiatal versus transthoracic esophagectomy in a tertiary referral center.

Background & Methods

Treatment of esophageal cancers is challenging. Besides (neo)adjuvant chemo(radio)therapy different surgical approaches are possible such as transhiatal (THE) or transthoracic esophagectomy (TTE) with a cervical or intrathoracic anastomosis. Studies have been performed to establish evidence which is the preferred procedure in terms of postoperative morbidity, survival and short- and long-term health-related quality of life (HR-QoL).

All patients after THE or TTE for distal esophageal or gastroesophageal junction carcinoma performed between 2003 and 2016 received EORTC QLQ-C30 and EORTC QLQ-OG25 questionnaires. All questionnaires with a follow-up of more than two years after surgery were analysed. Three HR-QoL domains were chosen as primary endpoints: problems with eating, reflux and nausea and vomiting. The secondary endpoints were the remaining HR-QoL domains, postoperative complications and pathology results. The results were corrected for possible confounders such as age and gender.

Results

The questionnaire response rate was 47.6%, with 56 patients in the THE group and 134 in the TTE group. The mean age was 63.5 years and a median follow-up of 3.7 years (range 24-137 months) was reached. No significant difference was found in any of the HR-QoL domains or postoperative complications between the two groups. Significantly more lymph nodes were resected in the TTE group (p<0.001). No difference was found in the lymph node metastases or radicality of surgery between the two groups.

Conclusion

After a long follow-up of more than two years no differences in HR-QoL or postoperative complications were found between patients with distal esophageal or gastroesophageal junction carcinoma undergoing THE or TTE esophagectomy. Based on this study we conclude that long-term quality of life should not influence the decision making for surgical approach between THE and TTE esophagectomy.
P140 LAPAROSCOPIC MODIFIED BELSEY TYPE FUNDOPLICATION FOR REFLUX AFTER ROUX Y GASTRIC BYPASS – A POTENTIAL SAVIOR WHEN THE SAVIOR IS IN TROUBLE!
Authors: Hatem Al Saadi , Syed Raza , Alistair Sharples , Vittal Rao , Balaji Nagammapudur
Published: November 2019

Background

Roux Y Gastric Bypass (RYGB) is the preferred primary bariatric surgical option in patients with preoperative gastro oesophageal reflux disease (GERD). It is also the preferred revisional bariatric surgery after when GERD develops after an alternate primary bariatric surgery. However reflux after RYGB although uncommon can present due to a variety of factors. Management can be challenging.

Aim/Hypothesis

A modified version of the Belsey IV fundoplication can be done laparoscopically to reconstitute the antireflux barrier in the absence of a Fundal remnant in the gastric pouch after RYGB.

Methods

We present a single patient experience/case study where there was evidence of recurrent GERD in spite of a successful RYGB in terms of weight loss and comorbidity resolution. A 42 year old female with a BMI > 40 and metabolic co-morbidities and GERD was deemed fit for RYGB. After a technically uneventful RYGB with standard limb lengths ( Roux 120cms and BP limb 70 cms) there was significant weight loss ( > 70% EBWL) and co-morbidity resolution. However her symptoms of GERD persisted.

An gastroscopy confimed esophagitis and a barium swallow showed evidence of GERD with a small hiatal hernia and a 3-4 cms Candy cane limb. There was no evidence of a gastrogastric fistula.

Revisonal surgery was done which revealed no significant candy cane limb. A small (<2cms) hiatal hernia was found. Complete esophageal mobilization and a hiatal hernia repair was done in a standard fashion.

Furthermore the anterior wall of the long gastric pouch was invaginated to obtain an approximate coverage of 200 degrees in a single layer Belsey technique. The procedure was completed laparoscopically.

Results

The post-operative period was uneventful. Patient reported complete absence of reflux after surgery and remains off PPI in the short term. Temporary dysphagia was noticed in the first few weeks after surgery which improved with expectant treatment.

Conclusion

A Laparoscopic modified Belsey type fundoplication serves as an effective method to treat GERD after a RYGB if other potential causes of GERD are excluded.
P146 AN IMPROVEMENT TO THE CIRCULAR STAPLING ANASTOMOSIS TECHNIQUE DURING MINIMALLY
Authors: Giovanni Capovilla , Elisa Sefora Pierobon , Lucia Moletta , Luca Provenzano , Mario Costantini , Renato Salvador , Stefano Merigliano , Michele Valmasoni
Published: November 2019

Aim

The circular stapled (CS) technique with transoral placement of the anvil is commonly used to perform the esophago-gastric anastomosis during minimally invasive esophagectomy (MIE). The procedure is safe, efficient and highly reproducible, however the intersection between the circular plane of the stapler and the linear staple line of the esophageal stump can expose the anastomosis to the formation of dog ears and therefore increase the risk of anastomotic leakage (AL). We describe a simple modification of the CS technique that avoid the formation of staple lines intersection.

Background and Methods

We prospectively collected data on a small group of patients who underwent MIE for cancer using our modified CS technique. Our technical modification consists in folding the linear esophageal transection line with a stitch around the anvil shaft, in order to include the staple line in the resection during the EEATM firing (figure 1).

Feasibility has been evaluated as the percentage of cases in which the improved anastomosis technique has been carried out successfully with the formation of a complete anastomotic ring. Safety has been defined as the absence of procedure related complications.

Results

MIE was performed in ten patients using our modified CS technique, median age was 55 years. All the procedures were successfully completed with complete resection of the linear esophageal staple line and no intraoperative complication. Only one patient developed a postoperative AL, that was only detected by barium swallow and did not cause any symptom or clinical sign.

Conclusions

Our modified CS technique is simple, feasible and safe. Further studies are needed to evaluate its efficacy in preventing the occurrence of anastomosis leakage.
P147 IS HYBRID MINIMALLY INVASIVE ESOPHAGECTOMY SAFE FOR SIEWERT TYPE II OESOGASTRIC JUNCTION TUMORS?
Authors: Simon Gabriel , Alexandre Challine , Marguerite Messier , Clarisse Eveno , Maxime Warlaumont , Guillaume Piessen
Published: November 2019

Background

In the MIRO trial, hybrid minimally invasive Ivor Lewis (IL) resulted in a lower incidence of intraoperative and postoperative major complications, specifically pulmonary complications, than open IL without compromising oncological resection criteria and 3 years survival results. However, only infracarenal and Siewert I oesogastric junction (OGJ) tumors were included. Whether hybrid approach for Siewert II OGJ tumours remains unknown with a potential risk of tumor spillage. The aim of this study was to compare hybrid and open IL for patients with Siewert II OGJ tumours.

Materials and Methods

Data from 83 patients who underwent surgery for Siewert II OGJ tumours in our institution were collected prospectively between 2011 and 2017. Overall, 53 patients were included in the hybrid group and 30 in the open group. The main outcome was radicality of resection (R0 / R1 margins and number of lymph nodes resected). Groups were compared in univariate and multivariate analysis with a propensity score-adjustment.

Results

After adjustment, the hybrid and open groups were comparable in terms of number of lymph nodes resection: OR=0.65 (0.25-1.66) and radicality of resection; (R0/R1): OR=0.93 (0.10-8.58) with similar long term overall (OS) and disease-free (DFS) survival (5-year OS: 68% vs. 58%, p=0.463; 5-year DFS: 56% vs. 42%, p=0. 323). There were significantly fewer pulmonary complications in the hybrid group: OR=0.38 (.14-0.95).

Conclusion

Hybrid IL for Siewert II OGJ tumors do not compromise oncological quality resection and long term OS and DFS and results in a lower incidence of pulmonary complications than open IL.
O148 SHORT-TERM RESULTS OF A RANDOMIZED CONTROLLED TRIAL OF STANDARD VS. PROLONGED TIME TO SURGERY AFTER NEOADJUVANT CHEMORADIATION FOR CANCER
Authors: Nilsson K , Klevebro F ,   I,   M, Szabo E , Halldestam I , Johnsson E , Wallner B , Johansson J , Johnsen G , Aahlin E K , Hjortland G O , Bruns C , Schröder W , Nilsson M
Published: November 2019

Aim

The aim of this study was to clarify if prolonged time to surgery (TTS) improves postoperative outcomes in the curative intended treatment of an junctional cancer.

Background & Methods

sophagectomy is conventionally performed 4-6 weeks after completed neoadjuvant chemoradiotherapy (nCRT). However, studies have shown that prolonged TTS might be favourable.

A randomized multicentre clinical trial was performed with allocation to 4-6 or 10-12 weeks between finished nCRT and surgery. All patients received nCRT according to CROSS. Primary outcome of thstudy was postoperative. Smortality, need for intensive care, and length of hospital stay.

Results

The study randomized 248 patients, 202have to date undergone esophagectomy 98 patients were allocated to prolonged TTS, and the groups were well matched concerning baseline characteristics. Postoperative complications were reported in 106 patients (52.5%).There was no difference in postoperative Clavien-Dindo score.In the standardgroup 17 (16.4%) patients had anastomotic leak compared to 19 (19.4%) in the prolongedgroup (P=0.572). Conduit necrosis was reported in 9 (4.5%) patients, esophago-bronchial fistula in 1 (0.5%) patient,chyle leak in 5 (2.5%) neumoni in 54 (26.7%) patients and respiratory insufficiency in 36 (17.8%) patients without significant difference . In the standard group 5 (4.8%) patients had postoperative mortality due to a complication, compared to 2 (2.0%) patients in the prolonged group (P=0.446). Median length of hospital stay was 14 days in the standard group and 17.5 days in the prolonged group (P=0.040).

Conclusion

In this we found no significant differences in postoperative mortality comparing standard to prolonged TTS after nCRT. Although, an observandum is that the median length of hospital stay was significantly longer in the prolonged group. We need to compare response and survival to properly evaluate prolonged TTS, but these results suggest that timing is not cardinal in short-term postoperative outcomes.
P150 ULCERATING CMV ESOPHAGITIS – A UNIQUE COMPLICATION OF ACHALASIA
Authors: Corvinus F , Neumann H , Babic B , Kovalets I , Grimminger P
Published: November 2019

Aim

Ulcerating CMV associated esophagitis in an immuncompetent patient has not been described before. This case report highlights diagnostic pitfalls in differentiating achalasia from pseudo achalasia.

Background & Methods

A 41-year-old man presented to the high resolution manometry lab with progressive retrosternal dysphagia and regurgitation. Endoscopy revealed a dilated esophagus with a passable stenosis of the esophagogastric junction. Between 27 to 39 cm a deep 3 x 12 cm ulcer reaching the lamina muscularis was detected. Biopsies were taken and processed to the institute for pathology and microbiology.

A barium swallow revealed typical features of achalasia. A dilated hypomotile esophagus and a beak sign were seen.

Histopathology described a deep ulcer with a mixed inflammatory infiltration without any signs for malignancy. The virology finally revealed a strong positivity for CMV in PCR. Therefor the diagnosis of CMV esophagitis was made. Reasons for an immunodeficiency (HIV, Trypanosoma pallidum etc.) could be excluded. After endoscopic placement of a probe, high resolution manometry was performed. It showed a disturbed EGJ relaxation, an enhanced residual pressure (IRP) and panesophageal pressurizations in almost every swallow. These are typical features of Type II Achalasia (Chicago Classification v 3.0).

Results

The patient received antiviral therapy (Ganciclovir) for 2 months. Only a moderate symptom relief was achieved. Endoscopic reevaluation showed a complete remission of the huge esophageal ulcer. There was no esophageal scar or other reason for EGJ obstruction. CMV was no longer detected. A second high resolution manometry confirmed again a Type II Achalasia. The patient underwent laparoscopic myotomy an 180° degree fundoplication. 6 months after the intervention the patient is well and has a complete remission of his symptoms.

Conclusion

Although ulcerating CMV esophagitis may be a cause of pseudoachalasia, in this case for the first time primary achalasia is described to be the reason for ulcerating CMV esophagitis.
P151 NEVER SMOKER WITH ESOPHAGEAL SQUAMOUS-CELL CARCINOMA: DIFFERENT DEMOGRAPHICS BUT COMPARABLE SUVIVAL
Authors: Alexandru Lintis , Thibault Voron , Vincent Drbay , Marguerite Messier , Clarisse Eveno , Guillaume Piessen
Published: November 2019

Aim

To assess clinical characteristics, tumor behavior and long-term of esophageal squamous-cell carcinoma in never-smoker (NS) and smoker (or former smoker) (S) patients.

Background & Methods

Despite a progressive decrease in the incidence of esophageal squamous-cell carcinoma (ESCC) in Europe since decades, related to the decrease in smoking, new cases of ESCC are observed in patients who have never smoked. Similar cases are described for head and neck cancers and non-small cell lung carcinomas, for which increased radiosensitivity and favorable prognosis is described.

We conducted a retrospective analysis on single-center prospectively maintained database, including all patients undergoing esophagectomy for ESCC between 2010 and 2017. The primary endpoint was overall survival(OS). Secondary endpoints included disease-free survival(DFS), pathological response to preoperative treatment according to Mandard's classification (Tumor Regression Grade; TRG) and clinical characteristics of patients.

Results

Three hundred and two patients underwent esophagectomy for ESCC during study period, 57 in NS group and 245 in S group. Esophageal cancers in NS patients were more frequently observed in women (68.4% vs 20%;p<0.001) and older (65.42 vs 60.69; p<0.001) than patients in S group. Tumor location (ie. cervical, upper third, middle third, lower third/EGJ) was similar between the 2 groups. Neoadjuvant radiochemotherapy was more frequently performed in S group (64.2% vs 49.1%;p=0.035) and malnutrition was less frequent in NS group (6.3% vs 20.9%;p=0.05). Tumoral characteristics (usT and usN) were comparable between the 2 groups. Pathological response to preoperative radichemotherapy was similar between NS and S group: (TRG1-2: 53.8% vs 53.7%). Postoperative complications were more frequent in S group (77.4% vs 63.2%;p=0.024), with more postoperative deaths (5.8% vs 0; p=0.080). NS patients had better OS than S patients, without reaching significance (mean survival: 46.1±4.7 months vs 35.9±2.0 months;p=0.080), and better DFS (40.0±5.3 months vs 30.0±2.1;p=0.077)

Conclusion

Esophageal squamous cell carcinoma in never-smoker is characterized by low male-female sex-ratio, reduced post-operative morbidity and mortality. However, pathological response to preoperative radiochemotherapy and long-term outcomes seem to remain unaffected by tobacco use.
P157 GIANT PEDUNCULATED OESOPHAGEAL LIPOSARCOMAS: A CASE AND REVIEW OF RESECTION TECHNIQUES
Authors: Ng Y Annalisa , Lee June , Lin Jinlin , Ching Siok Siong , Wong S Andrew
Published: November 2019

Aim

Liposarcomas are rare causes of oesophageal tumours, accounting for <1% of tumours. We present a case of giant oesophageal liposarcoma with a discussion focusing on resection techniques.

Background & Methods

A 54-year-old gentleman presented to the hospital with symptoms of anaemia and weight loss for 3 months. A CT scan and oesophagogastroduodenoscopy (OGD) showed a giant, pedunculated polyp extending from the cervical oesophagus to cardioesophageal junction (CEJ) with mucosal ulceration at its distal aspect. Endoscopic ultrasound (EUS) revealed a 24 x 6 cm submucosal pedunculated mass with lipomatous regions and core biopsy only showed rare groups of spindle cells with no malignancy. Resection was advised in view of occult bleeding from polyp and endoscopic resection was deemed unsuitable in view of a highly vascular stalk and large size of polyp. He underwent surgical resection via a left cervical oesophagostomy with gastrostomy for polyp retrieval. Final histology showed a dedifferentiated liposarcoma arising within a giant fibrovascular polyp.

Results

Open surgery has classically been standard of treatment, but endoscopic resection is less morbid and invasive. Endoscopic techniques described include using a retraction suture followed by division of the polyp stalk using ultrasonic shears, using a snare, endoscopic submucosal dissection (ESD), and application of hemoclips following diathermy. In cases where endoscopic resection is not feasible, surgery such as oesophagostomy, oesophagectomy and laparotomy for resection and retrieval of the tumour have been described. Main reason for oesophagectomy was the presence of a submucosal (rather than polypoid, pedunculated) large tumour. For resection via oesophagostomy, stalk transection can be performed via stapling devices or suture ligation.

Conclusion

Giant oesophageal liposarcomas are very rare tumours. Such tumours are usually polypoid, arising from a pedicle in the proximal oesophagus. Resection techniques have shifted from oesophagectomy to less invasive means such as endoscopic resection or oesophagostomy. Decision on type of resection technique depends on tumour characteristics and location; with the guiding principle being resection with clear margins in order to prevent local recurrence.
P158 RESULTS OF A NATIONAL SURVEY ABOUT PERIOPERATIVE CARE IN GASTRIC RESECTION SURGERY
Authors: Bruna M , NAVARRO C , BAEZ C , RAMIREZ J , ORTIZ M , MINGOL F , VAQUE J
Published: November 2019

Introduction

Enhanced recovery after surgery programs in abdominal surgery are being established progressively. The aim of this study is to evaluate the application of different perioperative care measures in gastric surgery by Spanish surgeons.

Methods

A descriptive study of 162 surveys answered from September to December 2017 about the management and perioperative care in non-bariatric gastric resection surgery.

Results

Antibiotic and antithrombotic prophylaxis are always used by 96.9 and 99.4%, respectively; 62.7% recommend a fasting time for liquids greater than 6 hours and only 3% use preoperative carbohydrate drinks. Only 32.4 and 13.3% of subtotal and total gastrectomies are performed laparoscopically; 56.8% use epidural analgesia and drains are always placed by 53.8% in total gastrectomy. Nasogastric tubes are used selectively by 34.6% and always by 11.3%. Bladder catheters are removed during the first 48 hours by 77.2%. In the first 24 postoperative hours, less than 20% indicate oral intake and 15.4% mobilize their patients; 49.3% indicate walking after the first 24 hours; 30.4% apply a clinical pathway for the care of these patients and only 15.2% used an enhanced recovery after surgery protocol.

Conclusions

The implementation of enhanced recovery after surgery measures in nonbariatric gastric resection surgery is not widespread in our country.
P159 THE IMPACT OF POSTOPERATIVE COMPLICATIONS ON LONG-TERM SURVIVAL AND DISEASE RECURRENCE FOLLOWING OESOPHAGO-GASTRIC CANCER RESECTION
Authors: Saunders J H , Yanni F , Dorrington M S , Bowman C R , Vohra R S , Parsons S L
Published: November 2019

Aim

Postoperative complications following the resection of oesophago-gastric carcinoma can result in considerable early morbidity and mortality, however the long-term effects are less clear. Literature reports are mixed, so it remains unclear if complications reduce survival, as has been demonstrated in colorectal cancer.

Background & Methods

Some 1100 patients who underwent oesophago-gastric resection between 2006-16 were stratified by complication severity to determine the effect of leak and severe non-leak related complications on overall survival, recurrence and disease free survival.

Results

The median age was 69 years, 48% had stage III disease, with cancer recurrence in 39%. Clavien-Dindo (CD) complications ≥ III occurred in 22.2% of patients. The most common complications were pulmonary (30%), with a 13% incidence of pneumonia, 10% atrial dysrhythmia and 9.6% anastomotic leak. In comparison to CD 0-I complication free patients, those with CD III-IV leak did not suffer a significantly reduced survival. However patients with CD III-IV non-leak related complications were associated with a significant reduction in median overall survival (19.7 vs. 42.7 months) and disease free survival (18.4 vs. 36.4 months). Cox regression revealed age, stage, resection margin, and CD III-IV non-leak complications as independently associated with poor overall and disease free survival.

Conclusion

This cohort demonstrates that whilst leak does not affect long-term survival, other severe postoperative complications do significantly reduce overall survival and disease recurrence. A reduction in these complications, such as pneumonia, seen with adoption of hybrid / minimally invasive surgery may help change this pattern of disease recurrence and reduced survival.
P16 PREEMPTIVE ENDOLUMINAL VACUUM THERAPY TO REDUCE ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY: A GAME-CHANGING APPROACH?
Authors: Gubler C , Vetter D , Schmidt H , Müller P , Morell B , Raptis D , Gutschow C
Published: November 2019

Background

Endoluminal vacuum therapy (EVT) is an accepted treatment for anastomotic leakage (AL) after esophagectomy. A novel concept is to use this technology in a preemptive setting, with the aim to reduce AL rate and postoperative morbidity.

Methods

Preemptive EVT (pEVT) was performed intraoperatively in 19 consecutive patients undergoing minimally invasive esophagectomy, immediately after completion of esophago-gastrostomy. Twelve patients (63%) were high-risk cases with severe comorbidity. The EVT device was removed routinely three to six (median 5) days after esophagectomy. Endpoints of this study were AL rate and postoperative morbidity.

Results

There were 20 anastomoses at risk in 19 patients. One patient (5.3%) experienced major morbidity (Clavien-Dindo grade IIIb) unrelated to anastomotic healing. He underwent open re-anastomosis at postoperative day 12 with pEVT for redundancy of the gastric tube and failure of transition to oral diet. Mortality after 30 days was 0% and anastomotic healing was uneventful in 19/20 anastomoses (95%). One minor contained AL healed after a second course of EVT. Except early proximal dislodgement in one patient, there were no adverse events attributable to pEVT. The median comprehensive complication index 30 days after surgery was 20.9 (IQR 0-26.2).

Conclusions

PEVT appears to be a novel and safe procedure that may have the potential to improve surgical outcome in patients undergoing esophagectomy.