bluuebunny/crossref_metadata_2025 huggingface dataset:
495. UNIPORTAL VATS MCKEOWN ESOPHAGECTOMY: 4-YEAR EXPERIENCE FROM A TERTIARY CARE CENTER
Authors: Rajan Shiv , Kumar Vijay
Published: September 2022

A multidisciplinary approach is a cornerstone for the management of the carcinoma esophagus. Minimally Invasive Surgery (Total or hybrid) is essential for better postoperative outcomes. VATS assisted McKeown MIE is a well-established procedure. With the introduction of the uniportal VATS technique in lung surgeries, there is an increasing interest to replicate this in MIE too. Here we appraise our initial experience with the uniportal VATS (uVATS) MIE for the locally advanced squamous cell esophageal cancer.

This is a retrospective observational study. The cohort of carcinoma esophagus patients who underwent surgery from January 2018 to February 2022 in the department of surgical oncology was studied. Demographic data, clinical, treatment details, postoperative complications and short term oncological outcomes of patients who underwent the uVATS technique in semi-prone position were analyzed.

Total 32 (49.2%) patients underwent uVATS Mckeown esophagectomy. The majority of the patients had SCC (63%). All patients received NACT+/-RT. Each underwent extended mediastinal lymphadenectomy except two patients who had additional cervical lymphadenectomy. The mean thoracic phase time was 112+/- 25 min & blood loss was 115 +/- 20 ml. The median thoracic nodes dissected was 15 (8-36), postoperative pain score was 4 and hospitalization duration was 9 (8-12) days. Two patients had pneumonia and 2 had other complications. There was no 30-day mortality. After the median follow-up of 26.8 months, the OS & DFS was 93% & 86% respectively.

uVATS in a semi-prone position with fourth intercostals space access incision is a feasible and safe technique. It has all the advantages of MIE techniques over open surgery. The coaxial operating axis provides the best manipulation zone for operating without the need for CO2. Conversion to thoracotomy is quick if required. We believe it has a short learning curve than multiport VATS. More studies are needed to generate data for the uVATS technique in future.
497. INDOCYANINE GREEN FLUORESCENCE ANGIOGRAPHY VERSUS VISUAL ASSESSMENT FOR GASTRIC CONDUIT PERFUSION ASSESSMENT IN PATIENTS UNDERGOING ESOPHAGECTOMY: A RANDOMIZED CONTROLLED STUDY
Authors: Thammineedi Subramanyeshwar Rao , Syed Nusrath , Patnaik Sujit Chyau
Published: September 2022

Esophago-gastric anastomosis leakage is one of most feared complication after esophagectomy accountable for major postoperative morbidity and mortality. The high rate of anastomotic complications is due the tenuous perfusion of gastric conduit. This prospective randomized control trial compares the efficacy of intraoperative indocyanine green fluorescence angiography (ICG-FA) against visual assessment (VA) in evaluating the perfusion of gastric conduit and proximal esophageal stump in patients undergoing esophagectomy for cancer.

Fifty eight consecutive patients who underwent esophagectomy for carcinoma middle, lower third esophagus or gastro-esophageal junction from January 2020 till September 2021 were enrolled. Amongst them 30 patients were randomized to non ICG arm where the perfusion of gastric conduit and esophageal stump was evaluated by visual assessment (VA) based on inspection of the color, the palpation of warmth, pulse, and bleeding from the edges and 28 patients to ICG arm underwent initial appraisal of gastric conduit and esophageal stump perfusion was done by visual assessment followed by ICG-FA. Correlation coefficient was evaluated by Pearson’s R coefficient.

Both the groups were similar in demographic parameters. The anastomotic leak was significantly lower in ICG arm [4 % vs 8/28 (27 %) p 0.0261]. Most of the leaks were minor type 1. When visual assessment was compared with ICG assessment, 80% of the vascularized conduits on VA showed good perfusion on ICG-FA. 39% of gastric conduit which seemed to be dusky on VA had good vascularity on ICG-FA. Kappa value was 0.256 p 0.097 i.e., a fair agreement between ICG and visual assessment in evaluating vascularity of gastric conduit was fair.

VA of the gastric conduit perfusion can underrate perfusion and hence can jeopardize removal of the devitalized part. ICG fluorescence imaging is an accurate and promising means to ascertain the vascularity of gastric conduit during an esophagectomy. But its utility needs to be validated in larger randomized trials.
507. ENHANCED RECOVERY AFTER SURGERY FOR VIDEO-ASSISTED THORACOSCOPIC (VATS) ESOPHAGECTOMY- A PROPENSITY SCORE MATCHING ANALYSIS IN A LOCAL INSTITUTE
Authors: So Choi Kwan , Lam Chin Tou , Cheung Siu Hong , Chow Tam Lin
Published: September 2022

Enhanced recovery after surgery (ERAS) has been implemented in esophagectomy. In our center, a specific and structured ERAS program for esophagectomy was initiated since 2017. In this study, we reviewed the feasibility and value of ERAS program in patients undergoing VATS esophagectomy when compared to a historical cohort.

Total 81 Patients who underwent VATS esophagectomy from 2014-2021 were recruited and divided into “ERAS” and “non-ERAS” groups. Propensity score matching

(PSM) analysis was performed with patient baseline dermographics, tumour characteristics, and operation details. After PSM, 21 patients on each arm were identified. The primary outcome was hospital stay. The secondary outcomes included various perioperative outcome measures, complications, short-term mortality and overall survival.

ERAS group had shorter hospital stay (10 days vs. 23 days, p=0.026), while the readmission rate remained low (4.8%). There were statistically significant improvement in perioperative outcomes including less total parental nutrition use, faster resumption of oral feeding, earlier removal of foley and chest drain, and earlier mobilization. There was no difference in anastomotic leakage rate. Less chest complications was observed in ERAS group. Overall there was less significant morbidities in ERAS group (≥Grade III, 9.5% vs. 43%, p=0.009). While short-term mortality was similar, ERAS group had a trend towards better overall survival rate. (37.7 months vs. 15.6 months, p=0.287).

The implementation of ERAS protocol in esophagectomy was feasible. It resulted in a shorter hospital stay with improving perioperative outcomes. Its impact on long term overall survival necessitated further ongoing study.

ERAS table.xlsx (could not be inserted).
515. EXOCRINE PANCREATIC FUNCTION IN PATIENTS AFTER ESOPHAGECTOMY; IS TREATMENT WITH PANCREATIC ENZYMES NECESSARY?
Authors: Blonk Lotte , Wierdsma NJ , Kazemier G , Gisbertz SS , van Berge Henegouwen MI , van der Peet DL , Straatman J
Published: September 2022

Symptoms of malabsorption, such as diarrhea, steatorrhea, or unintended weight loss, are often reported by patients after esophagectomy for cancer. The etiology of these symptoms is hypothesized to be multifactorial, with exocrine pancreatic insufficiency being described as one of the possible contributing causes. Symptoms of malabsorption are therefore often treated with pancreatic enzymes. This study aimed to measure the exocrine pancreatic function to determine whether there is an indication for pancreatic enzymes after esophagectomy.

This prospective study included patients after esophagectomy for cancer in a stable postoperative situation (≥6 months after surgery) without signs of recurrent disease. Patients with and without pancreatic enzymes or symptoms of malabsorption were included. Exocrine pancreatic function was measured by fecal elastase-1 (FE-1) and fecal fat excretion. Three-day stool collections were performed to measure mean daily fecal fat excretion (g/d). Combined with a four-day (weighted) nutritional diary, to determine the mean daily fat intake (g/d), the percentage of fat absorption was calculated. Patients who were already treated with pancreatic enzymes stopped at least two days before stool collection.

This study included 38 patients after esophagectomy for cancer. Exocrine pancreatic function was measured after a median postoperative follow-up of 20 months (range 6-45). Low FE-1 (<200 μg/g) levels were found in seven patients (18%). Of these patients, one patient also had fat malabsorption (fat absorption <85%). Prior to participation in this study, 11 patients (28%) already received treated with pancreatic enzymes because of symptoms of malabsorption. In one of these patients (9%) low FE-1 levels were found and in three patients (27%) fat malabsorption was diagnosed.

These preliminary results indicate that, based on FE-1 levels, the secretion of pancreatic enzymes after esophagectomy is only impaired in a subgroup of patients. Most often this did not lead to malabsorption of fat. Based on these results routine prescription of pancreatic enzymes is not recommended in patients after esophagectomy, however a trial prescription can be considered in patients suffering from gastrointestinal complaints of malabsorption.
530. LAPAROSCOPIC REPAIR OF ESOPHAGEAL PERFORATION
Authors: Lim Xin Yan , Lee June
Published: September 2022

Esophageal perforation is associated with high morbidity and mortality. Early detection and treatment are vital as delays substantially increases mortality risk. Management options include surgical repair, drainage, diversion, endoscopic stenting/clipping and conservative management. Treatment of choice depends on etiology, location and duration between perforation and detection. Surgical repair remains as the mainstay of treatment if perforation is diagnosed <24 hours. However, for perforation detected > 24 hours, management is controversial with many advocating non-operative therapy.

We present the case of a 68-year-old gentleman who underwent laparoscopic repair of an iatrogenic esophageal perforation. He first presented with dysphagia secondary to esophageal peptic stricture, initial biopsy showing no signs of malignancy. Patient underwent serial endoscopic dilatations, which was complicated with an iatrogenic esophageal perforation during his second dilatation. He underwent an urgent laparoscopic distal esophagectomy and proximal gastrectomy to resect the diseased part of the esophagus- intraoperatively noted a 1cm perforation over distal esophagus. A double tract reconstruction was then performed to restore continuity of the gastrointestinal tract and reduce gastric reflux to the esophagus.

Patient was started on clear feeds on post-operative day 1 with gradual escalation of feeding to soft diet on post-operative day 4. His post-operative recovery was largely uneventful and he was discharged on post-operative day 7. Histological examination however returned as a pT3N1a moderately differentiated oesophageal squamous cell carcinoma. A PET-CT scan and repeat gastroscopy done showed no residual or distant disease. His condition was discussed in multidisciplinary meeting and patient then underwent definitive chemotherapy and radiotherapy.

Although early recognition, detection and treatment of esophageal perforation are important for good outcomes, delays in diagnosis and treatment are usually due to rarity of this condition and lack of familiarity with management. Our video aims to showcase the surgical repair of a distal esophageal perforation and reconstruction in a minimally invasive fashion. Aim of surgery should include repair of perforation, cleaning up contamination, restoring gastrointestinal continuity and resolution of any underlying etiology.
547. THORACOLAPAROSCOPIC MANAGEMENT OF ESOPHAGEAL PERFORATIONS
Authors: Ramakrishnan Parthasarathi , Balasubramanian Shankar , Natarajan Ramesh , Bharath Cumar M , Keerthiraj K , Chinnusamy Palanivelu
Published: September 2022

Esophageal perforation carries a high morbidity and even mortality when not promptly treated. The rarity of the condition makes it challenging to diagnose and optimally manage it. We report our experience in managing such patients using minimally invasive approach.

Six consecutive patients with esophageal perforation who were managed using thoracoscopic or laparoscopic approach between 2015 and 2022 were included in the study.

The underlying etiology was spontaneous perforation in two patients, swallowed denture in two patients, ingested meat bone in one patient and iatrogenic perforation in one patient. The mean time between diagnosis and surgery was 48 hours. After mediastinal toileting the perforation was sutured with PDS 2-0. Covered metal stent was placed and fixed using PDS 2-0. The mean operating time was 180 minutes. The mean ICU stay was 2 days and the mean hospital stay was 10 days. Stent migration was seen in two patients which were retrieved laparoscopically. There was no in-hospital or 90- day mortality.

Esophageal perforations can be safely managed by minimally invasive approaches with acceptable morbidity in selected patients in high volume centres.
548. THORACOLAPAROSCOPIC EXCISION OF ESOPHAGEAL DUPLICATION CYST
Authors: Ramakrishnan Parthasarathi , Balasubramanian Shankar , Natarajan Ramesh , Bharath Cumar M , Keerthiraj K , Chinnusamy Palanivelu
Published: September 2022

Esophageal duplication cysts are rare developmental anomalies. The prevalence is estimated at 1 in 8200 live births. In adults they are usually an asymptomatic incidental radiographic or endoscopic finding. Definitive diagnosis requires surgical excision and histological examination.

Retrospective review of five consecutive patients with esophageal duplication cyst who were managed thoracolaparoscopically between January 2020 and March 2022 in a tertiary care teaching hospital.

Four patients underwent thoracoscopic excision while one patient underwent transhiatal excision. The longitudinal muscle layer of the esophagus was opened. The proximal and distal limits of the lesion were delineated and then excised. The lesion was excised using endoGIA stapler in one patient where the lesion was tethered to the mucosa. The overlying layers were sutured. The size of the largest lesion was 9.2 cm x 5.8 cm. The median operating time was 150 minutes (90 to 220 minutes). The median hospital stay was 5 days (5-7 days). The post operative recovery was uneventful in all the patients.

Esophageal duplication cysts can be safely managed with minimal morbidity by minimally invasive approaches even when the lesion is large.
549. LAPAROSCOPIC CARDIOPLASTY FOR FAILED PRIMARY TREATMENT OF ACHALASIA
Authors: Ezz Reda , Sabry Karim
Published: September 2022

Treatment of primary achalasia includes many modalities. All of these procedures have an associated failure rate. The resulting fibrosis from these methods of treatment (dilation, POEM or Heller's myotomy) makes re-Heller’s more difficult and less effective especially if associated with esophageal body aperistalsis suggesting esophagectomy to be the only surgical option. Cardioplasty whether open or Laparoscopic (LSC) may be an acceptable option after failure of these primary treatment (dilation, POEM or Heller's myotomy).

Patients with recurrent achalasia following failed primary treatments, were managed by cardioplasty either open or LSC. All patients were thoroughly investigated by upper endoscopy, dye study and manometry to confirm the failure of primary treatment and the need for redo surgery. Postoperative contrast swallows were done for all patients before discharge as well as manometry. We followed patient clinically and by investigations (dye study and manometry) to check the result of cardioplasty.

From May 2019 to April 2022, we operated 23 patients having failed primary achalasia treatment: 3 cases open (13%) and 20 cases (87%) by laparoscopy. Mean operative time was (62 min). Mean hospital stay was 2.6 days. Rapid esophageal emptying by dye studies was noted on all cases. LES pressure decreased in all patients (mean 11 mmhg). No anastomotic leak. During the follow up period, all patients were free from dysphagia. Four patients (17%) had developed heartburn and regurgitation controlled by medical treatment. No mortality recorded.

Laparoscopic cardioplasty is a feasible and effective option to treat patients for resistant achalasia with failed primary treatment (dilation, Heller’ myotomy and POEM) avoiding the high morbidity and mortality esophagectomy.
563. MAGNETIC DETECTION OF ESOPHAGEAL SENTINEL LYMPH NODES – A PROOF OF CONCEPT STUDY IN A PORCINE MODEL
Authors: Felinska Eleni , Billeter Adrian , Chen Zi-Wei , Willuth Estelle , Wise Philip Anthony , Nickel Felix , Müller-Stich Beat
Published: September 2022

Superparamagnetic iron oxide particles (SPIONs) have been used to mark sentinel lymph nodes in breast and prostate cancer surgery. Their suitability for other tumor entities remains unclear. In esophageal surgery, the future focus may shift to tailored lymph node resection to reduce the extent of surgery and to minimize perioperative complications. Still, there are very few tracers available to detect draining lymph nodes. In this study, we investigated the suitability of SPIONs for this issue.

Seven male piglets underwent surgery and SPIONs were injected into the esophageal wall. The distribution of the tracer into the adjacent local lymph nodes was investigated by a magnetometer over 120 minutes. Then, the specimens were harvested and examined histologically.

SPIONs were detected in all cases in the draining lymph nodes within the first 5 minutes after injection reaching a positive magnetic signal at 2160 ± 422 (magnetic count). The maximum was reached after 15 minutes at the magnetic count of 4880 ± 554.

The histological specimen confirmed the presence of the tracer in the esophageal wall and in the draining lymph nodes.

SPIONs are suitable for the detection of esophageal lymph nodes and should be evaluated in the clinical setting.
565. MOVING FROM OPEN ESOPHAGECTOMY TO MINIMALLY INVASIVE ESOPHAGECTOMY: A PARADIGM SHIFT IN AN UPPER GASTROINTESTINAL CENTER
Authors: Cheng Shi Yu , Lim Jolene , Voon Kelvin
Published: September 2022

Esophagectomy is a complex procedure that is traditionally associated with high morbidities. Minimally invasive esophagectomy (MIE) has the benefits of reduced post-op complications and improved quality of life in comparison to open esophagectomy (OE). This study aimed to compare the outcomes of MIE vs OE since the advocation of MIE as the standard approach in an upper gastrointestinal center.

A retrospective review of prospectively collected data from the institutional online databank. OE was the main approach for esophageal cancer between year 2015 to 2017, while MIE was the standard approach in 2020 to 2021. Patient’s demography, tumour’s characteristics, operative approach, perioperative outcomes such as operation time, blood loss, post-op length of hospital stay, number of lymph node yield, post-op morbidities and mortality were compared between the OE (Jan 2015 – Dec 2017) and the MIE (Jan 2020 – Dec 2021) group. 28 patients were included in this study, 15 in the OE group while 13 in the MIE group.

Mean age was similar in both groups (60.4vs59.4). 46.7% were of squamous cell carcinoma in the OE group vs 76.9% of adenocarcinoma in the MIE group. Ivor-Lewis approach was more common in the OE group (53.3%vs38.5%). MIE was associated with shorter mean operative time (489.38minutes vs 526minutes), less blood loss (110ml vs 250ml), shorter length of stay post-op (10.38days vs 24.67days) and higher number of lymph node yield (44vs31.67). Post-op morbidity was lower in MIE (30.7%vs73.3%) with Clavien-dindo grade-III and above complication rate of 7.69% vs 26.67%. 90-day mortality was 0 in the MIE vs 1 in the OE group.

MIE was associated with shorter operative time, higher number of lymph node yield, reduced post-op morbidity, mortality and shorter post-operative hospital stay in patients with esophageal cancer. The encouraging results marked the paradigm shift from OE to MIE in our center.
567. MDT OPTIMIZATION FOR DIAGNOSTIC WORKUP OF ESOPHAGEAL CANCER
Authors: Van Doesburg Jasmijn , Nilsson Magnus , Lindblad Mats , Gisbertz Suzanne , Luttikhold Joanna , Daams Freek
Published: September 2022

Rapid and complete workup of esophageal cancer is vital for a timely and individual treatment strategy. The aim of this study is to uncover potential delay, inefficiencies and non-contributing investigations in the diagnostic process.

This retrospective cohort study included all esophageal cancer patients referred to or diagnosed in the Amsterdam UMC or Karolinska Institutet between July 2020 and July 2021. Radiology, pathological assessment and MDT meeting reports were reviewed. To assess time interval from diagnosis to treatment, information on date of diagnosis, admittance to referral hospital, MDT and start treatment was collected.

This study included 252 esophageal cancer patients, 187 were treated with curative intent. Curative patients had a median age of 68, were predominantly male (74.9%) with adenocarcinoma (71.4%). Patients had a median of 34 days (IQR:27-43) between diagnosis and start treatment and a median time to referral of 6 days (IQR:0-11). Main denominators for prolonged time between diagnosis and treatment was need for additional diagnostics (45.5%) and local protocol (Amsterdam UMC 39 days vs Karolinska 27 days). However, for 33 out of 77 patients (42.9%), no other than logistical reasons could be found.

Differences in time between diagnosis and treatment in the centers can be explained by variations in workup protocol, MDT regulations and the need for additional diagnostics.
576. ESOPHAGEAL ACHALASIA: VERY LONG FOLLOW-UP STUDY ON PATTERNS AND COMPLICATIONS OF POST MYOTOMY GERD
Authors: Tassi Valentina , Lugaresi Marialuisa , Mattioli Benedetta , Daddi Niccolo' , Pilotti Vladimiro , Mattioli Sandro
Published: September 2022

Since the adoption of the Heller myotomy, surgeons have modified the original technique to balance the cure of dysphagia and the consequent cardial incontinence. Surprisingly, today post POEM 30-50% erosive-ulcerative esophagitis rates are by some put inside normality. Our group had the opportunity to follow up methodically patients submitted to Heller myotomy since 1955. Aim is to provide information on long-term outcomes of Heller myotomy for esophageal achalasia with or without an antireflux fundoplication.

In first instance 83 patients underwent a long abdominal myotomy (AM 1955-72), 30 patients a transthoracic myotomy according to Ellis (TM 1973-78), 364 patients the Heller-Dor operation with intraoperative manometry to calibrate myotomy, length and pressure of the Dor fundoplication (HD 1979-2021). Starting on 1973 these patients underwent a prospective follow-up program of timed lifelong clinical, radiological, endoscopic evaluations. Since 1973 an endoscopic-radiologic-clinical timed follow up has been established. GERD symptoms/esophagitis were evaluated.

AM, TM and HD groups were followed up for a median period of 25, 27, 14 years respectively. GERD symptoms-esophagitis occurred in AM 29.5%-28.1%, TM 30%-30%, HD 6.6%-5.8%. Timing of esophagitis after HD revealed: early onset (6-24 months) in 8 (2.2%), late onset (25 months-14 years) in 13 (3.6%). PPIs controlled reflux symptoms (71%vs14%, p<0.0001) but not esophagitis (43%vs46%, p= 0.075). Among 50 patients with erosive/ulcerative reflux esophagitis, Barrett’s esophagus was diagnosed in 21 (42%) at a median period of 112 months since myotomy. In this group low-grade dysplasia occurred in 12 (24%) and high grade dysplasia/adenocarcinoma in 5 (10%).

After surgical Heller myotomy not associated with an efficient antireflux procedure, GERD occurred in 30% which decreased to 6% after HD. A Heller-Dor operation is a competitive option for the cure of esophageal achalasia if this operation is performed according to the rules of surgical physiology learned by means of intraoperative manometry. The adoption of POEM in alternative to HD for the treatment of achalasia should be questioned.
579. LONG TERM RESULTS OF THE PULL-DOWN HELLER-DOR TECHNIQUE FOR ACHALASIA PATIENTS WITH SIGMOID ESOPHAGUS
Authors: Tassi Valentina , Lugaresi Marialuisa , Daddi Niccolò , Pilotti Vladimiro , Mattioli Benedetta , Bassi Francesco , Mattioli Sandro
Published: September 2022

The outcome of achalasia treatment in patients with sigmoid esophagus is worse than that achieved for fusiform achalasia. We compared two groups of sigmoid achalasia patients, in which we performed the standard Heller-Dor procedure (HD) and the Heller-Dor plus a technique aimed to restore the vertical axis of the intraabdominal portion of the esophagus pull-down Heller-Dor (PD-HD). Long-term results were evaluated.

We considered 48 patients affected by primitive esophageal sigmoid achalasia operated upon consecutively (1979-2021) in first instance. After 1987, we routinely isolated 360° of the gastro-esophageal junction and the lower esophagus and applied U stitches at the right side of the lower esophagus to pull down and rotate the gastro-esophageal junction toward the right. Twenty-five patients underwent the standard HD and 23 patients underwent the PD-HD technique. Postoperative follow-up included barium swallow, clinical interview investigating dysphagia and reflux symptoms and endoscopy. The overall outcome was graded from excellent to poor according to the severity of symptoms and esophagitis.

The median follow-up period was 11 years (IQR 6-22) for HD group and 9 (IQR 6-14) for PD-HD (p=0.22). At postoperative barium swallow, patients in the PD-DH group had smaller esophageal diameter [4 cm (IQR 4-4.7) vs 4.7 cm (IQR 4-5), p=0.04] and lower residual barium column [10 cm (IQR 6-13) vs 6 cm (IQR 0-8), p=0.001] than those in the HD group. Postoperative moderate-severe (D2-D3) dysphagia rates were 40% for HD and 13% for PD-HD group (p=0.003). The outcome of treatment revealed satisfactory (excellent, good, fair) results in 68% and 91.4% of HD and PD-HD group patients, respectively.

The Heller-Dor operation is effective in the presence of sigmoid achalasia. The clinical and instrumental evaluations showed better results with the PD-HD technique. This technique may be the first choice for end-stage achalasia with null or low risk for cancer.
582. REPORT ON A 42 YEAR EXPERIENCE WITH THE LAPAROTOMIC/LAPAROSCOPIC HELLER-DOR OPERATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR ESOPHAGEAL ACHALASIA
Authors: Tassi Valentina , Lugaresi Marialuisa , Baldi Fabio , Mattioli Bendetta , Daddi Niccolò , Pilotti Vladimiro , Mattioli Sandro
Published: September 2022

In 1979 our surgical group proposed the Heller-Dor operation (HD) to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Aim is to report very long-term results of the treatment of esophageal achalasia with the Heller-Dor operation performed with intra operative manometry.

In the period 1979-2021 HD was in first instance adopted in 202 patients (97 men; median age 45 years; IQR 31–59) in laparotomy (L-HD) and in 162 (79 men; age 48 years; IQR 35–63) in laparoscopy (V-HD). At intraoperative manometry, the complete abolition of the high-pressure zone was always obtained and the Dor length and pressure were trimmed according to reference values. Follow-up consisted of interview, endoscopy and barium swallow performed every 3 years. The overall outcome was graded from excellent to poor according to the severity of symptoms and esophagitis.

Median follow-up was 14.8 years in HD, 7.5 years in V-HD (p<0.001). Esophageal diameter and residual barium column decreased substantially during the first 3 years after the operation, but not successively. In the L-HD group poor results were 22 (10.9%): due to esophagitis in 17 (8.4%) and to recurrent dysphagia in 5 (2.5%). In V-HD, 4 (2.5%) had esophagitis and 2 (1.2%) severe dysphagia. Outcome was satisfactory in 89% of L-HD and in 96% of V-HD (p<0.001). Postoperatively, according to the Kaplan Mayer curve, dysphagia, reflux symptoms and esophagitis occurred within 60-65 months after surgery.

Timing of dysphagia relapse and post-myotomy reflux occurrence indicate that after five years, surgical results can be considered definitive. The 96% of satisfactory results we achieved with VL-HD, at a median follow-up time of 8 years, shows the potentiality of this surgical technique. In our experience, the learning process, not the follow-up length or the laparotomy/laparoscopy method is the cause of improved results of the laparoscopy HD.
585. INDIAN SINGLE CENTRE EXPERIENCE USING CROSS PROTOL IN CARCINOMA ESOPHAGUS AND GASTROESOPHAGEAL JUNCTION (GEJ)
Authors: Jethani Manish , Mistry Rajesh
Published: September 2022

Last decade has changed the treatment modality in esophageal cancer. Neoadjuvant chemoradiation followed by surgery is proven to be highly effective in locally advanced esophageal and GEJ tumors by Dutch CROSS protocol. The aim of neoadjuvant treatment is to increase R0 resection, down staging and pathological complete response which eventually increases disease free and overall survival.

This is a prospective observational single arm study of 51 patients who were treated with neoadjuvant chemoradiation with radiation therapy (RT) to 41.4 Gy/23 Fr/4.5 weeks and weekly paclitaxel and carboplatin, followed by surgery at our institute between 2013 and 2021. Eligibility for the use of CROSS protocol was expanded beyond the clinical stage T1N1 or T2-3N0-1, which includes T4aN0-1, T3N2-3.

The median age of this cohort was 58 years. 37/51 (72%) had T3 disease, 8/51 (15%) had T4a and 14/51 (27%) had N2/N3 disease. 90% patients had squamous cell carcinoma. All patients completed the intended dose of radiation; 11/51 (22%) patients had a treatment delay due to haematological toxicity; one patient died. 42 (82%) successfully completed esophagectomy with R0; one patient had inoperable disease, four defaulted and three refused surgery; 26 (62%) had pCR, 12 (28.57%) PR and one had SD. At last follow up 35 patients were alive, 12 died of disease and 7 had recurrent disease.

Our experience of neoadjuvant chemo radiation therapy (CROSS protocol) is in line with published data. Surgery post induction therapy was not associated with increased morbidity. It was associated with high complete resections and pathological complete response.
595. LAPAROSCOPIC HELLER’S MYOTOMY WITHOUT FUNDOPLICATION. CURRENT EVIDENCE
Authors: Davakis Spyridon , Liakakos Theodoros , Sdralis Ilias , Stratigopoulou Panagiota , Ntoka Polyxeni , Giagkos Christos , Andreas Alexandrou , Charalabopoulos Alexandros
Published: September 2022

Achalasia is a rare esophageal motility disorder which affects the esophageal smooth muscle layer, causing absent or spastic peristalsis, and absent or partial lower esophageal sphincter (LES) relaxation with an increased LES tone. Laparoscopic Heller’s myotomy is the gold standard surgical therapy of esophageal achalasia. The role of fundoplication to minimize GERD after myotomy is debatable. We studied our experience with Laparoscopic Heller Myotomy Without Fundoplication (LHM) for the treatment of esophageal achalasia.

A retrospective analysis of prospectively collected data regarding consecutive patients that underwent LHM without fundoplication for the treatment of esophageal achalasia was conducted. All patients were operated between September 1st 2018 and January 1st 2022. Patients included in this study were adults (>18 years old) without upper age limit. All participants completed a subjective dysphagia score questionnaire, received an Eckardt Score preoperatively, as well as at 6 and 12 months following the myotomy procedure. Patients that were treated with endoscopic dilation POEM or esophagectomy were excluded from the study.

Twenty-five patients underwent LHM myotomy without fundoplication during the study period. Median age was 42 years (Range: 25-90 years). Median operative time was 70 min (Range: 60-80 min). There was no conversion. Median length of stay was 2 days (Range: 1-15 days). There was one (n=1) mucosal perforation, in a 28-year-old male patient due to overeating, 4 days post LHM. He was treated with laparoscopic primary suturing. There was n=1 (4%) pathologic GERD noted post-operatively. The Eckardt score decreased from 6.5 ± 1.7 to 0.9 ± 1.4 at 1 month and to a 0.8 ± 1.1 at 12 months.

Therapy of esophageal achalasia focuses on decreasing the outflow resistance of the GEJ caused by the dysfunctional LES. LHM is considered as the gold-standard therapy for most achalasia patients. LHM is considered safe and effective, while it has been associated with excellent results regarding the relief of dysphagia. There is a reportedly low incidence of new gastroesophageal reflux symptoms. There is no need for fundoplication following LHM since the incidence of GERD is relatively low.
596. MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL AND GASTRO-ESOPHAGEAL JUNCTION TUMORS. A SINGLE CENTER EXPERIENCE
Authors: Davakis Spyridon , Liakakos Theodoros , Mpaili Efstratia , Ziogas Dimitrios , Sakellariou Stratigoula , Theochari Maria , Stratigopoulou Panagiota , Ntoka Polyxeni , Charalabopoulos Alexandros
Published: September 2022

Esophagectomy carries high rates of post-operative morbidity and mortality. Minimally invasive esophagectomy was introduced more than 20 years ago offering all the advantages of minimally invasive surgery and significantly reducing post-operative pulmonary and cardiac complications associated with open esophagectomy. Clinical and oncological outcomes are vastly improved standardizing this approach as inferior in the hand of experts. Herein, we aim to present our results of minimally invasive esophagectomy for esophageal and gastro-esophageal junction cancer.

This is prospective analysis of consecutive patients that underwent 2-stage minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. Operations included hybrid 2-stage esophagectomy (laparoscopic/open thoracotomic or open laparotomy/thoracoscopy) and 2-stage totally minimally invasive esophagectomy (laparoscopic/thoracoscopic). Study included adult patients with no upper age limit (>18 years). All esophagectomies for benign disease, as well as emergency operations were excluded from the study. Primary endpoints were 30- and 90-day mortality rate, anastomotic leak, anastomotic stricture, pulmonary complications, and length of hospital stay. Secondary endpoints were overall survival and progression-free survival rates respectively.

During an 8-year-period, n=350 consecutive patients underwent 2-stage minimally invasive esophagectomy for cancer. Our team has a cumulative experience of more than 300 open-esophagectomies. Since September 1st, 2013, hybrid 2-stage esophagectomy program was initiated. On September 1st, 2016, the program offered 2-stage totally minimally invasive esophagectomy in-all comers. Most patients were males. Anastomotic leak complicated 5.1% of the patients; 10% of the patients presented anastomotic stricture post-operatively, while pulmonary and cardiac complications reached up to 25 and 12% respectively. Medial LOS was 8 days. Median follow-up was 60 months. OS survival rate was 53 months and PFS was 48 months.

Advances in minimally invasive surgery can benefit all patients with esophageal and gastro-esophageal junction tumors. Hybrid and totally minimally invasive 2-stage esophagectomy are well established approaches, with safe and feasible profile in tertiary cancer centers. They can lead to significantly improved clinical and oncological outcomes comparing to open esophagectomy and its complications burden.
597. THE ROLE OF SURGERY IN THE ESOPHAGEAL INVOLVEMENT IN SYSTEMIC SCLEROSIS: A SYSTEMATIC LITTERATURE REVIEW
Authors: Cerinic Pietro Matucci , Akpabio Akpabio , Hughes Michael , Schoones Jan , Terrosu Giovanni , Martino Antonio , Vecchiato Massimo , Petri Roberto , Cerinic Marco Matucci , Alunno Alessia
Published: September 2022

In Systemic Sclerosis (SSc), gastroesophageal reflux disease (GERD) occurs in 75% of patients. Chronic doses of proton pump inhibitors may elicit in the general population long-term risk. When medical therapy fails, surgery can be employed but consensus on surgical procedures for refractory GERD is still lacking in SSc. Our aim was to evaluate the surgical approaches employed in the management of refractory GERD with a systematic literature research (SLR).

Four research questions, based on the PICO framework, guided the SLR which was conducted up to December 22nd, 2021. The search was performed across different databases including PubMed, MEDLINE (OVID), EMBASE, Cochrane Library, Web of Science, Google Scholar, Emcare and Academic Search Premier. References were independently screened by two reviewers (PMC and AA) who also independently assessed the full text of eligible articles, and extracted data. Due to heterogeneity of retrieved studies, narrative summaries are used to present the data.

In 30/916 papers, eligible for review, 348 patients were identified: 257 underwent an anti-reflux surgical procedure and included in the analysis. Refractory GERD was the most frequent indication for surgery, and post-operative dysphagia was a frequent complication. In 18 studies, fundoplication (FP) was effective, whereas 4 studies had equivocal findings and 5 didn’t report efficacy. Surgical procedures have changed in time: overall, the Collis-Nissen FP was the most popular in old studies, followed by Nissen FP, while Dor FP has been used more recently. The data extracted show also an acceptable rate of mortality and morbidity related to surgery.

In SSc, FP seems a safe and effective procedure for GERD management. In many studies, transient post-operative dysphagia was related with the posterior FP. Our SLR shows that the surgical management of GERD is still highly challenging and minimal requirements should be provided to perform surgical studies in SSc, designing studies to define clinical criteria for surgical referral. In SSc, the right timing for surgery and the best surgical procedure still remain an unmet need.
598. EPIPHRENIC DIVERTICULUM CAUSING GASTROESOPHAGEAL JUNCTION OUTFLOW OBSTRUCTION (EGJOO)
Authors: Lee June , Lim Annabelle , Lim Xin Yan
Published: September 2022

Oesophageal diverticulum is a rare cause of dysphagia. They are classified based on location- Zenker’s diverticulum distal to the cricopharyngeus; epiphrenic diverticulum above the lower oesophageal sphincter (LES)- or pathophysiology – traction vs pulsion. The prevalence of epiphrenic pulsion diverticulum ranges from 0.2% to 0.8%. We present a case of epiphrenic diverticulum and its management.

A 68 year old lady presents with dysphagia to solids and liquids, belching, food regurgitation, and acid brash for 10 years. She had no loss of weight, but experienced daily regurgitation and occasional retrosternal pain. Physical examination was unremarkable. We worked her up with further investigations and scans.

A CT abdomen reported a hiatus hernia and mural thickening of distal oesophagus with upstream oesophageal distension. A oesophagogastroduodenoscopy showed residual food in oesophagus. The lower oesophagus was dilated and the LES appeared tight with no masses. There was no hiatus hernia on endoscopy. Barium swallow revealed the lower oesophageal dilatation to be an epiphrenic diverticulum. Manometry studies showed oesophago-gastric junction outflow obstruction.

She underwent laparoscopic excision of esophageal diverticulum, cardiomyotomy and anterior partial fundoplication. The video serves to highlight the surgical key steps. She was discharged on post-operative day 3 without complications and barium swallow pre/post op as shown.

Oesophageal diverticulum, although rare, remains a differential for dysphagia. For epiphrenic diverticulum, it is important to understand that this is a pulsion diverticulum, with an accompanying gastro-oesophageal outflow obstruction. In addition to surgical management with a laparoscopic diverticulectomy, a cardiomyotomy and partial fundoplication to treat underlying motility disorder is important. This case study and video serves to highlight the condition and present minimally invasive surgical management.
599. TOLL-LIKE RECEPTORS AND ESOPHAGEAL CANCER. DIAGNOSIS, PROGNOSIS AND THERAPY
Authors: Davakis Spyridon , Kapelouzou Alkistis , Sakellariou Stratigoula , Mpoura Maria , Stergiou Dimitrios , Liakakos Theodoros , Charalabopoulos Alexandros
Published: September 2022

Esophageal cancer is the sixth leading cause of cancer related morbidity worldwide. It has to predominant subtypes, esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC). Despite all the advances in surgical therapy and adjuvant therapies, prognosis of esophageal cancer remains poor. EAC develops through Barrett’s esophagus (BE) and columnar dysplasia, preceded by gastro-esophageal reflux disease (GERD). Incidence of ESCC is increased with tobacco smoking and alcohol abuse.

Toll-like receptors (TLRs) can act as prognostic factors and potential therapeutic targets of esophageal cancer. TLRs, an important family of pattern recognition receptors, allow immune cells to recognize pathogens, triggering inflammation. TLRs-signaling pathway activates signaling elements, regulating inflammatory response, possibly correlating to carcinogenesis. In normal esophagus, TLRs play an important role in innate immunity, recognizing molecular patterns on microorganisms and inflammatory responses produced by tissue damage.

It is known that TLR3, TLR4, TLR5 and TLR are increasingly expressed from GERD to AC, with TLR4 known for being a mediator of proliferation in AC, while TRL1 and TLR4 overexpression in AC is related to poor prognosis and metastatic potential. Additionally, TLR3, TLR4 and TLR9 expression in stromal cells of ESCC has been associated with lymphatic metastasis, while TLR7 and TLR9 increased expression has also been addressed to advanced disease.

Herein, we aim to present all available data regarding the relations of TLRs and EC. It seems that TLRs expression can indicate esophageal metaplasia, dysplasia, and cancer. Toll-like receptors can act as significant and valuable indications in diagnosis, prognosis and potentially can be used as therapeutic target of esophageal cancer.
600. TREATMENT OUTCOME OF CLINICALLY UNRESECTABLE ESOPHAGEAL CANCER AFTER NEO-ADJUVANT CHEMOTHERAPY WITH DOCETAXEL, CISPLATIN AND 5-FLUOROURACIL
Authors: Chan Wing Lok , Wong Ian YH , Choi Horace Cheuk-Wai , Tsang Terence , Lam Adrian , Tse Rosa , Zhang Riki , Chan KK , Wong Claudia , Law Betty , Lam Ka-On , Chan Fion , Kwong Dora , Law Simon
Published: September 2022

Standard therapy for locally advanced unresectable esophageal cancer is neoadjuvant chemotherapy followed by definitive chemoradiotherapy (CRT). However, the prognosis was modest with the mean survival being around 1 year. Emerging evidence shows the efficacy results of using neo-adjuvant chemotherapy docetaxel-cisplatin-5FU (DCF) for locally advanced esophageal tumor.

We reviewed the long-term clinical outcomes and safety data of neo-adjuvant chemotherapy DCF and subsequent definitive treatment in locally advanced clinically unresectable esophageal cancer.

All patients with locally advanced clinically unresectable esophageal cancer without any distant metastases and received induction DCF (docetaxel 70 mg/ m2 D1, cisplatin 70  mg/ m2 D1, 5-fluorouracil 750  mg/ m2 on D1-5 Q3 weeks for 3 cycles) with an aim for conversion to definitive surgery or CRT were included.

Primary outcomes were overall survival (OS) and conversion rate (from unresectable to resectable tumor after DCF). Secondary outcomes include relapse pattern, safety data of chemotherapy and post-op complications.

Total 47 patients (median age 62yo, male: 41 (87.2%)) received neo-adjuvant DCF. 24 patients (41.4%) had subsequent surgery and 7 (14.9%) had definitive CRT.

The median OS was significantly longer in the surgical group than CRT group (40.2 vs. 9.1months, HR 3.33, 95%CI 1.22–9.07, p=0.02) and no definitive treatment (40.2 vs. 6.3months, HR 8.51, 95%CI 3.7–19.73, p<0.001).

Patients with surgery had a lower risk of local relapse (100% vs. 33%, p<0.001) but comparable risk of distant metastasis (47.8% vs. 58.6%, p=0.538) than those without surgery.

The incidence of G3/4 adverse events of DCF was 44.7%. 11 patients had post-op complications.

Neo-adjuvant chemotherapy with DCF and subsequent conversion surgery offered a chance of cure with long-term survival benefit and manageable toxicities in patients with locally advanced unresectable esophageal cancer.
613. DOUBLE LUMEN JEJUNAL FREE FLAP RECONSTRUCTION AFTER PROXIMAL ESOPHAGEAL RESECTION FOR MALIGNANCY
Authors: Chow Geoffrey , Hughes Timothy , Liu Changxing
Published: September 2022

Malignancies located at the level of the upper esophageal sphincter pose a challenge due to the proximity to pharyngeal, laryngeal, and upper esophageal anatomic structures. Poorly differentiated tumors in this area can pose both diagnostic and therapeutic dilemmas, and patients with prior neck radiation may require surgery. In cases that are treated with laryngectomy, pharyngectomy, and proximal esophagectomy, jejunal free flap reconstruction can restore gastrointestinal continuity and function.

A single institution early experience with multidisciplinary complex head and neck reconstruction requiring pharyngectomy and proximal esophagectomy was reviewed. Charts were reviewed for demographic details, operative details, and 30 day perioperative occurrences. Radiographic, clinical, and endoscopic records were reviewed. Method and approach for jejunal harvest and abdominal complications were obtained. Location of microvascular anastomoses were recorded for implantation of the jejunum. Length of small bowel utilized was recorded along with details of operative technique and methods for both proximal and distal anastomoses. Pre-operative and post-operative pathology reports were reviewed and compared.

The initial 4 cases of pharyngeal and esophageal resection requiring jejunal free flap reconstruction were reviewed. Mean age was 65.3 (50-74), mean BMI was 31.7 (21.7-49.8), and 75% of patients were female. Median length of stay was 13.5 days (8-14) after the index operation. Flap survival rate was 100%, and there was 0% leak rate. Three patients had previous neck surgery, 75% survived to 30 days with 1 patient opting for palliative care. All flaps were harvested using a laparoscopic approach. There were no abdominal donor site related complications. Pathology 50% SCC, mucoid epidermoid carcinoma, and anaplastic thyroid carcinoma.

Reconstruction of complex pharyngeal and proximal esophageal defects after oncologic resection for malignancy involving the proximal esophagus abutting the upper esophageal sphincter poses a complex challenge. These proximal esophageal defects are managed effectively with jejunal free flap reconstruction utilizing microvascular anastomoses. A double lumen jejunal free flap should be considered to restore pharygo-esophageal continuity, provides good pharyngeal size match, and can also be safely performed in patients with a re-operative field or prior neck radiation.