bluuebunny/crossref_metadata_2025 huggingface dataset:
PS01.121: DISTRIBUTION OF MEDIASTINAL LYMPH NODE INVOLVEMENT IN ADENOCARCINOMA OF THE ESOPHAGOGASTRIC JUNCTION
Authors: Mine Shinji , Watanabe Masayuki , Imamura Yu , Okamura Akihiko , Yamashita Kotaro , Hayami Masaru , Yuda Masami , Fukudome Ian
Published: September 2018

Background

The distribution of mediastinal lymph node involvement is not clear in patients with adenocarcinoma of the esophagogastric junction (AEG). Based on our experiences with radical lymphadenectomy of upper mediastinum for esophageal squamous cell carcinoma, we applied this technique to patients with AEG. We retrospectively investigated it and compared it with that in patients who had lower esophageal squamous cell carcinoma (ESCC) with clinical invasion of the esophagogastric junction.

Methods

Sixty-four patients underwent esophagectomy via a right thoracotomy or a minimally invasive esophagectomy for Siewert type I tumor or type II with ≥ 3 cm esophageal invasion. The incidences of mediastinal lymph node involvements and the characteristics of patients with mediastinal nodal involvement were analyzed retrospectively. In addition, these outcomes were compared with 72 patients who had lower ESCC with clinical invasion of the esophagogastric junction.

Results

In 64 patients with AEG, mediastinal lymph node involvement was seen in 23 patients (36%). The incidences of upper, middle, lower mediastinal nodal involvement were 19%, 16%, and 22%, respectively. No significant differences were found for cStage, Siewert type, endoscopic tumor length, pT or pN status, residual tumor, or survival between patients with upper nodal involvement and those with middle or lower nodal involvement. The incidence of each mediastinal lymph node involvement was similar between AEG and lower ESCC patients.

Conclusion

Although our outcomes were based on limited data, the incidence of upper, middle, and lower mediastinal lymph node involvement might not be low, and its clinical characteristics were similar to those for middle or lower mediastinal nodal involvement in esophageal adenocarcinoma.

Disclosure

All authors have declared no conflicts of interest.
PS01.124: AN OPTIMAL SURGICAL APPROACH AND THE EXTENT OF LYMPH NODE DISSECTION FOR BARRETT’S ADENOCARCINOMA
Authors: Gokon Yusuke , Taniyama Yusuke , Sakurai Tadashi , Heishi Takahiro , Sato Chiaki , Okamoto Hiroshi , Takaya Kai , Maruyama Shota , Kamei Takashi
Published: September 2018

Background

An optimal surgical approach and the extent of lymph node dissection for Barrett's adenocarcinoma remain controversial. The standard surgical approach for Barrett's adenocarcinoma at our institution is performing thoracoscopic esophagectomy. Proximal gastrectomy is preferred in cases where distance between the proximal edge of the primary tumor and the esophagogastric junction is < 3 cm. However, some studies suggest a complete resection of Barrett's esophagus.

Methods

The clinicopathologic data of 36 patients with Barrett's adenocarcinoma who were admitted to our institution between 1994 and 2017 were retrospectively analyzed to assess the efficacy of lymph node dissection at each station using the index of estimated benefit from lymph node dissection (IEBLD).

Results

The tumor locations were found to be the middle thoracic, lower thoracic, and abdominal esophagus in 2 (5.6%), 17 (47.2%), and 17 (47.2%) cases, respectively. A total of 28 (77.8%), 6 (16.7%), and 2 (5.5%) patients underwent esophagectomy, proximal gastrectomy, and transhiatal esophagectomy, respectively. The overall lymph node metastasis rate was 41.6%. The IEBLD indexes of the middle/lower thoracic lymph and the abdominal lymph nodes were comparable, whereas those of the paraesophageal lymph nodes (#108 and 110) were relatively high. Conversely, the metastasis rates of the upper thoracic lymph nodes were 13.9%, with no IEBLD values. Cervical lymph node metastasis was not identified, and the significance of dissection was unclear. Stratified by the location of tumor, the ILBLD index of middle/lower thoracic lymph node was relatively high in Lt cases. Conversely, those of abdominal lymph nodes were high and those of middle thoracic lymph nodes were not identified in Ae cases. In proximal gastrectomy cases, the complete resection of Barrett's esophagus was not achieved in 2 (40%) cases with LSBE. Lymph node metastasis was identified in one case (#110). The recurrence-free survival rate was 100%.

Conclusion

The significance of upper thoracic lymph node dissection was unclear, whereas those of middle/lower thoracic lymph and the abdominal lymph nodes were comparable. The selection of an appropriate surgical approach at our institution was acceptable. The efficacy of complete resection of LSBE was not observed.

Disclosure

All authors have declared no conflicts of interest.
PS01.131: POSTOPERATIVE ANASTOMOTIC LEAKAGE AND PNEUMONIA FOLLOWING ESOPHAGECTOMY: A RETROSPECTIVE SINGLE-CENTER ANALYSIS
Authors: Herzberg Jonas , Strate Tim , Honarpisheh Human
Published: September 2018

Background

Anastomotic leakage and pneumonia following esophagectomy remain a significant clinical challenge and contribute to the postoperative outcome. Aim of this study was to investigate the relation between risk factors for the occurrence of leakage or pneumonia and the postoperative outcome and to identify further risk factors.

Methods

We analyzed 53 consecutive patients who underwent a surgical resection of the esophagus (distal esophagectomy and abdominothoracical esophagectomy) from January 2015 until August 2017. Patients demographics, perioperative parameters, and postoperative events were analyzed. Patient data were expressed as mean ± SD (range). P < 0.05 was considered statistically significant.

Results

Postoperative pneumonia and anastomotic leakage occurred in 15 (28%) and 8 (15%) patients, respectively. Median operative time was 330.7 (± 69.6) minutes, and median length of stay was 24.8 (± 10.6) days. 2 (3.8%) of the patients required blood transfusion due to intraoperative bleeding. BMI, ASA-score, and an intraoperative performed lymphadenectomy did not affect the occurrence of pneumonia or anastomotic leakage. Patients with anastomotic leakage stayed longer at the ICU. However, the overall hospitalization rate did not differ significantly. As an independent risk factor, we identified that hypoproteinaemia with a protein level ≤ 5 g/dl (p-value 0.036) leads to a significant higher occurrence of anastomotic leakage. We could not identify any risk factors with regards to postoperative pneumonia.

Conclusion

The prevalence of hypoproteinaemia in patients after esophagectomy was associated with a higher occurrence of postoperative anastomotic leakage. These results indicate the importance of the perioperative nutrition aiming for a balanced protein level irrespective of comorbidity and surgical procedure.

Disclosure

All authors have declared no conflicts of interest.
PS01.134: WHERE TO START? COMPARING INDUCTION CHEMORADIOTHERAPY AND UPFRONT SURGERY IN THE TREATMENT OF CLINICAL T2N0 ESOPHAGEAL CANCER
Authors: Agzarian John , Inra Matthew , Abdelsattar Zaid , Allen Mark , Blackmon Shanda , Cassivi Stephen , Nichols Iii Francis , Wigle Dennis , Shen K
Published: September 2018

Background

The purpose of this study was to evaluate the survival difference in clinical T2N0 esophageal cancer patients receiving neoadjuvant chemoradiotherapy (CRT) vs. upfront surgery.

Methods

Between 1/1/1995 to 12/31/2012, a prospectively maintained database was used to identify patients with cT2N0 esophageal adeno- and squamous cell carcinoma. Exclusion criteria included: lack of endoscopic esophageal ultrasonographic (EUS) staging, incomplete resection, and prior treatment with endoscopic mucosal or submucosal resection. Cox-proportional hazard ratios were used to compare the primary outcomes of overall (OS) and disease-free survival (DFS). Secondary outcomes included: rate of postoperative complications, rate of pathologic upstaging/response, and induction/adjuvant treatment completion rate. Pre-hoc subgroup analysis compared pathologically upstaged patients receiving upfront surgery followed by adjuvant chemotherapy to those treated with neoadjuvant CRT.

Results

A total of 161 cT2N0 esophageal cancer patients were identified based on EUS staging. Upfront surgery was offered to 134 patients (83%), with 27 patients (17%) receiving induction CRT. Univariate analysis did not demonstrate any significant baseline differences between the two groups. In the upfront surgery group, 53 (39.6%), 28 (20.9%) and 53 (39.6%) patients were pathologically down-staged, accurately staged and upstaged respectively. Upstaging was higher in the upfront surgery group (53/134, 39.6% vs. 4/27, 14.8%; P = 0.02), while 11/27 (40.7%) patients receiving neoadjuvant CRT demonstrated complete pathologic response. Of those eligible for adjuvant chemotherapy, only 21/55 (38.2%) received treatment. In the neoadjuvant CRT group, 51.9% completed all planned therapy, compared to 23.6% of patients treated with upfront surgery followed by adjuvant chemotherapy (P = 0.01). Cox proportional hazard ratio did not demonstrate an advantage to induction CRT in terms of OS (HR = 1.64, P = 0.43) or DFS (HR = 1.36, P = 0.69). In general, patients with pathologic upstaging had worse OS (HR = 2.73, P = 0.001) and DFS (HR = 4.18, P = 0.003).

Conclusion

EUS was only accurate in staging T2N0 patients in 20.9% of cases. While neoadjuvant CRT did not confer a survival advantage, these results likely reflect the low number of patients being referred for induction therapy. Neoadjuvant CRT was however associated with lower rates of pathologic upstaging and higher rates of treatment completion. Further research should evaluate the survival outcomes in pathologically upstaged cT2N0 patients not receiving neoadjuvant therapy.

Disclosure

All authors have declared no conflicts of interest.
PS01.137: CLINICAL IMPACT OF SURGICAL APGAR SCORE IN PREDICTING POSTOPERATIVE COMPLICATIONS AND LONG-TERM PROGNOSIS AFTER ESOPHAGECTOMY
Authors: Ishida Sonoko , Nakagawa Akio , Nakamura Tetsu , Oshikiri Taro , Hasegawa Hiroshi , Yamamoto Masashi , Kanaji Shingo , Matsuda Yoshiko , Yamashita Kimihiro , Matsuda Takeru , Sumi Yasuo , Suzuki Satoshi , Kakeji Yoshihiro
Published: September 2018

Background

Surgical Apgar Score (SAS) is a risk calculator, and is known to predict postoperative complications after surgery. Because it applies three intraoperative parameters, namely estimated blood loss, lowest mean arterial pressure, and lowest heart rate, actual surgical stress is reflected to its scoring system and many studies have reported its usefulness. And in recent years, close relationship between postoperative complications and long-term prognosis has been reported, but there are almost no studies about the relevance between risk calculator of complications and long-term prognosis.

Methods

A total of 400 patients who underwent esophagectomy for esophageal cancer between January 2007 and January 2017 at our institution were included in this study. Clinicopathological and intraoperative data to calculate SAS were collected from medical records, and a 10-point scoring system based on the original method was used to assign points. Complications classified as Clavien-Dindo grade III or higher were defined as postoperative complications. The relationship between SAS and postoperative complications and long-term prognosis was investigated.

Results

Postoperative complications occurred in 145 cases (36%). From ROC analysis, we set the SAS cut-off value to 5 points in this study. There were no significant differences in patient's background between the group of SAS ≤ 5 and > 5. Multivariate logistic regression analysis showed that hypertension (P = 0.049) and SAS ≤ 5 (P < 0.0001) were significant predictive factors for postoperative complications. In the prognostic analysis, log-rank analysis showed that patients with SAS ≤ 5 had a significantly poorer prognosis than those with SAS > 5 (P = 0.043), especially in clinical stage 2 or higher esophageal cancer (P = 0.027). In the multivariate analysis, SAS ≤ 5 was revealed to be a significantly poor prognostic factor in clinical stage 2 or higher esophageal cancer (P = 0.029).

Conclusion

The Surgical Apgar Score can predict postoperative complications, and is also useful to predict long-term prognosis after esophagectomy for esophageal cancer.

Disclosure

All authors have declared no conflicts of interest.
PS01.146: THE ANALYSIS OF THE SAFETY OF A MODIFIED LEFT RECURRENT LARYNGEAL LYMPH NODES DISSECTION IN THORACOSCOPIC ESOPHAGEAL CARCINOMA SURGERY
Authors: Jiang Jie , Yu Xiuyi , Geng Guojun , Liu Hongming
Published: September 2018

Background

To explore the thoroughness and safety of a modified left recurrent laryngeal lymph nodes dissection in thoracoscopic esophageal carcinoma surgery.

Methods

Retrospectively analyzed the clinical data of 136 patients with the left recurrent laryngeal lymph nodes dissection from October 2015 to October 2017 in the First Hospital Affiliated to Xiamen University. 67 cases were divided to the traditional dissection group (double lumen endotracheal intubation, 90 ° lateral position) and 69 cases were classified to the modified dissection group (single cavity tracheal intubation, thoracic CO2 positive pressure ventilation, lateral prone position and esophageal suspension technology). Observed and compared the left laryngeal recurrent nerve lymph nodes cleaning and time, intraoperative complications including thoracic duct injury, tracheal injury, hoarseness and pneumonia.

Results

The cleaning time of the modified dissection group (23 + 8 min) was significantly less than that of the traditional cleaning group (32 plus or minus 5min) (P < 0.01). 5 patients occurred left laryngeal nerve injury in the modified dissection group, with statistically significance (P < 0.01), less than traditional dissection group of 12 patients. The modified dissection method improves the exposure of intraoperative field, the probability of thoracic duct and tracheal injury (1/69, 0/69) were lower than the traditional group (2/67, 1/67), but the difference was not statistically significant (P > 0.05). Moreover, there was no significant difference in lymph nodes metastasis and complications incidence rate (P > 0.05).

Conclusion

The modified dissection method, including single cavity tracheal intubation, thoracic CO2 positive pressure ventilation, lateral prone position and using esophageal suspension technology, can achieve good operation field exposure, the left recurrent laryngeal lymph nodes ‘the whole block’ cleaning, and the greatest degree protection of laryngeal recurrent nerve, thoracic duct, trachea and other organs damage. It is worthy of clinical popularization and application.

Disclosure

All authors have declared no conflicts of interest.
PS01.156: THE PATTERN OF LYMPH NODE METASTATIC AND ITS CLINICAL SIGNIFICANCE FOR THORACIC SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMATHE PATTERN OF LYMPH NODE METASTATIC AND ITS CLINICAL SIGNIFICANCE FOR THORACIC SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Wang Shaohua , Chen Xiaofeng , Wang An
Published: September 2018

Background

The pattern of lymph node metastasis and surgical method in superficial esophageal squamous cell carcinoma (sESCC) remains to be established.

Methods

Clinical data of all patients from 2003 to 2015 who underwent curative esophagectomy for thoracic sESCC were collected based on a prospectively-maintained database. The pattern of lymph node metastasis was analyzed based on depth of tumor invasion and tumor location.

Results

The involved lymph node region was associated to the tumor location, however, upper mediastinal and perigastric region was the most vulnerable region. As for the depth of tumor invasion, the incidence of lymph node metastasis increased with the depth of tumor invasion going deeper. No lymph node involvement was found in tumors invading proper mucosa (M2), while the distribution of positive lymph nodes in tumors invading the deepest 1/3 submucosa was similar to that in advanced ESCC. Lymphatic invasion, tumor location and upper mediastinal lymph node involvement were independent predictors for cervical lymph node metastasis. For patients without lymphatic invasion, the positive predictive value of upper mediastinal lymph node metastasis for positive cervical lymph node was low (0∼25%), while the negative predictive value was very high, wherever the tumor located (93.8∼100%).

Conclusion

Tumors invading till proper mucosa was the best indication for endoscopic mucosa resection; Tumors invading the deepest 1/3 submucosa might benefit from neoadjuvant therapy; Mediastinal-abdominal lymphadenectomy was essential for sESCC. For those without lymphatic invasion, cervical lymphadenectomy might be avoided in case of negative upper mediastinal lymph node.

Disclosure

All authors have declared no conflicts of interest.
PS01.157: APPLICATION OF THE COMPLETELY MOBILIZED REMNANT STOMACH IN ESOPHAGOPLASTY FOR LOWER THORACIC ESOPHAGEAL CARCINOMA FOLLOWING DISTAL GASTRECTOMY
Authors: Mao Zhangfan , Huang Jie , Xie Songping
Published: September 2018

Background

Reconstruction of the esophagus for the patients following distal gastrectomy (DGE)is a significant challenge for surgeons. Remnant stomach seems to be a better choice compared with colon or jejunal. But many complicated surgical methods were performed because of limitation of feeding vessels. We found the remnant stomach remained viable when all the feeding vessels were dissected. We used the completely mobilized stomach to reconstruct esophagus successfully in 29 lower thoracic esophageal carcinoma patients with a history of DGE.

Methods

The clinical data of 29 patients were retrospectively analyzed from August 2005 to March 2017 who accepted esophagoplasty by the completely mobilized remnant stomach. All the vessels of the remnant stomach were dissected including short gastric, posterior gastric, left gastric and left gastroepiploic vessels. The DGE included 2 Billroth I and 27 Billroth II.

Results

No perioperative death, no remnant stomach necrosis occurred. One Leakage was the iatrogenic injury on the remnant stomach. The other postoperative complications were the pulmonary infection(5) and arrhythmia(4).

Conclusion

The completely mobilized remnant stomach was viable and functional after dissecting all the feeding vessels. Application of it was a new and feasible surgical method to perform esophagoplasty with the simpler procedure and less complication.

Disclosure

All authors have declared no conflicts of interest.
PS01.158: WHAT IS THE IDEAL RECONSTRUCTIVE TECHNIQUE FOR TYPE 2 GEJ TUMOURS—ESOPHAGOGASTROSTOMY OR ESOPHAGOJEJUNOSTOMY
Authors: Chandramohan Servarayan , Varadharajan Visvarath , Chinnathambi Madeshwaran , Manickavasagam Kanagavel , Jebaraj Abishai , Chandramohan Apsara
Published: September 2018

Background

In the management of OG junction tumors the border issue arises in type 2 cancers. It can be managed with various options like esophago gastrectomy (Ivor Lewis), transabdominal extended transhiatal gastrectomy or total esophago gastrectomy depends upon the extent strectomy of the tumor above and below. After resection the reconstruction can be either with stomach or jejunum or colon. However the functional result after either of these procedures varies. The aim of this study is to know the functional outcome of different reconstruction methods after esophagogastrectomy for locally advanced Type 2 OG junction tumours.

Methods

148 consecutive patients who underwent surgery for OG junction tumors in the last 6 years were evaluated. Of them 62 locally advanced type2 OG junction tumors were included in our study. 26 underwent Ivor Levis procedure with gastric replacement. 36 underwent extended transhiatal gastrectomy with esophago jejunal anastamosis. Intra operative details like pyloroplasty, Operative time, blood loss, the distal margin, nodal clearance was noted. The functional outcome since immediate postoperative period to 1 year of follow up is reviewed retrospectively and prospectively in few cases.

Results

There is no significant difference in operating time, blood loss. Two patients with Partial gastrectomy had positive distal margin even though it is not statistically significant. The average number of nodes harvested is higher with total gastrectomy group with jejunal anastamosis and it is statistically significant between 2 groups (P < 0.05).The GERD is more with gastric conduit when compared to Jejunal reconstruction but the weight loss is more with jejunal reconstruction when compared with gastric reconstruction.

Conclusion

The functional outcome and oncological outcome are superior with jejunal reconstruction after total gastrectomy when compared with gastric reconstruction after Ivor Lewis procedure.

Disclosure

All authors have declared no conflicts of interest.
PS01.160: PERIOPERATIVE PERFUSION ASSESSMENT WITH QUANTITATIVE FLUORESCENCE ANGIOGRAPHY
Authors: Nerup Nikolaj , Bo Svendsen Morten , Bo Svendsen Lars , Achiam Michael
Published: September 2018

Background

Anastomotic leakage (AL) occurs relatively frequent in oncologic esophageal surgery and is associated with increased morbidity and mortality, and risk of local recurrence of cancer. Poor anastomotic perfusion is probably an important factor of AL.

Traditionally; perfusion has been assessed visually and manually by palpation, methods proven to be irreproducible and not possible in a minimal-invasive environment. Few studies on ICG-FA used in esophageal resection exists and some have shown promising results. However, most studies only use a visual interpretation of the angiography, leading to observer bias. In addition, this subjective visual assessment only allows a binary outcome; perfusion or no perfusion. A quantitative (q-ICG) approach enables a scaled, objective assessment, useful in lowering the risk of AL, however, also in exploring interventions and risk factors leading to improved or attenuated perfusion. The aim of this study was to establish a valid, reproducible perioperative q-ICG method.

Methods

Design and validation: A Q-ICG method for assessment of ICG-FA was developed in a porcine model, using seven pigs. To establish which metric of Q-ICG to use, neutron labeled microspheres were injected intraarterially as microspheral flow is considered the gold standard in microvascular flow assessment. Tissue samples from the stomach were excised and the regional flow was calculated, this was compared with Q-ICG metrics by correlation analysis. Attenuated perfusion: In seven pigs, the stomach and segments of small bowel were partly devascularized and local lactates were correlated to Q-ICG. Improved perfusion: As glucagon-like peptide-2(GLP-2) enhances fore- and midgut perfusion, 20 pigs underwent small bowel resection and anastomosis and randomized to GLP-2 or placebo, to test if Q-ICG could determine a difference in perfusion.

Results

We found excellent correlation of the q-ICG metric ‘normalized slope’ to regional microspheral flow (r = 0.92–0.96, P = 0.001). In addition, local lactate measurements of the devascularized stomach and small bowel correlated to the normalized slope of q-ICG (Spearman rho = 0.8). Q-ICG found significant improved anastomotic perfusion of pigs treated with GLP-2 (P < 0.05).

Conclusion

We established and validated a method of Q-ICG in normal, attenuated and improved perfusion, that may be useful in esophageal surgery, where construction of an anastomosis requires an optimal perfusion.

Disclosure

All authors have declared no conflicts of interest.
PS01.163: EVALUATION OF A TECHNIQUE OF SINGLE LAYER CONTINUOUS ESOPHAGOGASTRIC ANASTOMOSIS USING POLIGLECAPRONE 25
Authors: Parshad Sanjeev , Karwasra Rajendra , Kumar Ravinder
Published: September 2018

Background

Methods

This was a prospective study on patients who underwent esophagectomy for carcinoma oesophagus from May 2016 to August 2017. The patients who expired in immediate post operative period were excluded from study for evaluation of anastomotic leak and those patients who could not be followed up for at least six months were also excluded from study for evaluation of development of post operative stricture. End to side anastomosis was placed on the anterior surface of stomach using two suture lengths of 2–0 polyglecaprone 25. Anastomosis was done in single continuous layer with full thickness bites. At the end the stomach conduit was tucked to prevertebral fascia by a single stitch. During post operative period, Jejunal feeding was started on 2nd post operative day. Ryle's tube was removed on 5th post operative day and clear liquids were started. Gastrograffin study was done only if clinical suspicion of leak was there on day 7. Semisolid puree diet was started on day 7 and neck drain was removed on day 10.

Patients were followed up for six months and specifically asked for symptoms of dysphagia.Symptoms of dysphagia were recorded and graded on the basis of Mellow-Pinkas scoring system.

Results

Mckeowns esophagectomy was performed in 18 patients, transhiatal in 8 patients and Ivor Lewis in 1 patient. Average time taken for anastomosis was 17 min. Anastomotic leak was seen in four patients(14.81%) and all leaks could be managed conservatively. Only two patients(7.40%) presented with dysphagia which required dilatations. The cost of suture used was least as compared to other techniques.

Conclusion

Anastomotic leak rate of the present technique was found to be comparable to other techniques whereas the post operative stricture formation was significantly less. Poliglecaprone 25 looses all its tensile strength by third week and this may be the reason for low stricture rates. We conclude that Esophagogastic anastomosis with a single layer continuous technique using 2–0 poliglicaprone 25 gives good results having comparable leak rates to other techniques. The rate of anastomotic stricture formation is quite low as compared to other techniques.The anastomosis takes less than seventeen minutes and is quite cost effective.

Disclosure

All authors have declared no conflicts of interest.
PS01.167: MUMELE STUDY: MULTICENTER STUDY ON INCIDENCE OF MEDIASTINAL LEAKS AFTER ESOPHAGECTOMY
Authors: Fumagalli Romario Uberto , Celotti Andrea , De Pascale Stefano , Rosati Riccardo , Cossu Andrea , Parise Paolo , Bonavina Luigi , Bernardi Daniele , Degiuli Maurizio , Reddavid Rossella , De Manzoni Giovanni , Weindelmayer Jacopo , Portolani Nazario , Baiocchi Gianluca , Santi Stefano , Pallabazzer Giovanni
Published: September 2018

Background

Mediastinal anastomotic leak (ML) represent one of the most feared complication of esophageal resection. The incidence of ML, and of the associated mortality rate and the treatment strategy are variously reported. A standard strategy for diagnosis and treatment is difficult to establish

Methods

In order to evaluate the incidence, predictive factors, treatment and mortality of ML in 7 Italian surgical centers with interest in esophageal surgery (5 high volume centers) a retrospective study including all esophagectomies (E) with intrathoracic esophagogastric anastomosis performed in a 3 year period (2014–2017), was planned. ML were defined according to the classification proposed by the Esophagectomy Complications Consensus Group.

Results

The data of 501 E were collected. Overall incidence of ML was 11.8%. Surgical approach significantly influenced the rate of ML: leakage rate was highest for totally minimally invasive (TMIE) and lowest for hybrid esophagectomy (HE) (respectively 20 and 9%). No other predictive factor was found. Overall 30 and 90 day (d) mortality rate (M) were respectively 1,4% and 3,2%; 30 and 90 d M for leaks were respectively 5% and 15,3%; 90 d M for TMIE and HE were 5,9% and 1,8% respectively. Endoscopy was the first line treatment in 49% of leaks, with a need for retreatment in 17,2% of cases. Surgery was needed globally in 44,1% of ML. Endoscopic treatment appeared to have the lowest M (6,9%). Removal of the gastric tube with stoma formation was necessary in 8 cases (13.6%).

Conclusion

The incidence of mediastinal leaks after esophagectomy in the MUMELE study is high mainly in TMIE group. General and specific (leak) mortality rate is however low. Early ‘aggressive’ treatment of severe leaks is mandatory, with no hesitation to redo surgery if first attempt of conservative management fails.

Disclosure

All authors have declared no conflicts of interest.
PS01.168: IS IT POSSIBLE TO PREVENT GASTRIC TUBE NECROSIS FOLLOWING ESOPHAGECTOMY?
Authors: Nishikawa Katsunori , Tanaka Yujiro , Tanishima Yuichiro , Akimoto Shunsuke , Yano Fumiaki , Mitsumori Norio , Yanaga Katsuhiko
Published: September 2018

Background

Gastric tube necrosis (GN) following esophagectomy is a rare, but critical and life threatening complication. Unlike anastomotic leakage due to local ischemia, GN involves extensive full thickness ischemia resulting from vascular insufficiency. Most cases of GN need total or partial replacement of gastric tube. Although quantitative assessment of tissue perfusion during esophageal surgery contributed to reduce the incidence of postoperative anastomotic complications, GN remains a serious complication to be solved.

Methods

Data were collected retrospectively from 271 patients who underwent esophagectomy and gastric tube reconstruction at a single center between 2008 and 2018, in which cases of GN were identified. Gastric mobilization was mainly performed laparoscopically using a hand-assisted maneuver. The short gastric and left gastric arteries were divided, and the right gastric and gastroepiploic arteries were both preserved. The gastric tube 3.5 cm in width was created along the greater curvature. Intraoperative assessment of perfusion of the gastric tube was performed using our novel Thermal Imaging System (TIS) in all patients. Quantitative tissue perfusion scores defined as anastomotic viability index (AVI) were calculated at various points from the anastomosis.

Results

The inpatient mortality rate was 1.8% (n = 5). Anastomotic leak (AL) developed in 8.8% (n = 24) of the study group. The mean AVI score of cases with AL was 0.58, which was significantly lower than that without AL (0.71, P < 0.001). GN occurred in two patients (0.7%). The AVI score of the both GN cases were relatively high at 0.74 and 0.82. In one of the cases, circumferential full thickness ischemia 10 cm in length from the esophagogastric anastomosis was revealed by contrast CT scans and endoscopy, which was later identified to be due to severe vascular impairment.

Conclusion

TIS can be used as a reliable intraoperative assessment tool for perfusion of the gastric tube. We assume that most AL would be caused by delayed anastomotic healing due to poor vascularization of the gastric tube. On the other hand, obvious difference in AVI scores between AL and GN may indicate the involvement of different etiology. Given that development of GN seemed to be caused by acute failure in vascularization during the early postoperative period.

Disclosure

All authors have declared no conflicts of interest.
PS01.173: MANAGEMENT OF INTRATHORACIC AND CERVICAL ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A SYSTEMATIC REVIEW
Authors: Verstegen Moniek , Bouwense Stefan , Van Workum Frans , Ten Broek Richard , Siersema P D , Rovers Maroeska , Rosman Camiel
Published: September 2018

Background

Anastomotic leakage affects up to 30% of patients after esophagectomy each year and leads to considerable morbidity and mortality. The aim of this study was to determine which treatment for anastomotic leakage after esophagectomy has the best clinical outcome, based on currently available literature.

Methods

A systematic literature search was performed in Medline, Embase and Web of Science until April 2017. All studies reporting on the treatment of anastomotic leakage following esophagectomy with gastric tube reconstruction for esophageal or cardia cancer were included. The primary outcome parameter was postoperative mortality. Methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale.

Results

Nineteen retrospective cohort studies including 273 patients were identified. Methodological quality of all studies was poor to moderate. Regarding intrathoracic anastomotic leakages, mortality rates in the conservative, endoscopic stent, endoscopic drainage, endoscopic vacuum assisted closure system and surgery treatment group were 14%, 8%, 8%, 0%, and 50%, respectively. Regarding cervical anastomotic leakages, mortality rates in the conservative, endoscopic stent and endoscopic dilatation group were 8%, 29%, and 0%, respectively.

Conclusion

Due to small cohorts, heterogeneity between studies, and lack of data regarding leakage characteristics, no evidence supporting one treatment for anastomotic leakage after esophagectomy was found. A severity score based on leakage characteristics instead of treatment given is essential for determining the optimal treatment of anastomotic leakage. A prospective registration study could provide answers to issues as which leakage characteristics determine its severity and which treatment options have the best outcomes for a given anastomotic leakage severity.

Disclosure

All authors have declared no conflicts of interest.
PS01.183: ENDOSCOPIC TREATMENT OF ESOPHAGOGASTRIC ANASTOMOSIS FISTULA AFTER MINIMALLY INVASIVE ESOPHAGECTOMY: REPORT OF THREE CASES AND REVIEW OF THE LITERATURE
Authors: Antonio Guimaraes Filho Marco , Sabino Flávio , Camara Eduardo , Ferreira Andre , Mello Gustavo , Pelosi Alexandre , Guaraldi Simone
Published: September 2018

Background

Anastomotic leaks after esophagectomy can lead to severe complications and account for 40% of postoperative deaths. During the last decades, several types of endoscopic treatments have became available, such as the use of esophageal stent and the use of vacuum therapy. In this paper we report one case of cervical anastomotic fistulas after esophagectomy treated with vacuum therapy and two cases treated with stent.

Methods

Three cases of cervical anastomotic fistulas after esophagectomy treated with an endoscopic aproach (stent and vacuum therapy) are reported.

Results

Case 1

61-year-old male with an mid-esophagus adenocarcinoma was treated with neoadjuvant chemotherapy and minimally invasve esophagectomy. On the 10th post-operative day (POD) a partial dehiscence of the anastomosis with communication with the mediastinum was identified, forming a cavity with a large amount of purulent secretion. A sponge attached to a nelaton probe, similar to the VAC device, was positioned inside the mentioned cavity and coupled to a continuous aspiration system. There was a gradual clinical improvement and on the 30th POD the sponge was finally removed. The patient was discharged on the 50th POD. Case 2: A 62-year-old male with a adenocarcinoma in the thoracic esophagus received neoadjuvant chemoradiotherapy and a minimally invasive esophagectomy. On the 7th POD, an anastomotic fistula draining by the chest tube was diagnosed. A stent that was positioned over the fistula area. The patient was discharged on the 28th POD with the stent, that was removed six weeks later. Case 3: 58 years old male patient presented with a superficial squamous cell carcinoma of the mid-thoracic esophagus. A minimally invasive esophagectomy was performed.On the 7th POD, a EGD was performed and showed a fistulous orifice in the esophagogastric anastomosis. A metal stent that was positioned over the fistula area. The patient evolved with empyema and a pulmonary decortication was performed by on the 17th POD. After progressive clinical improvement he was discharged on the 34th POD.

Conclusion

Esophageal stent has been successful used in treating this surgical complication. Recently, VAC therapy, is becoming an promising therapy for this complication, with lower morbidity and mortality rates and greater success in the closure of the anastomotic fistula when compared to the esophageal stent.

Disclosure

All authors have declared no conflicts of interest.
PS01.186: QUANTITATIVE PERFUSION EVALUATION AFTER GASTRIC TUBE RECONSTRUCTION USING FLUORESCENCE IMAGING
Authors: Jansen Sanne , De Bruin Daniel , Strackee Simon , Van Bavel Ed , Van Leeuwen Ton , Van Berge Henegouwen Mark I , Gisbertz Suzanne
Published: September 2018

Background

Poor fundus perfusion is seen as the major factor for the development of anastomotic necrosis, leakage and strictures. Quantitative imaging of tissue perfusion during reconstructive surgery, therefore, may reduce the incidence of complications. Imaging the fluorescense of intravenously administered fluorophores is an optical, non-contact method to image blood flow in real-time. However, quantitative parameters for perfusion evaluation are stil lacking. The objective of this study is to test fluorescence imaging derived quantitative parameters for perfusion evaluation of the gastric tube during surgery and to correlate these parameters to patient outcome in terms of anastomotic leakage.

Methods

This study included 22 patients (October 2015 - June 2016). Indocyanine green (ICG) was injected intravenously and the fluorescense intensity of the gastric tube was imaged for 2–3 minutes. At 4 locations, quantitative analysis of the fluorescent intensity over time was performed to obtain perfusion related parameters: the maximal intensity, mean slope and influx timepoint. These parameters were tested for significant differences between the four perfusion areas of the gastric tube (from normal to decreased perfusion) with a repeated ANOVA test. Furthermore, these parameters and the distance of the end of the gastroepiploic artery to the fundus and distance of the demarcation of the fluorescent signal to the fundus were compared with patient outcome in terms of anastomotic leakage development.

Results

The fluorescent signal could be detected in all analyzed patients (n = 20). Maximal intensity, mean slope and influx timepoint were significantly different between the base of the gastric tube and the fundus (P < 0.0001). While the distance of the watershed and the demarcation of ICG to the fundus varied between patients, the distance of the demarcation of ICG to the fundus was significantly higher in the three patients who developed anastomotic leakage (P < 0.0001). No allergic reactions on ICG were witnessed.

Conclusion

Intra-operative fluorescence imaging is feasible to visualize perfusion quantitatively in gastric-tube surgery, using the parameters maximal intensity, mean slope and influx timepoint. A low slope and a large distance between the fluorescence demarcation and the fundus were seen in patients who developed anastomotic leakage and could therefore allow for early risk stratification of necrosis.

Disclosure

All authors have declared no conflicts of interest.
PS01.188: NOVEL ESOPHAGEAL RECONSTRUCTION VIA TRANS-MEDIASTINAL ROUTE FROM POSTERIOR TO ANTERIOR MEDIASTINUM AFTER ESOPHAGECTOMY FOR GASTRECTOMIZED PATIENTS WITH HIGH RISKS
Authors: Yasuda Takushi , Shiraishi Osamu , Iwama Mitsuru , Kato Hiroaki , Hiraki Yoko , Yasuda Atsushi , Shinkai Masayuki , Kimura Yutaka , Imano Motohiro
Published: September 2018

Background

Elderly patients or those who have undergone surgery for head and neck cancer (HNC) have a potential risk of dysphagia, in addition, the latter has a considerable difficulty for surgery for the neck. Intrathoracic anastomosis is preferable to preserve swallowing function and reduce surgical risk, because the cervical procedure can be avoided. However, the stomach cannot be used as a substitute in gastrectomized patients; thus, securing graft blood supply is critical. Nevertheless, microvascular anastomosis cannot easily be added in procedures for intrathoracic posterior mediastinal reconstruction. We therefore designed a novel technique for esophageal reconstruction to enable both intrathoracic anastomosis and microvascular anastomosis simultaneously even in gastrectomized patients. The purpose of this study was to evaluate the usefulness and safety of this technique.

Methods

Esophagectomy with mediastinal lymphadenectomy is performed through a right thoracotomy in the left decubitus position, and temporary chest closure is done after the esophagus is divided at the upper mediastinum with safe margin. Next, the patient is placed in the left half side-lying position, and the jejunal or ileocolic graft for reconstruction is created after removal of the remnant stomach in the supine position. Then, after the patient's position is changed to the left decubitus one and rethoracotomy is performed, the graft is pulled up through the anterior mediastinum, and is then passed into the right thoracic cavity via a small hole made in the anterior mediastinal pleura. The graft is then finally anastomosed with the remnant esophagus in the upper posterior mediastinum. Thereafter, microvascular anastomosis is performed in the retrosternal space through the skin incision in the supine position. Finally, the continuity of alimentary tract is completed.

Results

This new reconstruction procedure was performed for 4 patients with no significant postoperative complications, good swallowing function postoperatively, and no retention of food in the graft. There was no in-hospital death.

Conclusion

This novel trans-mediastinal reconstruction technique is a possible option in terms of enabling intrathoracic anastomosis and addition of microvascular anastomosis for highly selected gastrectomized patients with advanced age or a past history of HNC surgery.

Disclosure

All authors have declared no conflicts of interest.
PS01.189: A STUDY ON THE UTILITY OF INTRAOPERATIVE NEUROSTIMULATION MONITORING SYSTEM FOR RECURRENT LARYNGEAL NERVE IN ESOPHAGECTOMY
Authors: Kawano Fumiaki , Takeno Shinsuke , Tashiro Kousei , Hamada Rouko , Miyazaki Yasuyuki , Munakata Syun , Hamada Takeomi , Wada Takashi , Nakamura Kunihide , Nanashima Atsushi
Published: September 2018

Background

Recurrent laryngeal nerve paralysis in esophagectomy is one of the most concerned complications. In recent years, intraoperative neurostimulation monitoring system (IONM) in thyroid surgery have been widespread for identification of recurrent laryngeal nerve and assessment of soundness. Therefore, IONM is often used during esophagectomy in Japan. In this study, we examined the efficacy of IONM in the patients undergoing esophagectomy.

Methods

Of 66 patients underwent esophagectomy since April 2015 until December 2017, IONM used in 27 patients in the surgery for the examination of recurrent nerve paralysis. We retrospectively reviewed these cases for intraoperative findings, neurostimulation monitoring findings and their outcomes.

Results

Of 27 patients, 25 were male and two were female, and the median age at operation was 66 years old. Although IONM was used in cervical lymph node dissection, there were no vocal cord responses in 5 patients (left side in 4 and right side in 1) with stimulation of the vagus nerve. Because all patients had no vocal cord paralysis due to stimulation of the cervical recurrent laryngeal nerve, it was diagnosed that there was the recurrent laryngeal nerve injury due to thoracic para recurrent nerve lymph node dissection. IONM was able to facilitate the identification and preservation of cervical recurrent nerve in all patients. Three out of 5 patients with no vocal cord response by IONM were confirmed recurrent laryngeal nerve paralysis in postoperative endoscope. In patients with vocal cord paralysis by IONM, it was possible to carefully performed postoperative management. On the other hand, in patients without paralysis, extubation on the operation day seemed possible without the concern for aspiration.

Conclusion

By using IONM in esophagectomy, we were able to evaluate the damage of the recurrent laryngeal nerve in real-time. Confirming the intraoperative recurrent nerve injuries is important for postoperative management or prediction of postoperative aspiration pneumonia. IONM in esophagectomy was useful not only in terms of surgical procedures but also in the evaluation of postoperative management.

Disclosure

All authors have declared no conflicts of interest.
PS01.190: FLEXIBLE GASTRIC TUBE: A NOBLE METHOD OF GASTRIC TUBE RECONSTRUCTION WITHOUT ANASTOMOTIC LEAKAGE
Authors: Nakajima Yasuaki , Kawada Kenro , Tokairin Yutaka , Hoshino Akihiro , Okada Takuya , Ryotokuji Tairo , Okuda Masafumi , Kume Yuichiro , Kawamura Yudai , Yamaguchi Kazuya , Kojima Kazuyuki , Kinugasa Yusuke
Published: September 2018

Background

Anastomotic leakage is one of the most frequent and severe morbidities after esophagectomy. For preventing anastomotic leakage, it is important to design a gastric tube with sufficient blood supply and to perform precise anastomosis at a well-conditioned site. We herein show our method of gastric tube reconstruction and evaluate the outcome.

Methods

Seven hundred and forty-six esophageal carcinoma patients who received subtotal esophagectomy with gastric tube reconstruction via the retrosternal route between 1994 and 2017 were enrolled in the present study. Although we previously used a greater curvature gastric tube with a 4 cm in diameter (narrow group), since 2000, a ‘flexible gastric tube,’ which was designed on an individual basis with the aim of preserving the vascular plexus in the center of the anterior and posterior stomach wall to the maximum possible extent in order to supply a sufficient amount of blood to the tip of the gastric tube was used (flexible group). Cervical esophagogastric end-to-side anastomosis using the circular stapler was performed during the whole period. The clinical outcomes were compared between the two groups.

Results

Anastomotic leakage was observed in 36 (4.8%) patients. While 24 of 155 (15.5%) patients showed anastomotic leakage in the narrow group, 12 of 591 (2.0%) patients showed anastomotic leakage in the flexible group and the clinical outcomes were significantly improved.

Conclusion

Our method of gastric tube reconstruction helped to improve the rate of anastomotic leakage after esophagectomy. At present, we are investigating the status of the blood flow using an ICG fluorescence method and by measuring the degree of oxygen saturation and hemoglobin using a new non-invasive monitoring tool during the operation. Postoperative assessments of the anastomotic site are performed using endoscopic examinations. We herein report the results of these assessments.

Disclosure

All authors have declared no conflicts of interest.