bluuebunny/crossref_metadata_2025 huggingface dataset:
623 MINIMALLY INVASIVE VERSUS OPEN MCKEOWN FOR PATIENTS WITH ESOPHAGEAL CANCER: A RETROSPECTIVE STUDY
Authors: Zheng Yan , Xing Wenqun , Liu Xianben , Sun Haibo
Published: September 2021

McKeown Minimally invasive esophagectomy(McKeown-MIE) offers advantages in short-term outcomes compared with McKeown open esophagectomy(McKeown-OE). However, debate as to whether MIE is equivalent or better than OE regarding survival outcomes is ongoing. The aim of this study was to compare long-term survival between McKeown-MIE and McKeown-OE in a large cohort of esophageal cancer(EC) patients.

Methods

We used a prospective database of the Thoracic Surgery Department at our Cancer Hospital and included patients who underwent McKeown-MIE and McKeown-OE for EC during January 1, 2015, to January 6, 2018. The perioperative data and overall survival(OS) rate in the two groups were retrospectively compared.

Results

We included 502 patients who underwent McKeown-MIE (n = 306) or McKeown-OE (n = 196) for EC. The median age was 63 years. All baseline characteristics were well-balanced between two groups. There was a significantly shorter mean operative time (269.76 min vs. 321.14 min, P < 0.001) in OE group. The 30-day and in hospital mortality were 0 and no difference for 90-day mortality (P = 0.116). The postoperative stay was shorter in MIE group, 14 days and 18 days in the MIE and OE groups(P < 0.001). The OS at 32 months was 76.82% and 64.31% in the MIE and OE groups (P = 0.001); hazard ratio(HR) (95% CI): 2.333 (1.384–3.913).

Conclusion

These results showed the McKeown-MIE group was associated with a better long-term survival, compared with open-MIE for patients with resectable EC.
624 A PHASE III STUDY ON NEOADJUVANT TORIPALIMAB PLUS CHEMOTHERAPY VERSUS NEOADJUVANT CHEMOTHERAPY FOR LOCALLY RESECTABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Zheng Yan , Zhang Jiangong , Xing Wenqun
Published: September 2021

In recent years, immune checkpoint inhibitors (ICIs) have shown promising results in the treatment of ESCC. More than 20 phase II clinical trials have been launched to explore combinations of ICIs in the neoadjuvant setting for ESCC. Based on our phase II clinical trial, a two-arm phase III trial was launched in our Hospital.

Methods

A two-arm phase III trial was launched in April 2020 in our Hospital. Patient recruitment will be completed within 18 months. The primary endpoint is event-free survival (EFS). The secondary endpoints include pathologic complete response (pCR), disease-free survival (DFS) rate, overall response rate (ORR), R0 resection rate, major pathologic response (MPR), adverse events (AEs), complication rate and quality of life (QOL). A biobank of pretreatment, resected tumor tissue and paired blood samples will be built for translational research in the future.

Results

Until Dec. 2021, one hundred and twenty ESCC patients recruited in the trial. The trial is ongoing.

Conclusion

This RCT directly compares NAC with neoadjuvant toripalimab plus chemotherapy in terms of EFS for locally advanced ESCC. The results may usher in a new era of resectable ESCC treatment.
625 EFFICACY OF MYOTOMY IN PATIENTS WITH SIGMOID MEGAESOPHAGUS: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Orlandini Marina , Serafim Maria Carolina , Datrino Letícia , Santos Clara , Tristão Luca , Tavares Guilherme , Tustumi Francisco , Bernardo Wanderley
Published: September 2021

Megaesophagus progress to sigmoid megaesophagus (SM) in 10–15% of patients, presenting tortuosity and sigmoid colon aspect. Esophagectomy is the choice treatment but is associated with high complications and mortality rates. To avoid the esophagectomy inherent morbidity, several authors recommend Heller myotomy (HM) with pull-down technique for SM, mainly for patients with comorbidities and the elderly. This systematic review and meta-analysis is the first to analyze the effectiveness of HM for treating SM.

Methods

A systematic review was conducted in PubMed, Embase, Cochrane Library Central, Lilacs (BVS), and manual search of references. Inclusion criteria were: a) clinical trials, cohort studies, case series; b) patients with SM and esophageal diameter ≥ 6 cm; and c) patients undergoing primary myotomy. The exclusion criteria were: a) reviews, case reports, cross-sectional studies, editorials, letters, congress abstracts, full-text unavailability; b) animal studies, c) previous surgical treatment for achalasia; and d) pediatric studies. There were no restrictions on language or date of publication, and no filters were applied for the selection process. Random model and a 95% confidence interval (CI) were used.

Results

Sixteen articles were selected, encompassing 231 patients. The mean age ranged from 36 to 61 years old, and the mean follow-up ranged from 16 to 109 months. The analyzed outcomes include mortality, complications (pneumonia, pneumothorax, gastroesophageal reflux), need for reintervention (remyotomy, dilation and esophagectomy), and results classified as ‘good’ and ‘excellent’. Mortality rate was 0.035 (CI: 0.017–0.07; p < 0.01). Complications rate was 0.08 (CI: 0.04–0.153; p = 0.01). Need for retreatment rate was 0.161 (CI: 0.053–0.399; p < 0.01). Probability of good or excellent outcomes after myotomy was 0.762 (CI: 0.693–0.819; p < 0,01).

Conclusion

Heller myotomy is an option for avoiding esophagectomy in achalasia, with a low morbimortality rate and good results. It is effective for most patients but will fail in a minority of patients and demand retreatment, be it a remyotomy, endoscopic treatment or esophagectomy.
633 CONVERSION TO TOUPET FUNDOPLICATION WITH DISTAL GASTRECTOMY AND ROUX-EN-Y GASTROJEJUNOSTOMY AFTER FAILED NISSEN FUNDOPLICATION
Authors: Braghetto Italo , Korn Owen , Figueroa Manuel , Mandiola Carlos , Burgos Ana Maria , Valenzuela Camila , Sotomayor Camila , Villa Eduardo
Published: September 2021

Laparoscopic Nissen Fundoplication fails in almost 15% of patients and most of them must be re-operated in order to improve reflux symptoms, esophagitis, or hiatal hernia. Surgical options are to redo LNF, distal gastrectomy alone or combination of both procedures. Redoing LNF, is associated with high rate of postoperative complications and re-failure.

Purpose

To present the early and medium-term postoperative outcomes of patients submitted to Laparoscopic Toupet Fundoplication combined with Distal Gastrectomy with Roux-en-Y gastrojejunostomy.

Methods

prospective study including 23 patients submitted to Laparoscopic Nissen Fundoplication who presented recurrence of gastroesophageal reflux after the operation. They were studied with endoscopy, barium swallow, manometry and 24 h pH monitoring in order to determine presence of esophagitis, anatomical deformities, defective Lower Esophageal Sphincter and pathologic acid reflux. Surgical process consisted on re-establishing the anatomy of the esophago-gastric junction, and then perform laparoscopic Toupet fundoplication combined with distal gastrecvtomy and Roux Y gastrojejunostomy.

Results

After surgery statistically significant improvement regarding heartburn (p < 0.0001), dysphagia (p < 0.0001) and retrosternal chest pain (p < 0.0001) as well as in the endoscopic esophagitis was observed. No significant LES pressure increase after the operation was observed. (from 7.88 + 2.7 to 10.5 + 3.36) (p = 0.15), but the abnormal acid reflux improved significantly after the reoperation, %time pH < 4 decreases from 12.00 + 6.62 to 4.3 + 4.04 (0.0004) and DeMeester score from 44.82 + 21.8 to 11.95 + 5.14 (0.0008) respectively.

Conclusion

The proposed procedure is safe option to treat successfully patients after failed Nissen fundoplication. Reflux symptoms, esophagitis, presence oh hiatal hernia and reflux score improved after the procedure.
636 SHORT-TERM OUTCOME FOR HIGH-RISK PATIENTS AFTER ESOPHAGECTOMY
Authors: Plat Victor , Stam Wessel , Bootsma Boukje , Straatman Jennifer , Klausch Thomas , Heineman David , Peet Donald , Daams Freek
Published: September 2021

Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection, however it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity.

Methods

This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions.

Results

Of 5438 patients, 945 and 431 high-risk patients underwent TTE and THE respectively. After propensity score matching, mortality (6.3% vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0% vs 2.2%, P = 0.020).

Conclusion

Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.
641 CLINICAL SYMPTOM PATTERNS IN PATIENTS WITH REFLUX ASPIRATION
Authors: Khoma Oleksandr , Park Jinsoo , Lee Felix , Van der Wall Hans , Falk Gregory L
Published: September 2021

Multiple papers have discussed pulmonary manifestation of gastro-oesophageal reflux disease (GORD), however little primary reported data exists on presenting symptoms of patients in whom reflux aspiration is confirmed. The aim of this study is to report symptoms and presenting patterns of a large group of patients with confirmed reflux aspiration.

Methods

Data was extracted from a prospectively populated database of patients referred to a tertiary specialist centre with severe, refractory, or atypical reflux. Patients with reflux aspiration on scintigraphy were included in this study. Separate group included patients with evidence of proximal reflux to the level of pharynx when supine and/or upright.

Results

Inclusion criteria were met by 243 patients (33% males; mean age 59). Most common symptoms amongst patients with aspiration were regurgitation (72%), cough (67%), heartburn (66%), throat clearing (65%), and dysphonia (53%). The most common two-symptom combinations were heartburn/regurgitation, cough/throat clearing, regurgitation/throat clearing, cough/regurgitation and dysphonia/throat clearing. The most common three-symptom combinations were cough/heartburn/regurgitation, cough/regurgitation/throat clearing and dysphonia/regurgitation/throat clearing. Clusters analysis demonstrated two main symptom clusters one suggestive of proximal large volume reflux symptoms (regurgitation, heartburn) and the other with IBS type symptoms (bloat, dysphagia, constipation).

Conclusion

Combination of typical symptoms of GORD and a respiratory or upper aero-digestive complaint should prompt consideration of reflux aspiration. Cluster analysis of symptoms in this group supports previously postulated hypothesis of reflux aspiration pathogenesis by either large volume proximal reflux or by ineffective oesophageal motility.
646 PREDICTING RESPONSE TO NEOADJUVANT CHEMOTHERAPY IN PATIENTS WITH OESOPHAGEAL ADENOCARCINOMA
Authors: Bott Rebecca , George Gincy , McEwen Ricardo , Zylstra Janine , Knight William , Baker Cara , Kelly Mark , Griffin Nyree , Mcaddy Naami , Maisey Nick , Van Hemelrijck Mieke , Gossage James , Lagergren Jesper , Davies Andrew
Published: September 2021

Neoadjuvant chemotherapy is often used prior to surgical resection for oesophageal adenocarcinoma but remains ineffective in a high proportion of patients. The histological Mandard tumour regression grade is used to determine chemoresponse but is not available at the time of treatment decision-making. The aim of this study was to identify factors that predict chemotherapy response prior to surgery.

Methods

A prospectively collected database of patients undergoing surgical resection for oesophageal adenocarcinoma from a high-volume UK institution was used. Patients were subcategorised using pathological tumour response into ‘responders’ (Mandard grade 1–3) and ‘non-responders’ (Mandard grade 4&5). Multivariable logistic regression analysis was performed to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for responder status adjusting for a variety of parameters. Receiver-operator curves (ROC) were calculated.

Results

Among 315 patients included, 102 (32%) were responders and 213 (68%) non-responders. A decrease in radiological tumour volume (OR 1.92 95%CI 1.02–3.62; p = 0.05), a ‘partial response’ RECIST score (OR 7.16 95%CI 1.49–34.36; p = 0.01), a clinically improved dysphagia score (OR 2.79 95%CI 1.05–7.04; p = 0.04) and lymphovascular invasion (OR 0.06 95%CI 0.02–0.13; p = 0.000) influenced responder status. ROC curve analysis for responder status utilising all available parameters had an area under the curve (AUC) of 0.86.

Conclusion

This study has highlighted the potential for using pre-defined factors to identify those patients who have responded to neoadjuvant chemotherapy, prior to surgical resection, potentially facilitating a more individualised therapeutic approach.
649 EFFECTS OF THE PREPARATION METHOD ON THE ICG FLUORESCENCE BLOOD FLOW IN THE GASTRIC CONDUIT AFTER ESOPHAGECTOMY
Authors: Koyanagi Kazuo , Ozawa Soji , Ninomiya Yamato , Yatabe Kentaro , Higuchi Tadashi , Yamamoto Miho , Tajima Kohei
Published: September 2021

In this study, we investigated how the blood flow of gastric conduit changed due to the difference in the lesser curvature cut line using ICG fluorescence imaging in patients with esophageal cancer.

Methods

A total of 193 cases of esophageal cancer surgery with gastric conduit reconstruction were included. (Conventional method) The lesser curvature cut line of the stomach was started from a distance of 5 cm from the pylorus (141 cases). (Current method) Gastric lesser curvature dissection was started from the last branch of the left gastric artery (52 cases). Blood flow of the gastric conduit was measured by the ICG fluorescence imaging, and the correlation between the changes in the gastric conduit and both blood flow and anastomotic failure was examined.

Results

Median length of the lesser curvature cut line was 10 cm from the pylorus in the current method, which was significantly longer than that in the conventional method (P < 0.001). Congestion at the tip of the gastric conduit were more observed in the conventional method (P = 0.02). The ICG fluorescent blood flow speed in the gastric conduit wall was 2.54 cm/s by the conventional method and 2.82 cm/s by the current method (P = 0.03). There were 23 cases (16.3%) of anastomotic leakage in the conventional method and 4 cases (7.7%) in the current method (P = 0.09).

Conclusion

By preserving the right gastric artery and vein, improvement of venous return is expected, and it is suggested that blood flow in the gastric conduit wall can be well maintained.
653 LAPAROSCOPIC TOUPET FUNDOPLICATION RARELY INFLUENCES THE DECLINE IN FEV1 SEEN AFTER LUNG TRANSPLANT
Authors: Frankel Adam , Keller Trina , Zahir Syeda Farah , Gotley David
Published: September 2021

Lung allografts have the shortest survival of any solid organ transplant. The leading cause of chronic lung allograft dysfunction (CLAD) is bronchiolitis obliterans syndrome (BOS). The aetiology of BOS remains poorly understood, with infections, immunosuppression and gastro-oesophageal reflux disease (GORD) amongst the proposed co-factors. A recent systematic review of GORD and BOS examined six retrospective case series with relatively small numbers and conflicting results. Our dataset is the largest cohort reported to date.

Methods

Retrospective review of a prospectively maintained database containing 149 consecutive lung transplant recipients undergoing laparoscopic Toupet fundoplication. A single expert surgeon (>5000 procedures) with published high-quality long-term outcomes in the non-transplant population did the operations. All were referred with symptoms of GORD and/or positive 24-hour ambulatory pH study. FEV1 was measured at three time points before (6, 3 and 1 month) and after (3, 6 and 12 months) surgery. Data were analysed using random intercept generalised linear (mixed) models to examine changes in FEV1 across time, as well as graphical methods (least squares method for FEV1 trendlines and two-tailed t-test).

Results

Median age was 56 (IQR 44–66) years; 84/149 were male. 132 had bilateral sequential single lung transplantation. The underlying pathologies were representative—emphysema, cystic fibrosis, interstitial lung disease. 8 patients died within 6 months of fundoplication. Using a linear mixed model there was no significant change in FEV1 across time after surgery compared with the last pre-operative measurement (p = 0.48). A significant reduction in FEV1 was seen in those undergoing fundoplication after CLAD was diagnosed (1.47 L, 95% CI 1.21–1.72, p < 0.001). There was no change in trajectory of FEV1 when trendlines for each patient were analysed (p = 0.777).

Conclusion

As with any solid organ transplant, lung allografts unfortunately suffer failure with time. Laparoscopic Toupet fundoplication performed in a high-volume centre by an experienced surgeon did not appear to alter this. In particular, once CLAD is diagnosed it seems that the decline in function (FEV1) is accelerated and cannot be salvaged by fundoplication. A minority of patients had their declining FEV1 stabilised or improved by surgery, but it is not yet possible to predict response.
657 ROUTINE ESOPHAGRAMS FOLLOWING HIATUS HERNIA REPAIR MINIMISES REOPERATIVE MORBIDITY: A MULTICENTER COMPARATIVE COHORT STUDY
Authors: Liu David , Wee Melissa , Grantham James , Ong Bee , Ng Stephanie , To Minh-Son , Zhou Xuanyu , Irvine Tanya , Bright Tim , Thompson Sarah , Dandie Lachlan , Shenfine Jonathan , Watson David
Published: September 2021

Hiatus hernia repairs are common. Early complications such as re-herniation, esophageal obstruction and perforation, although infrequent, incur significant morbidity. Here, we determine whether routine postoperative esophagrams following hiatus hernia repair may expedite the surgical management of these complications, reduce reoperative morbidity, and improve functional outcomes.

Methods

Analysis of a prospectively-maintained database of 1829 hiatus hernia repairs undertaken in 14 hospitals from 1 January 2000 to 30 September 2020. 1571 (85.9%) patients underwent a postoperative esophagram which was reviewed. An early (<14 days) reoperation was performed in 44 (2.4%) patients.

Results

Compared to those without an esophagram, patients who received one prior to reoperation (n = 37) had a shorter time to diagnosis (2.4 vs. 3.9 days, p = 0.041) and treatment (2.4 vs. 4.3 days, p = 0.037) of their complications. This was associated with decreased open surgery (10.8% vs. 42.9%, p = 0.034), gastric resection (0.0% vs. 28.6%, p = 0.022), postoperative morbidity (13.5% vs. 85.7%, p < 0.001), ICU admission (16.2% vs. 85.7%, p < 0.001), and length-of-stay (7.3 vs. 18.3 days, p = 0.009). Furthermore, patients who underwent early reoperations for asymptomatic re-herniation had less complications and superior functional outcomes at one-year follow-up than those who needed surgery for symptomatic recurrences later on.

Conclusion

Postoperative esophagrams decreases the morbidity associated with early and late reoperations following hiatus hernia repair, and should be considered for routine use.
66 SHORT-TERM RESULTS OF RADICAL SURGERY FOR ESOPHAGEAL CANCER WITHOUT THORACOTOMY
Authors: Rino Yasushi , Yukawa Norio , Aoyama Toru , Yosuke Atsumi , Hara Kentaro , Tamagawa Hiroshi , Numata Masakatsu , Kazama Keisuke , Onodera Atsushi , Sato Tsutomu , Ogata Takashi , Yamada Takanobu , Oshima Takashi , Masuda Munetaka
Published: September 2021

In recent years, surgery without thoracotomy for esophageal cancer has been reported by performing mediastinoscope and laparoscope-assisted esophagectomy. It is reported that this procedure reduces pulmonary complications.

Methods

Since June 2018, we introduced this surgical operation for esophageal cancer patients using mediastinoscope without thoracotomy. The patient was placed in a supine position and tilts head slightly to the right with bilateral lung ventilation. The upper mediastinal dissection, using a left cervical approach, was performed with a single-port mediastinoscopic technique using LigaSure™ Maryland. But the lymph nodes along the right recurrent laryngeal nerve (RLN) were dissected under direct vision using a right cervical approach. And then, the operation and the course after the operation were examined.

Results

We experienced 14 cases of surgery by February 2020 and have experienced only one pulmonary complication in the course of the surgery. This case had a left recurrent nerve palsy as a complication after surgery. For this reason, aspiration was combined, but it improved immediately. There were 2 patients that lung cancer and COLD (Chronic Obstructive Pulmonary Disease), but pneumonia did not occur. Suture failure was very high frequent. However, this complication decreased over time.

Conclusion

We reported that pneumonia after esophageal cancer surgery deteriorates the prognosis. Suppression of pneumonia by this operation formula can be expected to improve the prognosis.
665 PROPHYLACTIC THORACIC DUCT OBSTRUCTION DURING ESOPHAGECTOMY: THE IMPACT ON PERIOPERATIVE RISKS AND LONG-TERM SURVIVAL. A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Santos Clara , Santos Laura , Datrino Leticia , Tavares Guilherme , Tristão Luca , Orlandini Marina , Serafim Maria Carolina , Tustumi Francisco , Bernardo Wanderley
Published: September 2021

During esophagectomy for cancer, there is no consensus if prophylactic thoracic duct ligation (TDL), with or without thoracic duct resection (TDR), could influence the perioperative outcomes and long-term survival. This systematic review and meta-analysis compared patients who went through esophagectomy associated or not to ligation or resection of the thoracic duct.

Methods

A systematic review was conducted in PubMed, Embase, Cochrane Library Central and Lilacs (BVS). The inclusion criteria were: (1) studies that compare thoracic duct ligation, with or without resection, and non-thoracic duct ligation; (2) involve adult patients with esophageal cancer; (3) articles that analyses the outcomes—perioperative complications, perioperative mortality, chylothorax development and overall survival; (4) only clinical trials and cohort were accepted. A 95% confidence interval (CI) was used, and random-effects model was performed.

Results

Fifteen articles were selected, comprising 6,249 patients. TDL did not reduce the risk for chylothorax (Risk difference [RD]: -0.01; 95%CI: −0.02, 0.00). Also, TDL did not influence the risk for complications (RD: -0.02; 95%CI: −0.11, 0.07); mortality (RD: 0.00; 95%CI: −0.00, 0.00); and reoperation rate (RD: -0.01; 95%CI: −0.02, 0.00). TDR was associated with higher risk for postoperative complications (RD: 0.1; 95%CI 0.00, 0.19); chylothorax (RD: 0.02; 95%CI 0.00, 0.03). Both TDL and TDR did not influence the overall survival rate (TDL: HR: 1.17; 95%CI: 0.86, 1.48; and TDR: HR: 1.16; 95%CI: 0.8, 1.51).

Conclusion

Thoracic duct obliteration with or without its resection during esophagectomy does not change long term survival. Nonetheless, TDR increased the risk for postoperative complications and chylothorax.
674 TRANSITION FROM ESOPHAGECTOMY TO ENDOSCOPIC THERAPY FOR EARLY ESOPHAGEAL CANCER
Authors: Reyhani Arasteh , Dunn Jason M , Santaolalla Aida , Zylstra Janine , Gimson Eliza , Pennington Mark , Baker Cara R , Kelly Mark , Van Hemelrijck Mieke , Lagergren Jesper , Zeki Sebastian S , Gossage James A , Davies Andrew R
Published: September 2021

To assess the outcomes of patients with early esophageal cancer (EEC) and high-grade dysplasia (HGD) comparing esophagectomy, the historical treatment of choice, to endoscopic eradication therapy (EET).

Methods

Retrospective cohort study of consecutive patients with EEC/HGD, treated between 2000 and 2018 at a tertiary referral centre. Primary outcomes were all-cause and disease-specific mortality assessed by multivariable Cox regression and a propensity score matching sub analysis, providing hazard ratios (HR) with 95% confidence intervals (CIs), adjusted for age, tumor grade (G1/2 vs G3), tumor stage and lymphovascular invasion(LVI). Secondary outcomes included complications, hospital stay, and overall costs.

Results

Among 269 patients, 133 underwent esophagectomy and 136 received endoscopic mucosal resection (EMR)+/−further EET. Adjusted survival analysis showed no difference between groups regarding all-cause mortality (HR 1.85,95%CI 0.73,4.72) and disease-specific mortality (HR 1.10,95%CI 0.26,4.65). In-hospital and 30-day mortality was 0% in both groups. The surgical group had a significantly higher rate of complications (Clavien-Dindo ≥3 26.3% vs EMR 0.74%), longer in-patient stay (median 14 vs 0 days EMR) and higher hospital costs ($20.426 vs $10.988 per patient).

Conclusion

This series of patients with EEC/HGD treated during a transition period from surgery to EET, demonstrates a primary endoscopic approach does not compromise oncological outcomes with the benefit of fewer complications, shorter hospital stays, and lower costs compared to surgery. EET should be available as the gold standard treatment for patients with early esophageal cancer. Those with adverse prognostic features may still benefit from esophagectomy.
679 TREATMENT OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY (TENTACLE—ESOPHAGUS) STUDY: EFFICACY OF DIFFERENT INITIAL TREATMENT STRATEGIES FOR ANASTOMOTIC LEAKAGE
Authors: Ubels Sander , Verstegen Moniek , Bouwense Stefan , Hannink Gerjon , Siersema Peter , Klarenbeek Bastiaan , Van Workum Frans , Rosman Camiel
Published: September 2021

Anastomotic leakage (AL) is a common and severe complication after esophagectomy. It is largely unknown which primary treatments are most effective for which type of leak. We aimed to investigate the effectiveness of different primary treatments of AL.

Methods

International retrospective cohort study, in which patients with AL after esophagectomy with gastric tube reconstruction were included in the period 2011-2019. Detailed data regarding case mix, resection, leakage characteristics (e.g. organ failure, leak circumference, contamination, drains present) and leakage treatment (e.g. hours from diagnosis to treatment, primary and secondary treatment modalities) were collected. Primary outcome was 90-day mortality and secondary outcomes included length of stay and leak healing time. Different clinically relevant leakage groups have been defined. Efficacy of different treatment strategies adjusted for leakage severity will be analyzed in these clinical groups. The study protocol is accessible at www.tentaclestudy.com.

Results

Detailed data of 1451 patients with AL was collected from 71 centers in 20 countries. Data accuracy was 96.5%. Preliminary results showed that the overall 90-day mortality was 11.6%. The analysis of TENTACLE—Esophagus data is currently being performed and efficacy of different leakage treatment strategies is being assessed. The efficacy of initial leakage treatment strategies will be ready to be presented at the ISDE meeting.

Conclusion

This is the largest study on effectiveness of AL treatments. The final results of initial leak treatments, which will be available for presentation at the ISDE meeting, could provide an evidence-based basis that can be used by clinicians to determine the preferred primary treatment strategy in patients with a given type of anastomotic leakage.
689 MMS22L EXPRESSION AS A PREDICTIVE BIOMARKER FOR THE EFFICACY OF NEOADJUVANT CHEMORADIOTHERAPY IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Leng Xue-feng , He Wenwu , Mao Tianqin , Han Yongtao
Published: September 2021

Long-term survival in esophageal squamous cell carcinoma (ESCC) is related with pathological response after neoadjuvant chemoradiation therapy (NCRT) followed by surgery. However, effective biomarkers for prediction of pathologic response is still lacking. Therefore, a systematic analysis focusing on genes associated with efficacy of chemoradiotherapy in ESCC will provide valuable insights to understand the molecular features.

Methods

We collected genes associated with efficacy of chemoradiotherapy by screening publications deposited in PubMed. A specific subnetwork was constructed using Steiner minimum tree algorithm. Then the correlations between gene expression and prognosis of ESCC patients was analyzed using Kaplan–Meier Plotter online resources. The key gene expression was evaluated by quantitative real-time polymerase chain reaction, western blotting analysis and immunohistochemical staining. The predictive performance of biomarkers was estimated using receiver operating characteristic (ROC) curve analysis.

Results

We identified 101 genes associated with efficacy of chemoradiotherapy. Moreover, specific molecular network included some potential related genes, such as CUL3, MUC13, MMS22L, MME, UBC, VAPA, CYP1B1 and UGDH. MMS22L mRNA expression level had most significant association with the ESCC patient outcome (P < 0.01). Furthermore, MMS22L was downregulated at both the mRNA (P < 0.01) and protein levels in tumor compared with normal tissues. Lymph node metastasis was significantly associated with low MMS22L expression (P < 0.001). MMS22L levels were inversely correlated with NCRT response in ESCC (P < 0.01). MMS22L yielded an area under the ROC curve (AUC) of 0.847 (P < 0.01).

Conclusion

Low MMS22L expression could be an effective predictive biomarker for resistance to NCRT in ESCC.
690 MINIMALLY INVASIVE APPROACH FOR ESOPHAGEAL LEIOMYOMA
Authors: Hernandez Norberto Daniel Velasco , Horiuchi Héctor Rául , Abal Lucas , Sabatini Matías , Redondo Agustina , De Battista Santiago Bartolomé
Published: September 2021

Esophageal leiomyoma is the most common benign tumor of the esophagus. Although enucleation via thoracotomy has been considered standard treatment, minimally invasive surgery is increasingly used for the treatment of this disease. The authors report the clinical outcomes of three procedures for enucleation.

Methods

From November 2011 to December 2020, 3 females (52, 58, and 67 years old) patients were treated for leiomyoma of the middle third of the esophagus. A history of dysphagia and chest pain was present. Upper gastrointestinal endoscopic, computerized tomography, and endoscopic ultrasound were performed, in only one case barium swallow was used.

Results

The surgical approaches included right thoracoscopy in prone position, enucleation, and small thoracotomy for removing the specimen. There were no major morbidities, including deaths. One patient presented a leak, which was resolved with an endoscopic stent.

Conclusion

Minimally invasive enucleation of esophageal leiomyoma can be performed effectively and safely. Right thoracoscopic in prone position for the removal of esophageal leiomyomas may be recommended as the treatment of choice in centers experienced with esophageal surgery.
691 IS OPEN LEFT THORACO-ABDOMINAL ESOPHAGECTOMY A VIABLE OPTION IN THE ERA OF MINIMALLY INVASIVE ESOPHAGECTOMY?
Authors: Klevebro Fredrik , Han Shiwei , Ash Stephen , Mueller C , Cools-Lartigue Jonathan , Maynard Nick , Ferri Lorenzo , Low Donald
Published: September 2021

Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky tumors, but there are concerns that this approach is associated with significant morbidity. The aim of the current study was to evaluate short-term and oncological outcomes of left thoracoabdominal esophagectomy compared to minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction.

Methods

Prospectively entered esophagectomy databases from three high volume centers were reviewed for patients undergoing LTE or MIE 2012–2018. Patient demographics, tumour characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared. In total 844 patients were included in the study, LTE was applied in 654 (77.5%) patients, and MIE in 190 (22.5%) patients.

Results

LTE patients had more neoadjuvant treatment (LTE = 74.5%, MIE = 64.9%, P = 0.027). There was no difference in overall postoperative complications (LTE = 61.9%, MIE = 64.6%, P = 0.517), severe complications (Clavien Dindo >IIIa (LTE = 26.6%, MIE 26.5%, P = 0.982), pneumonia (LTE = 29.8%, MIE = 26.3%, P = 0.349), anastomotic leak (LTE = 7.7%, MIE = 9.9%, P = 0.348), or in-hospital mortality (LTE = 1.5%, MIE = 2.1%, P = 0.584). Median length of stay was 11 days after LTE vs. 8 days after MIE (P < 0.001). R0 resection rate was 92.4% and 95.6% respectively (P = 0.144). Median number of resected lymph nodes was 25 for LTE and 28 for MIE (P = 0.017). LTE had more node positive resections (LTE = 57.6%, MIE = 44.0%, P = 0.001).

Conclusion

LTE was used for tumors with greater lymph node burden in patients that were more likely to have received neoadjuvant treatment compared to MIE. MIE was associated with significantly shorter length of hospital stay, however postoperative morbidity and Clavien-Dindo scores were equal to that of MIE in this cohort.
705 SIGNIFICANCE OF CLEAR CIRCUMFERENTIAL RESECTION MARGIN IN ESOPHAGEAL CANCER
Authors: Cheang Catherine , Patil Pradeep
Published: September 2021

Circumferential resection margins (CRM) of an esophagectomy specimen for oesophageal cancer is a key prognostic factor of overall survival (OS). This retrospective study aims to compare OS of post-esophagectomy patients with CRM of >1 mm (R0) and < 1 mm (R1) with further subgroup analysis of locally advanced T3R0 vs T3R1 resection.

Methods

A total of 110 esophagectomies conducted between 2010 and 2020 were analysed. We recorded R stage based on pathological CRM >1 mm (R0) or < 1 mm (R1). OS was calculated from the day of surgery to day of death or otherwise censored. All patients underwent multimodal therapy including chemotherapy and similar pre-surgical and post-surgical management. 58 of these patients with pT3 stage esophageal cancer (EC) were selected and compared. Statistical analysis was carried out using SPSS.

Results

Of 110 patients, 78 (71.5%) patients had a R0 resection. Mean OS in R0 resections was 73 months (6 years) compared to 25.2 months (2 years) in R1 resection (p = 0.001). 58 of the 110 patients were pathological stage T3(pT3) despite downstaging with chemotherapy showing the burden of advanced disease. In patients with stage pT3 (n = 58), 32 patients were R0 resections, and 26 patients had R1 resections. Mean OS in T3R0 resections was 51.5 months compared to 28.5 months in T3R1 resection. OS comparison is significant (p = 0.011).

Conclusion

This study emphasizes the importance of clear CRM in all patients and especially in locally advanced pT3/T4a esophageal cancer in achieving long term survival. Techniques used to ensure a clear CRM such multimodality therapy combined with surgical radical resection concepts such as mesoesophagectomy should be employed.
708 A NEW DIAGNOSTIC PARADIGM FOR LARYNGOPHARYNGEAL REFLUX DISEASE: CORRELATION OF IMPEDANCE-PH MONITORING AND DIGITAL REFLUX SCINTIGRAPHY RESULTS
Authors: Park Jin-soo , Khoma Oleksandr , Van Der Wall Hans , Falk Gregory
Published: September 2021

No gold-standard investigation exists for laryngopharyngeal reflux (LPR). Multichannel intraluminal impedance (MII)-pH testing has uncertain utility in LPR. Meanwhile, reflux scintigraphy allows immediate and delayed visualisation of tracer reflux in the esophagus, pharynx, and lungs. The present study aimed to correlate MII-pH and scintigraphic reflux results in patients with primary LPR.

Methods

Consecutive patients with LPR underwent MII-pH and scintigraphic reflux studies. Abnormal values for MII-pH results were defined from existing literature. MII-pH and scintigraphic data were correlated.

Results

105 patients with LPR (31 males (29.5%), median age 60 years (range: 20–87)) were studied. Scintigraphic reflux was seen in the pharynx in 94 (90.4%), and in the proximal esophagus in 94 (90.4%). Delayed scintigraphic contamination of the pharynx was seen in 101 patients (96.2%) and in the lungs of 56 patients (53.3%). Abnormal reflux was seen in the distal esophagus in 12.4%, proximal esophagus in 25.7%, and in the pharynx in 82.9%. Patients with poor scintigraphic clearance had higher Demeester scores (p = 0.043), more proximal reflux episodes (p = 0.046), more distal acid reflux episodes (p = 0.023), and longer bolus clearance times (p = 0.002).

Conclusion

Reflux scintigraphy has a high yield in LPR patients. Scintigraphic time-activity curves correlated with validated MII-pH results. A high rate of pulmonary microaspiration was found in LPR patients. This study demonstrated a high level of pharyngeal contamination by scintigraphy and MII-pH, which supports the use of digital reflux scintigraphy in diagnosing LPR.
720 CONVENTIONAL AND SIMPLE METHODS OF MEASURING MEAN NOCTURNAL BASELINE IMPEDANCE SHOW EXCELLENT AGREEMENT
Authors: Park Jin-soo , Van der Wall Hans , Falk Gregory
Published: September 2021

Mean nocturnal baseline impedance (MNBI) is a measurement that shows promise in investigating reflux disease by reflecting esophageal mucosal integrity. The conventional method of measuring MNBI is time-consuming and operator-dependent. A new, simple method of measuring MNBI has been suggested. This study aimed to report MNBI measurements by both conventional and simple methods in a cohort of laryngopharyngeal reflux (LPR) and gastro-esophageal reflux disease (GERD) patients to validate the simple measurement method.

Methods

187 patients were divided into LPR (n = 105) or GERD (n = 82) groups by predominant symptom profile, and underwent off-therapy impedance-pH monitoring. MNBI was blindly measured by both conventional and simple methods, and values were correlated. Bland–Altman plots were constructed to assess mean differences and to identify bias between the two measurement methods.

Results

For the two measurement methods, mean difference in the distal esophagus was −89 (±328) ohms, in the proximal esophagus was −6 (±653) ohms, and in the pharynx was 128 (±577) ohms. There was strong correlation between conventional and simple MNBI values, with r = 0.940 in the distal esophagus, r = 0.463 in the proximal esophagus, and r = 0.712 in the pharynx (all p < 0.001).

Conclusion

There was excellent agreement between conventional and simple methods of measuring MNBI, with no evidence of proportional bias. Conventional and simple MNBI values correlated excellently in the distal esophagus, and moderately well in the proximal esophagus and pharynx. This study supports the use of the simple method of measuring MNBI to enhance diagnosis of reflux disease.
742 INITIAL RESULTS OF THE ‘TUBELESS’ OESOPHAGUECTOMY: LESS IS MORE
Authors: Abelló David , Navío Ana , Bruna Marcos , Rodríguez Pedro , Pérez Carla , Mingol Fernando , Vaqué Javier , García-Granero Eduardo
Published: September 2021

Oesophageal cancer surgery is a complex procedure with high morbidity and mortality rate. High volume centres, complete multidisciplinary support and clear clinical guidelines are required to obtain adequate results. One of the objectives of multimodal rehabilitation programs in this field is to reduce surgical aggression. Initial experience with the tubeless oesophagectomy technique is described.

Methods

Description of the technique and perioperative management of tubeless oesophagectomy. We performed a 3-stage esophagectomy with a minimally invasive approach, without NGT placement or any type of drainage. The procedure includes the so-called phantom jejunostomy, which require of fixing the first jejunal loop to the parietal peritoneum in order to position a percutaneous catheter if necessary. All patients were extubated at the end of the surgery, remaining in the ICU with high-flow glasses for the first 24–48 hours. Also in the first 2 days, the urinary catheter and the epidural catheter were removed, sitting and fluid tolerance began.

Results

Beteween June–November 2020 6 patients were operated on. Median age was 60 years (range: 52–70), 83.3% were squamous cell carcinoma located in the middle oesophagus, 4 patients received neoadjuvant CROSS treatment. No intraoperative complications reported and a median stay of 7 days (range: 6–28). There was no anastomotic leak, nor need to place a jejunostomy, nor need to place a nasogastric tube and neither reoperation. A thoracic tube was necessary for chylothorax and another for pneumothorax (in a patient with acute respiratory distress). There was no mortality at 30 and 90 days after the procedure.

Conclusion

Tubeless oesophagectomy is a feasible concept that can improve postoperative recovery in selected cases, reducing pain associated with drains and tubes, facilitating early mobilization and correct performance of respiratory physiotherapy exercises. Improving functional recovery and quality of life during the postoperative period. Studies with a greater number of cases and well designed are necessary to strongly evaluate this type of procedure.
746 EXPERIENCE IN RECONSTRUCTION OF LARYNGOPHARYNGOESOPHAGECTOMIES IN A THIRD LEVEL CENTER
Authors: Navío-Seller Ana , Abelló-Audí David , Bruna-Esteban Marcos , Vaqué-Urbaneja Javier , Mingol-Navarro Fernando , García-Granero-Ximénez Eduardo
Published: September 2021

Pharyngoesophageal reconstruction after laryngo-pharyngo-esophagectomy, due to malignant or benign causes, is challenging due to its high morbidity and mortality. There are different reconstructive flaps: visceral flaps (pedicle stomach and colon flaps and free jejunum or colon grafts) and myocutaneous flaps (pedicle local flaps, such as the pectoralis major flap, or free grafts, such as the anterolateral thigh-ALT). The objective is to evaluate the morbidity and mortality and functional results of the reconstruction after laryngo-pharyngo-esophagectomy.

Methods

This is a retrospective study of patients who underwent laryngo-pharyngo-esophagectomy in our center, due to a benign cause (ingestion of caustic) or malignant (cancer of the larynx, pharynx, parathyroid and cervical esophagus) with circumferential pharyngeal reconstruction with flap, from 2008 to November 2020. Demographic variables, neoadjuvant treatment, procedure performed and flap used for reconstruction, complications related to reconstruction (fistula, stenosis, necrosis), postoperative complications, days until adequate swallowing, functional result of the flap, hospital stay, recurrence and mortality were collected.

Results

Twelve patients, with a median age of 59 years (45–78), underwent surgery, 1 case due to benign cause and 11 cases with an oncological diagnosis. There were complications related to the reconstruction in 42% of the patients (see table 1). Postoperative morbidity was 67% (75% Clavien-Dindo ≥ III). The median hospital stay was 21 days (16–94). The median time to swallowing was 13 days (3–73). An optimal functional result (oral intake) was achieved in 75% (only 3 patients with poor results). The median follow-up was 18 months (4–56), with a survival rate of 50%. 30-days mortality was 8% (1 case).

Conclusion

Our study shows a high morbidity and mortality after circumferential pharyngeal reconstruction, similar to literature published. We have observed a higher rate of reconstruction related complications (fistulas and stenosis) and worse functional results in reconstructions performed with gastroplasty and coloplasty after total laryngo-pharyngo-esophagectomy, compared to less aggressive local resections (laryngopharyngeal) with ALT free flap reconstruction.
754 STEEP RAMP TEST: AN ALTERNATIVE TO ASSESS PHYSICAL FITNESS BEFORE OESOPHAGECTOMY IN CANCER PATIENTS
Authors: Crull David , Mekenkamp I , Ruinemans G M F , Det M J , Kouwenhoven E A
Published: September 2021

Oesophagectomy patients are at high risk of perioperative complications. An important predictor for a complication is inadequate preoperative physical fitness. Cardiopulmonary Exercise Test (CPET) is the golden standard for measuring VO₂ max. The Steep Ramp Test (SRT) is an alternative with a lower patient burden and cost, but provides an estimation of VO₂ max. The aim was to determine whether SRT is an adequate alternative for CPET to determine preoperative fitness in oesophageal cancer patients.

Methods

The population consisted of 113 oesophageal cancer patients of a single centre that have performed CPET and SRT within a timeframe of two weeks. The agreement between SRT and CPET was analysed using a t-test, the Pearson correlation, the Intraclass Correlation Coefficient (ICC) and the Bland-Altmann analysis. A CPET-measured VO₂ max of 17 mL/kg/min was the set threshold for adequate operative fitness, based on current literature.

Results

The mean difference between the CPET and SRT was 2.77 mL/kg/min (95% CI, 2.14–3.41). The Pearson correlation was 0.792 (P < 0.001). The ICC was 0.879 (95% CI, 0.825–0.917). In 93 (82.3%) patients, SRT was higher than the CPET. The limits of agreement (LOA) for the Bland-Altmann were − 3.89 − +9.44. Thirty-one (27.4%) patients performed better on SRT than the set threshold plus the upper LOA. Twenty-three patients scored inadequate on CPET, of whom 14 patients (60.9%) SRT was sufficient.

Conclusion

VO₂ max as estimated by SRT differs from the VO₂ max as measured by CPET. In patients that are well above the threshold of adequate preoperative fitness, the difference is of clinical irrelevance. In conclusion: SRT is a promising alternative to CPET for determining preoperative physical fitness, it might render CPET obsolete for fit individuals which leads to a lower burden for the patient and substantial cost reduction.