bluuebunny/crossref_metadata_2025 huggingface dataset:
178 RANDOMIZED CONTROLLED TRIAL COMPARING ANGLE OF HIS ACCENTUATION WITH TOUPET FUNDOPLICATION IN PATIENTS UNDERGOING LAPAROSCOPIC HELLERS MYOTOMY: INTERIM RESULTS
Authors: Parshad Rajinder , Bale Manjunath , Bhattacharjee Hemanga , Singla Vitish , Saraya Anoop , Sharma Raju
Published: September 2021

Laparoscopic Heller’s Cardiomyotomy (LHCM) is the surgical treatment of choice for achalasia. Addition of an antireflux procedure is recommended to reduce the postoperative reflux. However, there is no consensus regarding the ideal antireflux procedure. In an earlier study we have shown that Angle of His accentuation (AOH) is similar to Dor fundoplication. In this study we present the interim results of an RCT comparing AOH with Toupet fundoplication as an adjunct to LHCM.

Methods

Patients of Achalasia cardia presenting after October 2017 were randomised to receive either AOH or Toupet following Heller cardiomyotomy based on computer generated random sequence. Primary outcome was incidence of post-operative symptomatic reflux and esophagitis on endoscopy. Secondary outcome was relief of dysphagia and Achalasia specific health related Quality of life assessment (ASHRQoL). Symptom scores for dysphagia, regurgitation and heartburn as well as ASHRQoL were noted pre operatively and at 3 monthly intervals. Objective evaluation was done using timed barium swallow, Upper GI endoscopy and oesophageal manometry. Data was recorded on excel spreadsheet and analysis done using SPSS v5.

Results

A total of 52 patients (25 Toupet, 27 AOH) were included in the analysis. All patients were successfully operated laparoscopically with no conversions, intraoperative perforations or perioperative mortality. The mean operative duration was 128 min in the AOH group and 146 min in the Toupet group (p < 0.05). There was significant improvement in symptom scores as well as objective parameters in both groups with no difference between the 2 groups at a mean follow-up of 6 months (5-9 months; Table 1). 3 patients in AOH group (11%) and 4(16%) patients had new onset reflux with esophagitis in 2 patients in each group.

Conclusion

AOH is technically easier and can be performed in a shorter time. The symptom relief is similar in both groups with similar incidence of heartburn and esophagitis in the short term. A longer follow up is recommended in a larger number of patients.
189 GLUCOCORTICOID RECEPTOR AND SERUM- AND GLUCOCORTICOID-INDUCED KINASE-1 IN ESOPHAGEAL ADENOCARCINOMA AND ADJACENT BARRETT’S ESOPHAGUS
Authors: Gokon Yusuke , Fujishima Fumiyoshi , Taniyama Yusuke , Ueki Shunsuke , Kamei Takashi , Sasano Hironobu
Published: September 2021

Barrett’s esophagus (BE) is a consequence of gastroesophageal reflux disease and is predisposed to esophageal adenocarcinoma (EAC). EAC is an exemplar model of inflammation-associated cancer. Glucocorticoids suppress inflammation through glucocorticoid receptor (GR) and serum- and glucocorticoid-induced kinase−1 (Sgk1) expressions.

Methods

We immunolocalized GR and Sgk1 in EAC and the adjacent BE tissues and studied their association with clinical disease course in 87 patients with EAC who underwent surgical resection (N = 58) or endoscopic submucosal dissection (N = 29).

Results

Low GR and Sgk1 expressions in adjacent BE tissues were associated with adverse clinical outcomes (P = 0.0008 and 0.034, respectively). Patients with low Sgk1 expression in EAC cells exhibited worse overall survival (P = 0.0018). In multivariate Cox regression analysis, low GR expression in the adjacent nonmalignant BE tissues was significantly associated with worse overall survival (P = 0.023).

Conclusion

The present study indicated that evaluation of GR and Sgk1 expressions in both the EAC cells and adjacent nonmalignant BE tissues could help to predict clinical outcomes following endoscopic and surgical treatments. In particular, the GR status in BE tissues adjacent to EAC was an independent prognostic factor.
191 CURRENT STATUS OF ESOPHAGECTOMY IN JAPANESE NATIONAL CLINICAL DATABASE
Authors: Kakeji Yoshihiro , Takahashi Arata , Hasegawa Hiroshi , Takiguchi Gosuke , Oshikiri Taro , Nakamura Tetsu , Miyata Hiroaki , Kitagawa Yuko
Published: September 2021

The Japanese National Clinical Database (NCD) started its data registration since 2011, has grown up to a large nationwide database covering more than 95% of the surgeries performed by regular surgeons in Japan. The NCD grew rapidly harvesting over 11 million cases data between 2011 and 2018 from more than 5,000 facilities.

Methods

In this period, the surgeries of the esophagus were performed for 70,528 cases. In 2018, 93.8% of surgeries were performed at certified institutions, and 94.7% did with the participation of the board-certified surgeon. The board-certified surgeons operated 75.2% of the surgeries.

Results

Esophagectomy was performed for 47,055 patients in eight years. In 2018, 23.3% of the cases were 75 years old or more. Postoperative complications of Clavien Dindo classification grade III or higher occurred in 22.9% of all. As the patients have been getting older, the morbidities have been increasing. However, the mortalities have been kept at a low level. Postoperative 30-day and 90-day mortalities were 0.9% and 1.9%, respectively. The rates of endoscopic surgery have been increasing year by year, especially high in esophagectomy, which was 61.0% in 2018.

Conclusion

A risk-adjusted analysis based on nationwide data allows personnel to establish and provide feedback on the risks that patients face before undergoing a procedure. The risk calculator for eight main procedures are available on the websites of the hospitals that are a part of NCD. Nationwide this database is surely expecting to ensure the quality of board certification system and surgical outcomes in gastroenterological surgery.
212 USEFULNESS OF ENDOSCOPIC ESOPHAGECTOMY IN A PRONE POSITION FOR ELDERLY PATIENTS OVER 75 YEARS OLD
Authors: Ito Ken , Kamei Takashi , Chin Masahiro , Hagiwara Motohisa , Hara Yasuyuki , Kumata Hiroyuki , Hashizume Eiji
Published: September 2021

Surgery for esophageal squamous cell carcinoma(ESCC) is one of the most invasive surgery and high mortality rate because operation is centered on the thoracic cavity. Recently, Japan has been facing aging society, and surgery for elderly ESCC patient is increasing. In our hospital, we changed surgical position from left lateral position to prone. In this study, we investigated the surgical outcome and prognosis of ESCC operation in the patients aged ≧ 75.

Methods

From April 2011 to March 2019, 39 ESCC operations for patients aged ≧ 75 were performed in our hospital. We compered surgical position. We retrospectively examined clinicopathological factors, long-term prognosis, preoperative nutritional status (albmin, neutrophil and lymphocyte ratio), and operation factors (operation time, blood loss, recurrent nerve paralysis, complication, hospital stay).

Results

Cases in lateral position surgery were 22 and prone position were 17. The median age was 79 vs 79 years old, and the gender ratio was male: female = 16:6/14:3. No significant differences were observed in preoperative nutritional status. The operation time was 458 min vs 501 min (p = 0.126). The blood loss was 318 mL vs 195 mL (p = 0.003). The rate of recurrent nerve paralysis was 42.1% vs 29.4% (p = 0.262). The number of patients in Clavien-Dindo ≧ III complications was 40.9% vs 41.2% (p = 0.987). 3-year OS was 74.7% vs 77.3%, DFS was 78.6% vs 67.7%.

Conclusion

In ESCC patients aged ≧ 75, surgery in prone position was relatively safe. The blood loss and the recurrent nerve paralysis ware tend to be less. Recurrent nerve monitoring during operation and evaluation of perioperative swallowing function seemed to be the next subject.
258 MANAGEMENT OF OESOPHAGO-GASTRIC LEAKS FOLLOWING MINIMALLY INVASIVE IVOR LEWIS OESOPHAGO-GASTRECTOMY USING DOUBLE PIGTAIL STENTS
Authors: Tan Jeremy , Wong Wai Keong , Yeung Baldwin , Toh Bin Chet , Ong Lester , Lim Chin Hong , Lim Eugene , Eng Alvin , Ong Hock Soo , Lee Zhen Jin , Lye Tiffany , Chan Weng Hoong
Published: September 2021

Anastomotic leak following Ivor Lewis oesophago-gastrectomy is a major complication with high morbidity and mortality. We report our experience with three such cases where endoscopically deployed double pigtail stents (DPT) were used to help manage the leaks.

Methods

Three patients from October 1, 2019 to February 29, 2020 experienced leakage from the oesophago-gastric anastomosis following minimally invasive Ivor Lewis oesophago-gastrectomy. These occurred on post-operative day 9, day 29 and day 7 respectively. All cases were managed with endoscopic deployment of double pigtail stents along with other adjunctive measures.

Results

To date all patients remain alive, with sepsis under control. One of the patients had been able to have his double pigtail stent removed at six weeks and he has been able to commence adjuvant chemotherapy. Another patient had a follow-up contrast study one week after DPT insertion which showed no further contrast extravasation and was able to recommence oral intake. The third patient has a left empyema (managed conservatively with a combination of internal DPT and external pigtail drainage) which is gradually resolving.

Conclusion

Endoscopically deployed DPTs are a useful tool in the armamentarium for managing oesophago-gastric anastomotic leaks in selected patients following Ivor Lewis oesophago-gastrectomy. They are advantageous in that stent migration does not appear to be an issue, nor is there any problem with leakage around the stent. Patients are mostly able to restart oral intake soon after insertion of DPTs. This reduces the morbidity associated with these anastomotic leaks, and reduces the number of interventions needed.
267 INTESTINAL STEM CELL MARKERS AND ITS POTENTIAL USE IN THE CLINICOPATHOLOGICAL SETTING OF ESOPHAGEAL ADENOCARCINOMA
Authors: Shibahara Yukiko , Espin-Garcia Osvaldo , Conner James , Weiss Jessica , Derouet Mathieu , Allen Jonathan , Wilson Gavin , Allison Frances , Kalimuthu Sangeetha , Wong Rebecca , Elimova Elena , Yeung Jonathan , Darling Gail
Published: September 2021

Barrett’s esophagus (BE) is the primary precursor lesion of esophageal adenocarcinoma (EAC), which not only resembles the intestinal mucosa morphologically but also expresses various intestinal stem cell (ISC) markers. We hypothesized that ISC markers, Lgr5 (also a cancer stem cell marker), Ascl2 (fate determinator of ISC),Bmi1 (quiescent counterpart of Lgr5) and Cdx2 (primary regulator of ISC gene expression) have clinicopathological significance and could potentially be a predictor for survival in EAC.

Methods

Tissue microarray consisted of 64 EAC and 22 BE, and the expressions of Lgr5, Ascl2, Bmi1 and Cdx2 were analyzed using immunohistochemistry and scored independently by two pathologists. Clinicopathological factors (age, pathological grade and stage, affected lymph nodes, neoadjuvant therapy) were confounding factors, and univariable analysis using Fisher's exact tests as well as survival analysis using the Kaplan–Meier (KM) method and Cox proportional hazards regression (Cox PH) were performed to investigate its statistical significance. We performed a bioinformatic analysis of the TCGA dataset to validate the immunohistochemical findings.

Results

Among EAC, 69%, 88%, 64% and 70% expressed high Ascl2, Lgr5, Bmi1 and Cdx2, respectively. High Ascl2 and low Lgr5 expression significantly correlated to a higher number of involved lymph nodes; high Bmi1 expression significantly correlated to the pathological stage. Cdx2 was not correlated to any markers. KM analysis showed a negative impact of high Ascl2 expression on overall survival (OS; p = 0.0276) as well as progression-free survival (PFS; p = 0.0466), but not Lgr5, Bmi1 nor Cdx2. Cox PH analysis revealed Ascl2 (p = 0.011), and Cdx2 (p = 0.015) expression are independent prognostic factors for EAC.

Conclusion

Our results suggest that among the four ISC markers, Ascl2 and Cdx2 protein holds potential to be utilized as a prognostic biomarker. TCGA dataset revealed the association of ASCL2 mRNA expression with the number of positive lymph nodes but not overall survival, which implies further research is needed to explain the mechanism of Ascl2 overexpression in EAC carcinogenesis via ISC regulation.
270 LYMPHADENECTOMY ALONG BILATERAL RECURRENT LARYNGEAL NERVE UNDER SINGLE-PORT INFLATABLE MEDIASTINOSCOPY THROUGH LEFT NECK APPROACH
Authors: Wu X , Gan X , Cao Q
Published: September 2021

Mediastinal lymphadenectomy is a crucial part of minimally invasive esophagectomy, and requires transthoracic operation, which is a crucial independent risk factor for the incidence of pulmonary complications. Conventionally, non-transthoracic esophagectomy was often achieved by mediastinoscope-assisted laparoscopic transhiatal surgery. Because of the small space, the lymphadenectomy could be only performed partially under mediastinoscope in upper mediastinal. We propose a new approach of lymphadenectomy along bilateral recurrent laryngeal nerve under mediastinoscopy through one left-neck incision.

Methods

A 3-cm incision paralleling the clavicle was made at 2-cm from the supraclavicular region in the left neck. After established pneumomediastinum (10-12 mmHg carbon dioxide), esophagectomy begins to perform over the aortic arch to the level of lower edge of the left main bronchus, and the lymphadenectomy along the left RLN has also accomplished during this process. At the level of lower edge of the right subclavian artery (RSA), between the trachea and the esophagus, the instruments could get accessed to the right RLN. The lymphadenectomy could get accomplished up to 2-cm at the upper edge of the RSA.

Results

The mean age of 56 esophageal squamous cell cancer patients was 67.4 years, 46 males and 10 females. Tumor location: middle thoracic, 31 patients, lower thoracic, 23 patients. Preoperative TNM staging: T1b was 10 cases, T2 was 35 cases, and T3 was 11 cases. The median number of mediastinal LNs removed was 17 (9 to 23); 6 (2 to 9) along the left RLN; 3 (1 to 6) along the right RLN. 7 patients (12.5%) developed RLN palsy. Postoperative laryngoscopy showed that all of the 7 RLN palsy were left side, none of them appeared at 3 months postoperation.

Conclusion

This approach enables the lymphadenectomy along bilateral RLN through one left neck incision. During the operation, the upper mediastinal LNs along the bilateral RLN were clearly revealed and en bloc excised. Meanwhile, the bilateral RLN were fully exposed and protected during the procedure. Compared with the previous surgical methods,this procedure is less invasive, and the bilateral RLN could be exposed much clearer. It would provide a novel approach for the minimally invasive esophagectomy, especially lymphadenectomy.
281 ANALYSIS OF NON-CANCER-RELATED DEATH CASES AFTER ESOPHAGEAL CANCER SURGERY
Authors: Uemura Norihisa , Saiki Takahiro , Arai Toshiyuki
Published: September 2021

Many patients with esophageal cancer have problems with preoperative physiological functions related to smoking, drinking, and malnutrition. Therefore, a certain frequency of patients die from other diseases after radical resection of esophageal cancer. In this study, we examined non-cancer-related death cases after esophageal cancer surgery to clarify the clinical significance and to consider its improvements.

Methods

In this retrospective cohort study, we examined 52 patients with esophageal cancer treated surgically from 2011 to 2016. Of the 52 patients analyzed, 7 died of other diseases during postoperative follow-up. Seven of the 52 patients were women, but all 7 died of other diseases were men. The median age of the 7 patients was 72 (65–76) years, slightly older than the median age of 66 (50–76) years in all cases.

Results

The postoperative survival of the 7 patients who died from other diseases was 9.4 months, including four patients who died early within one year without recurrent lesions. Their death was due to aspiration pneumonia in 5, 1 asphyxiation, and 1 unknown. The median preoperative BMI of the 7 patients who died of other diseases was 19.5, lower than 21.4 in all cases. The median preoperative one second forced expiratory volume was 2.36 L for the 7 patients, which was lower than 2.54 L in all cases.

Conclusion

Other deaths after esophagectomy were more common in men, the elderly, thinner, and patients with reduced respiratory function. Because there are some cases of death from other diseases early after esophagectomy, early rehabilitation intervention and nutrition management are required after surgery.
342 SURGICAL TREATMENT OF ESOPHAGEAL CANCER WITH VARIATIONS OF THE AORTIC ARCH AND ITS BRANCHES
Authors: Li Baiwei , Dai Liang , Jiang Haoyao , Li Zhigang , Chen Keneng
Published: September 2021

The variations of the aortic arch and its branches are rare. The surgical treatment of esophageal cancer would be challenged for combination with this anomaly. This study intends to review significant group cases to analyze the influence of this variation on esophagectomy.

Methods

From 2013 to 2019, 19 patients with aortic arch and brachiocephalic vessels variations underwent esophagectomy, accounting for 0.3% during the same period. The abnormalities were distributed as follows: left-sided aortic arch combined with aberrant right subclavian artery (LAA + ARSA) occurred 13 cases, right-sided aortic arch anomalies with mirror image arch branches (RAA + MIAB) in 1 case, and right-sided aortic arch combined with aberrant left subclavian artery (RAA + ALSA) in 5 case. Of the patients with LAA + ARSA, 11 patients underwent the McKeown esophagectomy, and 2 patients via transhiatal. All patients with RAA underwent left thoracotomy approach.Perioperative outcomes and long-term survival were analyzed.

Results

The tumors were mostly located in the upper and middle thorax (47.4% and 42.1%). The R0 resection rate was 89.5% (17/19). Recurrent laryngeal nerve injury occurred in 2 patients, anastomotic fistula in 1 patient. Two patients died within 30 days postoperatively. The yield of lymph nodes was 21.8 ± 9.4. The sampling rate of lymph nodes along the recurrent laryngeal nerve was 61.5% in LAA + ARSA group, while 16.7% in RAA group. Recurrence happened in 5 cases (29.4%), including 2 regional relapse. Four patients died after recurrence, with a median time to death of 20 months (range: 10–48 months).

Conclusion

For aortic arch and brachiocephalic artery variations in esophageal cancer, aberrant right subclavian artery and right-sided aortic arch are the most common types. The surgical strategy is closely related to the aortic arch position. Due to the combined variation of the recurrent laryngeal nerve, the upper mediastinal lymph nodes dissection would be conservative, but with acceptable oncologic results.
362 SUPERIOR POLAR GASTRECTOMY ASSOCIATED WITH ANTI-REFLUX TECHNIQUE: CASE REPORT
Authors: Navío-Seller Ana , Jiménez-Rosellón Raquel , Bruna-Esteban Marcos , Vaqué-Urbaneja Javier , Mingol-Navarro Fernando
Published: September 2021

Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence.

Methods

This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer.

Results

A 55 year-old female diagnosed with gastric adenocarcinoma. Tumor was 3 cm long, from esophago-gastric junction to subcardial region (cT3N1M0). Patient underwent perioperative chemotherapy and surgical intervention 6 weeks later. A laparoscopic superior polar gastrectomy was performed and D1+ lymphadenectomy. A laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of gastric pouch and two seromuscular flaps were dissected. Gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis. Seromuscular flaps were sewn overlapping the esophago-gastric anastomosis.

Patient presented an optimal postoperative evolution, without heartburn, dysphagia neither vomiting.

Conclusion

The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.
384 SHORT-TERM OUTCOMES OF INTRA-THORACIC ESOPHAGO-GASTRIC ANASTOMOSES UNDER MINIMALLY INVASIVE ESOPHAGECTOMY VIA A PRONE POSITION
Authors: Mine Shinji , Watanabe Masayuki , Kanamori Atushi , Imamura Yu , Okamura Akihiko , Hashimoto Takashi , Hashiguchi Tadasuke , Kuniyasu Tetsushi , Nasu Motomi , Fujiwara Daisuke , Ozaki Asako , Yoshino Kohei , Kajiyama Yoshiaki , Tsurumaru Masahiko
Published: September 2021

Although minimally invasive esophagectomy (MIE) has been performed for esophageal cancer worldwide, intra-thoracic anastomosis under prone positions is still challenging. In this retrospective study, we reviewed our short-term results of this anastomotic technique in our institution.

Methods

From November 2016 to December 2019, we performed 319 esophagectomies. Of these patients, 28 patients (9%) underwent intra-thoracic esophago-gastric anastomosis under MIE.

Procedures

The left side of an esophageal stump which had been closed using a linear stapler was opened for anastomosis. Then, the anterior wall of a gastric conduit, around 5 cm below the tip, was opened for anastomosis. Linear staplers were inserted in both esophageal stump and gastric conduit and side-to-side anastomosis was performed. The opening for insertion was closed using a hand-sewn anastomosis in 2 layers.

Results

Five patients (18%) suffered anastomotic leakage with Clavien-Dindo 2 and 3a, and all of them recovered by conservative treatments. Two patients (2/19, 11%) showed anastomotic stricture which improved by several endoscopic dilatations. Six patients (6/19, 32%) showed the reflux esophagitis of Grade C.

Conclusion

Although we have not experienced severe or critical post-operative complications, the short-term results of intra-thoracic anastomosis under MIE were not sufficient. Additional progresses in techniques are required.
444 CORRELATION BETWEEN PATHOLOGIC COMPLETE RESPONSE TO NEOADJUVANT THERAPY AND RECURRENCE IN PATIENTS WITH ESOPHAGEAL CANCER
Authors: Pandey Durgatosh , Pandey Rambha , Julka Pramod Kumar
Published: September 2021

Multimodal treatment options in carcinoma esophagus include neoadjuvant chemoradiotherapy or chemotherapy followed by surgery. The degree of pathologic response to different neoadjuvant options and its impact on the oncologic outcome is a matter of debate.

With this background we carried out this study to analyze the rate of pathologic complete re-sponse (pCR) and its effect on recurrence in patients with carcinoma esophagus treated with various combinations of neoadjuvant chemotherapy/radiotherapy and surgery.

Methods

The records of all patients with carcinoma esophagus registered in our clinics between June 2012 and December 2014 were retrieved from a prospectively maintained database and were analyzed. of the 70 patients with histologically proven esophageal cancer who were treated with curative intent during this period, those with pCR (15) were followed up for a minimum of 5 years. These 15 patients are the subjects of this study.

Results

Forty eight (48) patients received neoadjuvant chemotherapy (NACT), 16 were treated with short course radiotherapy (SRT), and 3 patients received neoadjuvant chemoradiation (CRT). Four patients developed metastatic disease on neoadjuvant therapy.

66 patients (63 after neoadjuvant therapy and 3 upfront) underwent transthoracic esophagect-omy. Pathological CR was seen 12 patients (25%) in NACT-surgery arm, 2 (12%) in SRT-surgery and 1 (33%) in CRT-surgery groups. Three patients had postoperative mortality due to pulmo-nary complications. At 5 yrs, 14 out of 15 patients with pathological CR are alive and disease free. One patient developed brain metastases after 3 years and died.

Conclusion

Neoadjuvant therapy followed by radical surgery is a safe and effective treatment option for the management of carcinoma esophagus. Pathologic CR strongly correlates with recurrence-free survival. The relative significance of pCR after different types of neoadjuvant therapies need to be tested in future studies.
450 FACTORS AFFECTING CIRCUMFERENTIAL RESECTION MARGIN AFTER ESOPHAGECTOMY AND ITS PROGNOSTIC SIGNIFICANCE-LARGE SINGLE CENTRE EXPERIENCE
Authors: Jiwnani Sabita , Pramesh C S , Ashok Apurva , Tiwari Virendra
Published: September 2021

The evidence regarding the importance of circumferential resection margin (CRM) as a prognostic factor after esophagectomy is inconclusive in the era of neoadjuvant therapy. We retrospectively analysed our prospectively maintained database for factors that affect CRM positivity, and whether a positive CRM affects event free and overall survival. 2843 patients underwent esophagectomy with curative intent from October 2004 to 2019 at our centre. CRM was analysed as negative, close but technically free (<1 mm) and involved.

Methods

Data on the following variables was retrospectively extracted from prospective database. CRM status was noted for clinic-radiological T and N stage, level of growth, histology, differentiation grade and neoadjuvant treatment. Intra-operative details such as surgical procedure, approach, surgeon grade, lymphadenectomy and resection status were analysed. On final histopathology; proximal and distal margins, lymph node positivity, lymphovascular invasion(LVI), tumour regression grade(TRG) were analysed. The effect of CRM on development of recurrence and overall survival was evaluated. CRM data was available for 2439 (85.78%) patients. 71.2% of the patients received neoadjuvant chemotherapy. Factors were analysed separately for both close and positive margins.

Results

75.8% had negative, 15.6% close and 8.6% positive CRM. Univariately, T stage, adenocarcinoma, poor differentiation, transhiatal approach, R+ resection, positive margins, TRG > 3, LVI and upfront surgery predicted positive CRM. On multivariate, negative CRM was seen in T1/T2 stage [OR 0.325, 95% CI-0.144-0.732, p = 0.007], squamous carcinoma [OR 0.574, 95% CI-0.351-0.958, p = 0.027], R0 resection [OR 0.228, 95% CI-0.086-0.599, p = 0.003] while positive CRM was seen in upfront surgery [OR 2.32, 95% CI-1.55-3.46, p < 0.001], positive nodes [OR 1.748, 95% CI-1.19-2.56, p = 0.004] and LVI [OR 2.73, 95% CI-1.87-3.98, p < 0.001]. Median event-free survival in CRM negative was 64 months compared to 14 months in CRM positive (p < 0.001).

Conclusion

Positive CRM involvement is a prognostic indicator in patients undergoing esophagectomy and associated with worse event-free and overall survival. CRM-positive disease in esophageal cancer may represent residual tumor, advanced disease, aggressive biology, or poor response to neoadjuvant treatment. All attempts should be made to achieve a clear circumferential resection margin. More evidence is needed to evaluate if adjuvant therapy is justified in these patients and the type of therapy also needs to be determined.
486 UTILITY OF 18F-FDG/PET FOR PREDICTING HISTOPATHOLOGICAL RESPONSE TO NEOADJUVANT INDUCTION CHEMOTHERAPY AND CHEMORADIOTHERAPY FOR ESOPHAGEAL AND JUNCTIONAL CARCINOMA
Authors: Sabino Flávio , Guimarães-Filho Marco , Carneiro Michel , Ribeiro Luciana , Fernandes Daniel , Felipe Pinto Luis
Published: September 2021

Neoadjuvant treatment followed by esophagectomy is the standard therapy for patients with resectable esophageal cancer. Data have demonstrated that patients with pathologic complete response (pCR) have better survival. Several studies have been exploring whether 18F-FDG/PET performed during neoadjuvant treatment can predict a pCR, but the results are conflicting. The aim of this study was to assess the role of 18F-FDG PET/CT for predicting the histopathological response to neoadjuvant induction chemotherapy (IC) and chemoradiotherapy (CR).

Methods

Patients with proven squamous cell or adenocarcinoma of the esophagus or GEJ were enrolled in this prospective study. Patients received two cycles of IC with carboplatin and paclitaxel followed by concurrent CR and then esophagectomy. Metabolic response was evaluated according to PERSIST criteria by 18F-FDG PET/CT performed at baseline, at day 14 of chemotherapy and four to eight weeks after the completion of CR. Tumoral pretreatment, induction and posttreatment FDG-standardized uptake value normalized to lean body mass SULmean and percentage change were assessed. These parameters were correlated with the pathologic response using the Mandard tumor regression grade (TRG) scale.

Results

Thirty patients finished the IC plus CR and 16 had esophagectomy. The median age was 57 years, 75% were male and 56% had adenocarcinoma. The mean of SULmean prior to treatment, after one cycle of IC and after CR were respectively 6.12, 4.67 and 1.52. After one cycle of IC, one patient had metabolic progression, eight remained stable and seven had partial metabolic response. All metabolic responders had good histopathological response (Mandard 1 or 2). After CR, five patients had complete metabolic response (CMR). However, three of them had poor histopathological response (Mandard >2).

Conclusion

Our initial results suggests that the early PERSIST-based metabolic response evaluation appears useful to predict a good histopathological response. Thus, an interim 18FFDG PET/CT may help to identify good responders during the neoadjuvant treatment. However, the late metabolic response evaluation after CR had a poor pathologic correlation. In this way, a CMR after CR should not be assumed to be synonymous of complete pathologic response.
546 INTENSIVE SURVEILLANCE AFTER CURATIVE INTENT SURGERY FOR ESOPHAGEAL CANCER: INITIAL RESULTS OF THE ENSURE STUDY
Authors: Elliott Jessie A , Markar Sheraz R , Klevebro Fredrik , Ni Melody Zhifang , Nilsson Magnus , Zaninotto Giovanni , Hanna George B , Reynolds John V ,   ENSURE Study Group
Published: September 2021

Emerging data demonstrate long-term survival after salvage interventions for local or oligometastatic recurrence after planned curative resection for esophageal cancer, providing rationale for postoperative surveillance. However, the impact of intensive surveillance on oncologic outcome is unknown. This multicenter collaborative study aimed to characterize oncologic surveillance protocols across esophageal cancer centers internationally and determine the independent effect of intensive surveillance on oncologic outcome.

Methods

The ENSURE international multicenter study included consecutive patients who underwent surgery with curative intent for cTxNxM0 esophageal cancer from June 2009 to June 2015. Intensive surveillance was defined as use of cross-sectional imaging, at least annually, during the first three postoperative years. The estimated sample size of 4425 provided 90% power to detect a 5% increase in 5-year overall survival (OS, primary outcome measure). Secondary outcome measures included disease-free (DFS) and disease-specific survival (DSS), surveillance strategies, incidence of oligometastatic recurrence, treatment strategies, and HRQOL. The study was registered on ClinicalTrials.gov (NCT03461341).

Results

4597 patients were included. The participating 27 centres undertook mean(SD) 52.3(17.1) esophageal cancer resections annually between 3.5 ± 1.3 attending surgeons. 37%, 11% and 19% centers utilized postoperative surveillance CT, PET-CT and endoscopy, respectively. Among all patients, intensive surveillance was associated with improved OS (HR0.92 [0.85–0.99]) but not DSS (HR0.93 [0.85–1.01]) or DFS (HR0.97 [0.90–1.04]), and on multivariable analysis, intensive surveillance did not provide oncologic benefit (OS HR1.10 [0.99–1.22], DSS HR1.12 [1.00–1.25]), but reduced observed DFS (HR1.19 [1.08–1.31]). Evaluating surveillance modalities, neither surveillance endoscopy nor laboratory tests improved oncologic outcome, however flexible nasolaryngoscopy was associated with improved OS (HR0.84 [0.69–1.0]).

Conclusion

ENSURE, the first study powered to assess the impact of postoperative surveillance protocols on oncologic outcome in esophageal cancer, demonstrated no overall survival benefit following intensive imaging surveillance, with reduced observed disease-free survival time. However, routine assessment for secondary aerodigestive malignancies may be of oncologic benefit. The present data do not support the use of intensive imaging surveillance among all patients following esophageal cancer surgery. Further reports detailing subgroup analyses and HRQOL impact are anticipated.
558 OUTCOMES OF PER ORAL ENDOSCOPIC MYOTOMY IN ACHALASIA IN PATIENTS WITH END-STAGE ESOPHAGUS
Authors: Raja Siva , Adhikari Saurav , Sudarshan Monisha , Sanaka Madhusudhan , Murthy Sudish , Thota Prashanti , Gabbard Scott , Ahmad Usman
Published: September 2021

Per oral endoscopic myotomy (POEM) has emerged as a favorable alterative to Heller myotomy for achalasia. However data is limited on the effectiveness in palliation of symptoms in patients who have an esophagus with a sigmoid/tortuous configuration, or a mega-esophagus with width more than 5 cm, due to long-standing achalasia. Our objective is to investigate the outcomes after POEM procedure in patients diagnosed with achalasia and considered end-stage.

Methods

A retrospective cohort study was conducted in a large hospital between April 2014 and July 2019. A total of 504 patients were identified with 218 undergoing POEM during the study time period of which 57 patients had a sigmoid or tortuous esophagus, and/or had a barium column width of more than 5 cm on timed barium esophagograms (TBE). Primary outcome was symptom relief during follow-up, defined as a post-operative Eckardt score ≤ 3. We also explored integrated resting pressure (IRP) on manometry, barium column height and width on TBE, complications and procedure related parameters. Statistical analyses were performed using R.

Results

Significant decrease in median Eckardt scores were observed, 7.5 [6,8.8] pre-operatively to 0 [0,1] at 2 months (p < 0.001). At 2 years, 12 of 14 patients (85%), reported scores of ≤3. Improvements at 2 months were noted in median IRP (25.4 mmHg [15.5, 35.9] vs. 4.0 mmHg [2.2,9.0]), 1 min TBE height (11.5 cm [7.5,15.0] vs. 6.8 cm [4.7,9.0]) and width (5.0 cm [4.1,6.1] vs. 2.8 cm [1.9,3.1]), p < 0.001. At 2 years, they were 9.5 cm [5,12.8] and 3.0 cm [2.4,4.5], respectively. Post-operative pH studies in 35(61%) patients demonstrated a DeMeester score ≥ 14.72 in 17(49%) patients. Almost all patients reported return to activities of daily living within 7 days.

Conclusion

POEM is an effective and safe modality in achalasia patients with end-stage esophagus. Patients in this cohort historically have had poor outcome to interventions and our data shows excellent short-to-medium term outcome with low morbidity after POEM. Given its efficacy, minimal invasiveness and short return to function, POEM is a reasonable first and gold standard palliative therapy in this difficult cohort and should be attempted before considering esophagectomy.
590 VARIATION IN RECEIPT OF THERAPY AND SURVIVAL WITH PROVIDER-VOLUME IN NON-CURATIVE ESOPHAGO-GASTRIC CANCER: A POPULATION-BASED ANALYSIS
Authors: Hallet Julie , Davis Laura , Mahar Alyson , Lui Ying , Zuk Victoria , Gupta Vaibhav , Earle Craig , Coburn Natalie
Published: September 2021

While surgical care by high-volume providers for esophago-gastric cancer (EGC) yields better outcomes, volume-outcome relationships are unknown for systemic therapy. We examined receipt of therapy and outcomes in the non-curative management of EGC based on medical oncology provider-volume.

Methods

We conducted a population based retrospective cohort study of non-curative EGC over 2005–2017 by linking administrative healthcare datasets. The volume of new EGC consultations per medical oncology provider per year was calculated and divided into quintiles. High-volume (HV) providers were defined as the 4-5th quintiles. Outcomes were receipt of chemotherapy and overall survival (OS). Multivariate logistic and Cox-proportional hazards regressions examined the association between management by HV provider, receipt of systemic therapy, and OS.

Results

7,011 EGC patients with non-curative management consulted with medical oncology. One-year OS was superior for HV providers (>11 patients/year), with 28.4% (95%CI: 26.7–30.2%) compared to 25.1% (95%CI: 23.8–26.3%) for low-volume (p < 0.001). After adjusting for age, sex, comorbidity burden, rurality, income quintile, and diagnosis year, HV provider was independently associated with higher odds of receiving chemotherapy (OR 1.13, 95%CI 1.01–1.26), and independently associated with superior OS (HR 0.89, 95%CI 0.84–0.93).

Conclusion

Medical oncology provider-volume was associated with variation in non-curative management and outcomes of EGC. Care by a HV provider was independently associated with higher odds of receiving chemotherapy and superior OS, after adjusting for case-mix. This information is important to inform disease care pathways and care organization; increase in the number of HV providers may reduce variation and improve outcomes.
619 HIGH DISCOVERY RATE OF GASTRODUODENAL EOSINOPHILIA BUT NOT EOSINOPHILIC ESOPHAGITIS IN PATIENTS WITH CHRONIC GASTROINTESTINAL SYMPTOMS
Authors: Talley Nicholas , Kamboj Amol , Chey William , Rasmussen Henrik , Lacy Brian , Hirano Ikuo , Chehade Mirna , Gonsalves Nirmala , Peterson Kathryn , Lembo Anthony , Schmitt Colleen , Rothenberg Marc , Genta Robert , Pletneva Maria , Turner Kevin , Pasha Malika , Dellon Evan , Sandborn William
Published: September 2021

Although the prevalence of eosinophilic gastrointestinal disorders (EGIDs) is increasing, there is evidence that eosinophilic gastritis and/or duodenitis (EG/EoD) are underdiagnosed. Patients with EG/EoD often present with chronic, non-specific gastrointestinal (GI) symptoms, similar to patients with functional GI disorders. We hypothesized that systematic evaluation, including multiple esophageal, gastric and duodenal biopsies, of patients with chronic GI symptoms might reveal a high rate of gastroduodenal eosinophila, with or without eosinophilic esophagitis (EoE).

Methods

We performed a prospective multi-center study of patients with non-specific GI symptoms for ≥6 months, from 20 sites. Patients completed a questionnaire assessing abdominal pain, abdominal cramping, early satiety, bloating, nausea, vomiting, diarrhea, and loss of appetite. Those with daily average symptom severity scores ≥3/10 for any single symptom underwent esophagogastroduodenoscopy (EGD) with collection of 4 esophageal (EoE), 8 gastric, and 4 duodenal biopsies, analyzed by central pathologists. Histologic criteria for EoE was ≥15eos/hpf in ≥1 esophageal site and for EG/EoD was peak eosinophil counts ≥30/hpf in ≥5 gastric hpfs and/or 3 duodenal hpfs—criteria used in randomized trials.

Results

Of 556 patients screened, 405 (73%) met symptom criteria and underwent EGD; 181 patients (45%, mean age 45, 73% female) who underwent EGD met the histologic criteria for EG/EoD, and of these, 7% also had EoE diagnosed. Overall 2% met histologic criteria for EoE alone. Of patients who met the histologic criteria for EG/EoD, 93% were previously diagnosed with gastroesophageal reflux disease (GERD), irritable bowel syndrome (IBS), or functional dyspepsia (FD) (Figure 1). The average duration of GI symptoms in the screened population as well as those that met histologic criteria for EG/EoD was 11 years.

Conclusion

Forty-five percent of patients with moderate-to-severe GI symptoms who underwent EGD met histologic criteria for EG/EoD. Over 90% of these patients had previously been diagnosed with GERD, IBS, and/or FD, and had minimal overlap with EoE. EGD with systematic gastroduodenal biopsies, and intentional evaluation for tissue eosinophilia, should be performed in patients with chronic GI symptoms. Accurate diagnosis of EG/EoD is required for appropriate, targeted treatment and improved outcomes of patients with moderate-to-severe GI symptoms.
621 PL02.05 LONG-TERM TREATMENT OF PATIENTS WITH EOSINOPHILIC GASTRITIS AND/OR EOSINOPHILIC DUODENITIS WITH LIRENTELIMAB, A MONOCLONAL ANTIBODY AGAINST SIGLEC-8
Authors: Peterson Kathryn , Chehade Mirna , Murray Joseph , Falk Gary , Gonsalves Nirmala , Genta Robert , Rothenberg Marc , Bledsoe Adam , Durrani Sandy , Vaezi Michael , Shaw Camilla , Rasmussen Henrik , Singh Bhupinder , Chang Alan , Kamboj Amol , Hirano Ikuo , Dellon Evan
Published: September 2021

Eosinophilic esophagitis (EoE), gastritis (EG), and/or duodenitis (EoD) are associated with accumulation and activation of eosinophils and mast cells in the esophagus, stomach, and/or duodenum, respectively. Lirentelimab (AK002), an antibody against siglec-8, depletes eosinophils and inhibits mast cells. We performed an open-label extension (OLE) study of subjects who completed ENIGMA (a randomized, double-blind, placebo-controlled phase 2 study of lirentelimab in adults with symptomatic, biopsy-confirmed EG and/or EoD, with or without EoE) to evaluate long-term responses.

Methods

Subjects who received 4 monthly infusions of lirentelimab or placebo during ENIGMA (n = 59) were eligible for the OLE; they received monthly, escalating doses of lirentelimab (0.3 or 1 mg/kg escalating to 3 mg/kg). Symptoms were assessed weekly using an electronic daily patient-reported outcome questionnaire and total symptom scores (TSS) were calculated. Patients underwent upper endoscopy with biopsy at screening and at the end of ENIGMA (day 99, week 16, blinded); in the OLE, endoscopies were performed on day 323 (30 weeks after the first dose in the OLE). Histopathology was assessed by a single pathologist.

Results

Fifty-eight subjects entered the OLE; 45 completed ≥52 weeks lirentelimab (including exposure during ENIGMA) and 29 completed 70 weeks. Mean TSS improved through week 70 (Figure 1). Subjects receiving 70 weeks lirentelimab (ENIGMA+OLE) had further improvements in TSS from baseline (mean reductions: 68% at weeks 29–30, 70% at weeks 51–52, 75% at weeks 69–70). Symptom scores (abdominal pain, nausea, vomiting, early satiety, appetite loss, abdominal cramping, bloating, diarrhea) decreased significantly from baseline. Treatment response was not associated with concomitant EoE. The most common adverse event was mild to moderate infusion-related reactions, usually with the first infusion.

Conclusion

In the OLE of the ENIGMA study, patients with EG and or EoD (with or without concomitant EoE) who received lirentelimab had sustained tissue eosinophil depletion and significant long-term symptom improvement. Symptoms continued to improve with duration of treatment. Lirentelimab appears to be a promising targeted treatment for EG and/or EoD.
627 PL11.02 ENSURE: AN INTERNATIONAL MULTICENTRE STUDY EXPLORING WHETHER SURVEILLANCE AFTER ESOPHAGEAL CANCER SURGERY IMPACTS ONCOLOGICAL AND QUALITY OF LIFE OUTCOMES
Authors: Elliott Jessie A , Markar Sheraz R , Klevebro Fredrik , Johar Asif , Goense Lucas , Lagergren Pernilla , Zaninotto Giovanni , Hillegersberg Richard , Nilsson Magnus , Hanna George , Reynolds John V ,   ENSURE Study Group*
Published: September 2021

Although established and emerging therapies for recurrent esophageal cancer (EC) may impact on survival and health related quality of life (HR-QL), surveillance protocols after the primary curative treatment of EC are varied and inconsistent, reflecting a limited evidence-base to guide an optimum approach. Specifically, whether advantages exist for an intensive surveillance protocol is unknown and was the focus of this study.

Methods

ENSURE was an international multicentre observational study of consecutive patients undergoing surgery with curative intent for esophageal and junctional cancers (2009–2015) across 20 European and North American centers (NCT03461341). Intensive surveillance (IS) was defined as routine annual CT/PET-CT during the first three postoperative years, and compared with standard surveillance (SS) with investigation as clinically indicated. The primary outcome measure was overall survival (OS), secondary outcomes included treatment, disease-specific survival (DSS), disease-free survival (DFS), recurrence pattern, and HR-QL. Multivariable linear, logistic and Cox proportional hazards regression analyses were performed to determine the independent impact of surveillance on oncologic outcomes and HR-QL.

Results

4,682 patients were studied, 45.5% underwent IS. At median follow-up of 60 months, 47.5% developed recurrence; oligometastatic in 39% of cases, with 31% receiving best supportive care, 60% chemotherapy and/or radiation, and 8% surgical resection. IS was associated with reduced symptomatic recurrence (OR0.17 [0.12–0.25]), increased tumor-directed therapy (OR2.09 [1.58–2.77]), and improved OS (HR0.90 [0.82–0.98], 5-year OS 47.9 ± 1.2% versus 43.2 ± 1.1%). On multivariable analysis, significantly improved OS with IS was maintained for patients who underwent surgery alone (HR0.60 [0.47–0.78]) and in those with lower pathological (y)pT stages (Tis-2, HR0.72 [0.58–0.89]). IS was associated with greater anxiety (P = 0.016), but similar overall HR-QL.

Conclusion

These data suggest that IS may improve oncologic outcomes, particularly in patients with early stage disease at presentation or with a favorable pathological stage post induction therapy. This may be relevant to guideline development and provide a framework and rationale for RCTs. It may also inform shared decision-making with patients at a time where therapeutic options for recurrence are expanding.
631 CLINICAL APPLICATION VALUE OF THE SYSTEMIC-IMMUNE-INFLAMMATION-INDEX FOR PREDICTING SURVIVAL IN PATIENTS WITH ESOPHAGEAL SQUAMOUS CELL CARCINOMA UNDERGOING CHEMORADIOTHERAPY OR RADIOTHERAPY
Authors: Wang Yuan , Lyu Jiahua , Xiao Ling , Liu Yudi , Liu Xiao , Li Ke , Zhang Rongke , Chen Taiyu , Zhang Hangyue , Tang Chunhan , Li Tao
Published: September 2021

The systemic immune-inflammation index(SII), a prognostic index integrating neutrophils, platelets and lymphocytes, has been shown to have predictive value for several common cancers. The study aim was to explore the clinical application value of the SII for prognosis of patients with esophageal squamous-cell carcinoma (ESCC) treated with radical chemoradiotherapy (CRT) or radiotherapy (RT).

Methods

Overall, 180 patients with ESCC who received radiotherapy with or without chemotherapy, from March 20, 2012 to December 25, 2017 were retrospectively analyzed. Based on serum measurements before/after/during treatment, the SII at ESCC was calculated by multiplying the sera absolute neutrophil and platelet counts, and then, divided by the absolute lymphocyte count. The Kaplan–Meier method and Cox proportional regression models were used to analyze the relationship between SII at different time points, the ratio of before and after radiotherapy and overall survival (OS).

Results

The area under ROC-curve of Ratio of SII before and after radiotherapy(RT-pre/Post-SII) was 0.635. The AUC of SII-values before, during and after radiotherapy was 0.618, 0.624 and 0.453, respectively. The cutoff-value of RT-pre/Post-SII was 0.498, and the patients were divided into low RT-pre/Post-SII group(<0.498) and high RT-pre/Post-SII group(≥0.498). RT-pre/Post-SII was related to tumor-length, KPS and severe thrombocytopenia in ESCC patients(P < 0.05). The median-OS in the high and low RT-pre/Post-SII group were 909 days, and 466 days, respectively. Multivariate analysis showed that KPS(P = 0.045), lymphatic-metastasis(P = 0.032), Mid-RT SII(P < 0.001) and RT-pre/Post-SII(P = 0.003) was independent prognostic factors affecting the prognosis of patients in ESCC treated with RT/CRT.

Conclusion

The calculation of SII value is simple, reliable and repeatable and can improve the accuracy of a patient’s prognosis. ESCC patients treated with RT or CRT with high SII before, and during radiotherapy are most likely to benefit from early anti-inflammatory or immunotherapy before and during radiotherapy, while immunological intervention for SII after radiotherapy is of little significance. Confirmation of these results by a large-sample prospective study is desirable.