bluuebunny/crossref_metadata_2025 huggingface dataset:
506. MANAGEMENT OF POST INTUBATION TRACHEO-ESOPHAGEAL FISTULA. HOW, WHEN AND WHY TO FACE OFF A POTENTIALLY FATAL INJURY
Authors: Russo Emanuele , Caronia Francesco Paolo , Guggino Gianluca
Published: September 2022

Post-orotracheal intubation tracheal injuries are rare but potentially fatal events. The data in the literature show differences in incidence for single-lumen and double-lumen tube intubations. Esophageal involvement may evolve into mediastinitis with poor prognosis. Treatment depends on the location of the lesion, size, extent and the patient's status. Timing and multidisciplinary team evaluation is mandatory for best decision.

In a multi-centric observational study between January 2018 and December 2021 we observed 6 consecutive patients with iatrogenic post oro tracheal intubation tracheo-esophageal laceration underwent to multidisciplinary management.

4 patients were treated with end-to-end tracheal resection and anastomosis and closure of the esophageal fistula with cervicotomy access + interposed muscle flap without esophageal exclusion

1 patient was treated with tracheostomy and anterior fistula repair with cervicotomy access + esophageal exclusion

1 patient was treated conservatively for poor performance status. Surgical treatment was within 12 hours from diagnosis.

30-days mortality was observed in one case.

Post-orotracheal intubation tracheal injuries are rare but potentially fatal events. Fast and multidisciplinary decision with aggressive treatment are the goal to improve results and reduce mortality.
513. RISK FACTORS OF CERVICAL LYMPH NODE METASTASIS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA AND ESTABLISHMENT OF RISK PREDICTION MODEL
Authors: Gong Taiqian
Published: September 2022

Cervical lymph node metastasis of esophageal squamous cell carcinoma (ESCC) is an important basis for lymph node dissection of ESCC. Now, there are still disputes about whether to perform two field lymph node dissection or three field lymph node dissection. Establishing prediction model by analysis big data could promote the accuracy of prediction of cervical lymph node metastasis in patients with ESCC which can help clinicians to select individualized surgical scheme for patients

The clinical data of 102 consecutive patients with ESCC who underwent radical esophagectomy and three-field lymph node dissection between September 2015 to December 2021 were retrospectively analyzed. They were divided into positive group and negative group according to cervical lymph node metastasis. The differences between the two groups were compared, and after the univariate analysis those who were statistically significant were included in multivariable logistic regression analysis to establish the risk prediction model and plot a nomogram by software R.

Among the 102 patients, univariate analysis (P<0.2) indicated that cervical lymph node metastasis of ESCC was related to the distance from upper edge of the tumor to the incisors (P=0.085), vascular invasion (P= 0.141) and recurrent laryngeal nerve lymph nodes metastasis (P = 0.157). Multivariate logistic regression analysis showed that the distance from upper edge of the tumor to the incisors (P=0.153) and the vascular invasion (P=0.198) were independent risk factors. The AUC of ROC curve is 0.682 (95% confidence interval: 0.578-0.786) and the Youden index is 0.294, 95% CI (0.620, 0.742).

The prediction model includes two variables: the distance from upper edge of the tumor to the incisors and the vascular invasion. It plays a certain role in predicting the risk of cervical lymph node metastasis of ESCC, and can assist doctors in individualized treatment for patients with ESCC.
519. CLINICAL OUTCOMES OF ESOPHAGECTOMY IN ADVANCED AGE PATIENTS – A PROPENSITY SCORE MATCHING STUDY IN A LOCAL INSTITUTE
Authors: So Choi Kwan , Lam Chin Tou , Cheung Siu Hong , Chow Tam Lin
Published: September 2022

Esophagectomy for esophageal cancer is associated with high operative morbidity and mortality. While more patients diagnosed with esophageal cancer in advanced age, current study was to address the feasibility and safety of esophagectomy for advanced age patients.

Total 62 patients who underwent esophagectomy from 2017-2021 were recruited from local institute database. These patients were divided into 2 groups: group I (age <70), group II (age ≥70). Propensity score matching (PSM) analysis was performed with patient baseline demographics, tumour characteristics, and operation details. After PSM, 19 patients on each arm were identified. Primary outcome was major surgical morbidity rate (Clavien-Dindo Grade ≥3). Secondary outcomes included perioperative parameters, length of hospital stay, short-term mortality and overall survival.

The perioperative outcomes included day to resume oral feeding and mobilization were similar between two groups. There was a trend toward higher rate of chest infection (5.3% vs 26.3%, p=0.180) in group II. The length of hospital stay was significantly longer in older age group as well (9 days vs. 13 days, p=0.032). Nevertheless, there was no statistically significant difference in major surgical morbidity rate (10.5% vs. 5.3%, p=1.000) and 30-day mortality rate (0% vs. 5.3%, p=1.000) between two groups.

Esophagectomy was safe and feasible in selected advanced age patients with good performance status. There was no increase in major surgical complication rate and short-term mortality.

oldage.xlsx (could not be inserted)
534. CHEMORADIOTHERAPY FOR ESOPHAGEAL CANCER: DO WOMEN RESPOND BETTER THAN MEN?
Authors: Abdulrahman Maan , Abdulrahman Rand , Kumar Nitya , Corbally Martin , Walsh Thomas
Published: September 2022

The incidence of esophageal cancer is higher in men, with evidence that men present at a more advanced stage. Randomized trials of neoadjuvant treatments have hitherto not stratified for gender, but it is unclear whether the response to neoadjuvant chemoradiotherapy (NeoCR) and outcome is similar for both genders. The aim of this study is to compare presentation, response to treatment and survival of esophageal cancer between men and women.

A prospectively maintained database of 205 patients (143 males; 70%) diagnosed with esophageal carcinoma and treated with curative intent (definitive chemoradiotherapy, neo-adjuvant chemoradiotherapy followed by surgery or surveillance, or surgery alone), between 1998 and 2019 at one teaching hospital, was interrogated for impact of gender on response to treatment (complete versus incomplete clinical response) and survival.

Of 36 females who had NeoCR, 28 (78%) had a complete clinical response, compared to 52 of 116 males (45%). The complete pathological response rate was 21 of 36 (58.3%) of females compared to 31% of men (P<0.001). Controlling for age, stage at diagnosis, and type of therapy, females survived significantly longer than males [HR 0.72 CI 0.53-0.98 (p=0.038)].

Our results suggest a gender difference in response to chemoradiotherapy, which is reflected in outcome and survival. It is suggested that future randomized trials of neoadjuvant and indeed adjuvant therapy stratify for gender which may impact on management guidelines.
541. DO WE NEED ANOTHER QUESTIONNAIRE FOR GASTRO-ESOPHAGEAL REFLUX DISEASE? PRELIMINARY ANALYSIS OF A NEW QUESTIONNAIRE
Authors: Zanoni Andrea , Marchetti PierPaolo , Torroni Lorena , Vesentini Roberta , Lauro Enrico , Casella Francesco , Guerzoni Giacomo , Alessandro Carrara , de Manzoni Giovanni , Verlato Giuseppe
Published: September 2022

Gastroesophageal reflux is a very frequent condition and different questionnaires to describe it have been proposed overtime. Nevertheless available questionnaires don’t allow to fully describe all different aspects of the disease.

The aim of this study was to validate a new questionnaire (RoRex) on gastroesophageal reflux disease.

The RoRex questionnaire was administered via web in two Italian centres, Rovereto and Verona, to patients attending specialized gastrointestinal surgical units, and to volunteers. Up to now, 54 patients and 50 volunteers participated in the study. Median age was 52 years (range 23-75 years) in patients and 47.5 years (range 25-80 years) in volunteers. Women were more prevalent than men in both groups (57% and 56% respectively).

The RoRex questionnaire comprises 15 questions, where symptoms are scored on a frequency base: no, sometimes, several times per week, every day. Information on smoking habits, alcohol use, diet was also collected.

The two groups largely differed as regards major symptoms. Regurgitation, heartburn, epigastric pain, retrosternal pain, laryngospasm were reported several times per week/every day in 50%, 39%, 30%, 22%, 23% of patients and 9%, 11%, 7%, 7%, 0% of volunteers.

Preliminary analysis showed a different pattern in principal components between patients and volunteers. The 1st component, comprising heartburn and epigastric/retrosternal pain, was similar in both groups. The 2nd component comprised reclage, peevish cough, hoarseness in patients, and postnasal drip, hoarseness, dysphagia in volunteers. The 3rd component included regurgitation/laryngospasm in the former and peevish cough/belching in the latter.

The new questionnaire, based on symptom frequency, allows to distinguish among major symptoms, i.e. heartburn/pain, upper airways irritation, and regurgitation in patients suffering from gastroesophageal reflux disease. These results, as well as the comparison of RoRex questionnaire with already validated ones and its usefulness as a screening tool in the general population, will be verified in larger samples.
545. THE NATURE, SEVERITY AND IMPACT OF CURATIVE OESOPHAGEAL RESECTION FOR OESOPHAGEAL CANCER ON SWALLOWING THROUGHOUT SURVIVORSHIP: PRELIMINARY FINDINGS
Authors: Gillman Anna , Reynolds John V , Hayes Michelle , Walshe Margaret , Regan Julie
Published: September 2022

Survivors of curative oesophageal resection for oesophageal cancer present with oropharyngeal and oesophageal dysphagia for many years following surgery. Few studies have explored the presentation of oropharyngeal dysphagia throughout survivorship or its impact on swallow-related quality of life (QoL). This prospective observational study investigated 1) the nature, severity and QoL impact of transhiatal, 2 stage and 3 stage surgeries on swallowing at least 12 months post-operatively, and 2) relevant surgical and clinical associations.

Seventeen adults were recruited from a national centre for oesophageal cancer, including 14 males, 3 females (mean age = 62.59+/-10.44 years), who were a mean of 35.12 months (+/- 23.03) post curative oesophageal resection. Participants were assessed using videofluoroscopy (rated via MBS Impairment Profile), the EORTC-QLQ-OES-18 and Reflux Swallow Index (RSI) between November 2021 and March 2022. The Functional Oral Intake Scale (FOIS) was used to evaluate oral intake status. Bivariate analysis was conducted to investigate associations between the surgical approach, time since surgery, presence of dysphagia, altered diet, reflux, and QOL.

Participants presented with reduced laryngeal elevation (100%), delayed pharyngeal swallow initiation (94.2%), reduced hyoid movement (88.2%), reduced UES opening (70.7%) and oesophageal retention (89%). Mean MBS Imp Total Oral and Pharyngeal Scores were 5.41+/-2.58 and 7.53+/-2.6 respectively. 3 participants penetrated food/fluids (PAS mean 1.24 +/-.56). Mean FOIS, RSI and EORTC scores were 6.53+/-.514, 8.47+/-10.17 and 37.59+/-9.17 respectively. Surgical approach was associated with altered diet (FOIS) (p = 0.039). Time since surgery was associated with pharyngeal dysphagia (Total Pharyngeal Score (p = 0.023)), QOL was associated with altered diet (p= 0.038), RSI (p <0.001) and reduced anterior hyoid excursion (p= 0.046).

This preliminary study found that 1) all participants presented with an element of oropharyngeal dysphagia and 2) there are significant associations between surgical elements and oropharyngeal dysphagia, and between quality of life and altered diet, reflux, and hyoid movement. Further research and improved clinical practices are therefore required to minimise the severity of dysphagia experienced, to manage this chronic dysphagia throughout survivorship, and to ultimately reduce the impact it has on survivors.
556. MANAGEMENT OF INTRAOPERATIVE TRACHEAL TEAR DURING ESOPHAGECTOMY
Authors: Thammineedi Subramanyeshwar Rao , Shukla Srijan , Patnaik Sujit Chyau
Published: September 2022

Tracheal tears are serious complications of esophagectomy

With limited options available in a potentially unstable patient, timely management is a must

Using minimal access skills and endosuturing, an experienced surgeon can tackle this surgical emergency with primary repair

Adjunct step of omental wrapping can be added to buttress this repair

55 year gentleman with middle 1/3rd esophageal SCC post CROSS protocol neoadjuvant chemoradiation

Underwent thoracic dissection thoracoscopically with no events

During neck dissection, while looping the cervical esophagus, there is a sudden gush of air with fall in Oxygen saturation

Following is the video of how the surgical and anesthestic team handled the situation.
557. AN EXPERIENCE OF LAPAROSCOPIC GASTRECTOMY AND FUNDOPLICATION FOR A PATIENT WITH NEUROENDOCRINE TUMOR AND LARGE HIATAL HERNIA WITH UPSIDE-DOWN STOMACH
Authors: Kamiya Satoshi , Furukawa Kenichiro , Nagata Masato , Koseki Yusuke , Fujiya Keiichi , Hikage Makoto , Tanizawa Yutaka , Terashima Masanori , Bando Etsuro
Published: September 2022

The case of a neuroendocrine tumor arising from an upside-down stomach due to a large hiatal hernia is rare but occasionally encountered in clinical practice. As we experienced such a case and successfully treated by simultaneous laparoscopic distal gastrectomy and hernia repair with fundoplication, we here report our experience.

A 79-year-old woman was referred to our hospital with suspicion of a stomach submucosal tumor. Detailed examination revealed the submucosal tumor in diameter of 20mm located on the middle third of stomach, and the pathology of biopsy showed the positivity for Chromogranin-A and Synaptophysin. CT scan also demonstrated the large hiatal hernia with prolapsing the almost whole stomach and transverse colon to the left thoracic cavity. We diagnosed that as Rindi classification type III neuroendocrine tumor and complex esophageal hiatal hernia, and we planned laparoscopic distal gastrectomy and hernia repair with fundoplication.

Laparoscopy showed the prolapse of almost whole stomach and colon through the esophageal hilum to left thoracic cavity. We pull them back to abdominal cavity and divided the hernia sac at the level of hilum. After distal gastrectomy, we managed to close the enlarged esophageal hilum without using artificial mesh by suturing the crus of diaphragm. We added the Toupet fundoplication to remnant stomach, and reconstructed the digestive tract by means of Roux-en-Y method. There were no findings of passage obstruction or regurgitation in the peroral contrast examination. The patient was discharged 7 days after surgery with good postoperative course.

Simultaneous laparoscopic gastrectomy and esophageal hiatus hernia repair was successfully performed. Enlarged esophageal hilum could be closed without using the artificial mesh even for the patient with an upside-down stomach, and Toupet fundoplication could be added for a small remnant stomach after distal gastrectomy. Therefore, our procedure was considered to be a safe and feasible minimally invasive surgery for such patients.
558. SURVIVAL IMPACT OF CLINICAL AND NONCLINICAL REASONS FOR DELAY TO ESOPHAGECTOMY AFTER NEOADJUVANT CROSS THERAPY
Authors: Dave Yatee , Kapcio Kevin , Linville Wendy , Strawderman Myla , Peyre Christian , Jones Carolyn , Lada Michal
Published: September 2022

The optimal time interval between completion of standard-of-care neoadjuvant CROSS chemoradiation and esophagectomy (CRT-S) in patients with esophageal cancer remains controversial. Precise reasons for prolongment of this interval are not well described, although studies have associated a prolonged CRT-S with variable survival outcomes. We aimed to evaluate whether specific reasons for delay to esophagectomy beyond the recommended period of 8 weeks post-chemoradiation are associated with differences in overall survival (OS).

A prospectively maintained database was reviewed for patients with esophageal cancer at a single academic institution who completed neoadjuvant CROSS therapy and underwent subsequent esophagectomy from 2012 to 2019. Patients were grouped by time interval of CRT-S into a no-delay group (≤56 days) and delay group (>56 days). The delay group was then further stratified by clinical and nonclinical reasons for delay. Demographics, comorbidities and complications were compared. A multivariable Cox regression model was used to evaluate the impact of variables on OS from time of surgery. Survival outcomes were described using standard Kaplan-Meier curves.

Of 96 patients, 48 (50.5%) had delays, with 62.5% (n=30) being for nonclinical reasons. Post-operative complications were similar between the no-delay and delay subgroups, except that the clinical delay group had more unplanned intensive care unit admissions (p=0.032). The median CRT-S for the no-delay, overall delay, clinical delay, and nonclinical delay groups were 47, 71, 79, and 68 days, respectively. On multivariable analysis, nonclinical delay, male gender, pathologic complete response, and tumor location were independent predictors of improved survival. A nonclinical delay was associated with improved OS (p=0.010) while clinical delay was not significantly different (p=0.968) from the no-delay group.

Patients with delay to esophagectomy greater than 8 weeks for nonclinical reasons after completion of chemoradiation had improved survival compared to patients undergoing esophagectomy within 8 weeks or who had delayed surgery for clinical reasons. Delay for nonclinical reasons was not associated with increased rates of postoperative complications. Future studies regarding the optimal time interval between the completion of neoadjuvant chemoradiation and esophagectomy need to consider the specific reasons for delay to surgery.
575. MANUAL LAYER EMBEDDED ANASTOMOSIS: A NEW TECHNIQUE TO REDUCE ANASTOMOSIS LEAKAGE AFTER ESOPHAGECTOMY
Authors: He Xuedong , Han Yongtao , Peng Lin , Mao Tianqin , He Wenwu
Published: September 2022

The suturing after esophagectomy includes mechanical anastomosis and hand-sewn anastomosis. At present, various of anastomosis methods with potential anastomosis leakage, the optimal anastomosis methods still remain debates. This study described a new technique for creation of an anastomosis in thought to reduce the incidence of anastomosis leakage.

Between September 2020 to December 2021, the patients who received this new anastomosis technique enrolled into this retrospective study. The anastomosis method as follows. Firstly, the gastric conduit was shaped secondary to get adapt embedded length and anger. Secondary, the embedded posterior wall was sutured and layer sew anastomosis. And then, embedded the anastomosis after layer sew into gastric tube and suture the embedded anterior wall lastly. And the anastomosis was pushed into thorax from neck to ended this anastomosis procedure.

A total of 56 patients enrolled into this study comprised 51 males and 5 females with mean age of 65.4 years. Among of them 9 patients received neoadjuvant therapy. And all of them performed minimally invasive surgery by thoracoscope combined laparoscopic. The median intraoperative blood loss volume was 79.8ml (range 20-150ml). The median operate time was 331 minutes (range 220-465 minutes). The median postoperative feeding time was 6.3 days (range 3-8 days). All the patients without anastomosis leakage. The incidence of anastomotic stricture and the acid reflux ration were lower than the average of literature reports.

This new manual layered embedded esophagogastric anastomosis significantly reduce the incidence of anastomosis leakage and stricture, prevent the acid reflux. This technique has good short outcome and suitable for popularization and application.
580. EFFECTS OF NEOADJUVANT CHEMOTHERAPY ON PREOPERATIVE DISEASE SPECIFIC SYMPTOMS AND HEALTH RELATED QUALITY OF LIFE FOR PATIENTS WITH GASTROESOPHAGEAL CANCER
Authors: Holmén Anders , Klevebro Fredrik
Published: September 2022

Guidelines promotes neoadjuvant chemotherapy in treating gastroesophageal cancer, but little is known concerning effects on disease specific symptoms and health-related quality of life. We therefore wished to study how preoperative neoadjuvant chemotherapy might affect disease specific symptoms and preoperative health-related quality of life in patients with gastroesophageal cancer.

We performed a single center cohort study with prospectively collected data on patients with curative intended surgery due to gastroesophageal cancer between 2013 and 2020. Patients were asked to voluntarily assess their health-related quality of life prior to surgery and stratified with regards to neoadjuvant chemotherapy or surgery alone. Our primary endpoint was self-assessed health-related quality of life evaluated with validated quality of life questionnaires, transferred from a Likert scale to a 0-100 score according to scoring manuals. A multivariable adjusted model was constructed including for age, ASA-score, and clinical tumor T- and N-stage.

In total 361 patients were included of which 239 were treated with neoadjuvant chemotherapy. Patients that received neoadjuvant chemotherapy were in median 10 years younger and included more males (77 vs 65).

Patients treated with neoadjuvant chemotherapy reported better physical functioning (6.1, p=0.013), less pain (-10.9, p=0.004)), less insomnia (-12.6, p=0.004), and less trouble concerning eating restrictions (-11.9, p=0.005). Some symptoms were further reduced in patients with EC, such as dysphagia (-15.2, p=0.006), eating restrictions (-23.2, p= p<0.001), and odynophagia (-18.0%, p=0.002). Patients with GC had better physical functioning (11.06, p=0.015) and less pain (14.9, p=0.017).

With exception of sense of taste and hair loss, neoadjuvant chemotherapy may improve preoperative Health Related Quality of Life in patients with gastroesophageal cancer. This is even more clear concerning nutritional aspects and is more pronounced for patients with esophageal cancer.
584. PREVALENCE AND SURGICAL TREATMENT OF TRUE SHORT ESOPHAGUS IN GERD AND HIATUS HERNIA
Authors: Lugaresi Marialuisa , Tassi Valentina , Daddi Niccolò , Bassi Francesco , Pilotti Vladimiro , Mattioli Sandro
Published: September 2022

Prevalence and surgical treatment of true short esophagus (TSE), defined as the intra operative position of the apex of the gastric folds (endoscopic cardia- EC) <1.5 cm below the apex of the diaphragmatic hiatus after extend isolation of lower esophagus, are controversial. We report on 441 patients affected by GERD/HH, consecutively operated upon with three different minimally invasive surgical techniques, successively regularly followed up according to protocol, in the period 2004-2022.

The distance between the endoscopically-localized EC marked with clips by the surgeon and the apex of the diaphragmatic hiatus after maximal thoracic esophagus mobilization was measured during the laparoscopic procedure. A standard Nissen fundoplication (SN) was performed in cases with an abdominal length >1.5 cm; in cases of TSE a laparoscopic-thoracoscopic Collis-Nissen (CN) or laparoscopic Stomach Around Stomach Fundoplication (SASF) in elderly patients was performed. The fundoplication superior margin was always fixed below the hiatus, over the EC. Patients’ symptoms, radiological and endoscopic data were pre/postoperatively recorded.

After intra-thoracic esophageal mobilization (median =9 cm), TSE was diagnosed in 30.38 % of 441 cases (31,8% in 311/2004-2017; 27,7% in 130/2017-2022). SN was performed in 69%, CN in 23% and SASF in 7%. On 441 cases regularly followed up with a median of 106 months, HH relapse was radiologically diagnosed in 3%, with excellent, good, fair, and poor outcomes respectively in 46.3%, 43.2%, 6.7%, and 3.8% of cases. No outcome significant differences among SN CN and SASF, were recorded.

In the period 2004-2022, prevalence of TSE was constant in a significant third of patients routinely submitted to GERD/HH surgery. In the presence of TSE, CN and SASF performed according to determined surgical principles may achieve results as satisfactory as those obtained with SN.
591. THE ROLE OF INTRAOPERATIVE HYPERSPECTRAL IMAGING (HSI) IN THE CASE OF USING COLON INTERPOSITION AFTER OESOPHAGECTOMY
Authors: Zimmermann Anne , Köhler Hannes , Gockel Ines , Moulla Yusef
Published: September 2022

Colon conduit is an alternative option for the reconstruction after oesophagectomy. The impact of using Hypersepctral Imaging (HSI) has been already proved in evaluating the perfusion of gastric conduit, but not in the case of using colon conduit. This is the first study described a new tool evaluating the perfusion of colon conduit and allowing us as esophageal surgeons to choose the appropriate side (left or right) of colon conduit and anastomosis site intraoperatively

In 10 patients, who underwent reconstruction with a long segment colon conduit after oesephagectomy from 01.01.2018 till 01.04.2022. HSI was recorded in 8 of these patients at the root and tip of colon conduit after clamping the colic middle vessels allowing us to evaluate the perfusion and the appropriate side of colon conduit (Figure 1)

Anastomosis Leakage (AL) grad I° was detected only in one patient (12.5%) of all included patients (n=8). There was no conduit necrosis in all of these patients. Re-anastomosis was necessary only in one patient. There were no need to conduit resection and esophageal diversion or to stent placement in all of included patients. Furthermore, there were no change of the selected side of colon conduit intraoperatively

HSI is a promising novel intraoperative imaging tool to evaluate the perfusion of colon conduit objectively, which helping us to make the right decision regarding the side of the colon conduit as well as the site of the anastomosis intraoperatively.
592. CLINICAL EVALUATION OF A HYPERSPECTRAL IMAGING SYSTEM FOR MINIMALLY INVASIVE SURGERY (HSI-MIS)
Authors: Thomaßen Madeleine T , Köhler Hannes , Maktabi Marianne , Pfahl Annekatrin , Chalopin Claire , Gockel Ines , Moulla Yusef
Published: September 2022

Hyperspectral Imaging (HSI) provides surgeons intraoperative colored images of abdominal organgs detecting the perfusion and oxygenation. Limiting factors such as missing colour video, camera size, and long acquisition times have been overcome in the first CE-certified HSI-System for Minimally-Invasive Surgery (HSI-MIS; TIVITA® Mini Endoscopy Edition, Diaspective Vision GmbH, Am Salzhaff, Germany). This system was evaluated in-vivo during surgery and compared with an HSI-System for Open Surgery (TIVITA® Tissue, Diaspective Vision GmbH, Am Salzhaff, Germany).

Hyperspectral imaging was performed with both the HSI-MIS and the HSI-System for Open Surgery at the Region of Interest. 19 patients undergoing gastroenterologic resections were included in the study. The images acquired with the HSI-MIS were registered onto the images from the open HSI system, and spectra, as well as parameter images, were pixel-wise compared. Violin plots were created for Tissue Oxygen Saturation (StO2), Near-Infrared Perfusion Index (NIR PI), Tissue Water Index (TWI) and Organ Hemoglobin Index (OHI). The raw data was analyzed using a partial least squares (PLS) and compared with the parameters as calculated by the original software

The MAE results for the in-vivo evaluation were: StO2: 17.4% ± 7.6%, NIR PI: 16.3 ± 9.4, OHI: 14.3 ± 4.5, and TWI: 18.3 ± 7.8. The results obtained by PLS were StO2: 11.1% ± 3.9% (improved by 36%), NIR PI: 9.5 ± 5.8 (improved by 42%), OHI: 10.7 ± 2.7 (improved by 25%) and TWI: 9.6 ± 4.3 (improved by 48%)

Laparoscopic hyperspectral imaging during minimally invasive procedures shows promising results. Parameter deviations might be attributable to technical differences and on how the parameters are calculated. The PLS method has shown significant improvement compared to the original calculation.
593. UPPER MEDIASTINAL LYMPHADENECTOMY IN PRONE POSITION TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: Davakis Spyridon , Sakellariou Stratigoula , Stratigopoulou Panagiota , Ntoka Polyxeni , Giagkos Christos , Ziogas Dimitrios , Theochari Maria , Liakakos Theodoros , Charalabopoulos Alexandros
Published: September 2022

Minimally invasive esophagectomy (MIE) is a challenging procedure associated with high rate of complications and mortality. Routine lymphadenectomy includes 2-field lymphadenectomy for distal esophageal or esophago-gastric junction Siewert I-II cancers. SML refers to extended 2-field lymphadenectomy or total mediastinal lymphadenectomy. The exact benefits of superior mediastinal lymphadenectomy (SML) have long been debated with no clear evidence pertaining to improved outcomes.

N=150 consecutive patients underwent totally MIE under a surgical team from September 2016 to September 2020. SML included right paratracheal nodes and lymph nodes along the right recurrent laryngeal nerve throughout its mediastinal route (including the paratracheal-retrocaval compartment) in cases of extended 2-field lymphadenectomy, as well as left paratracheal nodes and lymph nodes along the left recurrent laryngeal nerve during total mediastinal lymphadenectomy. Eligible patients underwent SML during 2-stage or 3-stage MIE.

N=20 consecutive cases were identified as eligible according to the inclusion criteria during the study period. 30- and 90- day mortality rates were 0. There were no anastomotic or chyle leaks noted. Pulmonary complications were observed in 16.5% of the patients. There was 1 right recurrent laryngeal nerve palsy noted. Median length of hospital stay was 9 days. Median number of resected lymph nodes was 45 (Range: 37-68), with median SML nodes count being 8 (Range: 2-25). Median follow up was 24 months.

The small sample size is immediately recognised as a limiting and influencing factor in the results of this study. However, MIOs with SML may provide some, although not comprehensive, benefit in oncological outcomes without adding any further significant morbidity. Larger studies are needed to assess the role SML can play in improving patient outcomes.
601. SINGLE-PORT VATS ESOPHAGECTOMY. SAFE AND FEASIBLE TECHNIQUE
Authors: Caronia Francesco Paolo , Russo Emanuele
Published: September 2022

Minimally invasive esophagectomy represents the gold standard for the treatment of esophageal carcinoma. The improvement of surgical techniques and the development of the single port vats for the thoracic time represent a safe and efficacy option. We show some technical aspects showing the feasibility of this approach and the potential troubles to face up.

We show a single port vats esophagectomy combined with full laparoscopy in a patient with esophageal adenocarcinoma and esophageal stent.

Patient discharged in 7post operative day. Course was uneventful.

The minimally invasive approach represents the gold standard for the treatment of esophageal carcinoma. Single port vats may be a feasible and safe option.
602. LONG-TERM OUTCOME OF COLON INTERPOSITION IN SEVERE CORROSIVE UPPER DIGESTIVE TRACT INJURY
Authors: Tharavej Chadin , Chobarporn Thitiporn
Published: September 2022

Long-term outcome of colonic interposition in patients with severe corrosive upper gastrointestinal tract injury is less known.

Patients diagnosed of severe corrosive upper digestive tract injury were included. Patients with full-thickness organ necrosis underwent emergent surgical resection without primary reconstruction. Subsequent esophageal reconstruction with substernal colonic interposition approximately 6 months after the ingestion was undertaken in physically and mentally fit patients. Esophageal dilatation program was applied as first line treatment in all patients with esophageal stricture at a median duration of 5 weeks after the injury. Esophageal replacement procedure was offered to the patients who had failed dilatation. Late complications, swallow function, nutritional autonomy and overall survival in patients who underwent colonic interposition were evaluated.

There were 70 patients undergoing colonic interposition. Of 70 patients, 50 (71%) had cervical pharyngo-colonic and 20 had cervical esophago-colonic anastomoses. There was one (1.4%) 90-day hospital mortality. Anastomosis leakage was 8%. At median follow up of 58 months, late deaths were observed in 6 patients causing by nesidioblastosis (2), resuicidal attempt (2) and intestinal volvulus (2). Adhesive small intestinal obstruction requiring laparotomy was observed in 7(10%). Nutritional autonomy was achieved in 55 of 60 (92%) patients. Strictures were developed in 10 (16%) and dumping syndrome in 20 (30%) patients. Five- and ten-year overall survival were 72% and 61%, respectively.

Colonic interposition in patients with severe corrosive upper digestive tract injury was safe and effective. Long-term survival, function and nutritional outcome are good regardless of the proximal level of cervical anastomosis. However, the late negative impact of the reconstructive procedure on metabolic derangement and small intestinal obstruction cannot be overemphasized.
628. THE BEST METHOD OF THE GASTRIC TUBE RECONSTRUCTION AFTER ESOPHAGECTOMY
Authors: Inoue Seiya , Yoshida Takahiro , Goto Masakazu , Fujiwara Satoshi , Toba Hiroaki , Takizawa Hiromitsu
Published: September 2022

As a postoperative complication of esophageal cancer, anastomotic leakage (AL) is a serious complication that affects not only the delay in the start of oral intake but also the prognosis. Anastomotic stenosis (AS) also has a significant effect on postoperative quality of life. The blood flow evaluation of gastric tube was introduced for the purpose of improving these, and then the anastomosis method was changed from hand-sewn to Collard's modified method.

Esophageal cancer patients who underwent gastric tube reconstruction as a radical operation for esophageal cancer during the period from January 2017 to November 2021 were included (n=120). The blood flow evaluation of gastric tube using the ICG was started in 2019, and the anastomosis method was changed from hand-sewn to Collard modified method from April 2021. These patients were divided into 3 groups and the surgical results were compared and examined. Group A (without blood flow evaluation, hand-sewn): 55 cases, Group B (with blood flow evaluation, hand-sewn): 42 cases, Group C (with blood flow evaluation, modified Collard method): 23 cases.

In the blood flow evaluation of gastric tube, the A and B groups were compared, and the AL incidence rate tended to be higher in the B group (A/B: 18.2%/33.3%, p=0.087). The incidence of AS was significantly higher in group B (A/B: 32.7%/66.7%, p=0.001). There was no difference in the incidence of AL between groups B and C (B/C: 33.3%/26.0%, p=0.586). The incidence of AS was significantly lower in group C (B/C: 66.7%/5.9%, p<0.001). The incidence of AL was compared by anastomotic method, but no difference was observed (P = 0.444). In addition, there was no difference in postoperative complications.

It is considered that the modified Collard method could reduce AS because a constant anastomosis diameter could be maintained even when a difference in diameter between the esophagus and the gastric tube was observed during the anastomosis. However, both AL and AS have increased due to the evaluation of gastric tube blood flow, and it is necessary to review the blood flow evaluation method.
636. EVOLUTION OF THE INDICATION OF COLONIC INTERPOSITION FOR THE ESOPHAGUS - THE PAST AND THE PRESENT
Authors: Lai Wai Yin
Published: September 2022

Although the stomach is the most common organ used for reconstruction after esophagectomy, some situations precluded its use. The colon is a common alternative. The outcomes of colonic interposition from previous literature were very variable. Our study aims at reviewing the evolution in the indications and outcomes of colonic interposition over the past 38 years.

This is a retrospective cohort study of all patients who underwent colonic interposition from November 1982 to October 2021 at our centre. Primary outcomes included 30- and 90-day mortality. Secondary outcomes include surgical complications including anastomotic leakage, anastomotic stricture and graft ischaemia.

The major indication of colonic interposition shifted from palliation of esophageal cancer to substitute conduit for curative esophagectomy in the study period. Its use was also extended to the treatment of caustic esophageal injuries in recent years.

In terms of surgical techniques, there were significantly higher rates of the retrosternal route of reconstruction and more use of the right colon in recent years.

In patients who underwent colonic interposition after curative esophagectomy for esophageal cancer, the 30- and 90-day mortality were 1.9% and 5.7% respectively. The occurrence of anastomotic leakage, stricture and graft ischaemia were 9.6%, 17.3% and 7.7% respectively.

Colonic interposition represents a viable option when the stomach cannot be used to replace the diseased esophagus. Despite its complexity, we demonstrated reasonable survival and comparable outcomes of the technique.
648. HYPOXIA-INDUCIBLE FACTOR 1α (HIF-1α) STIMULATES THE PROGRESSION OF ESOPHAGEAL SQUAMOUS CELL CARCINOMA BY ACTIVATING THE WNT/β-CATENIN SIGNALLING PATHWAY
Authors: Toyozumi Takeshi , Tang Kang , Murakami Kentaro , Endo Satoshi , Matsumoto Yasunori , Otsuka Ryota , Kinoshita Kazuya , Sasaki Takuma , Iida Shinichiro , Morishita Hiroki , Hu Jie , Uesato Masaya , Urahama Ryuma , Kurata Yoshihiro , Nakano Akira , Matsubara Hisahiro
Published: September 2022

Hypoxia inducible factor -1α (HIF-1α) and Wnt/β-catenin signal pathway has been reported to be involved in tumor progression in various types of cancers. However, the molecular mechanism by which HIF-1α regulate malignant features in esophageal squamous cell carcninoma (ESCC) are still poorly understood. This study aimed to clarify the significance of the crosstalk between HIF-1α and the Wnt/β-catenin pathway in ESCC.

The oncogenic role of HIF-1α in ESCC was investigated using in vitro and in vivo assays. The clinicopathological significance of HIF-1α, β-catenin and TCF4/TCF7L2 in ESCC were evaluated using quantitative real-time PCR and immunohistochemistry. Then we performed qRT-PCR, western blotting, Cell Counting-8 assay, trans-well assay, flow cytometry, immunofluorescence, Co-IP and ChIP assays, chemo resistance test in vitro, tumor xenograft model in vivo.

The expression level of HIF-1α, β-catenin, and TCF4/TCF7L2 in ESCC cell lines were elevated under hypoxia in vitro. HIF-1α knockdown suppressed proliferation, igration/invasion and EMT progression, induced G0/G1 cell cycle arrest, promoted apoptosis and inhibited 5-fluorouracil chemoresistance in vitro. In vivo assays showed that HIF-1α is essential in maintaining tumour growth and 5-fluorouracil chemoresistance. Mechanically, we identified the complex between HIF-1α and β-catenin, HIF-1α can directly bind to the promoter region of TCF4/TCF7L2. The mRNA level of HIF-1α, β-catenin and TCF4/TCF7L2 were increased in ESCC tumor tissues. High levels of HIF-1α and TCF4/TCF7L2 were correlated with poor prognosis in ESCC.

HIF-1α serves as an oncogenic transcriptional factor in ESCC, probably by directly targeting TCF4/TCF7L2 and activating the Wnt/β-catenin pathway. Our study clarifies the critical role of HIF-1α in ESCC progression.
650. ROBOTIC ESOPHAGEAL LEIOMYOMA ENUCLEATION
Authors: Jiwnani Sabita , Gopinath Srinivas Kodaganur , Niyogi Devayani , Tiwari Virendra , Karimundackal George , Pramesh CS
Published: September 2022

Leiomyomas are rare benign esophageal neoplasms. Surgery is indicated in symptomatic patients or if malignancy is suspected. A 20-year-old female presented with dysphagia to solids. Contrast enhanced computed tomography showed a 33-mm by 30-mm by 51 mm well circumscribed lobulated mass arising from the right anterolateral wall of the upper thoracic esophagus, causing luminal narrowing and abutting the azygos vein. An esophageal ultrasound performed for confirmation showed the lesion arising from the muscularis propria.

Patient was scheduled for a robotic leiomyoma excision. Patient was placed in left lateral position, lung isolation was obtained with a double lumen tube. Four standard ports were placed in the sixth intercostal space. Robotic instruments used were the monopolar scissors, Maryland bipolar forceps, fenestrated bipolar forceps for dissection and needle holder for suturing. The leiomyoma was identified, mediastinal pleura and muscle layer were incised longitudinally. The leiomyoma was dissected all around in the submuscular plane taking care not to injure the underlying mucosa. However, while delivering the deep lobulated portion, there was an inadvertent injury to the mucosa.

The mucosal tear was repaired with interrupted sutures utilising 4-0 Polydiaxanone sutures and the muscle layer was closed with V-Lock sutures. A check endoscopy was performed on table along with air insufflation with saline in the pleural cavity to check for an air leak. A nasogastric tube was placed, specimen was retrieved in a bag through the assistant port. Surgery was completed in 155 minutes with 50 ml blood loss. Post-operative course was uneventful, and the patient was discharged on full diet on the fourth post-operative day. Histopathology showed a SMA and desmin-positive spindle cell neoplasm without conspicuous mitotic activity.

Precise dissection in a confined space is possible due to wrist-like movements, three-dimensional view and magnification offered by the robot. Repair of the injured mucosa and myotomy closure to prevent future diverticulum formation is easily accomplished with robotic suturing. Intraoperative endoscopy is useful in evaluating the integrity of the mucosa and muscle repair. Hence a robotic approach may be superior to a thoracoscopic/open leiomyoma enucleation and can be utilised even in moderate size masses.
Transcatheter treatment of severe aortic stenosis in patients with complex coronary artery disease: case series and proposed therapeutic algorithm
Authors: Soriano Francesco , Montalto Claudio , Calderone Dario , Nava Stefano , Esposito Giuseppe , Saia Francesco , Oreglia Jacopo A , Søndergaard Lars
Published: September 2022

Background

Patients with severe aortic stenosis (AS) and complex coronary artery disease with a clinical indication to both transcatheter aortic valve implantation (TAVI) and percutaneous coronary intervention (PCI) pose a clinical dilemma since it is unclear which lesion should be treated first and careful planning is required.

Case summary

We report two cases of AS with complex PCI (ASCoP) features. In the first one, easy coronary cannulation with an Acurate Neo2 valve and commissural alignment was predicted; therefore, TAVI was performed first, and subsequently complex high-risk PCI of the left main was performed in the same procedure but without the burden of ongoing severe AS. In the second case, complex coronary cannulation after TAVI with an Evolut PRO valve was predicted; therefore, balloon aortic valvuloplasty and Impella placement were performed first to allow for complex, high-risk multivessel PCI and subsequent TAVI. In both cases, a single-stage approach was preferred to reduce the use of large-bore arterial access with possible consequent adverse events.

Discussion

In this case series, we illustrate a possible approach to the treatment of ASCoP patients. In such complex cases, a thorough preprocedural planning is mandatory, and clinical decision-making should be centred upon the predicted chance of cannulation of coronary arteries after TAVI.
Adding gene transcripts into genomic prediction improves accuracy and reveals sampling time dependence
Authors: Perez Bruno C , Bink Marco C A M , Svenson Karen L , Churchill Gary A , Calus Mario P L
Published: September 2022

Recent developments allowed generating multiple high-quality ‘omics’ data that could increase the predictive performance of genomic prediction for phenotypes and genetic merit in animals and plants. Here, we have assessed the performance of parametric and nonparametric models that leverage transcriptomics in genomic prediction for 13 complex traits recorded in 478 animals from an outbred mouse population. Parametric models were implemented using the best linear unbiased prediction, while nonparametric models were implemented using the gradient boosting machine algorithm. We also propose a new model named GTCBLUP that aims to remove between-omics-layer covariance from predictors, whereas its counterpart GTBLUP does not do that. While gradient boosting machine models captured more phenotypic variation, their predictive performance did not exceed the best linear unbiased prediction models for most traits. Models leveraging gene transcripts captured higher proportions of the phenotypic variance for almost all traits when these were measured closer to the moment of measuring gene transcripts in the liver. In most cases, the combination of layers was not able to outperform the best single-omics models to predict phenotypes. Using only gene transcripts, the gradient boosting machine model was able to outperform best linear unbiased prediction for most traits except body weight, but the same pattern was not observed when using both single nucleotide polymorphism genotypes and gene transcripts. Although the GTCBLUP model was not able to produce the most accurate phenotypic predictions, it showed the highest accuracies for breeding values for 9 out of 13 traits. We recommend using the GTBLUP model for prediction of phenotypes and using the GTCBLUP for prediction of breeding values.
M6A RNA Methylation-Based Epitranscriptomic Modifications in Plasticity-Related Genes via miR-124-C/EBPα-FTO-Transcriptional Axis in the Hippocampus of Learned Helplessness Rats
Authors: Roy Bhaskar , Ochi Shinichiro , Dwivedi Yogesh
Published: September 2022

Background

Impaired synaptic plasticity has been linked to dynamic gene regulatory network changes. Recently, gene regulation has been introduced with the emerging concept of unique N6-methyladenosine (m6A)-based reversible transcript methylation. In this study, we tested whether m6A RNA methylation may potentially serve as a link between the stressful insults and altered expression of plasticity-related genes.

Methods

Expression of plasticity genes Nr3c1, Creb1, Ntrk2; m6A-modifying enzymes Fto, methyltransferase like (Mettl)-3 and 14; DNA methylation enzymes Dnmt1, Dnmt3a; transcription factor C/ebp-α; and miRNA-124-3p were determined by quantitative polymerase chain reaction (qPCR) in the hippocampus of rats that showed susceptibility to develop stress-induced depression (learned helplessness). M6A methylation of plasticity-related genes was determined following m6A mRNA immunoprecipitation. Chromatin immunoprecipitation was used to examine the endogenous binding of C/EBP-α to the Fto promoter. MiR-124–mediated post-transcriptional inhibition of Fto via C/EBPα was determined using an in vitro model.

Results

Hippocampus of learned helplessness rats showed downregulation of Nr3c1, Creb1, and Ntrk2 along with enrichment in their m6A methylation. A downregulation in demethylating enzyme Fto and upregulation in methylating enzyme Mettl3 were also noted. The Fto promoter was hypomethylated due to the lower expression of Dnmt1 and Dnmt3a. At the same time, there was a lower occupancy of transcription factor C/EBPα on the Fto promoter. Conversely, C/ebp-α transcript was downregulated via induced miR-124-3p expression.

Conclusions

Our study mechanistically linked defective C/EBP-α-FTO-axis, epigenetically influenced by induced expression of miR-124-3p, in modifying m6A enrichment in plasticity-related genes. This could potentially be linked with abnormal neuronal plasticity in depression.