bluuebunny/crossref_metadata_2025 huggingface dataset:
408. IS DYSPNOEA IN PARAOESOPHAGEAL HERNIA ONLY POST PRANDIAL? RELEVANCE TO THE POST TOOL DEVELOPMENT
Authors: Mugino Miho , Connell Louise , Paredes Steven , Khoma Oleksandr , Falk Gregory
Published: September 2024

Background

Paraoesophageal hernia (POH) presents with a unique symptomatology that may mimic respiratory and cardiovascular disease. Dyspnoea is increasingly recognised as a predominant symptom of POH. Post-prandial dyspnoea was included in a POH specific symptom reporting tool (POST). We have prospectively recorded the type of dyspnoea among patients with POH, and whether surgery improves dyspnoea.

Methods

Consecutive patients with POH managed in our service from 2009 to 2022 were identified. Preoperative dyspnoea was documented as 'post prandial' or 'with ordinary physical activity' on a symptom recording proforma. Post operative improvement in dyspnoea was evaluated.

Results

A total of 520 consecutive patients were diagnosed with POH between January 2009 to November 2022. 514 patients were included in the analysis; there were 383 females (75%) and mean age was 70. Improvement in dyspnoea was reported in 308 out of 355 (95%) patients. Pre-operative dyspnoea was categorised into activity induced (89%) and post-prandial (3%) or both (8%). Patients with both activity induced and post-prandial dyspnoea were 0.26 times less likely to report improvement in dyspnoea postoperatively than those with only activity induced dyspnoea (OR=0.26, 95% CI 0.07-0.94, P=0.041).

Conclusion

Symptom assessment of POH should include both post-prandial and activity induced dyspnoea, as both type of dyspnoea are associated with the presence of POH and is improved following surgical repair. There are multiple possible causes for dyspnoea including post prandial cardiac inflow obstruction, pulmonary aspiration, as well as anaemia (with or without iron deficiency) associated with the hernia. Any dyspnoea should be considered related to POH and therefore both post-prandial and activity induced dyspnoea should be included in diagnostic algorithm designed to evaluate POH.
440. QUANTIFICATION OF FLUORESCENCE ANGIOGRAPHY FOR ESOPHAGEAL PERFUSION ASSESSMENT: MEASURING AGREEMENT BETWEEN TWO SOFTWARE ALGORITHMS
Authors: Nijssen David J , Joosten Johanna J , Osterkamp Jens , van den Elzen Richard M , de Bruin Daniel Martijn , Svendsen Morten Bo Søndergaard , Dalsgaard Maria Winther , Gisbertz Suzanne S , Hompes Roel , Achiam Michael P , van Berge Henegouwen Mark I
Published: September 2024

Background

Indocyanine green fluorescence angiography (ICG-FA) may reduce perfusion related complications after esophagectomy with gastric conduit reconstruction. Software implementations for quantifying ICG-FA are emerging to overcome a subjective interpretation of the technology. Comparison between quantification algorithms is needed to judge its external validity. This study aimed to measure the agreement for esophageal perfusion assessment between two independently developed quantification software implementations.

Methods

This retrospective cohort analysis included standardized ICG-FA video recordings of patients who underwent esophagectomy with gastric conduit reconstruction between August 2020 until February 2022. Recordings were analysed by two quantification software implementations: AMS and CPH. The quantitative parameter used to measure visceral perfusion was the normalized maximum slope derived from fluorescence time curves. The agreement between AMS and CPH was evaluated in a Bland-Altman analysis. The relation between the intraoperative measurement of perfusion and the incidence of anastomotic leakage was determined for both software implementations.

Results

Seventy pre-anastomosis ICG-FA recordings were included in the study. The Bland-Altman analysis indicated a mean relative difference of +58.2% in the measurement of the normalized maximum slope when comparing the AMS software to CPH. The agreement between AMS and CPH deteriorated as the magnitude of the measured values increased, revealing a proportional (linear) bias (R2 = 0.512, p < .001). Neither the AMS nor the CPH measurements of the normalized maximum slope held a significant relationship with the occurrence of anastomotic leakage (median of 0.081 versus 0.074, p = 0.32 and 0.041 vs 0.042, p = 0.51, respectively). Divergent approaches in maximum slope determination and raw signal filtering were identified as contributing factors to the differences in outcome.

Conclusion

This is the first study to demonstrate technical differences in software implementations that can lead to discrepancies in ICG-FA quantification in human clinical cases. The possible variation among software-based quantification methods should be considered when interpreting studies that report quantitative ICG-FA parameters and derived thresholds, as there may be a limited external validity.
478. OVERVIEW ON USE OF THE TRANSCERVICAL MEDIASTINOSCOPIC APPROACH FOR MINIMALLY INVASIVE TREATMENT OF ESOPHAGEAL CANCER: ESTABLISHMENT OF INTERNATIONAL COLLABORATIVE GROUP
Authors: Riccio Federica , Fujiwara Hitoshi , Klarenbeek Bastiaan R , Cuesta Miguel A
Published: September 2024

Background

Minimally invasive esophagectomy has emerged as a promising alternative to open surgery, demonstrating reduced postoperative complications and comparable oncological outcomes. Despite advancements, pulmonary complications and anastomotic leakages remain concerns. Since 2015, a novel technique combining single-port transcervical and trans-hiatal laparoscopic mediastinal dissection for esophageal resection was introduced. This procedure exhibits lower pulmonary complication rates compared to traditional approaches. However, its global adoption is limited, necessitating collaborative efforts to standardize techniques and outcomes. Following the IDEAL framework stage 2B (exploration), an international collaborative group for transcervical esophagectomy has been established, aiming to exchange insights, experiences, and lessons learned.

Methods

A cross-sectional survey involving 13 surgeons currently practicing transcervical esophagectomy was conducted, revealing variations in surgical approaches, indications, and outcomes.

Results

Surgeons from China, Germany, Japan, and The Netherlands participated. Indications for surgery varied, with less selectivity in higher-volume centers. Large tumors near the carina, bulky primary lesions or T4 tumors were identified as contraindications.

Different surgical approaches were reported, with the left transcervical and abdominal laparoscopic/robotic dissection being the most common. The mean operative time was about 382.2±117.9 minutes. The mean blood loss was of 100.2±71.1 milliliters.

Surgeons reported high rates of R0 resection and lymph node harvesting, as well as low rates of pulmonary complications (8.6±3.7) and anastomotic leaks (10.1±5.2); however, concerns persist regarding recurrent laryngeal nerve injuries (27.2±18.2).

Conclusion

Transcervical esophagectomy is gradually gaining recognition, with varying adoption rates. The collaborative group aims to align techniques, share experiences, and standardize the procedure. Challenges include differences in indications, surgical approaches, and outcomes, highlighting the need for ongoing discussion and research. Despite concerns about recurrent laryngeal nerve injuries, the procedure shows promise in reducing pulmonary complications.

The establishment this collaborative group signifies a crucial step toward global acceptance. By fostering collaboration, the group aims to enhance patient care, minimize learning-associated morbidity, and contribute to the continuous advancement of this surgical technique. Future efforts will focus on standardization, comparative studies, and training protocols.
489. EVALUATION OF THE ONCOLOGICAL QUALITY OF MINIMALLY INVASIVE TRANSCERVICAL OESOPHAGECTOMY (MICE) USING A CADAVERIC MODEL
Authors: Riccio Federica , Rossato Thomas Bevilaqua , Hutteman Merlijn , Rosman Camiel , Cuesta Miguel A , Klarenbeek Bastiaan R
Published: September 2024

Background

Nodal involvement is a well-known factor of poor prognosis for esophageal cancer, but the extent of the lymph node dissection, or the number of the dissected lymph nodes, remains controversial questions. Western guidelines (ESMO and NCCN) suggest accomplishing esophagectomy with en-bloc two-field lymphadenectomy.

Minimally Invasive transCervical oEsophagectomy (MICE) is a novel technique for the minimally invasive treatment of esophageal cancer. In the literature, the radicality of this procedure still remains unknown, as evidenced by studies conducted in Eastern countries.

This descriptive study explores feasibility of MICE in Western countries using a cadaveric model.

Methods

A cadaver study was conducted in a real operating room setting, with bilateral lung ventilation induced to replicate a real-life situation. Mediastinal dissection was carried out via single port left transcervical mediastinoscopy. Subsequently, a right thoracoscopy in prone position was performed to access the clearance of the fatty tissue at the anatomical boundaries of the lymph node stations. The finalization of the dissection of the lower mediastinum via transhiatal approach was not performed because it was not in the aim of the study.

The extent and the radicality of the dissection were evaluated by an independent external expert.

Results

Results indicated effectiveness of MICE in dissecting lymph nodes around the lower and middle esophagus, as well as at the subcarinal station. At the upper esophagus level, harvesting was complete on the left side but some residual tissue was found on the right-side at the right recurrent laryngeal nerve and on the right pleura, this result was attributed to technical difficulty.

Conclusion

The findings suggest that MICE is adequate in accomplish a complete dissection of lymph nodes around the mediastinal esophagus, including a complete subcarinal dissection, adhering to Western lymphadenectomy standards. Further descriptive study on cadaver will help to understand if a more extensive lymphadenectomy is achievable.
500. PRIMARY ESOPHAGEAL LYMPHOMA: UNDERSTANDING PROGNOSTIC FACTORS AND OUTCOMES
Authors: Mylonakis Adam , Dimitrakoudi Maria , Vasilatou Diamantina , Tsapralis Dimitrios , Vasiliadis Georgios , Koliakos Nikolaos , Sakarellos Panagiotis , Kapetanakis Emmanouil I , Schizas Dimitrios
Published: September 2024

Background

Primary Esophageal Lymphoma (PEL) represents a rare subtype of gastrointestinal lymphomas, posing unique diagnostic and therapeutic challenges. Given its rarity, comprehensive insights into its prognostic factors and outcomes remain limited. This study examines the epidemiology, treatment modalities, and outcomes of PEL, aiming to identify significant prognostic factors that influence patient survival.

Methods

A systematic review of the literature was conducted across PubMed/Medline and Scopus databases, focusing on cases of adult PEL. Data extraction included demographic information, treatment modality, and patient outcomes. Survival rates were calculated, and prognostic factors were analyzed through unifactorial analysis.

Results

Out of 56 studies, 69 cases of PEL were analyzed, with a male-to-female ratio of 2.8:1 and mean age of 55.5 years. Patients were predominantly treated with chemotherapy (52.1%) while 20% underwent surgical treatment. The mean survival reported was 49.3 months with one-, three-, and five-year survival rates of 84.5%, 72.3%, and 28.9%, respectively, exhibiting a less favorable prognosis compared to common lymphoma types. Survival analysis revealed that local lymphadenopathy had a significant impact on prognosis (p=0.008), while gender, age, treatment approach, and type of lymphoma were not significant determinants of survival. Immunocompromised status showed a marginally significant effect on survival (p= 0.053).

Discussion

The study highlights the less favorable prognosis of PEL compared to more common lymphomas, emphasizing the importance of recognizing patients with unfavorable prognostic factors such as local lymphadenopathy and immunocompromised status. The findings advocate for the establishment of an international patient registry to better understand and manage PEL, aiming to standardize diagnostic criteria and treatment strategies.
504. SENTINEL LYMPH NODE NAVIGATED SURGERY IN ESOPHAGOGASTRIC JUNCTION ADENOCARCINOMA USING INDOCYANINE GREEN AND FLUORESCENCE IMAGING
Authors: Jarosciakova Silvia , Snajdauf Martin , Pazdro Alexandr , Jakubov Filip , Lischke Robert , Harustiak Tomas
Published: September 2024

Background

Sentinel lymph node navigated surgery (SNNS) has been adopted for various cancers to reduce the negative impact of lymphadenectomy. Limited lymph node dissection using SNNS might be employed in the management of clinically lymph node negative early esophagogastric junction adenocarcinoma (EGJAC). However, it must be sure that sentinel lymph nodes (SLNs) reflect the patient's overall pN status. The aim of this study was to determine the feasibility and safety of SNNS using near-infrared fluorescence imaging and to obtain preliminary data about sensitivity of prediction of lymph node metastasis using SNNS.

Methods

Patients with cT1-2cN0 EGJAC without neoadjuvant therapy were prospectively included. One patient was enrolled after non-radical endoscopic resection of a high-risk pT1 tumor. Solution of indocyanine green (ICG) and 10% human serum albumin (ICG concentration 1,25mg/mL) was injected endoscopically into the submucosal layer at four quadrants (á 0.5mL) around the tumor or endoscopic resection scar just before the surgery. Subsequently, SLNs were identified and removed laparoscopically using fluorescence imaging. Then, esophagectomy or gastrectomy with radical lymphadenectomy were performed in all patients.

Results

A total of nine patients underwent SNNS followed by radical surgery. Histopathology revealed pT0pN0 in 1 patient, pT1bN0 in 3 patients, pT1bN3 in 1 patient, pT2pN1 in 2 patients, pT3pN0 in 1 patient and pT3pN2 in 1 patient. Overall, 62 SLNs were detected (median 7 SLNs per patient, range 1-16). Metastases in SLNs were found in four patients. All patients with pathologically positive lymph nodes had at least one SLN positive for metastasis. Sensitivity of prediction of pN positive status was 100%, false negative rate was 0%. There were no ICG-related adverse events or complications associated with SNNS procedure.

Conclusion

These results suggest that SNNS using ICG and fluorescence imaging in early EGJAC is feasible and safe. Our pilot data show promising diagnostic accuracy of predicting pathological lymph node status using SNNS. However, further studies with a larger number of patients are needed before introducing SNNS into clinical practice.
523. FIVE YEARS OF FLOT THERAPY. RANDOMIZED CONTROLLED TRIAL EVIDENCE IN PRACTICE
Authors: Findlay Alasdair , Singh Urvashi , Cockbain Andrew , Dexter Simon , Sarela Abeezar , Hayden Jeremy , Mehta Samir , Coe Peter
Published: September 2024

Introduction

The combination of 5-flurouracil, oxaliplatin, leucovorin and docetaxel (FLOT) is an effective chemotherapy regime in locally advanced, resectable gastro-oesophageal adenocarcinoma. Since the FLOT4-AIO randomised controlled trial demonstrated superiority over ECF/ECX it has been standard of care at many centres and European Society of Medical Oncology’s recommended perioperative regimen. After over five years of offering this treatment to patients we assessed how this evidence had translated into practice; identifying factors that predict dose reduction or incomplete therapy and overall survival.

Method

Patients who had the combination of neoadjuvant FLOT chemotherapy and oesophagectomy for adenocarcinoma of the oesophagus or gastro-oesophageal junction between February 2018 and September 2023 were identified from a prospectively collected database. Data on completion of chemotherapy, perioperative outcomes and long-term survival were collected. Pathological regression was assessed using Mandard tumour regression grade (TRG). The peri-operative, pathological, and long-term outcomes of patients who completed four cycles of neoadjuvant FLOT was compared with those who had reduced dose or early cessation. Statistical analysis used IBM SPSS, with Mann-Whitney U and Chi squared for variable analysis and univariate cox regression for survival.

Results

Eighty patients were included with a median age of 66 (47-79), 84% were male. Full dose completion was achieved by 57 (71%) patients, 20 (25%) had dose reduction and 7(8%) did not complete four cycles. Age, anaerobic threshold and VO2 max were not significantly different between those completing or not completing neoadjuvant chemotherapy (p=0.460, p=0.624, p=0.104 respectively); or requiring dose reductions (p=0.317, p=0.587, p=0.82). Median TRG across all three groups was 3. Median follow up was 55.4 months and mean overall survival was 53.4 months. No difference in survival was observed between those who completed or did not complete neoadjuvant FLOT (p=0.45).

Conclusion

Completion of neoadjuvant chemotherapy was lower in this cohort of patients than FLOT4-AIO. Rates of pathological complete response were similar. This translated into similar mean overall survival. Median survival was unable to be calculated as survival exceeds 50% at the time of our study. The use of FLOT has translated well into the routine neoadjuvant clinical setting with acceptable short- and long-term outcomes.
527. SURGERY FOLLOWING ENDOSCOPIC RESECTION OF EARLY OESOPHAGO-GASTRIC CANCER AT ONE LARGE TERTIARY UNIT: A RETROSPECTIVE AUDIT
Authors: Khan Sharib , Boag Katie , Michel Martin , Sood Ruchit , Rembraken Bjorn , Coe Peter O
Published: September 2024

Background

Endoscopic resection (ER) is a therapeutic option for early oesophago-gastric (OG) cancer. It is recommended as primary treatment for T1a cancers and as an option in T1b cancers. Following ER, surgery is recommended if high-risk features are identified on post-operative pathology. The aim of this retrospective audit is to evaluate the outcomes of patients who underwent curative intent surgery following ER in a tertiary centre in the United Kingdom, to inform patient selection.

Methods

Data were retrospectively collected from 2015-2020 at one large tertiary referral centre. Patients were included if they underwent EMR for T1 oesophageal or gastric cancer. Patient demographics, information regarding referral and diagnosis, histology, staging, treatment and outcomes were recorded. Patients were offered surgical resection after EMR after discussion at a multidisciplinary team meeting. Data were analysed descriptively.

Results

186 patients underwent ER. Seventeen subsequently underwent curative surgery (Females, n=4), see Table 1 for further details. 41% experienced Clavien-Dindo complications Grade I-V.

Final histology were: 24% no residual cancer, 35% T1a, 24% T1b, 18% T2. The final stage was upgraded in 29%, 47% had the same grade or downgraded. Lymph node metastases were found in 24% of cases. In patients with no residual cancer after oesophagectomy: two had malignant deep margins on ER histology (T1b), one was recommended surgery, and one underwent chemo-radiation. Two patients had clear margins on ER (T1a m1), one had poorly differentiated histology and proceeded to surgery, the other underwent surveillance. Both patients who did not initially undergo surgery had recurrence (8 and 48 months).

Conclusion

Almost 10% of patients underwent surgery following ER. Despite selection criteria following international guidelines, 25% of those who underwent major surgery had no residual cancer following ER although a similar portion had positive lymph nodes. Morbidity and mortality following OG cancer remains significant and further work is required to better identify patients for surveillance following ER.
534. EVALUATION OF SURGICAL OUTCOMES IN ROBOTIC-ASSISTED ESOPHAGECTOMY
Authors: Takabe Yuya , Okabe Hiroshi , Sunagawa Hideki
Published: September 2024

Background

The adoption of robotic surgery for the treatment of esophageal cancer is on the rise, with reports indicating favorable short-term outcomes. This study aims to evaluate the performance of robotic-assisted esophagectomies at our hospital.

Methods

We conducted a retrospective analysis of perioperative outcomes in patients who underwent robotic-assisted esophagectomies. Cases requiring a two-stage operation were excluded.

Results

A total of 64 cases were evaluated, with a median age of 72.0 years (range 46-83). Histological types included SCC/AC/ASC/Other: 49/10/1/4 cases. Clinical stages were 0/I/II/III/IVA/IVB: 1/20/11/27/4/1 cases, respectively. Postoperative complications, classified as Clavien-Dindo (CD) Grade II or higher, occurred in 24 cases (37.5%), which included respiratory complications (pneumonia, atelectasis, pneumothorax) in 7 cases (10.9%), anastomotic leakage in 7 cases (10.9%), recurrent laryngeal nerve palsy in 3 cases (4.7%), anastomotic stricture in 2 cases (3.1%), wound infection in 2 cases, gastric conduit necrosis in 1 case (1.5%), cervical lymphorrhea in 1 case, tracheoesophageal fistula in 1 case, and other complications in 3 cases.

Conclusion

Robotic-assisted esophagectomies have demonstrated favorable short-term outcomes when compared with prior reports. Further studies are warranted to elucidate the reduction of complications and to determine long-term outcomes.
546. ESOPHAGEAL FUNCTION TESTS BEFORE AND AFTER LAPAROSCOPIC SLEEVE GASTRECTOMY FOR SEVERE OBESITY
Authors: Masuda Takahiro , Uno Kohei , Watanabe Atsushi , Tsuboi Kazuto , Hoshino Masato , Takahashi Keita , Sakashita Yuki , Fukushima Naoko , Takeuchi Hideyuki , Sato Kazuhide , Omura Nobuo , Yano Fumiaki , Eto Ken
Published: September 2024

Background

Gastroesophageal reflux disease is common in patients with severe obesity. However, changes in esophageal motility and gastroesophageal reflux in patients undergoing sleeve gastrectomy have not been well-studied. In this study, we evaluated the effects of sleeve gastrectomy on esophageal function.

Methods

All patients undergoing laparoscopic sleeve gastrectomy (LSG) at our institution are entered into a prospectively maintained database. We queried this database to identify patients who underwent pre- and post-LSG esophageal function tests (ie, high-resolution manometry [HRM] and 24-hour pH monitoring). Post-operative was esophageal function tests done at 12 months after surgery.

Results

A total of 44 patients underwent LSG between Jul. 2018 and Dec. 2022, of which 11 patients underwent both pre and post-LSG esophageal function tests. The study cohort had a mean age of 65.4 years with 5 males. BMI was significantly decreased after LSG (40.0 vs. 27.4 kg/m2，p=0.004). Manometric hiatal hernia was increased post-LSG (0% vs. 45.5% [n=5/11]), though this difference did not reach statistical significance (p=0.063). Esophagogastric junction contractile integral (EGJ-CI), thoraco-abdominal pressure gradient, and distal contractile integral (DCI) were similar between the two groups (p=0.155, p=0.154, and p=0.131, respectively). Post-LSG 24-hour pH monitoring showed higher acid exposure time (0.4% vs. 11.2%, p=0.005) and DeMeester score (3.5 vs. 33.2, p=0.003).

Conclusions

Gastroesophageal reflux was significantly exacerbated post-LSG, although esophageal motility and EGJ pressures were preserved after LSG. This may indicate that the change in EGJ morphology and disruption of the angle of His have an important role in mechanism of LSG-related GERD.
557. POTENTIAL THERAPEUTIC TARGETS OF TRPV2 AND SLC12A2 IN ESOPHAGEAL ADENOCARCINOMA CANCER STEM CELLS
Authors: Nakamichi Naosuke , Shiozaki Atsushi , Inoue Hiroyuki , Kosuga Toshiyuki , Shimizu Hiroki , Kudou Michihiro , Ohashi Takuma , Arita Tomohiro , Konishi Hirotaka , Morimura Ryo , Kuriu Yoshiaki , Ikoma Hisashi , Kubota Takeshi , Fujiwara Hitoshi , Otsuji Eigo
Published: September 2024

Background

Cancer stem cells (CSCs) are resistant to current anticancer drugs and radiation. The membrane transporters have recently been reported to play crucial roles for Esophageal adenocarcinoma (EA) CSCs. The aim of our study was to investigate ion channel expression profiles in esophageal adenocarcinoma CSCs (EACSCs) and to examine these potential as therapeutic targets.

Methods

Using the EA cell line OE33, cells with strong ALDH1A1 activity, a CSC marker, were isolated by flow cytometry. The characteristics of CSCs for the separated cells were verified by sphere formation assay, the expression of CSC markers on real-time reverse transcription-polymerase chain reaction and western blotting, and anti-cancer agent sensitivity assay. Gene expression profiles in EACSCs were examined by a microarray analysis. The transporters, high expression in CSC, were examined the anti-tumor effect of these inhibitors.

Results

Separated cells formed spheres in low-adhesion plates. The expressions of CSC markers were higher in CSCs than in non-CSCs. The CSCs also exhibited resistance to cisplatin and redifferentiation potential. The microarray analysis showed that the expression of transient receptor potential vanilloid 2 (TRPV2) and solute carrier family 12 member 2 (SLC12A2), which related to ion channels, were upregulated in CSCs. The cytotoxicities of tranilast and furosemide, which were TRPV2 and SLC12A2 inhibitors respectively, were added to cisplatin.

Conclusions

We revealed that TRPV2 and SLC12A2 are highly expressed in EACSCs and have potential as therapeutic targets for EA.
561. COMMONALITY AND VARIATION IN PERIOPERATIVE ESOPHAGEAL CANCER MANAGEMENT IN HIGH VOLUME EUROPEAN CENTERS
Authors: Jones Daniel , Seely Andrew , Grimminger Peter , Reynolds John , Rosati Riccardo , Hanna George , Nilsson Magnus , Markar Sheraz , van Hillegersberg Richard , van Berge Henegouwen Mark , Gisbertz Suzanne
Published: September 2024

Background

Esophageal cancer is a leading cause of cancer related death worldwide. For patients with locally advanced, non-metastatic, esophageal cancer (EC), surgical resection remains an essential pillar. The multitude of surgical options have driven innovation, however, lack standardization and at times high-quality data-driven practices. A surgeon-level in-depth interview and questionnaire was created to understand the perioperative care pathways and intraoperative techniques used by high-volume European EC centres to gain insight into commonality and variation of current practice.

Methods

Eight (8) expert upper gastrointestinal surgeons were invited to participate in an in-depth interview and questionnaire. The focus included preoperative care pathways for esophageal adenocarcinoma of the distal esophagus/GE junction, technical aspects of esophageal resection (Ivor-Lewis) and postoperative pathways. The involvement of allied health, dedicated research programs, multidisciplinary cancer conference (MCC), follow up protocols and management of T4b EC was also assessed.

Results

The response rate was 100% (8/8). Majority of respondents indicated a country-level regionalization of EC care. The number of centres performing esophageal resection varied from 4 – >100. Average number of esophagectomies/year ranged from 60-150. All centres presented EC patients at MCC, had dedicated research programs, and participated in National and International EC databases. Chemoradiotherapy was the predominate neoadjuvant treatment for GEJ cancers. Pretreatment clinical staging varied, with all centres having different, but pre-defined, preoperative and postoperative pathways. Intraoperative techniques including conduit preparation, feeding tube use, pyloric intervention, thoracic duct ligation and anastomotic technique varied substantially. There was no consensus regarding follow up or management of T4b EC.

Conclusion

The perioperative pathways and technical aspects of esophageal resection shared some commonalities however also differed substantially across high-volume EC centres in Europe. Multicenter, pragmatic randomized controlled trials (RCTs) are needed to better delineate which techniques should be included as standard of care, and which should be abandoned.
565. LAPAROSCOPIC TREATMENT OF HIATAL HERNIAS COMBINED WITH MODIFIED TOUPET FUNDOPLICATION. SURGICAL TECHNIQUE
Authors: Davakis Spyridon , Nitsa Zoi , Mylonakis Adam , Georgios Korovesis , Andreas Alexandrou , Charalabopoulos Alexandros
Published: September 2024

Introduction

Hiatal hernias are a common finding on radiographic or endoscopic studies. Hiatal hernias may become symptomatic or, less frequently, can incarcerate or become a volvulus leading to organ ischemia. This review examines latest evidence on the diagnostic workup and management of hiatal hernias.

Aim

This study aims to describe our surgical technique of laparoscopic repair in hiatal hernias, including sliding, paraesophageal and mixed types.

Material and Methods

A total of 65 consecutive patients underwent laparoscopic hiatal hernia repair by the same surgical team within 4 years.

Results

Asymptomatic hiatal and paraesophageal hernias become symptomatic and necessitate repair at a rate of 1% per year. Watchful waiting is appropriate for asymptomatic hernias. Symptomatic hiatal hernias and those with confirmed reflux disease require operative repair with an anti-reflux procedure. Key operative steps include the following: reduction and excision of hernia sac en bloc, 3 cm of intra-abdominal esophageal length, crural closure and an effective anti-reflux procedure as our modified Toupet fundoplication.

Conclusions

Hiatal hernias are commonly incidental findings. When hernias become symptomatic or have significant reflux disease, an operative repair is required. A minimally invasive approach is safe and can provide excellent outcomes in the hand of experts.

https://we.tl/t-KgcOuSyEMt
575. PATHOLOGIC RESPONSE AND RESIDUAL LYMPH NODE PATTERNS IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA PATIENTS UNDERGOING NEOADJUVANT IMMUNOCHEMOTHERAPY COMPARED TO NEOADJUVANT CHEMORADIOTHERAPY
Authors: Song Xinyun , Li Yue , Liu Jun , Lin Lin , Zhang Qin , Yu Wen , Fu Xiaolong
Published: September 2024

Background

Concurrent chemoradiotherapy is the cornerstone treatment for locally advanced esophageal cancer. Immunochemotherapy, established as the standard treatment for advanced esophageal cancer, concurrently exhibits excellent short-term efficacy in the neoadjuvant stage. Combining concurrent chemoradiotherapy with immunochemotherapy may enhance control over primary tumor and metastatic lymph nodes, potentially improving patients’ outcomes and survival. Therefore, comparing the pros and cons of these two treatment modalities in controlling primary lesions and lymph node metastasis is crucial for guiding clinical treatment.

Methods

Our study enrolled a total of 137 patients with esophageal squamous cell carcinoma (ESCC) who underwent neoadjuvant immunochemotherapy (NICT) and 151 ESCC patients who underwent neoadjuvant chemoradiotherapy (NCRT) between January 2019 and March 2022. We documented baseline patient characteristics, including clinical TNM stage, tumor location, and clinical metastatic lymph nodes, as well as pathologic outcomes such as pathological stage, pathologic complete response (pCR), tumor regression grade (TRG), and pathological metastatic lymph nodes. To balance baseline patient characteristics, we employed inverse probability of treatment weighting (IPTW) to adjust for confounding in different neoadjuvant treatment groups.

Results

After balancing baseline characteristics, there was no statistically significant difference in pathologic outcomes, including pCR rate, major pathologic response rate, TRG, yp-TNM stage, and R0 resection rate between NCRT and NICT. However, patients with clinical N2-3 stage (OR 2.66; 95% CI 1.05 to 6.79) or lower thoracic esophageal tumors (OR 2.31; 95% CI 1.05 to 5.04) had a higher chance of achieving pCR after NICT compared to NCRT. For patients undergoing NICT, the ypN0 rates for clinically N0 patients were 100.0% (5/5), while only 65.0% (13/20) of clinical N0 patients achieved ypN0 in the NCRT group. Even after adjusting for differences in clinical stage, tumor location, and baseline lymph node metastasis rates in various locations, the NICT group still demonstrated a lower rate of abdominal lymph node metastasis during surgery (p=0.030).

Conclusion

In comparison to concurrent chemoradiotherapy, immunochemotherapy exhibits comparable overall disease control for primary lesions and lymph node metastasis. Notably, patients with clinical N2-3 and lower thoracic esophageal cancer may derive greater benefits from NICT. The potential of immunochemotherapy in enhancing the effectiveness of chemoradiotherapy is evident in its ability to improve the control of occult metastatic lymph nodes and reduce abdominal lymph node metastasis.
577. OUTCOMES OF SIMULTANEOUS RESECTION AND RECONSTRUCTION OF ESOPHAGEAL SQUAMOUS CELL CARCINOMA SYNCHRONOUSLY ASSOCIATED WITH HEAD AND NECK CANCER
Authors: Kishino Takayoshi , Feng Dongping , Mastukawa Hiroyuki , Nishiura Bunpei , Kondo Akihiro , Ando Yasuhisa , Suto Hironobu , Asano Eisuke , Oshima Minoru , Kumamoto Kensuke , Okano Keiichi
Published: September 2024

In 1953, a study by Slaughter et al. on oral cancer proposed that field cancerization is the phenomenon of widespread carcinogenesis across multiple regions due to long-term exposure to common cancer-causing factors. Esophageal squamous cell carcinoma (ESCC) and head and neck cancer (HNC) share common risks, such as smoking and alcohol consumption, and are often observed synchronously. Therefore, treatment strategies based on tumor stages are important. In our hospital, for synchronous HNC and thoracic ESCC, local resection is indicated if the HNC is ≤T2, and resection with reconstruction is indicated if the HNC is ≥T3, and a one-stage operation for thoracic ESCC and HNC was generally performed. Here, we examined treatment strategies based on the results of simultaneous resection and reconstruction of synchronous thoracic ESCC and HNC in our hospital.

A total of 174 patients with esophageal cancer underwent surgery at our hospital between January 2008 and December 2023. Among them, 16 (9%) had 18 lesions of synchronous HNC and nine patients (5%) underwent simultaneous resection and reconstruction. Patients with thoracic ESCC had Ut/Mt/Lt; 1/6/2; T-factor, T1/2/3; 5/2/2; N-factor, N0/1:6/3; and clinical stage, stage I/II; 2/6. For synchronous HNC, hypopharyngeal/oropharyngeal/laryngeal/cervical esophageal cancer; 5/2/1/2; T factor was T2/3/4; 1/6/3; N factor was N0/1/2c/3a/3b; 4/2/2/2/1/1; and clinical stage was stage II/III/IV; 1/5/4. Six patients underwent surgery after preoperative chemotherapy or chemoradiotherapy. Total pharyngo-laryngo-esophagectomy (TPLE) was performed using a thoracoscopic transthoracic approach in six patients, transhiatal approach in two, and mediastinoscopic approach in one. Regarding reconstruction, a gastric tube was used in nine patients, including eight patients in whom it was interposed with the free jejunal autograft. The median operative time was 929 min (590–1248 min) and median blood loss was 622 mL (213–1764 mL). Only patients with skin valve necrosis underwent reoperation; however, there were no hospital deaths, and the median postoperative hospital stay was 39 days (28–59 days). Recurrence was observed in four cases. All cases were considered to be due to HNC, and three were stage IV cases with advanced lymph node metastasis.

Simultaneous resection and reconstruction for synchronous HNC and the thoracic esophagus is a highly invasive treatment that can be performed safely. Recurrence has been observed in advanced cases of HNC, and further development of multidisciplinary treatment, including preoperative chemotherapy, is necessary.
585. COMPREHENSIVE RISK SCORE OF THE E-PASS SERVES A PROGNOSTIC INDICATOR FOR PATIENTS AFTER NEOADJUVANT THERAPY AND CURATIVE ESOPHAGEAL CANCER SURGERY
Authors: Liu Yixin , Zhou Jianfeng , Yang YuShang , Chen Longqi
Published: September 2024

Background

Neoadjuvant chemoradiotherapy (nCRT) and curative surgery have been recommended as the standard treatments for locally advanced esophageal cancer. In addition, the comprehensive risk score (CRS) of the physiological ability and surgical stress (E-PASS) scoring system, incorporating both clinical and surgical factors, has proven effective in predicting postoperative complications and mortality. However, the impact of E-PASS scoring system on the prognosis of esophageal cancer remains uncertain. This study aimed to evaluate the comprehensive risk score of E-PASS scoring system for predicting the short- and long-term outcomes of patients treated with nCRT and esophageal cancer surgery.

Methods

Patients with esophageal cancer who underwent curative resection between 2010 and 2022 were retrospectively enrolled in this study. The cohort was divided into the low and high CRS groups. The CRS cutoff value was determined using the Youden index applied to overall survival (OS) curves. Prognostic value was assessed through Cox regression and Kaplan–Meier analyses.

Results

In total, 814 patients were enrolled, including 556 and 258 patients with low and high CRS, respectively. ROC curve analysis determined that the CRS was a highly specific and sensitive predictive tool for postoperative complication occurrence and severity (AUC=0.889 and 0.838, respectively). When the cutoff value was established using the Youden index applied to overall OS curves, multivariate analysis demonstrated that the CRS was an independent prognostic factor for OS (HR: 1.48; 95% CI 1.14–1.92, P=0.003) and recurrence-free survival (HR: 1.44; 95% CI 1.13–1.82, P=0.002), irrespective of esophageal cancer stage and tumor regression scores.

Conclusion

The E-PASS scoring system emerges as a visible predictor of short- and long-term outcomes in patients with esophageal cancer undergoing nCRT and curative surgery.
588. EFFICACY OF INTRAOPERATIVE RECURRENT LARYNGEAL NERVE MONITORING DURING MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A NATIONWIDE INPATIENT COHORT STUDY
Authors: Shigeno Takashi , Okuno Keisuke , Ogo Taichi , Fujiwara Hisashi , Tanioka Toshiro , Kawada Kenro , Haruki Shigeo , Tokunaga Masanori , Fushimi Kiyohide , Kinugasa Yusuke
Published: September 2024

Background

Lymphadenectomy around the recurrent laryngeal nerve (RLN) is an essential part of curative surgery for esophageal cancer. The rate of lymph node metastasis around the RLN is extremely high, and postoperative RLN palsy could lead to a poor prognosis in patients with esophageal cancer. Although several single-center studies have shown that intraoperative nerve monitoring (IONM) can avoid RLN palsy, this has not been confirmed in a large-scale multicenter study. This study was performed to evaluate whether intraoperative nerve monitoring IONM can reduce postoperative RLN palsy during minimally invasive esophagectomy (MIE) for esophageal cancer using a national database.

Methods

We retrieved data of patients with esophageal cancer who underwent MIE involving thoracoscopic or robotic esophagectomy with IONM (502 patients) and without IONM (4,353 patients) at 348 hospitals from April 2020 to March 2022 from the Diagnosis Procedure Combination database in Japan. We compared the frequency of postoperative RLN palsy and respiratory complications between the IONM (+) group and IONM (−) group using propensity score-matching (PSM) analysis. The propensity score was estimated using multivariable logistic regression models including age, sex, Body Mass Index, Brinkman index, Activities of Daily Living, comorbidities at admission, clinical TNM classification, approach of MIE, and hospital case volume with reference to previous studies of IONM.

Results

After PSM, the standardized bias was <10% for all covariates, which indicated improved balance in the covariates between the matched pairs. With 1-to-1 matching, 501 pairs (1,002 cases) were created between the IONM (+) and (−) groups. The postoperative RLN palsy rate was significantly lower in the IONM (+) than (−) group (odds ratio, 0.24; 95% confidence interval [CI], 0.13–0.46). The respiratory complication rate was also significantly lower in the IONM (+) than (−) group (odds ratio, 0.66; 95% CI, 0.45–0.97). The anesthesia time was significantly longer in the IONM (+) group (regression coefficient, 60.1 minutes; 95% CI, 44.2–76.9). The length of postoperative hospitalization tended to be shorter in the IONM (+) than (−) group (regression coefficient, −1.39 days; 95% CI, −3.91 to 1.14).

Conclusion

This nationwide cohort study showed that IONM during MIE for esophageal cancer can reduce postoperative RLN palsy and respiratory complications.
628. GUSTAVE ROUSSY IMMUNE SCORE IS A PROGNOSTIC MARKER IN PATIENTS WITH ESOPHAGEAL CANCER AFTER NEOADJUVANT THERAPY: A MULTICENTER RETROSPECTIVE STUDY
Authors: Fang Pinhao , Zhou Jianfeng , Yuan Yong
Published: September 2024

Background

GRIm-Score (Gustave Roussy Immune Score), a novel nutritional and inflammatory-based prognostic score, is an unfavorable prognostic factor in patients with esophageal carcinoma (EC). However, the prognostic importance of GRIm-Scores after neoadjuvant chemo-radiotherapy in these patients remains unclear.

Methods

A retrospective study including 432 EC patients undergoing surgical resection was performed. The GRIm-Score was calculated by lactate dehydrogenase (LDH), neutrophil-lymphocyte ratio (NLR), and albumin (ALB). The over survival (OS) and disease-free survival (DFS) were analyzed for the current study with Cox regression analyses, Kaplan-Meier methods, and propensity score matching (PSM).

Results

There were 374 (86.6%) men and 58 (13.4%) women with a mean age of 62.1 ± 7.7 years (range: 39-80 years). After PSM, cohorts consisted of 55 patients in the high GRIm-Score group and 55 in the low GRIm-Score group. Patient with a high GRIm-Score had poor OS (Cohort: p = 0.001; PSM: p = 0.007) and DFS (Cohort: p = 0.001; PSM: p = 0.008). The GRIm-Score, instead of NLR, LDH, or ALB in multivariate analyses, was an independent prognostic factor for OS (p = 0.019) before PSM. However, after PSM, it was a powerful independent prognostic factor for both OS (p = 0.028) and DFS (p = 0.039). Subgroup analyses showed that GRIm-Score could identify cases with worse OS or DFS among pT3-4 patients, indicating the complementary role of GRIm-Score in the decision-making of adjuvant therapy.

Conclusion

The GRIm-Score was an independent prognostic marker in patients with EC undergoing surgical resection after neoadjuvant therapy. Our study is also the first to discuss the prognostic value of GRIm-Score in patients with EC after neoadjuvant treatment.
647. INDOCYANINE GREEN (ICG) IDENTIFICATION OF A CISTERNA CHYLI LEAK FOLLOWING RADICAL OESOPHAGO-GASTRECTOMY WITH 2-FIELD LYMPHADENECTOMY: DESCRIPTION OF A NEW TECHNIQUE
Authors: Paine Heidi , Razi Kasra , Abbassi-Ghadi Nima , Preston Shaun R
Published: September 2024

Background

Chyle leak is a rare but feared complication post oesophago-gastrectomy, with far-reaching clinical and resource impacts including infection, re-admission and prolonged hospital stay, invasive procedures, and potentially missing the adjuvant therapy window. Low volume leaks can be managed medically via low-fat diet, nutritional support, and somatostatin analogues. Those of higher volume, or where medical management has failed, require radiological or surgical techniques. Where described, these techniques address leaks from a thoracic duct source and are therefore not applicable in patients having undergone oesophago-gastrectomy with radical two- or three- field lymphadenectomy, or where the suspected leak source is from abdominal lymphatics.

Methods

We report the case of a 78-year-old male diagnosed with cT4a N1 M0 oesophageal adenocarcinoma of the gastro-oesophageal junction. Following neoadjuvant chemotherapy, he underwent robotic-assisted two-phase oesophago-gastrectomy with two-field lymphadenectomy, in which the thoracic duct was identified and ligated. He returned one week post discharge with a left chylothorax. Drinage and medical management were unsuccessful, as were two radiological and one laparoscopic attempt at embolization of the leak. We describe a novel technique utilising indocyanine green (ICG) to identify and facilitate control of a cisterna chyli leak post-oesophago-gastrectomy with radical lymphadenectomy.

Results

Laparoscopy was performed and indocyanine green injected into the proximal jejunum submucosa, draining via mesenteric lymphatics to the cisterna chyli. Subsequent thoracoscopy revealed a prominent lymphatic channel around the left crus which was ligated. However, further leak was seen through the hiatus upon administration of high-fat jejunostomy feed. Re-laparoscopy revealed a leak from the cisterna chyli which was successfully ligated with ethibond sutures, leading to cessation of chyle leak and successful discharge of the patient, who subsequently received adjuvant therapy within the treatment window.

Conclusion

We describe a safe and effective novel technique for management of chyle leak from abdominal lymphatics or the cisterna chyli following oesophago-gastrectomy with radical two-field lymphadenectomy.

https://drive.google.com/file/d/1nCNnowdJVPlV0GOleXVNVMshuU19kCb/view?usp=sharing
743. HIATUS HERNIA AND GASTRO-OESOPHAGEAL REFLUX DISEASE. DOES SIZE MATTER?
Authors: Barghash Mohammed , Obayi Emmanuel , Itaman Usifoh , Furber Zoe , Caul Amy , Othman Ahmad , Mansour Moustafa
Published: September 2024

Background

Hiatus hernia occurs when part of the stomach bulges into the thoracic cavity through the hiatal opening of the diaphragm. In our study, we aimed to assess the impact of the hiatal hernia size on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies. The study also looked at the impact of various characteristics including age, smoking, alcohol consumption, body mass index (BMI), and presence of oesophagitis and/or dysmotility on DeMeester score, symptom correlation, and presence of pathological reflux on PH studies.

Methods

The study was conducted in an Upper Gastrointestinal surgery unit located in the North West of England. All patients aged over 18 who underwent laparoscopic fundoplication for gastro-oesophageal reflux disease between January 2017 and June 2023 were included. Patients who underwent fundoplication for para-oesophageal hiatus hernia, those who had fundoplication as a complementary step to Heller’s cardio-myotomy, or those who underwent revisional surgery were excluded.

Results

A total of 115 patients with a median age of 54 were included. Patients’ age was found to have a statistically significant association with hiatus hernia size above 2 cm, DeMeester score, and Symptom Association Probability with a P value of 0.011, 0.021, and 0.030 respectively. Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux (P=0.017). Smoking association with DeMeester score was found to be significant (P=0.027). Hiatus hernia size was not found to have a statistically significant association with DeMeester score, Symptom Index, or Symptom Association Probability (P=0.115, 0.315, 0.904) respectively.

Conclusion

Hiatus hernia size above 2 cm was found to have a statistically significant association with pathological reflux on PH studies but not statistically associated with elevated DeMeester score above 14.72 or symptom correlation indices. Thorough endoscopic assessment in addition to detailed oesophageal physiological studies are mandatory to evaluate patients with gastro-oesophageal reflux disease prior to considering surgery.