bluuebunny/crossref_metadata_2025 huggingface dataset:
P62 RISK FACTORS AND OUTCOMES ASSOCIATED WITH ANASTOMOTIC LEAKS (AL) FOLLOWING OESOPHAGECTOMY: A SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: Sivesh K Kamarajah , Aaron Lin , Thahesh Tharmaraja , Yashvi Bharwada , James R Bundred , Dmitri Nepogodiev , Richard PT Evans , Pritam Singh , Ewen A Griffiths
Published: November 2019

Introduction

Anastomotic leaks (AL) are a major complication after oesophagectomy. This meta-analysis aimed to determine identify risks factors for AL (pre-operative, intra-operative and post-operative factors) and assess the consequences to outcome on patients who developed an AL.

Methods

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 31st December 2018. A meta-analysis was conducted with the use of random-effects modelling and prospectively registered with the PROSPERO database (Registration CRD42018130732).

Results

This review identified 174 studies reporting outcomes of 74,226 patients undergoing oesophagectomy. The overall pooled AL rates were 11%, ranging from 0 - 49% in individual studies. Majority of studies were from Asia (n=79). In pooled analyses, 23 factors were associated with AL (17 preoperative and six intraoperative).

AL were associated with adverse outcomes including pulmonary (OR: 4.54, CI95%: 2.99 - 6.89, p<0.001) and cardiac complications (OR: 2.44, CI95%: 1.77 - 3.37, p<0.001), prolonged hospital stay (mean difference: 15 days, CI95%: 10 - 21 days, p<0.001 and in-hospital mortality (OR: 5.91, CI95%: 1.41 - 24.79, p=0.015).

Conclusion

AL are a major complication following oesophagectomy accounting for major morbidity and mortality. This meta-analysis identified modifiable risk factors for AL which can be a target for interventions to reduce anastomotic leak rates. Furthermore, identification of both modifiable and non-modifiable risk factors will facilitate risk stratification and prediction of AL enabling better perioperative planning, patient counselling and informed consent.
P63 REQUIREMENTS FOR A NEW DIAGNOSTIC TEST TO DETECT LYMPH NODE METASTASES IN ESOPHAGEAL CANCER: A HEALTH-ECONOMIC MODELLING STUDY
Authors: Scholte M , de Gouw D J J M , Klarenbeek B R , Grutters J P C , Rosman C , Rovers M M
Published: November 2019

Background

Curative treatment for esophageal cancer consists of neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy with lymph node dissection (LND). Despite only 31-38% of patients harbour positive lymph nodes, all patients undergo LND with associated morbidity. Ideally, a non-invasive diagnostic test would indicate if LND is needed, however it is unknown what requirements such a test should have to justify minimizing LND from a cost-effectiveness perspective.

Objective

To determine the potential cost-effectiveness, minimally required accuracy and maximum cost of a hypothetical new diagnostic test.

Methods

A decision tree with state-transition model was constructed for patients with resectable esophageal cancer who received nCRT and are scheduled for esophagectomy. The current strategy including LND was compared to omitting LND based on a hypothetical diagnostic test in terms of costs and QALYs. Input data for the LND strategy was derived from literature. Consequences of omitting LND on procedure time, complications and hospital stay were based on a worldwide case vignette study among esophageal surgeons (N=89). Deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty.

Results

Assuming 100% sensitivity of LND and 100% accuracy of the hypothetical test at zero costs, the hypothetical test yielded 0.004 QALYs (95%CI -0.020 – 0.013), while saving €3,025 (95%CI -5652 – 3576) per patient compared to LND. Assuming 100% sensitivity of LND, the hypothetical test would require 98% sensitivity at zero costs to be cost-effective compared to LND. Sensitivity of LND might be lower, since not all LN stations are routinely dissected. Assuming 90% sensitivity of LND, it would require 88% sensitivity at zero costs or 89% at a maximum cost of €1,674 per patient to be cost effective.

Conclusions

The room for improvement for new diagnostic techniques is highly dependent on the sensitivity of LND. A new diagnostic test may have up to 2% lower sensitivity than LND to be cost-effective compared to LND.
O64 META-ANALYSIS OF PROGNOSTIC FACTORS FOR OVERALL SURVIVAL IN PATIENTS UNDERGOING OESOPHAGECTOMY FOR OESOPHAGEAL CANCERS
Authors: Kamarajah Sivesh K , Marson Ella J , Zhou Dengyi , Wyn-Griffiths Freddie , Richard P T Evans , Bundred James R , Singh Pritam , Griffiths Ewen A
Published: November 2019

Aims

The objective of this meta-analysis was to assess statistically the impact of patient-level, operative, and tumour characteristics on overall survival of patients undergoing curative resection for oesophageal cancer.

Introduction

Oesophageal cancer is staged using the American Joint Comission on Cancer (AJCC) staging system. Numerous other prognostically important histopathological and demographic characteristics have been reported.

Methods

This systematic review was performed according to PRISMA guidelines and eligible studies were identified through a search of PubMed, Scopus and Cochrane CENTRAL databases up to 31st December 2018. A meta-analysis was conducted with the use of random-effects modelling to determine pooled univariable hazard ratios (HRs) and prospectively registered with the PROSPERO database (Registration CRD42018130732).

Results

One-hundred and sixty-six articles including 70,299 patients were assessed quantitatively. Of the 122 factors associated with survival, 39 were significant on pooled analysis. Of these the strongly associated prognostic factors were T stage (HR: 2.07, CI95%: 1.77 - 2.43, p<0.001), N stage (HR: 2.24, CI95%: 1.95 - 2.59, p<0.001), perineural invasion (HR: 1.54, CI95%: 1.36 - 1.74, p<0.001), circumferential resection margin (HR: 2.17, CI95%: 1.82 - 2.59, p<0.001), poor tumour grade (HR: 1.53, CI95%: 1.34 - 1.74, p<0.001), and high neutrophil:lymphocyte ratio (HR: 1.47, CI95%: 1.30 - 1.66, p<0.001).

Conclusion

Several tumour biological variables not included in the AJCC 8th edition classification can impact on overall survival. These require incorporation into prognostic models to ensure a personalised approach to prognostication and treatment.
P66 ENSURE: EUROPEAN INVESTIGATION OF SURVEILLANCE AFTER RESECTION FOR ESOPHAGEAL CANCER
Authors: Jessie A Elliott , Sheraz R Markar , Fredrik Klevebro , Magnus Nilsson , Giovanni Zaninotto , George B Hanna , John V Reynolds ,   ENSURE Study Collaborators
Published: November 2019

Aim

To characterize oncologic surveillance protocols across European esophageal cancer centers and determine the independent impact of intensive surveillance on oncologic outcome.

Background

Emerging data demonstrate long-term survival after salvage interventions for local or oligometastatic recurrence after planned curative resection for esophageal cancer, providing rationale for postoperative surveillance. However, the impact of intensive surveillance on oncologic outcome and health-related quality of life (HRQOL) is unknown.

Methods

First, a survey of surveillance protocols across European esophageal cancer centres was undertaken (Phase 1). Then, an international multicentre study including consecutive patients who underwent surgery with curative intent for cTxNxM0 esophageal or junctional cancer from June 2009 to June 2015 was initiated (Phase 2). The estimated sample size of 4425, with 31% undergoing intensive surveillance, will provide 90% power to detect a 5% increase in 5-year overall survival (primary outcome measure). Secondary outcome measures include disease-free survival, incidence of oligometastatic recurrence, treatment strategies, and HRQOL. Subgroup analyses by age, histologic type and HER-2 status are planned. The study is registered on ClinicalTrials.gov (NCT03461341).

Results

For Phase 1, 27 centres across 13 European and North American countries participated. Centers undertook 52.3±17.1 esophageal cancer resections per year between 3.5±1.3 attending surgeons. The majority of centers utilized a standardized surveillance protocol for all patients (23, 85.2%). Routine laboratory investigations, nutritional profiling and tumor markers were assessed in 10 (37.0%), 9 (33.3%) and 4 (14.8%) of centers, respectively. 10 centers (37.0%) utilized routine postoperative surveillance computed tomography, of whom 3 (11.1%) also undertook routine postoperative PET-CT in follow-up. Surveillance endoscopy was performed in 7 centers (18.9%). Centers undertaking intensive imaging surveillance had fewer attending surgeons (P=0.036) but similar surgeon volume (P=0.832). Surveillance intensity was not associated with national health expenditure (P=0.733). For Phase 2, data for 4010 patients (31.1% intensive surveillance) from 18 centres across 9 European countries have been submitted to date, with results expected in September 2019.

Conclusion

The ENSURE study will provide the first appropriately powered evidence assessing the impact of postoperative surveillance strategies on oncologic outcome and HRQOL following potentially curative resection for esophageal cancer.
P67 SEMIMECHANICAL ANASTOMOSIS DURING ESOPHAGECTOMY: A NEW GOLD STANDARD?
Authors: Mazza E , Strignano P , Fop F , Patrono D , Catalano G , Salizzoni M , Romagnoli R
Published: November 2019

Aim

The aim of this single-center retrospective study was to compare the surgical outcomes of semimechanical (SM) and totally manual (TM) anastomoses during esophagectomy regardless of the surgical access and of the type of esophageal replacement.

Background and Methods

Several techniques for esophageal anastomosis during esophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the significant morbidity of esophageal fistula, reducing its incidence is of paramount importance. We report our single-center experience with the semimechanical technique, as compared to the totally manual technique.

312 partial esophagectomies performed between January, 1998 and April, 2018 were analyzed. The series was split into a training period (1/1998-9/2015), when both TM and SM techniques were used, and a validation period (10/2015-4/2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding.

Results

The training period included 212 esophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction of both fistula (0.8% versus 12.2%; p<0.001) and stricture rate (0% versus 6.7%; p=0.005). After propensity score matching the difference in fistula (0% versus 13.5%; p=0.013) and stricture rate (0% versus 9.6%; p=0.022) was confirmed. During the validation period, which included 100 esophagectomies performed with SM anastomosis, 1 fistula (1%) and 1 stricture (1%) were observed.

Conclusions

SM technique for esophageal anastomosis outperforms TM technique and allows achieving very low complications rates.
P68 DEFINITIVE RESULTS OF THE HELLER MYOTOMY ASSOCIATED WITH THE DOR FUNDOPLICATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR THE PRIMARY SURGICAL TREATMENT OF ESOPHAGEAL ACHALASIA: ONE CENTER EXPERIENCE
Authors: Valentina Tassi , Marialuisa Lugaresi , Benedetta Mattioli , Niccolò Daddi , Vladimiro Pilotti , Sandro Mattioli
Published: November 2019

Objective

In 1978 the Heller-Dor operation was proposed to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Proponents performed this operation under intraoperative manometric control. We report on results we achieved in the period 1978-2016.

Methods

The Heller-Dor was performed in 367 patients (laparotomy 1978-1993, 209, 96 men; median age, 45 years; IQR 31.8–59.4 years, laparoscopy 1994-2016,158, 78 men; median age, 48 years; IQR 35.5–63.7 years; age p=0.166; gender p=0.346). Intraoperative manometry was performed and interpreted according to standard criteria. Follow-up consisted of periodical interview, endoscopy, barium swallow, which reports were graded in semiquantitative scales of evaluation.

Results

Mortality occurred in 1/209 (heart failure), 1/158 (coagulation disorder). Median follow-up was 193 months (IQR 137.1–273.4 months) in the laparotomy group, 95 months (IQR 71.1–140 months) in the laparoscopy group. Myotomy achieved the complete abolition of the high pressure zone in 100% of the patients in both groups. In the laparotomy group poor results were assessed in 22 (10.5%), for esophagitis in 15 and recurrent dysphagia in 7 with sigmoid achalasia. In the laparoscopy group poor results occurred in 7 (4.3%), 5 for esophagitis and 2 for recurrent dysphagia in sigmoid achalasia. In the second period the fundoplication was always sutured to the diaphragm to avoid slipping, the number of sigmoid esophagus cases decreased significantly. In the laparotomy group, gastroesophageal reflux and esophagitis appeared after a median period of 74.8 months since myotomy, recurrent dysphagia was evident shortly after surgery.

Conclusions

In light of the timing of appearance of causes of poor results assed in the laparotomy group, we consider the 95.7% of satisfactory results achieved with the laparoscopic Heller-Dor after 95 months median follow up, the indicator of potential of cure of this operation.
P69 INTRAOPERATIVE ENDOSCOPY IS OF A GREAT IMPORTANCE IN COMPLEX REVISIONAL UPPER GI SURGERY. CASE PRESENTATION OF RECURRENT ACHALASIA PREVIOUSLY TREATED WITH 3 LAPAROSCOPIC HELLERS CARDIOMYOTOMIES.
Authors: Vrakopoulou Gavriella-Zoi , Daniel Foley , Edel Smyth , Abraham Botha
Published: November 2019

Aim

To demonstrate the ability to perform increasingly complex revisional surgery utilising minimally invasive techniques and synchronous endoscopy for recurrent achalasia.

Background & Methods

We present a case of recurrent achalasia previously treated with 3 laparoscopic Hellers cardiomyotomies. Traditionally such a case would be considered for either open revisional surgery or oesophagectomy. In this case a fourth laparoscopic Hellers cardiomyotomy was succesfully performed using 3D laparoscopy combined with synchronous intraoperative endoscopy. The 3D video footage we present demonstrates the added safety provided by depth perception and high resolution imaging in revisional laparoscopic surgery. Synchronous endoscopy confirms altered anatomy, pathology and luminal change from extraluminal interventions resulting in prompt recognition of LES and subsequent efficient gastric myotomy.

Results

After a laborious adhesiolysis using the advantages of 3D imaging system we faced difficulties recognizing the exact LES location, in order to proceed with the gastric myotomy. In our opinion this could be the reason for previous treatment failures. At this point the use of synchronous flexible endoscopy enabled the recognition of cardia, so we could safely and efficiently complete a fourth laparoscopic Hellers cardiomyotomy including repair of a distal oesophageal diverticulum and a substantially lengthened gastric myotomy. This resulted in a substantial improvement in dysphagia symptoms with the patient resuming consumption of liquid and solid food as well.

Conclusion

Early adoption of technological advancements facilitates organ preserving revisional surgery and the avoidance of significant patient morbidity. These techniques radically increase the safety profile of minimally invasive surgery by facilitating anatomic recognition and provisioning for tailored intervention.
P70 SEVERE DUMPING SYMPTOMS ARE UNCOMMON FOLLOWING TRANSTHORACIC ESOPHAGECTOMY BUT SIGNIFICANTLY DECREASE HEALTH-RELATED QUALITY OF LIFE IN LONG-TERM, DISEASE FREE SURVIVORS
Authors: Klevebro F , Boshier P R , Savva K V , Waller A , Hage L , Hanna G B , Low D
Published: November 2019

Aim

The aim of the study was to increase the knowledge about dumping symptoms after esophagectomy and the association to health-related quality of life.

Background and Methods

High quality documentation of dumping symptoms after esophagectomy is currently limited. The aim of the study was to describe the incidence of symptoms associated with dumping syndrome and their relationship with health-related quality of life after esophagectomy.

The study cohort was identified from prospective IRB-approved databases from two high volume esophagectomy centers. Patients that were alive and without evidence of recurrence in April 2018 completed the validated Dumping Symptom Rating Scale and health-related quality of life questionnaires. Compound dumping symptom score was created by combining the individual scores for severity and frequency for each symptom.

Results

In total, 171 patients who underwent esophagectomy 1995-2017 responded to the questionnaires, corresponding to a response rate of 77.0%. Median age was 66 years and median time from operation to survey was 5.5 years. Absent or mild problems in all nine dumping symptoms were reported by 94 (59.5%) patients, 19 (12.0%) patients reported moderate or severe problems in at least three symptoms, the most common being “a need to lie down,” “diarrhea,” and “stomach cramps.” Increasing compound dumping symptom score was associated with significantly decreased function scores in all aspects of health-related quality of life except physical functioning (P<0.005).

Conclusions

Esophagectomy has the potential to change long-term eating patterns, however the majority of patients in the study did not have severe postoperative dumping symptoms. On the other hand moderate to severe dumping symptoms, which were reported by 12% of patients in this study were strongly associated with decreased health-related quality of life.
P72 IS OPEN LEFT THORACO-ABDOMINAL ESOPHAGECTOMY A VIABLE OPTION IN THE ERA OF MINIMALLY INVASIVE ESOPHAGECTOMY?
Authors: Klevebro F , Boshier P , Mueller C , Cools-Lartigue J , Ferri L , Low D
Published: November 2019

Aim

To evaluate short-term and oncological outcomes of left thoracoabdominal esophagectomy compared to minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction

Background and Methods

Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky tumors, but there are concerns that this approach is associated with significant morbidity.

Prospectively entered esophagectomy databases from two high volume North American centers were reviewed for patients undergoing LTE or MIE in the 2012-2018. Patient demographics, tumour characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared.

Results

In total 247 patients were included in the study, LTE was applied in 170 (68.8%) patients, and MIE in 77 (31.2%) patients. LTE patients had more neoadjuvant treatment (LTE=78.2%, MIE=34.2%, P<0.001). There was no difference in overall postoperative complications (LTE=56.9%, MIE=55.0%, P=0.799), severe complications (Clavien Dindo>2 - LTE=26.1%, MIE17.0%, P=0.184), pulmonary complications (LTE=31.9%, MIE=20.0%, P=0.085), pneumonia (LTE=15.2%, MIE=13.6%, P=0.768), anastomotic leak (LTE=7%, MIE=10%, P=0.396), or postoperative mortality (LTE=0%, MIE=1.3%, P=0.140). Median length of stay was 7 days in both groups. R0 resection rate was 93.8% and 95.5% respectively (P=0.631). Median number of resected lymph nodes was 24 for LTE and 22 for MIE (P=0.226). LTE had more stage II-IV tumors (LTE=67.8%, MIE=40.7%, P<0.001), and more node positive resections (LTE=52.5%, MIE=31.4%, P=0.003).

Conclusion

LTE was used for larger tumors with greater lymph node burden in patients that were more likely to have received neoadjuvant treatment compared to MIE. Despite this the postoperative morbidity was equal to that of MIE, with no difference in short-term or oncological results in this cohort.
P79 CRITICAL APPRAISAL ON THE IMPACT OF SMOKING STATUS ON PERIOPERATIVE MORBIDITY, MORTALITY AND LONG-TERM SURVIVAL FOLLOWING OESOPHAGECTOMY FOR OESOPHAGEAL CANCERS: A TERTIARY UNIT ANALYSIS
Authors: Sivesh K Kamarajah , Maziar Navidi , Michael Griffin S , Alexander W Phillips
Published: November 2019

Aim

This study aimed to characterise morbidity and mortality profile by smoking status in patients undergoing oesophagectomy for oesophageal cancers.

Background

Oesophagectomy remains the mainstay for curative treatment of oesophageal cancer. Despite improvements in perioperative care, little is understood on the impact of smoking status on perioperative morbidity and mortality following oesophagectomy for oesophageal cancers.

Methods

Consecutive patients undergoing oesophagectomy cancer (adenocarcinoma or squamous cell carcinoma) between 1997 - 2016 at the Northern Oesophagogastric Unit were included from a contemporaneously maintained database. Primary outcome was overall survival. Secondary outcomes include overall complications, anastomotic leaks and pulmonary complications.

Results

During the study period, 1207 patients underwent oesophagectomy for cancer. Of these 1207 patients, most were current (74%) smokers with only 20% non-smokers. Median survival of current smokers was significantly shorter than ex-smokers and non-smokers (median: 35 vs 42 vs 44 months, p=0.031). On adjusted analysis, there were no significant difference in survival between non-smokers and ex-smokers with current smokers. Rates of overall complications were significantly higher with current smokers compared to ex-smokers or non-smokers (73% vs 66% vs 62%, p=0.015). There were no significant differences in anastomotic leaks and pulmonary complications between the groups.

Conclusion

In summary, this study demonstrated that current smokers have significantly reduced long-term survival compared to ex-smokers or never smokers, specifically patients undergoing surgery only or those with SCC. Future studies in patients with neoadjuvant therapy to further delineate genetic landscape of oesophageal cancers to identify high risk groups that may warrant further multimodality therapy.
P80 LONG-TERM OUTCOMES OF CLINICAL AND PATHOLOGICAL-STAGED T3N3 ESOPHAGEAL CANCER
Authors: Kamarajah S K , Newton N , Navidi M , Wahed S , Immanuel A , Hayes N , Griffin S M , Phillips A W
Published: November 2019

Objective

The aim of this study was to determine the outcomes of patients with T3N3 esophageal cancers and determine differences between the clinical stage and pathological stage.

Background

Locally advanced esophageal cancer is associated with poor long-term survival. Pre-treatment and post-treatment stage may differ due to the effect of neoadjuvant therapy and inaccuracies in staging. Multimodality staging followed by discussion at an MDT is considered the gold standard. Despite this, patients can be under-staged or over-staged leading to inadequate or unnecessary treatment associated with high levels of morbidity.

Methods

Consecutive patients from a single unit between 2010 - 2018 were included with either clinical (cT3N3) or pathological (pT3N3) esophageal cancer. Outcomes were compared between patients that underwent transthoracic esophagectomy and radical two field lymphadenectomy with or without neoadjuvant treatment and those patients staged cT3N3 treated non-surgically (NSR). Demographics, clinical and pathological stage, histological information and outcomes were recorded. Patients were staged using the TNM 8.

Results

This study included 156 patients, of which 63 had non-surgical treatment, only 3 of these had radical treatment. Of the remaining 93 patients who underwent esophagectomy, 34 were cT3N3, 54 were pT3N3 and five were unchanged before and after treatment. Median overall survival (OS) for surgical cT3N3 patients was significantly longer than pT3N3 and NSR (median: NR vs 19 vs 8 months, p<0.001). Twenty-seven patients with cT3N3 had lower staging following treatment whilst 3 had a higher stage.

Conclusion

T3N3 disease carries a poor prognosis. Within this cohort cT3N3 disease treated surgically has a high 5-year overall survival suggesting possible over-staging and stage migration due to neoadjuvant therapy. To contrast this those not having surgery have a dismal prognosis. The impact of neoadjuvant treatment cannot be predicted and, current staging modalities may be inaccurate. Clinical stage should be used with caution when counselling patients regarding management and prognosis.
P82 A PROPENSITY SCORE MATCHED COHORT STUDY TO EVALUATE THE ASSOCIATION OF LYMPH NODE RETRIEVAL WITH LONG-TERM OVERALL SURVIVAL IN PATIENTS WITH ESOPHAGEAL CANCER
Authors: Leonie R van der Werf, , Elske Marra, PhD , Suzanne S Gisbertz, PhD , Bas P L Wijnhoven, PhD , Mark I van Berge Henegouwen, PhD
Published: November 2019

Introduction

Previous studies evaluating the association of LN yield and survival presented conflicting results and many may be influenced by confounding and stage migration. This study aimed to evaluate whether the quality indicator ‘retrieval of at least 15 lymph nodes (LNs)’ is associated with better long-term survival and more accurate pathological staging in patients with esophageal cancer treated with neoadjuvant chemoradiotherapy and resection.

Methods

Data of esophageal cancer patients who underwent neoadjuvant chemoradiotherapy and surgery between 2011-2016 was retrieved from the Dutch Upper Gastrointestinal Cancer Audit. Patients with <15 LNs and ≥15 LNs were compared after propensity score matching based on patient and tumor characteristics. The primary endpoint was 3-year survival. To evaluate the effect of LN yield on the accuracy of pathological staging, pathological N-stage was evaluated and 3-year survival was analyzed in a subgroup of patients node-negative disease.

Results

In 2260 of 3281 patients (67%) ≥15 LNs were retrieved. In total, 992 patients with ≥15 LNs were matched to 992 patients with <15 LNs. The 3-year survival did not differ between the two groups (57% versus 54%, p=0.28). pN+ was scored in 41% of patients with ≥15 LNs versus 35% of patients with <15 LNs. For node-negative patients, the 3-year survival was significantly better for patients with ≥15 LNs (69% versus 61%, p=0.01).

Conclusions

In this propensity score matched cohort, 3-year survival was comparable for patients with ≥15 LNs, although increasing nodal yield was associated with more accurate staging. In node-negative patients, 3-year survival was higher for patients with ≥15 LNs.
P84 LOCALIZATION OF UNDETECTED RESIDUAL TUMOR AFTER NEOADJUVANT CHEMORADIOTHERAPY IN PATIENTS WITH ESOPHAGEAL CANCER
Authors: van der Wilk B J , Doukas M , Eyck B M , Spaander M C W , Schoon E J , Krishnadath K K , Oostenbrug L E , Lagarde S M , Wijnhoven B P L , Biermann K , van Lanschot J J B
Published: November 2019

Introduction

The preSANO-trial aimed to determine accuracy of clinical response evaluations (CREs) after neoadjuvant chemoradiotherapy (nCRT) in patients with locally-advanced esophageal cancer. After introduction of the ‘bite-on-bite’ biopsy-technique, most residual tumors were detected. Aim of this study was to determine the location of residual tumors that were not detected during CREs and whether or not endoscopic (bite-on-bite) biopsies had the theoretical potential to detect these tumors.

Methods

In this side-study of the prospective preSANO trial, biopsies and resection specimens were independently revised by two GI-pathologists. All patients were included that had residual tumor in the resection specimen that was not detected during two clinical response evaluations, 6 and 12 weeks after completion of nCRT. In the resection specimen, the tumor regression grade was defined for each esophageal wall layer. It was determined how often submucosal tumors under a tumor-free mucosal layer were missed during CREs. Biopsies taken during CREs were revised for the presence of submucosal tissue. This was defined as presence of submucosal structures, i.e. submucosal glands and/or thick-walled vessel-structures.

Results

Some 103 of 207 patients underwent CREs followed by surgery. Residual tumor was not detected during CREs in 33 patients. Resection specimens of 28 of these patients were available for revision. Missed residual tumors were located in the mucosal layer of the esophageal wall in 64% of these patients. Residual tumors were located in the submucosal layer, under a tumor-free mucosal layer, in 29% of patients. One patient still had tumor under a tumor-free mucosal- and submucosal layer. Submucosal structures were detected in two patients and it was uncertain whether submucosal tissue was present in six patients, while no specific submucosal structures were detected in 21 patients.

Conclusion

The majority of patients in whom residual tumor remained undetected during clinical response evaluations had tumor cells in the mucosal layer of the esophageal wall. Nearly one third of the patients had tumor in the submucosal layer under a tumor-free mucosa. Whether these submucosal tumors can be detected using endoscopic biopsies is uncertain. Further improvement of the accuracy of CREs should focus on sampling of larger mucosal areas, for example by using brush techniques.
P86 COMBINED ENDOSCOPIC AND SURGICAL PROCEDURE FOR EXCISION OF A GIANT FIBROVASCULAR POLYP
Authors: T Fraser , H Wadhawan , A Ariyarathenam , T Malik , T Wheatley , G Sanders , L Humphreys , R Berrisford
Published: November 2019

Aim

Giant fibrovascular polyp of the oesophagus is a rare benign condition.(1) We share our experience of removing a particularly large lesion and describe a combined endoscopic and surgical procedure used to remove it through only a cervical incision.

Background & Methods

A 53 year old year old female was referred to our department following endoscopy which demonstrated a giant fibrovascular polyp. A literature search was performed using EMBASE and Pubmed databases to identify any relevant case reports and articles. Written consent for presentation of the case and use of images was obtained from the patient.

Results

Surgery was carefully planned with thorough pre-operative assessment. Upper GI endoscopy was initially performed and a radio-opaque feeding tube was positioned around the base of the polyp and withdrawn proximally to delineate the proximal origin of the lesion in theatre with an image intensifier. A cervical oesophagotomy was performed under endoscopic guidance. The base of the polyp was divided with sharp dissection and transfixed. The polyp was then successfully delivered via the cervical oesophagotomy without causing any further trauma. The patient made a good recovery without any complications at follow-up.

Conclusion

Intraoperative endoscopy with a radio-opaque sling in these patients can direct the site of the cervical oesophagotomy, which can be guided to avoid the stalk of the lesion by an endoscope within the oesophagus.
P87 FLUORESCENCE ANGIOGRAPHY OF THE ANASTOMOTIC SITE DURING ESOPHAGECTOMY: TIME TO ENHANCEMENT AS QUANTITATIVE VALUE TO PREDICT ANASTOMOTIC LEAKAGE
Authors: Slooter¹ M D , de Bruin D M , Eshuis¹ W J , Gisbertz¹ S S , van Berge Henegouwen¹ M I
Published: November 2019

Aim

In this study we correlated time to fluorescent enhancement as a quantitative value of intraoperative fluorescence angiography (IFA) to anastomotic leakage (AL) after esophagectomy with gastric conduit reconstruction.

Background & Methods

IFA seems a helpful technique to visualize anastomotic perfusion after esophagectomy. However, IFA is interpreted subjectively. To evaluate fluorescence objectively and find a threshold to predict AL, we evaluated time to fluorescence enhancement.

All consecutive patients undergoing elective esophagectomy with gastric conduit reconstruction for a one-year period since the introduction of IFA in June 2018 were prospectively recorded. IFA was performed after injection of indocyanine green (ICG) before and/or after anastomotic reconstruction. During IFA, time to fluorescent enhancement was recorded (time points: ICG injection, enhancement in lung, base of gastric conduit, planned anastomotic site, tip of gastric conduit). The anastomotic site was changed according to subjective interpretation of IFA. AL was classified according to the ECCG classification.

Results

Sixty-five patients underwent esophagectomy with gastric conduit reconstruction for esophageal cancer. The anastomosis was either constructed in the cervical (13/65, 20%) or intrathoracic (52/65, 80%) region. The anastomotic site was adjusted due to IFA in 3/65 (4.6%) cases. AL occurred in 7/65 (10.8%) patients and in 1/3 (33.3%) after change of anastomotic site. Before anastomotic reconstruction, time between ICG injection and enhancement of the tip (injection-tip) and time between enhancement in the lung and base of the conduit (lung-conduit) were significantly correlated with AL (p=0.027 and p=0.042, respectively). ROC curve analysis revealed a cut-off value of 61 seconds for injection-tip with an area under the curve (AUC) of 0.91 and corresponding sensitivity 82.9% and specificity 100%. For lung-conduit a cut-off value of 11 seconds was found with an AUC of 0.71 and corresponding sensitivity 63% and specificity 83%.

Conclusion

In this study cut-off values for the time between injection-tip and lung-conduit were derived to predict AL after esophagectomy. Time to fluorescent enhancement is a quantitative fluorescent parameter, which is easy to implement, as no software is required. However, a larger cohort needs to be observed for potential significance of the difference between other time points and to confirm these thresholds.
O89 TWENTY-FIVE YEARS OF LAPAROSCOPIC TREATMENT FOR ESOPHAGEAL ACHALASIA: OUR EXPERIENCE ON 1001 LAPAROSCOPIC HELLER-DOR OPERATIONS
Authors: Salvador R , Capovilla G , Provenzano L , Moletta L , Pierobon E , Nicoletti L , Nezi G , Valmasoni M , Merigliano S , Costantini M
Published: November 2019

Background

In the last decade of the past century, primary Laparoscopic Heller-Dor (LHD) for Achalasia progressively became the procedure of choice in the new millennium. The aim of this study was to assess the long-term outcome of LHD to treat Achalasia at a single high-volume institution during the past 25 years.

Methods

1000 patients underwent LHD from 1992-2017 by 6 staff surgeons alternatively. Patients who had already been treated with surgical or endoscopic myotomy were ruled out. Symptoms were collected and scored using a detailed questionnaire; barium-swallow, endoscopy, manometry were performed, before and after surgery while, 24-hour pH monitoring were performed 6 months after surgery.

Results

LHD was the primary treatment for 1000 patients (M:F=536:464); the median age was 46 (IQR 36-54), 183 (18.3%) had a history of endoscopic treatments (pneumatic dilation or botox injections, or both).

The surgical procedure was completed laparoscopically in all but 7 patients (0.7%) and there was one perioperative death for heart attack.

There were 25 perforations (2.5%): 22 were recognized and repaired during the operation, 3 were detected by postoperative contrast swallow.

The outcome was positive in 902 patients (90.2%). In patients who had a previous treatment the failures were 25/183 (13.7%) while in the primary treatment group the failures were 73/817 (8.9%) (p=0.055). All the 98 patients whose LHD failed subsequently underwent one or more endoscopic pneumatic dilations, which ameliorated their recurrent symptoms in all but 11 patients (10 of whom required reoperation). The overall success rate of the combination of LHD and endoscopic dilations (where necessary) was 98.4%.

At univariate analysis, manometric pattern (p=0.001), sigmoid megaesophagus (p=0.003) and a chest pain score (p=0.002) were the only factors predictive of a positive final results. At multivariate analysis, these three factors were independently associated to good outcome.

Postoperative 24-hour pH-monitoring was abnormal in 50/590 patients (8.5%)

Two patients developed an esophageal cancer during the follow-up time.

Conclusions

In a university tertiary referral center LHD can durably relieve achalasia symptoms. Preoperative manometric pattern, a presence of a sigmoid esophagus and the chest pain score represent the strongest predictor of outcome.
P90 TRACTION ON THE SEPTUM DURING TRANSORAL SEPTOTOMY FOR ZENKER DIVERTICULUM IMPROVES THE FINAL OUTCOME
Authors: Provenzano L , Salvador R , Cutrone C , Moletta L , Pierobon E , Nicoletti L , Capovilla G , Valmasoni M , Merigliano S , Costantini M
Published: November 2019

Background

Transoral Diverticulostomy/Septotomy has become a popular treatment for patients with Zenker Diverticulum (ZD) because of the low complication rates, reduced procedure time, and shorter hospital stay. However, the outcome of this procedure is not, so far, as positive as the open techniques. In order to improve the results of transoral septotomy (TS), a modification of the technique by tractioning the septum with stiches, has been introduced. In this study we aimed to compare the final outcome of a Modify Transoral Septotomy (MTS) with those of the Traditional Transoral Septotomy (TTS) in patients with ZD.

Methods

Seventy-seven consecutive patients with ZD underwent Transoral Septotomy between 2010-2019. Patients who had already been treated with surgical or endoscopic procedures were excluded.

TTS was performed with the classic technique. Since 2015, we adopted a MTS, by positioning 2 sutures at the lateral edges of the septum, for traction. Symptoms were collected and scored using a detailed questionnaire; barium-swallow (to assess the size of the pouch), endoscopy and manometry were performed before and after surgical treatment. Failures were defined when a patient needed an additional procedure for recurrent symptoms.

Results

Of the 52 patients representing the study population (M:F=49:28), 25 had TTS and 52 had MTS. The patients’ demographic and clinical parameters (sex, age, symptom-score, duration of symptoms, diverticulum size) were similar in both groups. Only two intraoperative mucosal lesions were detected and mortality was nil. The median time of the procedure was 25 min (IQR:22-35) in the TTS and 30 min (IQR:25-36) in the MTS (p<0.07). The median follow-up was 85 months in the TTS and 24 months in the MTS. All the patients in both groups had a reduction in the symptom score after the procedure but the failure rate was 32% (8/25) in the TTS and 1.9% (1/52) in the MTS (p<0.01).

At the univariate and multivariate analyses, the surgical procedure was the only factor predictive of a positive final result.

Conclusions

Transoral Septotomy improves the final outcome of this treatment in patients with ZD.
P91 PHARYNGO-OESOPHAGEAL PERFORATION FOLLOWING CERVICAL SPINE SURGERY: A SINGLE CENTRE EXPERIENCE
Authors: Lucia Moletta , Giovanni Capovilla , Laura Gavagna , Giorgia Cornaviera , Marco Taufer , Elisa Sefora Pierobon , Renato Salvador , Mario Costantini , Stefano Merigliano , Michele Valmasoni
Published: November 2019

Aim

Pharyngo-oesophageal perforation is a rare, life-threatening complication of cervical spine surgery. Only isolated cases are reported in the English literature and correct management of these patients remains poorly defined. The aim of this study is to review our experience to better clarify the appropriate treatment of this dreadful complication.

Background and Methods

Data regarding demographics, clinical course, diagnosis, management and outcomes of 13 patients (8 M, 5F, mean age 49 years) with oesophageal perforation after cervical spine surgery were collected during the period from 2002 to 2019.

Results

Pharyngo-oesophageal perforation occurred at a median of 8 days (range 0-4745 days) after cervical spine surgery. Clinical manifestations included neck abscess in 7 cases, fever in 3 cases, dysphagia and regurgitation in 3 cases. In 2 patients conservative management with fasting and antibiotics was attempted but, in both cases, a subsequent surgical intervention was required. All patients underwent surgical treatment. A step-up approach with initial surgical drainage of a purulent cervical collection was performed in 7 patients, delaying definitive surgery after resolution of cervical infection. Definitive surgical treatment with total or partial removal of spine fixation devices, autologous bone graft insertion or plate/cage replacement, anatomical suture of the fistula and suture line reinforcement with myoplasty (either with sternocleidomastoid or pectoralis major muscle flap) was performed in 10 patients. Perforation recurred in two cases, requiring further surgical management. At a median follow-up of 23 months (range 5-149 months) all patients exhibited permanent resolution of the perforation.

Conclusions

Pharyngo-oesophageal perforation following cervical spine surgery is a rare but dreadful complication: prompt recognition and treatment of these injuries is critical to minimize morbidity and mortality. Partial or total removal of the fixation devices, direct suture of the oesophageal defect and coverage with tissue flaps seems to be an effective surgical approach in these patients.
P93 BELSEY MARK IV: STILL A VALID OPTION. SINGLE CENTER EXPERIENCE OF 100 CONSECUTIVE CASES
Authors: Sander Ovaere , Lieven Depypere , Hans Van Veer , Philippe Nafteux , Willy Coosemans
Published: November 2019

Aim

To share the single-center experience of a tertiary referral center using the Belsey Mark IV operation in the treatment of large primary hiatal hernias (PHH) and recurrent hernias after failed antireflux surgery.

Background & Methods

We conducted a retrospective analysis of all patients with PHH or recurrent hernia after antireflux surgery operated between May 1, 2012 and December 31, 2016 who received a Belsey-Mark IV antireflux procedure. Data on patient demographics, surgical history, pre-operative work-up, indication, short- and long-term complications graded by the Clavien-Dindo classification (CDC) and recurrence rate, defined as clinical symptoms confirmed with barium swallow test, were collected and analyzed.

Results

A total of 100 consecutive cases were included in this analysis. Median age at time of surgery was 67 years (range 0 - 86). Seventy-two were female. Indications were: PHH Type I (n = 2), Type II (n = 1); Type III (n = 55), Type IV (n = 3), redo after previous antireflux surgery (n = 39). Median follow-up was 23 months (range 4-80). Major peri-operative short-term morbidity (defined as CDC 3-4) was present in 14 cases, with respiratory complications being the most prevalent. Fundoplication leakage was present in five cases and managed conservatively in three of those. Hernia recurrence rate was 31% in the redo group (12/39) and 10% in the PHH group (6/61). Median time-to-recurrence was 22 months (range 2-78). Post thoracotomy pain syndrome requiring treatment (CDC 2) was present in 12 cases. One patient deceased due to respiratory complications after emergency Belsey Mark IV repair following early recurrence after laparoscopic Nissen fundoplication and two reinterventions.

Conclusion

The Belsey Mark IV repair is a safe and effective procedure in experienced hands, with well-defined risks and an acceptable recurrence rate, given the nature of the condition and patient’s comorbidities.
O94 GASTRIC CONDUIT NECROSIS AFTER ESOPHAGECTOMY: RISK PREDICTION, MANAGEMENT AND OUTCOMES
Authors: van Boxel Gijsbert I , van der Veen Arjen , Feike Kingma B , Borggreve Alicia S , Ruurda Jelle P , van Hillegersberg Richard
Published: November 2019

Background

Acute gastric conduit necrosis (AGCN) is a serious early complication of esophagectomy that can result in loss of the gastric conduit. The reported incidence is relatively low: 0.5-3.2%. Literature is thus scarce. However, vascular comorbidity has been shown to be a risk factor. This study aimed to assess the arterial calcification scores, clinical presentation, management, and outcome of patients who suffered from AGCN following esophagectomy in a high volume centre for esophageal cancer surgery.

Methods

Patients who underwent esophagectomy for esophageal cancer were selected (Jan-2011 till Feb-2019) from a prospectively maintained single-centre database that contains the patient characteristics, treatment details, and postoperative outcomes of all patients undergoing esophagogastric surgery. For the AGCN cases, additional information regarding their clinical course was retrieved from the electronic patient files. Arterial calcification scores were established by measuring calcifications at 4 arterial locations on preoperative computed tomography (CT) scans.

Results

From a total of 466 esophagectomies performed in the inclusion period, AGCN occurred in 8 cases (1.7%). Resection of the gastric conduit was required in 5 of these patients, of whom 3 patients had a fatal outcome. The other patients were successfully treated by conservative treatment involving a nil by mouth regimen (n=2) or a self-expanding metal stent (n=1). There was a high prevalence of supra-aortic (75%) and thoracic (87.5%) calcifications in the patients suffering from AGCN.

Conclusion

AGCN is a rare but serious complication following esophagectomy, with a high mortality. Patients with generalized vascular disease may be at particular risk of developing this complication.
P96 THE CURRENT ROLE OF ADJUVANT THERAPY IN PATIENTS FOLLOWING NEO-ADJUVANT CHEMOTHERAPY AND R0 RESECTION FOR LOWER OESOPHAGEAL AND GOJ ADENOCARCINOMA
Authors: Bott R , Zylstra J , Wilkinson M , Knight W , Baker C , Kelly M , Maisey N , Beckmann K , Van Hemelrijck M , Gossage J , Allum W , Smyth E , Cunningham D , Davies A
Published: November 2019

Aim

 The aim of this study was to assess the survival benefit of adjuvant therapy in R0 resection patients following neo-adjuvant chemotherapy and surgery for lower oesophageal and GOJ adenocarcinoma.

Background & Methods

 The role of adjuvant therapy in oesophago-gastric adenocarcinoma patients treated by neo-adjuvant chemotherapy is contentious. In UK practice surgical resection margin status is often used to stratify patients into receiving adjuvant treatment. Two prospectively collected institutional databases were combined. Patients were classified by the adjuvant therapy received. Crude and adjusted Cox regression analyses compared overall and recurrence free survival according to the adjuvant treatment, stratified by resection margin status. Recurrence patterns were assessed as a secondary outcome.

Results

 A total of 616 patients were included (373 R0, 243 R1). In hospital mortality following surgery was 1% and these patients were excluded from analysis (n=7). In the R0 resection group 220 patients (59%) had no adjuvant treatment and 137 patients (37%) had adjuvant chemotherapy. On adjusted analysis pathological N status (p<0.0001), poor differentiation (p=0.005) and poor response to neo-adjuvant chemotherapy (p=0.001) were independently associated with poor survival. The benefit of adjuvant chemotherapy did not reach independent significance (HR 0.65 95% CI 0.40-1.06; p=0.087) compared to no treatment. However, it was observed that responders to neo-adjuvant chemotherapy (Mandard 1-3) were more likely to demonstrate a survival benefit from adjuvant chemotherapy (HR 0.42 95%CI 0.15-1.11; p=0.081) than those who are deemed to be non-responders (Mandard 4&5, HR 0.71 95%CI 0.39-1.32; p= 0.280).

Conclusion

 Adjuvant chemotherapy may have a survival benefit in R0 resection patients following surgery, but this is likely to be limited to patients exhibiting a good response to neo-adjuvant chemotherapy.