bluuebunny/crossref_metadata_2025 huggingface dataset:
440. MULTIDISCIPLINARY TREATMENT CONFERENCE IMPROVES SURVIVAL IN ESOPHAGEAL CANCER
Authors: Linder Gustav , Lindblad Mats , Edholm David
Published: September 2022

The advantages of multidisciplinary treatment conferences (MDT) are advocated in staging and treatment of esophageal cancer. Improved timeliness to surgery, adherence to guidelines, increased probability of complete clinical staging and allocation to curative treatment have all been attributed to the introduction of MDTs but there are few studies published in support of MDTs positive effect on outcomes.

The aim is to investigate the association between MDT and survival in esophageal cancer.

All patients diagnosed with esophageal cancer in the Swedish Registry for Esophageal and Gastric Cancer between 2006-2018 were included in this retrospective cohort study. Patients were grouped according to whether or not they had been discussed at an MDT as part of their staging process. The cohort was followed until death, emigration, or end of follow-up. Factors possibly affecting group allocation was explored with multivariable logistic regression and the impact of MDT on survival was studied with Cox-regression and the Kaplan–Meier method.

Of 6607 patients diagnosed with esophageal cancer, 1338 (20%) were not discussed at an MDT. Median survival was 10.7 months with MDT and 4.4 months without MDT.

Age above 80, OR 0.29 (0.18-0.47 95%CI), Charlson Comorbidity Index>2, OR 0.79 (0.66-0.96) and clinical stage IVb, OR 0.66 (0.44-0-97) all decreased the probability of being presented at an MDT, whereas squamous cancer, OR 1.45 (1.18-1.77) and later year of diagnosis OR 1.33 (1.30-1.37 per year) increased the probability of an MDT.

Adjusted for the well-established prognostic factors above, the MDT was still an independent predictor of survival, HR 0.63 (0.58-0.69 95%CI).

The role of the MDT in the staging and treatment of patients with esophageal cancer is, in the present study, clearly associated with improved survival. Older, more comorbid patients with advanced disease are at a disadvantage since they are not consistently discussed in a multidisciplinary setting. Whether the survival benefit is due to the MDT alone or lack of ambition in what appears to be non-curable cases is yet to be determined.
441. ESOPHAGEAL CANCER MANAGEMENT IN A SWISS REFERRAL CENTER; A 20-YEAR EXPERIENCE
Authors: Gaspar-Figueiredo Sérgio , Mantziari Styliani , Teixeira-Farinha Hugo , Demartines Nicolas , Schäfer Markus
Published: September 2022

In the past decades, management of esophageal cancer (EC) has significantly changed with the widespread use of oncological treatments, as well as minimally invasive surgery and enhanced recovery protocols. Concurrently, the histological type, comorbidity status and life expectency of the ‘typical’ EC patient have also evolved. The aim of this study was to assess the evolution in epidemiology, management and outcomes of EC patients treated in a Swiss tertiary referral center the last 20 years.

Baseline demographics, clinico-pathological data, treatment details and postoperative outcomes were retrieved from our institutional prospective database for all consecutive patients operated for esophageal cancer with curative intent. Emergency surgery and endoscopic treatment of early EC were excluded, hence 332 patients (265 male, 67 female) were included in the final analysis. Patients were divided in 3 groups: ‘historical group’: 2000–2007, n = 73; ‘transition group’: 2008–2014, n = 108; ‘modern group’: 2015–2020, n = 151. Comparison was performed with the x2 test for discrete and the ANOVA tests for continuous variables, with the Bonferroni method to determine significance in pairwise comparisons (p < 0.05).

The annual caseload doubled (10 to 25 cases/y). Alcohol consumption (57.5% to 28.5%, p < 0.001), active smoking (64.4% to 38.4%, p = 0.001) and COPD (41.1% to 35.1%, p = 0.05) decreased. Squamous cell carcinoma (58.9% historic, 34.4% modern group) was replaced by adenocarcinoma as the most prevalent type (35.6% vs 64.2%, p = 0.001). Detection of locally advanced disease increased from 58.8% to 75.8% (p = 0.022), along with the use of neoadjuvant treatment (34.2% historic, 83.4% modern group, p < 0.001). Major postoperative morbidity was documented in 34.2% of patients (historic group) versus 58.3% (modern group, p = 0.002), but mortality remained stable. No differences were observed in long-term survival.

Centralization significantly increased the annual caseload. Improved preoperative workup enabled more accurate detection of locally advanced disease and subsequently appropriate multimodal treatment that is currently used in most patients. The ‘typical’ EC patient has shifted from the squamous cell to the adenocarcinoma type, but males are still more concerned. Postoperative complications are nowadays more rigorously detected and managed, keeping mortality rates low. Long-term survival remained unchanged over time.
448. THE PRIMARY TUMOR BURDEN SCORE: A NOVEL CLINICOPATHOLOGICAL STAGING TOOL FOR PATIENTS WITH ESOPHAGEAL CARCINOMA RECEIVING NEOADJUVANT CHEMORADIOTHERAPY PLUS SURGERY
Authors: Huang Xu , Tang Han , Tan Lijie , Hou Yingyong
Published: September 2022

The AJCC TNM staging system (8th edition) contains a ypTNM stage classification for patients with EC receiving neoadjuvant therapy prior to surgery. However, the ypTNM staging system may be unable to represent tumor changes occurring during the treatment. This study was to develop a prognostic model for esophageal carcinoma (EC) describing both the pretreatment pathological state of the tumor and its change after neoadjuvant chemoradiotherapy (nCRT) plus surgery.

187 patients with esophageal carcinoma treated with nCRT plus surgery were identified from two medical centers. The Primary Tumor Burden Score (PTBS) was calculated by multiplying the percentage of residual primary cancer cells and the pretreatment pathological T stage (prepT-stage). Univariate and multivariate Cox regression was used to determine the relationships between clinicopathological parameters and prognosis. The discriminatory power of the model was evaluated using the area under the curve (AUC) and goodness-of-fit Akaike information criterion (ΔAIC). The revised TNM stage was compared with the ypTNM stage using the AIC and the C-index.

The PTBS model (AUC:0.727) outperformed to the residual tumor ratio (AUC:0.588) and the pretreatment T stage (AUC:0.6) in OS prediction (P < 0.05). High PTBS scores were associated with significantly worse outcomes: five-year OS of stage 1, 2, and 3 were 73.1%, 42.0%, and 11.4%, respectively, P < 0.001. The PTBS model was more accurate in predicting patient prognosis than cT-stage or ypT-stage (ΔAIC: PTBS vs cT-stage and pT-stage, 30.38 vs −1.87 and 7.61). Multivariate analysis indicated that PTBS independently predicted OS and DFS, The PTBS-based revised TNM stage showed superior prognostic strength to the 8th AJCC ypTNM stage.

The PTBS model showed superior prognostic discriminatory ability than cT-stage or ypT-satge and may thus be useful for describing the influence of the primary tumor burden on survival in patients who had received neoadjuvant CRT before surgery. A revised TNM stage based on PTBS showed superior prognostic capability to the 8th AJCC ypTNM stage.
452. OUTCOME OF ESOPHAGEAL RESECTION IN PATIENTS WITH ESOPHAGEAL CANCER WITH HISTOPATHOLOGICALLY CONFIRMED DISTANT METASTASIS
Authors: Atanasova Elena
Published: September 2022

Patients suffering from esophageal cancer with metastatic disease are usually considered not eligible for resection. In selected patients, however, surgery including resection of distant metastasis, is performed.

This study aimed to study the frequency and outcomes after surgery for metastatic esophageal cancer.

A nationwide cohort study on all patients resected for esophageal cancer in Sweden, between 2006 and 2017, with histopathological verified metastatic disease (pM1). Complete follow-up regarding survival was acquired from the Cause of death registry. Overall survival was analyzed and presented with the Kaplan Meier method and multivariable Cox-regression with Hazard Ratios (HR) with 95% Confidence Intervals (CI).

Of 1572 patients who underwent esophageal resection 75 had pM1 disease. Of those, 70% (n = 53) had been preoperatively staged as cM0. Conversely, 3% of patients with pM0 disease were staged as clinical cM1 or cMX prior to surgery.

Advanced T or N-stage was more common in M1 patients compared to M0 patients. Additionally, neoadjuvant treatment was less common in M1 compared to M0 patients (40%vs52%) while adjuvant therapy was more common in M1 patients (38%vs14%).Five-year overall survival was significantly lower in M1 compared to M0 patients, 15%vs43% respectively (p < 0.001, log-rank test). In numbers, 11 out of 75 patients were alive after five years.

There are long-term survivors among patients with confirmed metastatic esophageal cancer that underwent radical resection. Selection of patients with limited metastatic disease and response to neoadjuvant therapy may contribute to this effect.
453. THE EFFECTIVITY OF NEOADJUVANT CHEMORADIOTHERAPY IN ESOPHAGEAL ADENOCARCINOMA WITH PRESENCE OF EXTRACELLULAR MUCINE, SIGNET-RING CELLS OR POORLY COHESIVE CELLS
Authors: Valkema Maria Joanna , Vos AM , van der Post RS , Ooms AHAG , Oudijk L , Eyck BM , Lagarde SM , Wijnhoven BPL , Rosman C , van Lanschot JJB , Doukas M
Published: September 2022

Five-year overall survival of patients with locally advanced esophageal adenocarcinoma treated with neoadjuvant chemoradiotherapy (nCRT) followed by surgery is 40%. Better understanding of histopathological factors that influence treatment response is necessary to identify patients with expected poor prognosis. Aim of the study was to assess whether pre- and post-treatment presence of excessive (≥1%) extracellular mucus accumulation, signet-ring cells (SRC) and/or poorly cohesive cells were associated with poor response to nCRT, independent of tumor differentiation grade.

This was a retrospective cohort study. Patients included were diagnosed with an adenocarcinoma of the esophagus or GEJ, who underwent CROSS and were planned to undergo esophagectomy between 2001–2019 at two university hospitals. Percentages of the factors extracellular mucus, SRC and poorly cohesive cells were scored by experienced pathologists in pre-treatment biopsies and resection specimen slides relative to the primary tumor area. Multivariable logistic regression models and Cox proportional-hazards models were used to evaluate the histopathological factors in relation to tumor regression grade (TRG) 1–2 (<10% tumor) vs TRG 3–4 (>10% tumor), overall survival (OS) and disease-free survival (DFS).

Some 325 patients were included (median age 65 years, 280/325 (86%) male). In pre-treatment biopsies, ≥1% extracellular mucus was present in 66/325 (20%); ≥1% SRC 43/325 (13%); ≥1% poorly cohesive cells 126/325 (39%). In patients undergoing esophagectomy, 150/284 (53%) had TRG 3–4. Median OS in all patients was 44 months (95%CI: 36–62). Factors in pre-treatment biopsies were not associated with outcomes independent of differentiation grade. Only patients with ≥1% SRC in the resection specimen had poorer OS (Fig 1): HR for death 1.71, 95%CI: 1.06–2.76, adjusted for age, sex, pre-treatment pathological tumor and nodal stage (pre-pT/pre-pN), ypN and tumor differentiation grade.

Extracellular mucus accumulation, SRC and/or poorly cohesive cells in pre-treatment biopsies in patients with esophageal adenocarcinoma treated with nCRT are not associated with response to nCRT, OS or DFS. Their presence should not be a reason to refrain from CROSS nCRT. However, persistence of SRC in the resection specimen after nCRT is an indicator of poor prognosis.
455. ESOPHAGOGASTRIC JUNCTION CANCER: A DIFFICULT BORDER: A WORLDWIDE SURVEY ON ONCOLOGICAL AND SURGICAL APPROACH
Authors: Leone Barbara , De Pasqual Carlo Alberto , Gervasi Maria Clelia , Zenzaro Matteo , Turolo Cecilia , Weindelmayer Jacopo , Giacopuzzi Simone , de Manzoni Giovanni
Published: September 2022

The incidence of esophagogastric junctional adenocarcinoma (EGJ) has been steadily increasing over the last 30 years, especially in Western countries. Surgical and oncological treatment of these malignancies are still debated, in particular in case of true junctional cancer (Siewert type II tumors). The aim of the study is to compare different approaches to EGJ cancers in high volume centers around the world.

We administered a survey to 39 international opinion leaders, working in high volume centers, with a minimum of 50 gastrectomies and 20 esophagectomies performed as first operator. The survey was structured in the form of clinical case scenarios, created to focus on different peculiar issues in the management of Siewert type II tumors. The main fields of investigation were the oncological approach of these malignancies (i.e. choice and type of neoadjuvant treatment) and the preferred surgical strategy.

Our first finding was that almost 80% of responders would choose a neoadjuvant treatment even in cT2N0 patients, fearing probably the low accuracy of the clinical staging. Secondly, 60% of surgeons would prefer chemotherapy over chemoradiotherapy in locally advanced Siewert II tumors, regardless of histological subtype and nodal diffusion.

As for the surgical strategy, we reported a strong preference (75% of responders) for two-field esophagectomy, over three-field esophagectomy (11%) and total extended gastrectomy (14%). However, in case of signet-ring cell carcinoma, up to 20% of surgeons would prefer an extended total gastrectomy, to avoid a distal positive margin.

Our survey confirms that the management of Siewert type II tumors is greatly debated, even among experts of the field, and it needs to be tailored on the patient and tumor characteristics. Even so, we observed a trend towards the choice of chemo over chemoradiotherapy for any histological subtype. When operating on Siewert type II tumors, a thoracic approach is considered necessary by most of responders.
461. SURGICAL TREATMENT OF STAGE IV ESOPHAGEAL CANCER AFTER CCRT IMPROVES SURVIVAL
Authors: Wang Hu-lin Christina , Chen Ke-Cheng , Cheng Chia-Hsien , Wu Ming-Shiang , Lee Yi-Chia , Wang Hsiu-Po , Liou Jyh-Ming , Kuo Yu-Ting , Han Ming-Lun , Chen Chien-Chuan , Huang Pei-Ming , Hsu Hsao-Hsun , Chen Jin-Shing , Kuo Shuenn-Wen , Lin Mong-Wei , Liao Hsien-Chi , Wu I-Hui , Lin Chia-Chi , Hsu Chih-Hung , Huang Ta-Chen , Guo Jhe-Cyuan , Hsu Feng-Ming , Tsai Chiao-Ling , Lu Shao-Lun , Chiang Yun , Chang Yeun-Chung , Chen Jo-Yu , Huang Yu-Sen , Chen Mei-Chi , Yeh Li-Hao , Chiang Pin-Yi , Chang Yu-Chien , Tsai Yu-Dian , Lee Yee-Fan , Yeh Ruoh-Fang , Cheng Mei-Feng , Ko Kuan-Yin , Liu Chia-Ju , Chang Yih-Leong , Hsien Min-Shu , Lee Yi-Hsuan , Lin Fang-Miao , Kang Ya-Chun , Jin Yng-Jiun , Chen Yen-Tsz , Lee Jang-Ming
Published: September 2022

Treatment of stage IV esophageal cancer is traditionally palliative, but treatment response is usually poor. The role of surgery in the treatment of advanced esophageal cancer remains controversial. We sought to determine whether surgical treatment followed by neoadjuvant chemoradiation therapy might provide survival benefits for these patients.

A retrospective review of 163 esophageal cancer patients with M1 disease (distant organ metastasis) treated at a tertiary medical center hospital was performed from April 2002 to June 2021. Patient demographics and cancer staging, treatment, and disease recurrence, and time of follow up were included for analysis. Univariate and multivariate analysis was performed for overall survival and progression-free survival analysis. Propensity score matching based on patient age and tumor staging characteristics was also performed for analysis.

124 patients were treated by CCRT alone and 39 treated by CCRT plus surgery. 3-year and 5-year progression free survival was 17.7% and 8.9% for CCRT+surgery group vs 0.8% and 0.0% in CCRT only group. (p = 0.019) 3- and 5-year survival was 24.0% and 12.0% in CCRT plus surgery group compared to 2.8% and 1.4% for CCRT only group (p = 0.009). Propensity matching of 39 CCRT plus surgery patients and 78 CCRT-only patients showed similar results (17.5% & 8.5% PFS vs 1.3% & 0.0% for PFS, 24.0% and 12.0% vs 3.9% and 1.9% OS).

Surgical resection following CCRT treatment may improve progression-free survival and overall survival for selected patients of esophageal cancer with M1 disease. Surgical indication should be judicious, and further follow up studies should be performed.
463. OESOPHAGEAL PERFORATIONS: CAUSES, MANAGEMENT, AND OUTCOMES AT A SPECIALIST UPPER GASTROINTESTINAL UNIT OVER A TEN-YEAR PERIOD
Authors: Toi Teri , Lam Stephen , Kumar Bhaskar
Published: September 2022

Perforation of the oesophagus is a relatively rare but life-threatening condition, which requires early laparoscopic or surgical intervention. The aim of this work was to describe the causes, management and outcomes of emergency patients treated at a single high volume upper gastrointestinal specialist unit in the United Kingdom.

In this retrospective case series, we identified all patients who presented to a tertiary upper gastrointestinal surgery unit with a spontaneous or iatrogenic oesophageal perforation. Patient demographics, clinical management, and outcomes were identified by hand review of the medical notes.

Between March 2011 to July 2020, 58 patients were identified. The median age was 71 years (interquartile range 52 years to 83 years) and 64% were male. A total of 83% of patients had benign perforations, the rest being malignant. Management of all patients was supportive in 41%, endoscopic in 19% and surgical in 40%. In total 63% of spontaneous benign perforations were managed surgically, and only 6% endoscopically. The median length of hospital stay for all patients that survived more than 90 days was 13 days. The 90-day mortality rate for all patients was 42%.

Oesophageal perforations are a relatively rare but lethal disease, carrying a mortality. Whilst surgery has historically been the most common management of benign spontaneous perforations, endoscopic treatments are likely to become increasingly common in the future.
467. USEFUL ANASTOMOSIS AFTER ESOPHAGECTOMY USING ICG FLOW AND COLLARD MODIFIED METHOD
Authors: Yamada Kazuhiko , Nohara Kyoko , Enomoto Naoki , Yagi Shuyu , Kato Daiki , Aso Kenta , Hogo Tomoki , Suyama Yuto , Takemura Nobuyuki , Kiyomatsu Tomomichi , Kokudo Norihiro
Published: September 2022

Risk of anastomotic leakage after esophagectomy is reported comorbidity, surgical technique, and others. One of management to reduce AL is to measure indocyanine green (ICG) of gastric conduit. It may be more sensitive and useful than traditional method. Furthermore, by changing the anastomotic technique with modified Collard method, AL rate was reduced from 15% to 4% and anastomotic stenosis was also reduced. In this study, we examined some marker of stomach roll depiction by ICG.

We enrolled 52 cases for which ICG data were obtained from August 2019 to December 2021. The distance from stump of the stomach roll was measured by marking the line ICG 5mg stained after 30, 60 seconds We examined some data of arterial network between left and right gastroepiploic arteries, the depiction of gastric conduit, and intra andextramural vessels from the wall from the recorded images. We decided anastomotic line stained with ICG in 30 second.

We reconstructed gastric conduit with 42 stomach roll and 10 subtotal stomach. The distance of gastric conduit stained with ICG was Mean ± SD: 47 ± 19 mm (0-80 mm) at 30 seconds and 28 ± 17 mm (0-60 mm) at 60 seconds. Arterial network between left and right gastroepiploic artery: yes/no (8:43), whole gastric wall depiction: yes/no (24/28), extramural blood flow: yes/no (44/7). There was no necrosis of gastric conduit, AL rate was 3.8% (2/52), and anastomotic stenosis requiring endoscopic bougie was 2%. Ten cases of subtotal stomach had no AL and stenosis.

By using ICG, anastomotic line drawn in 30 second was shorter than 60 seconds and gastric conduit was shorter than traditional line. Determining good blood flow sites using ICG in gastric conduit and widening anastomotic caliber using modified Collard method may have reduced AL and stenosis. It is considered to be very simple procedure that does not depend on surgeon.
468. THE EFFECT OF ROUTINE ENDOSCOPIC SCREENING FOR SYNCHRONOUS ESOPHAGEAL NEOPLASIA IN PATIENTS WITH HEAD AND NECK SQUAMOUS CELL CARCINOMA
Authors: Shimada Ayako , Hirano Yuki , Oyama Takashi , Tamura Takuya , Minagawa Takuya , Ishida Takashi , Tsuruta Masashi , Hoshimoto Sojun , Shinoda Masahiro , Itano Osamu
Published: September 2022

Esophageal squamous cell carcinoma (ESCC) and head and neck (H&N) cancer coincide in high frequency and early detection of synchronous cancer is inevitable for these patients. The aim of this study is to analyze the effect of routine endoscopic screening for synchronous esophageal cancer in patients with H&N cancer.

From April 2020 to March 2022, 35 patients with newly-diagnosed H&N cancer had routine screening endoscopy for synchronous esophageal cancer. All patients with H&N cancer were referred to our department prior to the treatment for H&N cancer.

The locations of H&N cancers were oral/oropharyngeal/hypopharyngeal/laryngeal/other H&N cancer; 9/6/9/9/2 respectively. Image-enhanced endoscopy using BLI (blue laser imaging) was performed in all patients. Lugol staining was used in 20 patients and multiple Lugol voiding lesions were detected in 9 patients. Among all patients, abnormal endoscopic findings in esophagus were detected in 15 patients (43%), and biopsy was performed in 11 patients (31%). Biopsy revealed SCC in 5 patients and atypical epithelium in 2 patients. Esophageal lesions were all found in early stage within indication of endoscopic treatment. 3 patients underwent endoscopic treatment after treatment of H&N cancer.

Routine endoscopic screening for patients with H&N cancer is effective in early detection of synchronous esophageal cancer with minimally invasive treatment for esophageal neoplasm. The treatment of chemotherapy for H&N cancer may be effective for esophageal lesions, therefore, careful surveillance is required during the treatment of H&N cancer. Routine endoscopy should be continued further for these patients for screening of metachronous cancer.
475. IMPACT OF SURGERY START TIME ON SHORT TERM OUTCOMES OF ELECTIVE ESOPHAGECTOMY FOR CANCER
Authors: Yang Tzu Yi , Chao Yin Kai
Published: September 2022

As the number of patients with esophageal cancer is increasing, it is expected to lead to an increased work for surgeons. However, surgeons would work less effectively with fatigue accumulation during the course of a normal workday. We examined the impact of surgery start time and work load on short-term outcomes of patients undergoing elective esophagectomy for caner.

This was a retrospective analysis of a single medical center dataset that included all patients (n = 614) who had undergone elective esophagectomy for cancer between 2010 and 2022. Patients were categorized according to the start times of surgery (AM group: 8am-1pm, n = 491; PM group: 1pm-5pm, n = 123). Post-operative outcomes and short-term survival were taken as primary end point.

The baseline characteristics of the AM and PM group were similar. The AM group had longer operation time (443.29±89.31 vs. 410±81.55, p < 0.001). The rate of unplanned conversion to laparotomy from laparoscopy was higher in the PM group with borderline significance (0.2% vs. 0.7%, p= 0.08). Both of the oncological outcomes and the incidence of the postoperative complications were similar between two groups (all p > 0.05). In short term survival, patients in the PM group had higher 180-day mortality (9.3% vs. 16.3%, p= 0.045).

Surgery start times might contribute to higher conversion rate in abdominal part of surgery. Otherwise, surgery start times and workload of surgeons during working time did not affect short-term outcomes of elective esophagectomy for cancer.
483. UTILITY OF ENDOLUMINAL FUNCTIONAL LUMEN IMAGING IN DIAGNOSIS OF ESOPHAGEAL DYSFUNCTION FOLLOWING BARIATRIC SURGERY
Authors: Yao Rebecca , Rapaka Babusai , Dayyeh Barham Abu
Published: September 2022

We present the case of a 46-year-old male with medically complicated class III obesity who presented with new-onset and persistent dysphagia after undergoing a successful laparoscopic Roux-en-Y gastric bypass surgery. An esophagogastroduodenoscopy was unrevealing, however, further workup with the endoluminal functional lumen imaging probe (EndoFLIP) device was suggestive of esophageal dysmotility with decreased distensibility index of the GE junction and absent/disorganized secondary esophageal peristalsis.

Thorough chart review was performed to elicit details of the case presentation. Further, a literature review was performed to supplement background knowledge and discussion.

We present a case of symptomatic esophageal dysphagia in a post-procedural bariatric surgery patient with normal EGD yet positive findings on functional lumen imaging, consistent with the newly described entity termed Post Obesity Surgery Esophageal Dysfunction (POSED). POSED is defined by aperistalsis and increased intragastric pressure seen after bariatric surgery. It is thought to occur due to a high-pressure gastric zone created in the noncompliant postoperative stomach after Roux-en-Y gastric bypass, or an increased esophageal afterload by a restrictive laparoscopic sleeve gastrectomy. No treatment guidelines exist, though options include botulinum toxin, dilation, and per-oral esophageal myotomy.

This case provides further insight into the role that functional lumen imaging has in the bariatric patient, as it may be able to more accurately detect patients who will develop esophageal dysmotility following bariatric surgery, or perhaps even those who may be predisposed prior to undergoing intervention for weight loss.
490. CORRELATION BETWEEN HISTOLOGICAL AND MOLECULAR ALTERATIONS WITH POOR SURVIVAL IN ESOPHAGEAL ADENOCARCINOMA
Authors: Bonora Elena , Mastracci Luca , Orsini Arianna , Bozzarelli Isotta , Isidori Federica , Tassi Valentina , Fiocca Roberto , Lugaresi Marialuisa , D'Errico Antonietta , Malvi Deborah , Spaggiari Paola , Tomezzoli Anna , Albarello Luca , Ristimäki Ari , Bottiglieri Luca , Krishnadath Kausilia , Rosati Riccardo , Romario Uberto Fumagalli , De Manzoni Giovanni , Räsänen Jari , Mattioli Sandro
Published: September 2022

The incidence of esophageal adenocarcinoma (EAC) has constantly risen in western countries over the past decades, often diagnosed at advanced stage and with a five-year survival around 20%1. In a previous study on EAC cases submitted to surgery (without neoadjuvant treatment) an algorithm (EACGSE classification)2 based on morphologic distinctions provided a significant prognostic impact. We aimed to evaluate the molecular basis underlying these differences, to improve patient management.

The EAC cohort classified according to EACGSE2 was included in the study. Genomic DNA was available from formalin fixed paraffin embedded surgical specimens for 207 cases. The cases were sequenced for 26 cancer-related genes (panel #226722257; IDT) with high coverage on NextSeq500 (Illumina). Data analysis was performed using a dedicated pipeline3. 245 cases were analyzed for SMAD4 immunostaining (IHC). Loss of SMAD4 immunostaining was reported as % of negative tumor cells (at least 35% of neoplastic cells).

TP53 was the most frequently altered gene (134/207 cases with at least one mutation). The presence of TP53 missense variants was associated to a poor cancer-specific survival (CSS) in the high-risk cases (glandular poorly differentiated, mucinous invasive, diffuse anaplastic, mixed) according to EACGSE2 (P=0.0005). A significant correlation was observed for TP53 truncative variants and loss of SMAD4 staining (P=0.008). Actually, SMAD4 loss was observed in 85/245 (35%) of all EAC cases analyzed via immunostaining. SMAD4 loss correlated with poor CCS (P=0.007) and disease-free survival (P=0.002) in EACGSE high-risk cases.

TP53 missense mutations correlated to poor outcomes (CSS) in high-risk cases, TP53 truncative mutations were associated to SMAD4 loss. SMAD4 loss itself resulted a frequent event in EAC and correlated with lower CCS and disease-free survival in high-risk cases. Therefore, we were able to correlate EAC histological classification, clinical outcomes and molecular phenotypes. Validation in independent samples is warranted to corroborate these findings.

References

1. Coleman et al. Gastroenterology2018;154:390–405.

2. Fiocca et al. Cancers 2021;13:5211.

3. Isidori et al. CTG 202011:e00202.
494. GIANT GASTROINTESTINAL STROMAL TUMOR OF THE ESOPHAGUS: REPORT OF TWO CASES
Authors: Sato Kota , Akuta Sohei , Yamazaki Shigeru
Published: September 2022

Gastrointestinal stromal tumor (GIST) accounts for 1-3% of all gastrointestinal tumors. Most of GIST occurs in the stomach and small intestine, but GIST from the esophagus is relatively rare at about 2-5%. Surgical resection is the treatment of choice, but no routine procedure has been established. We report two cases of esophageal GIST that underwent surgical resection.

[Case 1]

A 75-year-old woman. She was diagnosed with an 11 cm-sized submucosal tumor was found in the esophagus by upper gastrointestinal endoscopy. Histopathological examination showed that the tumor was GIST. The patient's postoperative course was uneventful and the patient was discharged home in good condition on the 22nd postoperative day.

[Case 2]

A 58-year-old man. He was diagnosed a 9 cm-sized elevated lesion in the by CECT. The tumor suspected esophageal cancer sarcoma, we underwent esophagectomy. Finally, histopathological examination revealed that the tumor was GIST. His postoperative course was uneventful and he was discharged on the 19th postoperative day.

[Case 1 result]

Postoperative adjuvant chemotherapy with imatinib was failed, but the follow-up period continued without recurrence.

[Case2 result]

Postoperative adjuvant chemotherapy with imatinib was introduced. Contrast-enhanced CT 6 months after surgery revealed multiple liver metastases. 2nd line chemotherapy with sunitinib is still ongoing.

[Discussion]

Surgical treatment is the first choice for esophageal GIST, but no standard surgical procedure has been established. In the past, esophagectomy similar to esophageal cancer was often performed, but thoracoscopic local resection may be selected in recent years. Even in the case of giant esophageal GIST as like this two cases, if the general condition is stable and preoperative treatment is possible, it is possible to choose to perform preoperative neoadjuvant chemotherapy.
500. DEVELOPMENT AND VALIDATION OF INTRAOPERATIVE RADIATION FIBROSIS SCORE (IRFS) IN PATIENTS UNDERGOING TRANSTHORACIC ESOPHAGECTOMY POST NEOADJUVANT CHEMORADIATION FOR ESOPHAGEAL CANCER
Authors: Shukla Srijan , Thammineedi Subramanyeshwar Rao , Patnaik Sujit Chyau
Published: September 2022

Esophagectomy performed for cancers of esophagus is a challenging surgery. Post radiation fibrosis makes identification of critical structures difficult. The exact relationship between radiation dose and timing of surgery to the intraoperative difficulty remains to be tested.

Surgical videos of transthoracic esophagectomy for carcinoma esophagus post neoadjuvant chemoradiation were reviewed and IRFS score was calculated based on three factors (esophageal pleural thickening, periesophageal planes, periadenitis). The IRFS score was then correlated with the radiation dose, interval between radiation completion and surgery, surgery duration, pathological response, major intraoperative complications and short term surgical outcomes.

Primary objective: Correlation of radiation dose and timing of surgery with the IRFS.

Secondary objectives: To study for correlation between surgery duration, pathological response, major intraoperative complications and short term surgical outcomes with IRFS

Surgical videos of 100 patients were analysed.

IRFS score which comprises of esophageal pleural thickening, periesophageal planes and periadenitis is a unique tool of assessing surgical difficulty which can be used to correlate radiation doses and interval to surgery. Further studies are required to validate it against post operative outcomes.
508. OUTCOME OF NEOADJUVANT CHEMORADIOTHERAPY PLUS SURGERY FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA IN EAST ASIA VERSUS WESTERN EUROPE
Authors: Eyck Ben , Gao Xing , Yang Yang , van der Wilk Berend , Wong Ian , Wijnhoven Bas , Liu J , Lagarde Sjoerd , Lam KO , Hulshof M , Li Zhi Gang , Law Simon , Chao Yin Kai , van Lanschot Jan
Published: September 2022

Patients with different ethnic and genetic backgrounds may respond differently to specific anticancer therapies. The present study aimed to assess whether patients with esophageal squamous cell carcinoma (ESCC) who are treated with neoadjuvant chemoradiotherapy (nCRT) according to the CROSS regimen in East Asia have an inferior response compared to patients treated in Western Europe.

Patients with ESCC who completed ≥80% of nCRT according to CROSS (five weekly cycles of carboplatin [AUC of 2 mg/mL/min] and paclitaxel [50 mg/m2] with concurrent 41.4 Gy radiotherapy in 23 daily fractions of 1.8 Gy) followed by esophagectomy between June 2012 and April 2020 were identified from Asian and Dutch databases. Primary endpoint was pathologically complete response (pCR), defined as ypT0N0. Asian and Dutch patients were compared with nearest-neighbor propensity score matching, adjusting for confounding factors: gender, Charlson comorbidity index, tumor location, cT and cN stage, interval from start of nCRT to surgery, and number of resected lymph nodes.

In total, 839 patients were included (Asian: 175, Dutch: 664). After matching, 154 remained in each group. Confounding factors were all significantly different before matching and 26% in the Asian versus 42% in the Dutch cohort had a pCR (p<0.001), which became 27% versus 42% after matching (p=0.008), respectively. Both ypT and ypN stage were significantly higher in the Asian cohort. R0 resection rate was comparable (Asian: 92% vs. Dutch: 95% resp., p=0.29). Asian patients more often had a cervical anastomosis (p=0.001) and less complications including pulmonary complications (21%-38%, p=0.002), chyle leakage (2%-10%, p=0.006) and anastomotic leakage (10%-21% resp., p=0.02).

The present study shows that after adjusting for patient and tumor characteristics, East Asian patients with ESCC have a poorer response to nCRT according to the CROSS regimen than Western European patients. The poorer response did not seem to have a negative effect on surgical outcome. Future studies investigating anticancer therapy for esophageal cancer should take into account ethnic and genetic differences in response to these regimens.
509. FULLY ROBOTIC IVOR-LEWIS ESOPHAGEAL RESECTION (RAMIE) – TECHNICAL DETAILS OF THE RAMIE PROCEDURE IN THE ROBOT2 TRIAL
Authors: Grimminger Peter
Published: September 2022

Robotic-assisted surgery is increasing, especially in cancer surgery. Minimal-invasive esophagectomy (MIE) is commonly the standard operation procedure in high-volume centers. Also, the fully robotic minimally invasive esophagectomy is performed more and more frequent. Over the past 5 years we continuously improved our 4-arm RAMIE procedure.

At the moment we are comparing the two total minimal-invasive Ivor-Lewis techniques in a RCT (ROBOT-2 trial).

Since January 2017 we perform RAMIE procedures and we would like to demonstrate the further developed robotic technique of one case as an example how we perform Ivor-Lewis RAMIE after a learning case of over 250 RAMIE cases in our case observation center in Mainz Germany.

The overall advantages between RAMIE and MIE are under evaluation in our recruiting ROBOT-2 trial, of which we like to report the progress at ISDE 2022.
512. COMBINATIONAL TREATMENT USING ENDOSCOPIC DILATION AND ORAL PREDNISOLONE FOR REFRACTORY ANASTOMOTIC STRICTURE AFTER ESOPHAGECTOMY
Authors: Tetsuo Hanako , Kobayashi Shinichiro , Enjoji Takahiro , Maruya Yasuhiro , Kobayashi Kazuma , HIdaka Masaaki , Ito Shinichiro , Kanetaka Kengo , Eguchi Susumu
Published: September 2022

Anastomotic strictures are common complications after esophagectomy, and frequent dilatations to refractory strictures reduce patient’s QOL. Yamaguchi and colleagues have developed new treatments using oral prednisolone. They have shown the safety and potential efficacy to prevent esophageal strictures after ESD. However, the efficacy and safety of oral prednisolone is not evaluated to anastomotic stricture after esophagectomy.

The aim of this study is to examine the safety of oral steroids therapy for postoperative esophageal stenosis.

The subjects were patients who passed 28 days after the esophagectomy and recurred stenosis symptoms within 2 weeks after the dilatation, and who have undergone more than three or more dilations. Indication of oral steroids therapy was based on the definition of Kochman.

Oral prednisolone was started at 30 mg/day after dilations, tapered gradually, and then discontinued for 12 weeks.

The primary endpoint was safety evaluation.

Secondary endpoints included stenosis rate at 85 days after initiation of steroid therapy, dysphagia score, number of dilations, change in weight, and duration of dilation interval, and enterostomy use rate.

Five of six patients with refractory anastomotic strictures were enrolled.

The risk factor for the incidence of refractory stenosis was ischemic changes around the entire anastomosis.

The duration of hospital stay was significantly prolonged.

All the patients completed the therapy and no adverse events were observed.

There were two cases of re-strictures.

Dilation frequency was significantly reduced (4.4 ± 1.1 vs. 1.4 ± 1.9, P < 0.01) and the intervals was significantly prolonged (11.9 ± 6.2 days vs. 60.5 ± 33.6 days, P = 0.02).

Dysphagia scores were significantly improved (3.2 ± 0.8 vs 0.2 ± 0.4, P < 0.01).

The rate of enterostomy use was significantly reduced (80% vs 0%, P = 0.02).

Steroid therapy for esophageal stricture after esophagectomy may be safe and effective. Further studies are needed to evaluate the efficacy of steroid therapy in a large number of patients.
518. VATS ESOPHAGEAL DIVERTICULECTOMY WITH LAPAROSCOPIC HELLER MYOTOMY AND DOR FUNDOPLICATION
Authors: Cheung Siu Hong , Leung Yuen Yee , So Choi Kwan , Wong Tiffany Wing Ka , Lam Chin Tou
Published: September 2022

60years old lady presented with dysphagia.

Upper endoscopy found a large esophageal diverticulum at distal esophagus which was the likely cause of symptoms.

Diverticulectomy was suggested in view of its large size and symptoms.

Video assisted thoroscopic surgery was utilized in this case.

VATS staple esophageal diverticulectomy was performed in left semi prone position under one-lung ventilation. Subsequent laparoscopic cardial myotomy was performed in supine position, with Dor fundoplication performed at last.

Patient had uneventful recovery.

She was extubated after the operation.

Diet was resumed on post operative day 2.

Patient was discharged on post operative day 4.

No complication was observed and there was complete symptoms resolution.

left VATS esophageal diverticulectomy is feasible and safe.
523. RISK FACTORS ASSOCIATED WITH NOT RECEIVING ADJUVANT CHEMOTHERAPY FOR LOCALLY ADVANCED ESOPHAGOGASTRIC ADENOCARCINOMA
Authors: Chmelo Jakub , Brown Joshua , Prasad Pooja , Convill James , Phillips Alexander W
Published: September 2022

Perioperative chemotherapy is standard of care in the curative treatment of locally advanced esophagogastric adenocarcinoma in the UK. Previously used MAGIC triplet is becoming less frequently used in favor of superior FLOT quadruplet. There is however large number of patients who don't undergo adjuvant component of both of these perioperative regimens. This study aimed to investigate factors which are associated with not receiving adjuvant chemotherapy after neoadjuvant chemotherapy followed by surgical resection for esophagogastric adenocarcinoma.

All patient receiving neoadjuvant chemotherapy for esophagogastric adenocarcinoma followed by curative surgery during 2010 till 2019 were identified from prospectively maintained single institution database. Patients who died in-hospital or within 90 days of surgery were excluded from analyses. Risk factors which could be associated with receiving/not receiving adjuvant component were studied. Mann U Whitney and chi-square test were used as appropriate. Multivariable logistic regression was carried out to identify risk factors independently predictive of not receiving adjuvant chemotherapy.

Analyses included 624 patients of whom 273 received adjuvant chemotherapy (44%). This included ECX/ECF in 233 patients, EOX in 5 patients, FLOT in 22 patients and other/unknown regimens in 13 patients. Age, Charlson comorbidity index, return to theatre, severe postoperative complications (Clavien-Dindo grade III+) and R1 resection were associated with not receiving adjuvant chemotherapy (p 0.005, p 0.006, p 0.026, p 0.043, p 0.004 respectively). Statistically significant variables were entered into multivariable logistic regression model. Only R1 resection was independently associated with not receiving adjuvant component (OR 0.18, p 0.007).

This study confirms that only less than half of patients who undergo neoadjuvant chemotherapy followed by surgery with curative intent receive adjuvant chemotherapy. Reasons for this are multifactorial but age, comorbidities, severe complications and positive longitudinal margin might play important role. These results also highlight the importance of prevention, early detection and appropriate management of postoperative complications.
526. SALVAGE SURGERY FOR ESOPHAGEAL CANCER: IS IT TIME TO REFINE SURVEILLANCE CRITERIA?
Authors: Abdulrahman Rand , Abdulrahman Maan , Shamiya Khalid Adnan , Al-Khusaibi Mohamed , Picket Lianne , Monaghan Orla , O’Neill Brian , Grogan Liam , Kumar Nitya , Corbally Martin , Walsh Thomas Noel
Published: September 2022

There is no accepted surveillance strategy following curative oesophageal cancer management, with reinvestigation often relying on symptom development. Lack of a surveillance standard may impact on outcome and survival. We hypothesized that strict surveillance was more likely to detect curable recurrent disease. This study compared the outcome for salvage surgery for recurrent disease, detected on a strict surveillance program, with survival of patients that had undergone immediate surgery following an incomplete response to neoadjuvant chemoradiotherapy.

A prospective database of oesophageal carcinoma patients who were treated with curative intent (Surgery alone, Neoadjuvant Chemoradiotherapy (NeoCR) plus surgery, Definitive Chemoradiotherapy or Neoadjuvant Chemoradiotherapy with surveillance by choice), was interrogated for patients with recurrent disease amenable to salvage surgery. Surveillance for all consisted of 3-monthly endoscopy and 6-monthly CT scanning for 3 years, followed by 6-monthly endoscopy and yearly CT scanning to 5 years, and both yearly thereafter. If recurrence was diagnosed patients were restaged and, if suitable, underwent salvage surgery. Their outcome was compared with patients undergoing neoadjuvant chemoradiotherapy and having immediate surgery for an incomplete response.

Of 205 patients treated with curative intent, 18 (9%) underwent salvage surgery for locoregional recurrence. They had a median survival of 61.6 months (range 10.32 to 136.08) and a 3-year survival of 50%. This compares to 115 patients who underwent surgery following incomplete response to NeoCR, who had a median survival of 38.3 months (range 2.20 to 254.26) and a 3 year survival of 44%, which was statistically insignificant between the groups (p= 0.975). The overall mean survivals were 57.84 months and 57.9 months respectively.

Intensive surveillance identified a cohort of patients (9% of total) with recurrence amenable to salvage surgery and with outcomes non-inferior to immediate surgery following NeoCR. As most were asymptomatic, it is suggested that without surveillance the opportunity for curative intervention would have been lost. Even novel treatments will require detection of recurrence before disease becomes unmanageable. It is suggested that surveillance guidelines be updated to standardize interval endoscopy/imaging, as for other GI malignancies.
527. A RIGHT CERVICOTOMIC APPROACH TO RETRIEVE A DENTAL PROSTHESIS FROM THE ESOPHAGUS
Authors: Zanchetta Matteo , Monti Elisa , Latham Lorenzo , Costa Jessica , Marzorati Alessandro , Odeh Murad , Colombo Elisabetta Marta , Ietto Giuseppe , Inversini Davide , Iovino Domenico , Festi Luigi , Carcano Giulio
Published: September 2022

Foreign body (FB) ingestion in the upper gastrointestinal (GI) tract is a relatively common emergency presenting numerous diagnostic and therapeutic challenges. Adults most frequently ingest FBs accidentally while eating solid food. The esophagus accounts for 57% to 75% of all FBs impactions in GI tract. More than 80% FB pass spontaneously, around 10-20% require an endoscopic removal, and less than 1% have to be treated surgically, depending on the nature and location of the FB.

A 68 years old man presented to the Emergency Department complaining of a mild dysphagia since two days before. A laryngeal endoscopy showed edema of the right aryepiglottic fold; salivary stagnation hiding the pyriform sinus; edema of the right vocal cord; the airway caliber was adequate. A chest radiograph showed a dental prosthesis, probably ingested during a seizure, in the upper esophageal tract. The patient developed dyspnea and phonation difficulty due to neck swelling. An urgent CT scan showed signs of esophageal perforation and diffuse edema. A multidisciplinary equipe was assembled to properly treat the patient.

In the operating room, two attempts of retrieval with a flexible and a rigid endoscope failed because the dental prosthesis was stuck in the right pyriform sinus. After a careful evaluation of the FB location, the surgeon performed a right cervicotomy, uncommon when compared with the traditional left side approach to the neck, and retrieved it through an esophagotomy. A nasogastric tube was inserted and a paraesophageal 19 Ch drain in aspiration was placed in situ. Over time, no signs of esophageal leakages were detected post-operatively and eventually the patient was able to feed with solid foods without complications.

Any esophageal FB may cause potentially fatal injuries, therefore it must be retrieved within 12 to 24 hours. An endoscopic approach should be attempted first, with surgery being the extrema ratio. The surgical approach depends on the nature and location of the FB. A left cervical approach should not be regarded as dogmatic, and a right-sided approach, being equally safe and effective from a surgical point of view, could be appropriately chosen when clinically indicated.