bluuebunny/crossref_metadata_2025 huggingface dataset:
229. CARBON-13 BREATH TEST AS AN INVESTIGATIVE TOOL FOR DELAYED CONDUIT EMPTYING AFTER AN OESOPHAGECTOMY
Authors: Tham Ji Chung , Alcocer Bruno , Forbes Rosie , Ariyarathenam Arun , Humphreys Lee , Berrisford Richard , Wheatley Tim , Chan David , Lewis Stephen , Sanders Grant
Published: September 2022

The gold standard for diagnosing delayed conduit emptying (DCE) after an oesophagectomy is with scintigraphy. Current practice of using chest radiographs (CXR) and nasogastric tube (NG) output to diagnose DCE is useful clinically but is not as accurate as scintigraphy. A radiation-free procedure with higher accuracy that can be easily carried out at the bedside is needed. We proposal that the carbon-13 breath test is a viable option.

Oesophagectomy patients without pyloroplasty were recruited prospectively from 05/12/2017 to 31/12/2019 at a single centre. Age, gender, BMI, ASA grade, smoking status, and conduit size were used. DCE was diagnosed using parameters determined from CXRs and NG output described previously (1). At day 4/5/6, patients were fasted 6 hours prior to consumption of 100 mL of 193 kcal ice-cream laced with carbon-13 octanoic acid. Breath was captured at times 0, then every 30 minutes up to 4 hours and analysed using a gas spectrometer. Carbon-13 half-life excretion (t½) and estimated maximum excretion (tmax) was calculated using the formulas by Ghoos et al (2).

There were 65 patients with 24 DCE patients. Apart from gender (p = 0.015), there were no differences in demographics between DCE and non-DCE patients.

Differences were seen in both t½ and tmax. T½ was 3.04 hours [95%CI (2.91, 3.52)], and 3.54 hours [95%CI (3.41, 5.39)] in non-DCE, and DCE patients, respectively (p = 0.034). At time points 30, 60 and 90-minutes, Carbon-13 excretion were different, with p = 0.04, 0.015, and 0.034, respectively. Tmax was 1.68 hours [95%CI (1.45, 2.04)], and 2.15 hours [95%CI (1.98, 3.24)] in non-DCE, and DCE patients, respectively (p = 0.011).

This study has shown that the carbon-13 breath test is a viable tool to diagnose DCE. Further analysis and comparison with scintigraphy is required to validate the test. Although a gas spectrometer was used in this study to analyse patients’ breath, bedside testing devices are currently available and should be used in future studies.
231. A NOMOGRAM BASED ON BODY MASS INDEX CHANGES TO PREDICT PROGNOSIS AFTER CURATIVE RESECTION OF ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Chen Long-Qi , Gu Yi-Min
Published: September 2022

This study aims to investigate the relationship between preoperative body mass index changes (∆BMI) and prognosis in patients with esophageal squamous cell carcinoma who underwent esophagectomy.

We identified 1883 patients with esophageal squamous cell carcinoma who underwent R0 resection in our department between January 2005 and December 2013. Patients were grouped into no decrease (∆BMI = 0) group and any decrease (∆BMI > 0) group. The impact of ∆BMI on survival was investigated by using Kaplan–Meier curve and Cox regression modelling. A nomogram was constructed, and model performance was examined.

The ∆BMI > 0 patients had worse 5-year overall survival rate than ∆BMI = 0 patients (26.8% vs 44.7% respectively, P < 0.001). Preoperative ∆BMI was an independent prognostic factor in patients with esophageal squamous cell carcinoma (HR: 1.174, 95%CI: 1.014–1.358, P = 0.032). In subgroup analysis, major ∆BMI was associated with increased risk of poor prognosis when compared with minor ∆BMI (HR: 1.184, 95%CI: 1.031–1.359, P = 0.017). The prognostic nomogram presented good predictive ability with a C-index of 0.705 (Figure).

This study demonstrates that decreased body mass index had adverse impact on long-term survival in patients with esophageal squamous cell carcinoma who underwent curative esophagectomy. These results support application of nutrition support for the major ∆BMI group.
233. ENDOSCOPIC REFERENCE SCORE AND HISTOLOGICAL SCORING SYSTEM ARE COMPLEMENTARY ASSESSMENTS FOR CHARACTERIZING FIBROSTENOTIC OR INFLAMMATORY PHENOTYPES IN EOSINOPHILIC ESOPHAGITIS PATIENTS
Authors: Collins Margaret H , Rothenberg Marc E , Bredenoord Albert J , Wechsler Joshua , Chehade Mirna , Philpott Hamish , Chen Zhen , Radwan Amr , Pela Tiffany , Khodzhayev Angela , Jacob-Nara Juby A , Deniz Yamo , Rowe Paul J
Published: September 2022

The Histologic Scoring System (HSS) assesses severity/extent of histologic features (eosinophil density [ED]/basal zone hyperplasia [BZH]/eosinophil abscesses [EA]/eosinophil surface layering [SL]/surface epithelial alteration [SEA]/dyskeratotic epithelial cells [DEC]/dilated intercellular spaces [DIS]/lamina propria fibrosis [LPF]) in eosinophilic esophagitis (EoE). The Endoscopic Reference Score (EREFS) assesses endoscopic feature severity (edema/exudates/furrows/rings/strictures). We correlated HSS components with inflammatory/remodeling EREFS components in placebo-treated EoE patients from 2 trials—phase 2 proof-of-concept (POC; NCT02379052), phase 3 TREET part A (Phase3-PartA; NCT03633617).

POC was a 12-week trial in adults, and Phase3-PartA was a 24-week trial in adults and adolescents. Proximal/mid/distal esophagus biopsies were collected at baseline/end of treatment (EOT) and scored by HSS for grade (severity)/stage (extent)/components (higher scores = greater severity). Endoscopies were scored by EREFS (higher scores = greater severity) and inflammatory (edema+exudates+furrows) and remodeling (rings+stricture) subscores calculated. Pearson correlation and single co-variate regression model analyses were performed between baseline HSS grade/stage, total/individual components scores and EREFS total/components scores and subscores, and for the change in scores from baseline at EOT (ΔEOT).

Moderate-to-strong correlations (r > 0.3) were observed between total EREFS and HSS grade/stage for baseline/ΔEOT in POC and baseline in Phase3-PartA (Table). Moderate correlations were observed between BZH and EREFS remodeling subscore and rings for ΔEOT in Phase3-PartA; DIS grade and EREFS remodeling subscore and strictures for baseline and ΔEOT in POC but not Phase3-PartA; and EREFS inflammation and remodeling subscores and components for SEA and SL at baseline and ΔEOT in POC. Moderate-to-strong correlations were observed between EREFS inflammation subscore and DIS stage and between edema and DIS grade/stage at baseline in both studies. Similar results were observed using regression analyses.

Specific components of HSS and EREFS, reflecting inflammatory and remodeling processes, are closely correlated, when examined by Pearson correlations or regression analyses, and can aid identification of fibrostenotic or inflammatory phenotypes in EoE. Correlations of DIS with endoscopic inflammatory and remodeling features reflect the role of barrier dysfunction in maintaining chronic inflammation that ultimately leads to remodeling.
237. DIFFERENTIAL CLONAL EVOLUTION IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA IN RESPONSE TO NEO-ADJUVANT CHEMORADIOTHERAPY
Authors: Weng Zelin , Yuan Jianye , Xie Xiuying , Wen Jing
Published: September 2022

As a major component of esophageal squamous cell carcinoma (ESCC) treatment regimen, neo-adjuvant chemoradiotherapy (NCRT) affects ESCC genome is largely unknown. Deciphering the evolutionary history of ESCC following NCRT would reveal dynamic mutational processes and enable us identify the key molecular features associated with NCRT-resistance.

We performed whole exome sequencing (WES) on matched pre-NCRT endoscopic biopsy tissue (n = 29), post-NCRT cystectomy tumor tissue (n = 30). On the basis of a rigorous evaluation of estimated percentage of the estimated percentage of vital residual tumor cells, 29 pre-NCRT cases were classified into two groups: major response (n = 20) and minor response (n = 9). The computational method PyClone was used to define subclones within each tumor. The method Clonality Inference in Tumors Using Phylogeny (CITUP) was subsequently used to infer phylogenetic relationships among subclones.

By comparing the subclonal composition of each patient before and after NCRT, we found that resistant subclones were polyclonal and driver mutations improved the fitness of resistant subclones. The number of driver mutations existed in resistant subclones was positively related to the size of subclones. The most frequent driver genes in resistant subclones identified in our research included TP53, NOTCH1 and a novel gene RYR3.

Multi resistant subclones result in the resistance of ESCC genome to NCRT. The fitness of resistant subclones is relevant to the number of driver mutations.
243. INTRALUMINAL OXYGEN DELIVERY AT THE SITE OF THE ANASTOMOSIS AFTER A ROBOT ASSISTED MINIMAL INVASIVE ESOPHAGUS RESECTION; A FEASIBILITY STUDY
Authors: van der Steen Douwe , Leferink Anne M , Spruit Rutger J , van Etten Boudewijn , Dijkstra Frederieke A , Verhage Roy J , Keus Eric , Kolkman Jeroen J , Haveman Jan Willem
Published: September 2022

Anastomotic leakage (AL) is a severe complication after esophagus resection surgery. It is thought that local ischemia of the gastric conduit is one of the main reasons for the relative high incidence of AL (10–20%). Intraluminal oxygen delivery at the site of the anastomosis might improve the viability of the tissue and therefore reduce the incidence of AL. We present a feasibility study to the intraluminal oxygen delivery after an esophagus resection.

Patients undergoing a robot assisted minimal invasive esophagus resection with an intrathoracic anastomosis were included in the study. Intraluminal oxygen was administered via an esophagus manometry catheter. In the control group, consisting of 3 patients without oxygen delivery, only intraluminal pressure measurements were conducted. In the next 10 patients, 1 mL/minute of oxygen was given in the first 5 days after surgery. Primary endpoint was the feasibility of successful placement of the catheter at the right position. In addition, patients were asked to evaluate the comfort of the setup with the use of a daily visual analogue scale.

In 2 patients, intraoperative placement of the catheter did not succeed. These patients were replaced by 2 others according to the study protocol. Therefore, in total 15 patients were analyzed. In 4 patients, the catheter was accidently luxated or removed before the end of the study. No catheter related complications were observed. The measured intraluminal pressure stabilized on an average value of 7.6 mm Hg (± 2.1). As expected, the experiences comfort was decreasing over time. See the table 1 below for details on comfort evaluation of the catheter setup.

This study shows that it is feasible to administer intraluminal oxygen in the first 5 days after a robot assisted minimal invasive esophagus resection. Future studies are required to prove the effectiveness of intraluminal oxygen delivery and its effect on AL. When the effectiveness study shows promising results, the optimal dosage and period of oxygen delivery will have to be determined.
247. ALBUMIN AND DERIVED NEUTROPHIL-TO-LYMPHOCYTE RATIO IS A NOVEL PROGNOSTIC FACTOR FOR PATIENTS WITH ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Abe Tomoki , Oshikiri Taro , Goto Hironobu , Kato Takashi , Horikawa Manabu , Sawada Ryuichiro , Urakawa Naoki , Kanaji Shingo , Matsuda Takeru , Kakeji Yoshihiro
Published: September 2022

Various nutritional and inflammatory biomarkers have been reported to be associated with cancer prognosis, but most studies have focused on conditions before neoadjuvant chemotherapy (nCT). Developing real-time biomarkers reflecting changes in systemic conditions during nCT is important. We established a novel biomarker, represented as the albumin to derived neutrophil-to-lymphocyte ratio (Alb-dNLR ratio), and calculated the change in Alb-dNLR ratio (ΔAlb-dNLR) during nCT. We aimed to evaluate whether ΔAlb-dNLR is associated with prognosis in ESCC patients.

We investigated 172 patients who underwent nCT before esophagectomy between April 2010 and March 2018. dNLR was calculated as the ratio of neutrophil count to (white blood cell count—neutrophil count), Alb-dNLR ratio was calculated by dividing serum albumin level by dNLR, and ΔAlb-dNLR was evaluated by dividing the post-Alb-dNLR ratio by the pre-Alb-dNLR ratio. Patients were divided into ‘high’ and ‘low’ groups according to ΔAlb-dNLR.

Thirty-nine patients (22.7%) had a low ΔAlb-dNLR (≤0.8). The 5-year overall survival (OS) rates in patients with low and high ΔAlb-dNLR were 38.1% and 53.6%, respectively (p = 0.0072). Multivariate analyses demonstrated that estimated blood loss (p = 0.044), pathological T stage (p = 0.0005), pathological N stage (p = 0.017), and ΔAlb-dNLR (p = 0.005) were independent prognostic factors for OS.

ΔAlb-dNLR is a useful prognostic factor for OS in patients with ESCC receiving nCT.
254. TODAY’S ISSUES IN ROBOT-ASSISTED ESOPHAGECTOMY
Authors: Taniyama Yusuke , Okamoto Hiroshi , Sato Chiaki , Ozawa Yohei , Ishida Hirotaka , Koseki Ken , Kato Nobufumi , Yamauchi Takuro , Kamei Takashi
Published: September 2022

Recently, effectiveness of robot-assisted minimally invasive esophagectomy (RAMIE) has been reported however, there are some issues specific to RAMIE which may lead to major complications. The issues include 1) interference with the right shoulder, 2) compression of vertebral bodies and blood vessels, 3) energy devices, and 4) education to young surgeons. In this study, we evaluated the short-term outcome of RAMIE in our department, and show the ideas for improving those issues.

For 1), the assistant gives instructions to the surgeon, and uses a protector on right shoulder. In 2), port arrangement depending on the cases and switching the camera port is useful. 3) Because those devices are still under developing, careful procedure is required while using energy device, 4) Double console and extra thoracoscopic camera is useful in operating under the education. We conducted a comparative study of 81 cases of RAMIE performed at our institution from 2014 to January 2022 and 392 cases of prone thoracoscopic esophagectomy performed at about the same time, to evaluate the short-term outcomes including complications.

RAMIE showed an increase in thoracic operation time (median 286 min vs 260 min), but amount of thoracic bleeding tended to be smaller (median 13 mL vs 19 mL). Recurrent laryngeal nerve palsy (G1) was about 40%, and pneumonia was about 18%, which was about the same. One case encountered to in-hospital death from RAMIE group by aspiration pneumonia and one cardiac tamponade by thoracoscopic surgery, respectively, Also, there was no difference in short-term outcomes between experienced and non-experienced surgeons, except operation time.

It is difficult to educate young surgeons who cannot afford to pay attention to the surroundings because there is a possibility that the surrounding organs will be damaged without resistance. Therefore, experienced surgeon should observe and understand the situation using double console or an additional scope. Also, many other knacks and tricks are important to reduce the complications arises from robotic surgery.
257. DIFFERENCES IN PERIOPERATIVE STRATEGIES IN ESOPHAGEAL CANCER TREATMENT IN 13 NORDIC UNIVERSITY HOSPITALS CALL FOR HIGH-LEVEL EVIDENCE REGARDING THESE PRACTICES
Authors: Achiam Michael , Nilsson Magnus , Åkesson Oscar , Johansson Jan , Edholm David , Lindblad Mats , Szabo Eva , Sundbom Magnus , Lindberg Fredrik , Larsen Michael Hareskov , Aahlin Eirik Kjus , Mala Tom , Johannessen Hans-Olaf , Johnsen Gjermund , Kauppila Joonas , Löfdahl Per , Hedberg Jakob
Published: September 2022

The Nordic countries have similar health care systems and registries simplifying epidemiological research and the treatment of esophageal cancer is largely centralized. However, differences in treatment traditions can hamper the possibility to assess results and harmonize control arms in joint randomized trials. In setting up a Nordic multi-center randomized trial regarding the use of nasogastric tube (NG-tube) decompression, we aimed to investigate differences in perioperative routines after esophageal resection at Nordic University hospitals.

All Nordic University Hospitals with an upper gastrointestinal cancer center (UGC) were contacted regarding a Nordic randomized controlled trial exploring the effects and complications associated with the use of NG-tube after esophagectomy for cancer. Those who chose to join the trial were sent a questionnaire regarding surgical volumes and practices including mean annual number of esophagectomies, surgical method/access, and routine use of pyloric drainage and jejunostomy. In addition, the current standard postoperative use of NG-tube and routine X-ray/CT evaluation, along with postoperative traditions regarding the start of liquid diet was enquired. High volume centers were defined as performing >20 procedures/year.

Thirteen of 17 centers with a combined catchment area of 16 million inhabitants and an annual volume of 445 esophagectomies joined the trial network. All, but one center used a total minimally invasive- or hybrid surgical approach but otherwise, the routine use of pyloric drainage and jejunostomy varied widely without being statistically different. All 13 centers reported routine use of NG-tube and 4 employed continuous suction. The NG-tube was removed between 3 and 7 days postoperatively, but also strategies between the centers (suction on NG-tube, start of liquid diet, routine X-ray/CT evaluation) varied without being statistically significant

Firm adherence to standardized operations and safety protocols are implemented in Nordic UGCs to reduce the potential consequences of complications. However, the results find the differences in perioperative care after esophagectomy apparent, highlighting the need for high-level evidence regarding these practices. A unified approach may facilitate clinical trial initiatives. There is a paucity of evidence regarding optimal NG-tube use after esophagectomy for cancer and a randomized trial (kiNETiC ISRCTN39935085) investigating this issue is underway.
259. COMPARISON OF GREATER CURVATURE AND LESSER CURVATURE CIRCULAR-STAPLED ESOPHAGOGASTROSTOMY AFTER ESOPHAGECTOMY IN ESOPHAGEAL CANCER PATIENTS: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL
Authors: Sasaki Ken , Tsuruda Yusuke , Shimonosono Masataka , Noda Masahiro , Uchikado Yauto , Tada Nobuhiro , Okumura Hiroshi , Omoto Itaru , Natsugoe Shoji
Published: September 2022

Using a circular stapler to create an anastomosis for esophagogastrostomy after esophagectomy is well accepted; however, it remains uncertain if the greater curvature (GC) or lesser curvature (LC) of the gastric conduit is better for the anastomosis. We conducted this prospective study to compare the integrity of esophagogastrostomy between the esophagus and the GC or LC side of the gastric conduit.

The subjects of this study were 70 patients who underwent esophagectomy and were randomized to a ‘GC’ group and an ‘LC’ group (n = 35 each). The primary and secondary end points were anastomotic leakage (AL) and anastomotic stricture (AS), respectively.

The overall AL rate was 22.1%, without a significant difference between the groups. Stump leakage developed in eight of nine patients in the GC group, whereas leakage developed at the esophagogastric anastomosis in five of six patients in the LC group. The rate of stump leakage was significantly higher than that of esophagogastric AL in the GC group. The overall AS rate was 4.4%, with a significant difference between the groups (0% in the GC group vs. 9.1% in the LC group).

AL rates were comparable in the two groups, but the sites of leakage were significantly different.
260. EFFECT OF ENDOLUMINAL VACUUM THERAPY ON THE PERFUSION OF GASTRIC CONDUIT IN A PORCINE MODEL FOR ESOPHAGECTOMY
Authors: Felinska Eleni , Studier-Fischer Alexander , Wise Philipp Anthony , Özdemir Berkin , Chen Zi-We , Willuth Estelle , Allers Michael , Müller-Stich Beat , Nickel Felix
Published: September 2022

After esophagectomy, the postoperative rate of anastomotic leakage is between 5 and 30% and is the main driver of morbidity and mortality. Complication management is often based on endoluminal vacuum therapy (EndoVAC) with good success rates. Vacuum therapy has been shown to improve tissue perfusion in superficial wounds but this has not been shown for gastric conduits. The present study aimed to assess changes in gastric conduit perfusion in a porcine model for esophagectomy.

Porcine model (n = 18) underwent gastric conduit formation and induction of partial conduit ischemia. In three experimental groups EndoVAC therapy was used in the gastric conduit (−40 mmHg, −125 mmHg and − 200 mmHg) with continuous suction. The changes in tissue perfusion and edema were assessed using hyperspectral imaging (HSI).

During EndoVAC treatment with −125 mmHg a significant and stable increase in the oxygenation index from 44.9 ± 7.6% to 61.9 ± 5.5% and 62.9 ± 9.4%. (p = 0.02) was seen after 60 minutes and 120 minutes respectively. A similar trend was seen during EndoVAC treatment with −200 mmHg. There was a non-significant increase in tissue oxygenation during treatment with −40 mmHg. A significant increase of tissue water content from 40.8 ± 7.4 to 59.5 ± 10.3 (p = 0.004) was observed after 60 minutes of EndoVAC therapy with −200 mmHg. There were no significant differences in tissue water content during EndoVAC therapy with −40 mmHg and − 125 mmHg.

EndoVAC treatment with a pressure of at least −125 mmHg significantly increases perfusion of partial ischemic gastric conduit. With better understanding of underlying physiology, the optimal use of EndoVac treatment can be guided and determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion. This can potentially be translated into clinical practice.
267. CURRENT STATUS OF COMPREHENSIVE GENOME PROFILING FOR ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Yamamoto Shun , Koyama Takafumi , Hirose Toshiharu , Ohara Akihiro , Itoyama Mai , Yokoyama Kazuki , Honma Yoshitaka , Kato Ken
Published: September 2022

Esophageal squamous cell carcinoma (ESCC) is the dominant histological subtype of esophageal cancer in Japan. However, there are few effective drugs for advanced ESCC patients (pts), and the prognosis of advanced ESCC pts remains poor. In 2019, comprehensive genome profiling (CGP) tests were approved for patients with advanced solid cancers who were refractory or intolerant to standard treatments. However, there were little data on CGP tests for advanced ESCC patients.

The subjects were advanced ESCC patients received CGP tests between June 2019 and February 2022 and expected to be refractory or intolerant to standard treatments. This study evaluated characteristics of advanced ESCC patients who received CGP tests and the clinical utility of CGP tests to receive investigational new drugs.

Characteristics of 12 patients were follows; median age:61(range: 48–72), male/female:10(83.3%)/2(16.7%)pts, performance status 0/1/2:2(16.7%)/9(75.0%)/1(8.3%)pts, treatment line 2/3/4:3(25.0%)/8(66.7%)/1(8.3%)pts CGP tests FoundationOne CDx/OncoGuideTM NCC Oncopanel System:8(66.7%)/4(33.3%)pts. All pts(100%) and 7pts(58.3%), 5pts(41.7%), 4pts(33.3%), 2pts(16.7%) showed TP53 mutations and CDKN2A/B loss, FGF amplification, NFE2L2 mutations, TMB-high. Seven pts(58.3%) were candidates for investigational new drugs based on CGP, 1 pt(8.3%) received investigational treatment based on CGP (ERBB2 amplification), 1 pt(8.3%) received investigational treatment not based on CGP test. 5pts(41.7%) were ineligible to trials according to deteriorated general condition or prior treatments. In 5pts(41.7%) without druggable gene alteration based on CGP tests, 2pts(16.7%) received investigational treatments not based on CGP.

This study clarified the current status of CGP tests for advanced ESCC patients in our hospital. Due to the small population, further investigation was needed to evaluate the utility of CGP for ESCC pts.
272. IMPLEMENTATION OF AN ERAS PROTOCOL IN PATIENTS UNDERGOING ESOPHAGECTOMY: EVALUATION OF THE RESULTS
Authors: de Zadava Lissón Miriam Menéndez Jiménez , Esteban Marcos Bruna , Navarro Fernando Mingol , Urbaneja Francisco Javier Vaqué , Pardo Luis Hurtado , García Alberto Sánchez
Published: September 2022

Esophagectomy is a complex surgery and has classically been a surgery with high morbidity and mortality and high hospital stay. The implementation of ERAS protocols in esophageal surgery is lagging behind other digestive surgeries due to its complexity, but little by little ERAS protocols are starting to be implemented in high volume units.

Retrospective and descriptive analysis of 50 patients undergoing elective McKeown esophagectomy (April 2018–December 2021).

The ERAS protocol starts with prehabilitation. Unless contraindicated, they receive an epidural catheter and a minimally invasive approach; no abdominal or cervical drains, decompressive nasogastric tube or feeding jejunostomy are left in place unless risk of malnutrition. From the first postoperative day they begin to sit up and start respiratory and motor rehabilitation; after leaving the ICU, they begin to deambulate and the bladder catheter is removed.

The descriptive study used median and interquartile range (IQR) for quantitative variables and percentage of cases for qualitative variables.

A total of 50 patients were analysed.

The 70% were men, median age was 64,50 years (55,75–71), BMI 23.20 (20,9-26,3). The 20% were diabetic, 28% were bronchopathic and 14% had some type of heart disease. The 54% had an ASA ≥3. The etiology was neoplasic in 90% and 10% due to stenosis after caustic ingestion; 79,7% received neoadjuvant treatment. Feeding jejunostomy was performed in 42%, abdominal drainage was placed in 18% and thoracic drainage in 50%. The epidural catheter was removed on the 3rd day (2,25-5,75). Table 1 shows the postoperative results.

The implementation of an ERAS protocol in esophageal surgery is necessary and feasible with good results, without an increase in morbimortality and with a decrease in hospital stay and an improvement in patient comfort.
273. EVALUATION OF THE RESULTS OF ‘TUBELESS’ ESOPHAGECTOMY IN PATIENTS WITH ESOPHAGEAL CANCER WITHIN AN ERAS PROTOCOL
Authors: de Zadava Lissón Miriam Menéndez Jiménez , Esteban Marcos Bruna , Navarro Fernando Mingol , Urbaneja Francisco Javier Vaqué , Pardo Luis Hurtado , García Alberto Sánchez
Published: September 2022

Classically, esophagectomy used to routinely left chest drains, as well as decompressive nasogastric tube (NGT) and feeding jejunostomy, making the postoperative period slower and more uncomfortable for patients.

Our objective is to evaluate the results of not using tubes and drains (tubeless esophagectomy) in patients with esophageal cancer undergoing McKeown esophagectomy within an ERAS protocol in our center.

Retrospective, descriptive and comparative study of two consecutive groups undergoing McKeown esophagectomy. The first group (P) included 25 patients with tubes and drains (April 2018–August 2019) and the second group (T) 25 patients undergoing tubeless esophagectomy (July 2020–December 2021).

In group P all patients were left with thoracic drainage and jejunostomy and in selected cases abdominal drainage; no patient was left with NGT.

In group T (‘TUBELESS’) no drains or NGT were placed. No jejunostomy was performed except in those patients at high risk of malnutrition, and a phantom jejunostomy was used instead.

Both study groups are comparable in terms of epidemiological characteristics, etiology, preoperative tumor stage and neoadjuvant treatment.

In group P, 86% of the patients underwent or already had a jejunostomy, 100% of the patients were left with a left thoracic drain and 28% with an abdominal drain. None of the patients had a cervical drain or NGT.

In group T no cervical, abdominal or thoracic drain was placed, but 2 patients (8%) underwent a jejunostomy due to high risk of malnutrition.

Table 1 shows the postoperative results. There are no significant differences in 90-day mortality, readmission rate or anastomotic leakage.

Despite the widespread thought of the need for the use of chest drains after esophagectomy, abstention from their use, as well as abstention from the use of decompressive nasogastric tube and feeding jejunostomy (replacing it with the use of a ghost jejunostomy), does not increase morbimortality and improves the postoperative comfort of the patient, as well as the hospital stay.
275. PREOPERATIVE 3D-CT EVALUATION OF THE BRONCHIAL ARTERIES IN TRANSMEDIASTINAL RADICAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Maeda Tomohito , Fujiwara Hitoshi , Konishi Hirotaka , Shiozaki Atsushi , Nishibeppu Keiji , Ohashi Takuma , Kubota Takeshi , Kiuchi Jun , Arita Tomohiro , Shimizu Hiroki , Yamamoto Yusuke , Morimura Ryo , Kuriu Yoshiaki , Ikoma Hisashi , Otsuji Eigo
Published: September 2022

Transmediastinal radical esophagectomy (TME) is the esophagectomy without thoracotomy that can achieve the mediastinal lymphadenectomy equivalent to transthoracic procedure. Understanding of surgical anatomy in the deep mediastinum near the aortic arch or tracheal bifurcation is essential for the safe procedure. The present study aims to evaluate the bronchial arteries (BAs) with preoperative 3D-CT for TME.

Seventy-nine patients with thoracic esophageal cancer undergoing TME were examined by preoperative 3D-CT to evaluate BA variations in the number, branching pattern, and mediastinal course. For the right BAs (RBAs) crossing the esophagus, the mediastinal courses in transcervical view were classified in relation to the esophagus and tracheobronchi, and compared with surgical findings.

A total of 107 RBAs (1.35/person) were confirmed on preoperative 3D-CT. Of these, 61 (57.0%) crossed the esophagus dorsally (type Ed), and the remaining 46 (43.0%) crossed the esophagus ventrally (type Ev). During the left transcervical procedure, all type Ed RBAs were identified and mostly preserved (57/61, 93.4%) whereas most type Ev RBAs were identified (39/46, 84.8%), but more than half were sacrificed (26/46, 56.5%) for lymphadenectomy. The blood loss during the transcervical procedure was 17.0 ± 55.8 mL. The total number of dissected mediastinal lymph nodes was 23.7 ± 9.3. There were no significant complications related to extensive lymphadenectomy.

Preoperative 3D-CT evaluation is useful to understand the mediastinal courses of BAs specific to the transcervical approach, which may allow BAs to be handled more carefully according to the type during surgery, contributing to a safer procedure in the deep mediastinum.
283. DOES PROTON PUMP INHIBITOR EXPOSURE INCREASE THE RISK OF DEVELOPING EOSINOPHILIC ESOPHAGITIS IN CHILDREN WITH ESOPHAGEAL ATRESIA?
Authors: Tang Tiffany , Leach Steven T , Krishnan Usha
Published: September 2022

Children with esophageal atresia (EA) receive proton pump inhibitors (PPIs) long-term due to gastroesophageal reflux disease susceptibility. They have also demonstrated greater susceptibility to eosinophilic esophagitis (EoE) compared to the general pediatric population. No studies have investigated EoE risk factors in EA. This study aimed to determine whether PPI exposure and early-life factors are associated with an increased risk for subsequent EoE development in children with EA.

A retrospective chart review was undertaken at a paediatric hospital in Sydney, Australia. The study cohort consisted of children with EA who had their repair and/or follow-up at this hospital between 1 January 2005 and 31 December 2020. Children with EA and EoE (cases) were matched (1:2) with those with only EA (controls), for sex, prematurity and presence of long-gap, to compare PPI exposure. Other early-life factors were analysed without matching, using simple and multivariable logistic regression.

Of the 184 children with EA, 46 (25%) developed EoE during this period. Thirty-eight EoE participants were matched to 76 controls. Children with EA and EoE received PPI for significantly higher durations (p = 0.018) and at significantly higher cumulative doses (p = 0.017) than children with EA but no EoE. Food allergy (adjusted odds ratio [aOR], 10.515; 95% confidence interval [CI], 2.659–41.581), family history of atopy (aOR, 5.312; 95% CI, 1.575–17.911) and infantile antibiotic exposure (aOR, 1.048; 95% CI, 1.011–1.086) were also significantly associated with an increased risk of developing EoE in the EA cohort.

Longer durations of PPI exposure and exposure to higher cumulative doses of PPI were both associated with the subsequent development of EoE in children with EA. Other early life factors such as atopic family history, food allergy and infantile antibiotic exposure were also significantly associated with an increased risk of developing EoE in children with EA.
294. AN UNUSUAL CASE OF EPIPHRENIC DIVERTICULUM COEXISTING WITHIN ESOPHAGEAL LEIOMYOMA
Authors: Farooqui Marryam Riaz , Rauf Fatima , Bhatti Hamza Waqar , Javed Umer , Arshad Rabia , Hanif Muhammad
Published: September 2022

Oesophageal leiomyoma and epiphrenic diverticulum are two rare entities to be simultaneously occurring together. The preoperative diagnosis in such coexisting conditions is often difficult and leiomyoma is mostly an incidental finding. Till date there is no evidence of the pathogenesis that if the diverticulum causes leiomyoma or vice versa?: We report a case of 32-year-old male with no known co-morbids, previous history of accidental kerosine oil intake 7 months ago, with dysphagia and retrosternal burning pain since 4 weeks with no history of documented weight loss. General physical and systemic examinations were unremarkable.

Contrast studies showed left sided epiphrenic diverticulum. CECT was suggestive of traction diverticulum. Endoscopy showed a large diverticulum on left side of esophagous 38 cm from incisors. On laparoscopy a mass extending to GEJ was appreciated and patient underwent laparoscopy assisted transhiatal esophagectomy and esophagogastric anastomosis with feeding jejunostomy. Peroperatively a mass of 15 x 8 cm was arising from distal oesophagus histopathology of which came out to be a leiomyoma. On POD ‘0’ patient developed Rt sided pneumothorax for which chest intubation was done. Repeat contrast studies showed a patent anastomosisand patient was discharged home.

A careful history, thorough investigations, and surgeon’s awareness of possible synchronous disease processes helps in the management of such patients.
299. LEFT THORACOPHRENOTOMY OESOPHAGOGASTRECTOMY AS AN ALTERNATIVE APPROACH IN OESOPHAGEAL CANCER
Authors: Ammar Ahmed , Paul Melanie , El-Sharkawy Ahmed , Iftikhar Syed
Published: September 2022

The left thoracophrenotomy approach to oesophagectomy-also known as Sweet Oesophagectomy (SO)—for oesophageal cancer is performed by many centres worldwide but seldom used in the UK, owing to concerns over the extent of lymphadenectomy compared with the Ivor-Lewis oesophagectomy (ILO) approach. This study aims to compare the oncological and clinical outcomes following the Sweet approach with ILO.

A retrospective, single centre study was conducted, analysing all patient data following the SO approach and ILO for oesophageal cancer between August 2012 and March 2021.

Total number offered the Sweet and ILO were 72 and 197 patients respectively. 91.7% vs 80.2%, p = 0.071 were distal tumours. Median node count were 22 and 23 respectively, p = 0.980. The Sweet was associated with 69.4% circumferential, 94.4% proximal and 95.8% distal R0 resections compared with 72.6% (p = 0.365), 98% (p = 0.132) and 96% (p = 0.330) with ILO resection, respectively. Median operative time was 169 vs. 301 minutes for Sweet and ILO respectively, p < 0.001. Overall complication rate was 29.2% with Sweet and 45.7% with ILO, p = 0.015, including, Anastomotic leaks 0 vs. 11, p = 0.041, return to theatre 1 vs. 22, p = 0.04. The 30-day, 90-day and 5-year survival was 100% vs. 99% (p = 0.391), 98.6% vs. 95.9% (p = 0.281) & 51.4% vs. 50.3% (p = 0.869), respectively.

The Sweet procedure was associated with comparable oncological efficacy and survival to ILO. Furthermore, was associated with significantly shorter operative time and lower complication rates, therefore should be considered in selected cases. Having a reduced hospital stay and operative time may be more favourable in more frail patients with distal and junctional oesophageal tumours.
303. A NOVEL ‘WATERFALL METHOD’ OF FILLING THE POSTERIOR MEDIASTINAL CAVITY AFTER ESOPHAGECTOMY USING OMENTAL FLAP IN RETROSTERNAL GASTRIC TUBE RECONSTRUCTION
Authors: Yasuda Takushi
Published: September 2022

Post-esophagectomized mediastinal dead space can cause not only mediastinal abscess in R2 resection, but also airway trouble in salvage surgery or combined resection of the airway system due to intra-thoracic great pressure fluctuations. Therefore, dead space filling is critical to prevent them. Dead space is filled with an omentum pulled up in posterior mediastinal route along with the gastric tube. However, it causes delayed gastric empty, considerably decreasing the patient’s quality of life (QOL).

We have developed a new technique to fill the dead space by dropping the omentum from the anterior to the posterior mediastinum after lifting it in the retrosternal route along with the gastric tube, and named it the waterfall method. When creating a gastric tube, the omentum is taken as many as possible, and is fixed to pull-up thread so that it is about 15 cm below the tip of the gastric tube. After lifting the gastric tube to the neck, pull the omental flap down through a small incision in the anterior mediastinal pleura and fill the mediastinal dead space.

Of 630 esophageal cancer patients who underwent surgery from January 2012 to March 2022, this new technique was adopted to 20 patients (mean age: 65Y, male/female: 16/4). The reason for adaptation was R2 resection in 7, salvage surgery in 4, combined resection of the airway system in 8 and other in 1. All patients underwent chemoradiation with more than 50 Gy or triplet chemotherapy preoperatively. Minor anastomotic leakage was observed in 2 and pneumonia and pneumothorax in 3 and 3, respectively. But no development of mediastinal abscess or airway fistula was observed, and no patient complained delayed gastric empty.

Our new technique to fill the post-esophagectomized mediastinal dead space by dropping an omental flap from the anterior to the posterior mediastinum was considered useful, safe and feasible to prevent the development of mediastinal abscess or airway fistula. Since there is no symptom of delayed gastric empty, it is considered to be one of the useful surgical procedures that can maintain the patient’s QOL as well as prevent postoperative complications.
306. THE ROLE OF ADJUVANT CHEMOTHERAPY AFTER NEOADJUVANT THERAPY FOLLOWED BY SURGERY IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Park Seong Yong , Jeon Yeong Jeong , Lee Junghee , Cho Jong Ho , Choi Yong Soo , Zo Jae Il , Shim Young Mog , Kim Hong Kwan
Published: September 2022

This retrospective study was performed to investigate the efficacy of adjuvant chemotherapy after neoadjuvant therapy followed by surgery in esophageal squamous cell carcinoma (ESCC).

The data of 428 patients who received the neoadjuvant therapy and esophagectomy for ESCC between 2003 and 2018 were retrospectively reviewed. The 1:2 propensity score matching was performed to balance the patients’ characteristics. Eighty-three (19.4%) patients received the adjuvant chemotherapy, whereas 345 (80.6%) did not receive the adjuvant chemotherapy. The median follow-up period was 27.04 months (interquartile range: 15.85–62.04 months).

The patients who received the adjuvant chemotherapy showed better pulmonary function and ASA score, but there were no differences after propensity score matching. In matched patients, the adjuvant chemotherapy did not improve the OS, but subgroup analysis revealed that 5-year OS improved in ypT + N+ patients by adjuvant chemotherapy (20.2% vs. 27.7%, p = 0.012), whereas the benefit of adjuvant chemotherapy was no observed in ypT0N0, ypT + N0 and ypT0N+. Multivariable analysis showed that ypStage, ASA score and adjuvant chemotherapy (HR 0.462, p = 0.004) was associated with OS in ypT + N+ patients. The freedom from distant metastasis was significantly different according to the adjuvant chemotherapy (27.2% vs. 49.5%, p = 0.039).

Adjuvant chemotherapy after neoadjuvant therapy followed by surgery in ypT + N+ ESCC patients might improve the OS by reducing the distant metastasis. The consideration could be given to administration of adjuvant chemotherapy to ypT + N+ ESCC patients with tolerable conditions.
309. ASSESSMENT AND MANAGEMENT AFTER CORROSIVE INGESTION: WHEN IS SPECIALIST CENTRE REFERRAL NEEDED? A 10-YEAR UK EXPERIENCE
Authors: Di Maggio Francesco , Vergani Vittoria , Tomasi Ivan , Zhang Chuan , Gossage James , Botha Abrie , Baker Cara
Published: September 2022

Corrosive ingestion injuries are rare but clinically significant events, potentially associated with high morbidity and mortality. Low case-volumes limits guideline development. We report the largest UK cohort of patients admitted consecutively to a UGI tertiary referral centre after caustic ingestion, over a period of 10 years. Clinical presentation, diagnostics and treatment modalities as well as short and long-term outcomes were analysed, to produce evidence and the recommendation for centralization of management only of severe injuries.

All adults treated following corrosive ingestion between 2010 and 2020 were included. Eighty-one patients were included, with an average follow-up of 5 years. Blood results, imaging and endoscopic findings were reviewed. Patients were stratified based on endoscopic findings. Emergency and delayed management was analysed along with short and long-term outcomes. Predictive value of early outcome indicators was investigated.

Patients with injuries ≤ Zargar 2A had long-term outcomes similar to the ones with negative endoscopic findings.

All fifteen patients suffering injuries Zargar ≥2B required ITU and four died (26.6%). All deaths occurred within 50 days of ingestion, had Zargar grade ≥ 3 and airway involvement.

Five patients (33%) required emergency operations, two of which died.

All Zargar ≥2B injury survivors (n = 11) developed strictures and/or tracheo-esophageal fistulae (18%), required multiple admissions and prolonged nutritional support; five required delayed resections.

Zargar grade ≥ 2B, airway damage, and increased CRP on admission correlated with unfavourable outcomes.

Corrosive ingestion injuries up to Zargar 2A do not cause long-term sequelae and can be managed locally. Injuries.

> 2B bear high mortality and will cause sequelae. Early identification of severe injuries and transfer to specialist centres with multidisciplinary ITU, OG, thoracic and ENT expertise is recommended.
313. RISK FACTORS FOR RECURRENCE IN ADVANCED ESOPHAGEAL CANCER PATIENTS WHO RECEIVED NEOADJUVANT CHEMOTHERAPY FOLLOWED BY ESOPHAGECTOMY
Authors: Muneoka Yusuke , Ichikawa Hiroshi , Usui Kenji , Kano Yosuke , Hirose Yuki , Miura Kohei , Tajima Yosuke , Ishikawa Takashi , Shimada Yoshifumi , Sakata Jun , Kosugi Shin-ichi , Wakai Toshifumi
Published: September 2022

Recently, nivolumab adjuvant therapy has become a new treatment option in Japan. However, who is the good candidate of this adjuvant therapy has not been fully investigated. The aim of this study was to clarify the risk factors for recurrence in advanced esophageal cancer patients who received neoadjuvant chemotherapy (NAC) followed by esophagectomy.

We retrospectively reviewed the records of 83 patients with advanced thoracic esophageal cancer who received NAC followed by esophagectomy between 2000 and 2018 (69 men and 14 women with a median age of 65 years). We evaluated relapse-free survival (RFS) and investigated the risk factors for recurrence by multivariate analysis.

The regimen of NAC was Cisplatin +5-FU (CF) in 74 patients, Docetaxel + Cisplatin +5-FU in six, and CF with radiotherapy in three. The median follow-up period after esophagectomy was 53 months. The 3-year RFS rate was 58.8%. Multivariate analyses revealed ypT3–4 (Hazard ratio, 3.71; 95% confidence interval, 1.67–8.29), lymphatic invasion (3.45; 1.62–7.39), and postoperative infectious complications (2.99; 1.47–6.07) were significant risk factors for recurrence. Moreover, the prognosis of the patient group with 2 or more risk factors was significantly worse than that of the patient group with 0–1 factor (The 3-year RFS rates, 75.2% vs. 23.1%; p < 0.001).

ypT3–4, lymphatic invasion, and postoperative infectious complications were significant risk factors for recurrence after esophagectomy after neoadjuvant chemotherapy. The prognosis of the patient group with 2 or more these risk factors was significantly worse, therefore, it is considered to be a candidate for nivolumab adjuvant therapy.
317. ABSOLUTE LYMPH NODE YIELD AND LYMPH NODE RATIO ARE PREDICTORS OF SURVIVAL AND IMPORTANT QUALITY METRICS IN ESOPHAGEAL CANCER SURGERY
Authors: Bolger Jarlath , Tavakoli Iran , Espin-Garcia Osvaldo , Castro Pedro Perez , Marwah Anindita , Darling Gail , Yeung Jonathan
Published: September 2022

Surgical resection following neoadjuvant therapy remains the cornerstone of curative management of esophageal cancer. In spite of this, there remains uncertainty regarding the optimal radicality of lymphadenectomy, and whether increasing lymph node yields confer a true survival benefit. This study aims to assess the impact of lymph node (LN) yield and LN ratio on survival following surgery for esophageal cancer, in addition to identifying factors that may influence LN yield and radicality of resection.

All patients undergoing esophagectomy with curative intent from January 1, 2010 to December 31, 2020 were reviewed. Clinical and pathological variables were assessed, with univariable, multivariable, regression and survival analyses performed as appropriate. Cutpoint analysis was used to determine the optimal lymph node ratio.

397 patients underwent esophagectomy, with 288 having a minimally invasive operation (MIE). Stage (stage 3 HR: 1.64 (1.02–2.62), p = 0.04, stage 4 HR: 2.50 (1.43–5.01), p = 0.001), margin status (HR: 2.62 (1.57–4.36), p < 0.001), LN yield <15 (HR: 2.62 (1.57–4.36), p < 0.001) and elevated LN ratio (HR: 8.42 (2.85–24.90, p < 0.001) predicted survival. Patients undergoing MIE had higher LN yields compared with open (30.7 vs 25.3, p < 0.001). Patients undergoing neoadjuvant chemoradiation had lower LN yields compared with those without neoadjuvant therapy and those with neoadjuvant chemotherapy (26.4 vs 30.6 vs 36.8 respectively, p < 0.001). LN ratio < 0.05 was associated with a survival benefit.

Lymphadenectomy is a cornerstone of resection of esophageal cancer. Low LN yield and high LN ratio are associated with reduced overall survival. Maintaining a LN yield >15 should remain a key quality metric. A LN ratio of <0.05 is associated with a significant survival benefit.
318. PRE-TREATMENT CRP AND ALBUMIN DETERMINES PROGNOSIS FOR UNRESECTABLE ADVANCED ESOPHAGEAL CANCER
Authors: Sohda Makoto
Published: September 2022

Nutritional disorders due to cancer-related weight loss, such as cancer-impaired food passage, are prominent in many cases in advanced oesophageal cancer. Here, we investigated the nutritional factors that most affect the therapeutic effect and prognosis of unresectable oesophageal cancer.

One hundred four patients diagnosed with cT4b oesophageal squamous cell carcinoma were included in this study. The values of C-reactive protein/albumin ratio, Glasgow Prognostic Score, prognostic nutritional index, neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were calculated from the pre-treatment blood sampling results of the patients who received chemoradiotherapy, and the therapeutic effect and prognosis were analysed.

High- C-reactive protein/albumin group and Glasgow Prognostic Score 1 or 2 group showed significantly worse prognosis compared with the low- C-reactive protein/albumin group and Glasgow Prognostic Score 0 group in both disease-specific survival and overall survival.

Evaluation of pre-treatment CRP and albumin value in locally advanced oesophageal cancer leads to useful prognostic prediction.