bluuebunny/crossref_metadata_2025 huggingface dataset:
600. DETECTION OF ANASTOMOTIC LEAK THROUGH THE VALUE OF DRAIN FLUID AMYLASE
Authors: Ting Ying Che , Hsu Po Kuei
Published: September 2024

Background

Anastomotic leak in cervical anastomosis after esophagectomy has consistently been a serious problem. Esophagram has long been utilized to make sure the integrity of anastomosis before starting oral diet. However, the diagnostic accuracy is limited. Drin fluid amylase collected from the cervical anastomotic site is another useful method for its conveniency in specimen collection and the numerical value. But the clinical interpretation varied. The aim of the study was to share the experience in our facility regarding the diagnostic value of esophagram and drain fluid amylase exam.

Methods

A total of 116 patients with esophageal cancer were reviewed. All patients received open or minimally invasive Mckeown esophagectomy with cervical anastomosis, with or without a neoadjuvant chemoradiotherapy. For the prediction of leak, esophagram and drain fluid amylase were utilized. Esophagram was arranged on the 7th post operative day. And drain fluid amylase was collected twice on the 3rd and the 7th post operative day. We assumed that presence of an elevating trend of the drain fluid amylase level, and the amylase level on the 7th post operative day being more than 80 IU/L, would suggest an anastomotic leak.

Results

For the entire cohort, the leakage rate was 18.9% (22/116). 67 patients and 48 patients received esophagram exam and drain fluid amylase testing, respectively. The sensitivity and specificity for esophagram were 28.6% and 95%, respectively. The positive and negative predictive values were 40% and 91.9%, respectively. The diagnostic accuracy was 88.1%. The diagnostic value of testing drain fluid amylase by using our criteria yielded a sensitivity and specificity of 75% and 95%, respectively. The positive and negative predictive values were 75% and 95%, respectively. The diagnostic accuracy was 91.7%.

Conclusion

Comparing with esophagram, testing the drain fluid amylase provided an easier and more accurate way to predict the possible anastomotic leak. The criteria for prediction of leak by using drain fluid amylase were presence of an elevating trend (amylase on POD7 / POD3 >1) and the amylase level on the 7th post operative day being more than 80 IU/L.
611. THE UTILITY OF H ANASTOMOSIS IN INFLATABLE MEDIASTINOSCOPE-ASSISTED TRANSHIATAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Wu Na , Hu Yang
Published: September 2024

Objectives

In this article we present a novel technique to improve the outcome of mediastinoscope-assisted transhiatal esophagectomy (MATHE).

Methods

H anastomosis is derived from intussusceptive anastomosis, which reinforced the barrier from the alimentary canal cavity to the mediastinum and fromed an one-direction valve to preventing gastroesophageal reflux. H anastomosis improved the blood supply of gastric tube by reduce the thickness of intussuscepted tissue to adapt to the narrow esophageal bed in MATHE.

Results

Anastomotic leakage, gastroesophageal reflux and dysphagia were well controlled.

Conclusions

The good outcomes of H anastomosis in MATHE need further validation.

https://1drv.ms/v/s!AmCqlJJZqDPDjRjAwgLApB_mkRVp?e=diumNA
615. ROBOTIC REDO LAPAROSCOPIC HELLER’S CARDIOMYOTOMY
Authors: Parthasarathi R , Ramesh N , Cumar Bharath , Palanivelu C
Published: September 2024

Introduction

Robotic Heller’s cardiomyotomy is the preferred treatment option for achalasia cardia. However, following Heller’s cardiomyotomy up to 20% of patients experience dysphagia and regurgitation in the long term. The ideal management option for such patients needs to be determined.

Surgical Steps

The procedure is carried out with patient in supine position, legs abducted with the knees in slightly flexed position in reverse Trendelenburg position of approximately 30°.The pneumoperitoneum is created by closed Veress needle technique. After Relasing Adhesions, the gastrohepatic ligament is divided and the right crus is identified and retrocardiac window is formed; proximal short gastric vessels are divided for posterior wrap. The esophagus is separated by blunt dissection from the crus, the peritoneum and phrenoesophageal membrane are divided and the left crus is identified. If an anterior partial fundoplication is planned as antireflux procedure, the mobilization is limited to the lateral and anterior aspects. The anterior vagus nerve is identified and should be dissected and lifted away from the distal esophagus and proximal stomach in order to facilitate transhiatal dissection, myotomy and also to prevent injury to the esophagus and vagal trunks. Dissection is continued cranially around the esophagus for a distance of about 2–3 cm onto the dilated segment of the esophagus in the posterior mediastinum. If posterior partial wrap (Toupet) is planned, esophagogastric dissection is performed posteriorly from both crura and median arcuate ligament to get tension free wrap. Fundus of the stomach is dissected off the diaphragm and if needed two or three short gastric vessels are divided. Posterior vagal trunk is dissected along with esophagus.

Conclusion

Redo Robotic Heller’s cardiomyotomy can safely be performed with good symptomatic relief for patients who present with recurrent symptoms following Heller’s cardiomyotomy. Long term follow-up with larger sample size is needed to confirm these findings.

https://drive.google.com/file/d/1uFgx0Aal92o5FE-Ndp-tAsCg01NJ6Crm/view?usp=sharing
618. A COMPARISON OF HEALTH-RELATED QUALITY OF LIFE AT ONE YEAR FOLLOWING MINIMALLY INVASIVE VERSUS OPEN ESOPHAGECTOMY
Authors: Prasad Pooja , Brown Joshua , Cross Andrea , Wahed Shajahan , Phillips Alexander
Published: September 2024

Introduction

Minimally invasive esophagectomy (MIE) is being increasingly adopted in the surgical management of esophagogastric cancer. While equivalent clinical and oncological outcomes have been demonstrated in comparison with open resections, differences in health-related quality of life (HR-QOL) between the 2 modalities into survivorship remains unclear. The aim of this study was to determine the differences in HR-QOL between MIE and open esophagectomies (OE) at 1 year post-resection.

Methods

Consecutive patients undergoing an esophagectomy at a single, U.K based tertiary referral centre for esophagogastric cancer between January 2018 – December 2022 were evaluated. MIE was defined as utilisation of laparoscopic, thoracoscopic or robotic access for at least one phase of an esophagectomy. HR-QOL at 1 year following surgery was measured using the validated European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and esophagogastric cancer module (QLQ-OG25) and compared between groups.

Results

A total of 28 patients undergoing MIE and 25 patients undergoing OE were included. No statistical difference was noted in mean global HR-QOL between the OE and MIE cohorts at 1 year (69.33±19.50 vs 64.88±22.05; p=0.66). No statistically significant intergroup differences between OE versus MIE were observed at 1 year in physical functioning (82.67±16.89 vs 79.05±24.39; p=0.97) or role functioning (73.33±29.27 vs 67.86±32.37; p=0.60) domains. Similarly, no difference was observed in symptoms of nausea/vomiting (10.67±18.17 vs 8.93±14.69; p=0.56), pain (29.33±25.56 vs 26.79±33.44; p=0.26) or fatigue (29.78±25.40 vs 37.70±30.44; p=0.44).

Conclusion

HR-QOL remains comparable between MIE and OE at 1 year. Patient-reported outcomes must be assessed in the long-term to determine if minimally invasive approaches confer HR-QOL improvements well into survivorship.
619. ASSOCIATION OF PROLONGED ONE LUNG VENTILATION TIME WITH PERIOPERATIVE COMPLICATIONS IN PATIENTS UNDERGOING ESOPHAGOGASTRIC CANCER RESECTION
Authors: Prasad Pooja , Brown Joshua , Cross Andrea , Wahed Shajahan , Phillips Alexander
Published: September 2024

Introduction

Esophagectomy for esophagogastric cancer is associated with high rates of peri-operative morbidity and mortality. Little is known of the impact of one lung ventilatory (OLV) times during the thoracic phase of an esophagectomy upon perioperative outcomes. The aim of this study was to determine the impact of OLV upon post-operative complications following esophagogastric cancer resection.

Methods

Consecutive patients undergoing an esophagectomy at a single, U.K tertiary referral centre for esophagogastric cancer between January 2015–January 2022 were evaluated. OLV time was defined as the number of minutes there was iatrogenic occlusion of one of the main bronchi such that all ventilatory requirements were performed by one lung. Previously published OLV times were used to determine if the duration was standard (<150 minutes) or prolonged (>=150 minutes). Post-operative complications were prospectively evaluated and classified using the Clavien-Dindo (CD) classification system. Patients were grouped as either CD 0-I (none-minor complications) or CD II-V (moderate–severe complications including post-operative mortality).

Results

There were 361 patients included in the final analysis. OLV times of <150 minutes were recorded in 101 patients and >=150 minutes were recorded in 260 patients. Both groups were comparable in terms of development of CDII-V complications with no statistically significant intergroup differences (91/101 vs 241/260; p=0.075). Notably, 41/91 (45.1%) of patients with an OLV time <150 minutes developed a pulmonary complication versus 100/241 (41.5%) with prolonged OLV times.

Conclusion

Pulmonary and other peri-operative complications remain a considerable burden in the recovery of patients following esophagogastric cancer resection, independant of OLV times. Strategies to mitigate this are need in order to reduce peri-operative morbidity and improve overall quality of life into survivorship.
626. DO CALCIUM CHANNEL BLOCKERS AFFECT CLINICAL OUTCOMES IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA WITH HYPERTENSION? A MULTICENTER RETROSPECTIVE STUDY
Authors: Zhou Jianfeng
Published: September 2024

Background

Esophageal squamous cell carcinoma (ESCC), prevalent globally, especially in Asia, is primarily treated with esophagectomy. Concurrently, hypertension, managed often with calcium channel blockers (CCBs), is widespread. The influence of CCBs on post-esophagectomy outcomes in hypertensive ESCC patients is yet to be fully understood. This study seeks to elucidate CCBs' impact on these patients to improve clinical management and drug selection.

Methods

Patients who underwent esophagectomy between December 2008 and Nov 2022 were extracted from a 4-centre prospectively maintained database, and those with hypertension were categorized based on whether they have been taking CCBs for an extended period (more than 1 year). Survival was analyzed using the log-rank test and multivariable Cox regression analysis.

Results

Of the 7954 esophagectomies, 348 cases of hypertensive ESCC patients were eligible. 37% (129 out of 348) of the patients with hypertensive ESCC patients had been on long-term CCB therapy. In univariate analysis, ESCC patients with hypertension who were treated with CCBs had a better OS than those who were not. Multivariate analysis results indicated that postoperative T stage and N stage are independent risk factors for the OS of ESCC patients with hypertension, while the use of CCBs is an independent protective factor for their OS. Additionally, a nomogram was established to accurately predict the occurrence of adverse outcomes.

Conclusion

This study finds that long-term CCB use improves OS in hypertensive ESCC patients post-esophagectomy, highlighting the recommendation of CCB therapy in managing hypertensive ESCC patients post-surgery.
632. CAN CARDIOPULMONARY EXERCISE TESTING PREDICT NEOADJUVANT CHEMOTHERAPY TOXICITY IN OESOPHAGEAL ADENOCARCINOMA PATIENTS?
Authors: Dayanamby Abbienaya , Chmelo Jakub , Bradshaw Alexander , Sinclair Rhona , Phillips Alexander W
Published: September 2024

Background

Cardiopulmonary exercise testing (CPET) is a method of assessing cardiopulmonary fitness. In the context of surgery, it is used to risk-stratify patients, allowing targeted prehabilitation to optimise comorbidities and fitness prior to surgery, and triage patients to the appropriate level of care after the operation. Various CPET-derived variables have been shown to be associated with short- and long-term outcomes after various surgery. In patients post-oesophagectomy, these variables are predictive of long-term survival. This study aimed to assess the use of this tool to predict neoadjuvant chemotherapy (NAC) related complications in patients receiving neoadjuvant FLOT prior to oesophagectomy.

Methods

All patients who underwent routine CPET during the staging process prior to NAC with FLOT and oesophagectomy in a single high-volume centre between September 2018 and January 2023 were included. Data were extracted from the unit’s contemporaneously maintained database. The Mann-Whitney U test was used to compare CPET variables in patients who completed NAC with FLOT fully versus those who did not finish NAC with FLOT due to acute chemotherapy toxicities.

Results

There were 129 patients who received neoadjuvant FLOT and had routine CPET performed during the defined study period. Six of those patients (4.7%) did not complete neoadjuvant chemotherapy due to acute chemotherapy toxicities but progressed to surgery. The median anaerobic threshold, VO2 peak, and VE/VCO2 among those who completed NAC were 14.2 ml/kg/min, 20.3 ml/kg/min, and 28, respectively, compared to 13.4 ml/kg/min, 19.7 ml/kg/min, and 31 in those who did not complete NAC (p=0.595, p=0.695, and p=0.160, respectively).

Conclusion

Although patients who received all four cycles of NAC with FLOT prior to oesophagectomy demonstrated CPET values indicating better base-line fitness than those who had to discontinue NAC due to acute chemotherapy toxicity, these differences did not reach the level of statistical significance. This study, therefore, did not demonstrate any predictive value of CPET in assessing the risk of incomplete NAC treatment prior to oesophagectomy.
639. WHICH FACTORS LEAD PATIENTS WITH BENIGN ESOPHAGEAL STRICTURES FOR SURGICAL TREATMENT BESIDES ENDOSCOPIC TREATMENT?
Authors: Szachnowicz Sergio , Friedmann Ilan , Ferros Lucas Sousa Maia , Duarte Andre Fonseca , Bianchi Edno Tales , Seguro Francisco CBC , Sallum Rubens AA , Júnior Ulysses Ribeiro
Published: September 2024

Background

This work proposes to evaluate patients with benign esophageal strictures, excluding caustic strictures, about their etiologies and poor prognostic factors for the success of endoscopic treatment.

Methods

It was evaluated in our service 38 patients, from 1992 to 2023, with benign esophageal strictures not related to caustic strictures. We could follow-up 24 patients from 7 months and 384 months (average of 136 months). Four died during the follow- up. We could analyze these following outcomes: clinical symptoms, surgical indications, age, gender, alcohol abuse, smoking, length of stricture, number of endoscopic dilation and stricture etiology.

Results

Concerning the 24 patients with follow-up, 4 had esophagectomy; 10 underwent endoscopic treatment with fundoplication and 10 were treated with endoscopic and medical treatment. Both groups, endoscopic and medical treatment, and endoscopic treatment with fundoplication had 4 patients that continued symptomatic (40%). The number of endoscopic dilations range from 1 to 101 (average 18) in each patient. The etiology of 38 patients with benign esophageal strictures were:

35 gastroesophageal reflux disease (13 Barrett´s esophagus); one with infectious esophagitis; one eosinophilic esophagitis and another due to esophageal varicose sclerosis. The prognostic factors to surgical treatment will be analyzed by statistical analysis.

Conclusion

From our data, it is possible to conclude that the endoscopic treatment is effective to manage the majority of benign esophageal strictures, even in association with fundoplication. Moreover, the main etiology was gastroesophageal reflux disease. Only few patients have developed indication to esophagectomy.
646. MCKEOWN VS IVOR-LEWIS ESOPHAGECTOMY FOR PATIENTS WITH A HISTORY OF TOTAL PHARYNGOLARYNGECTOMY: A COMPARISON STUDY
Authors: Kuriyama Kengo , Kanamori Jun , Terayama Masayoshi , Watanabe Masayuki
Published: September 2024

Background

Oncologic esophagectomy in patients with a history of total pharyngolaryngectomy (TPL) is challenging. There are two different esophagectomy procedures: total esophagectomy with cervical anastomosis (McKeown) and subtotal esophagectomy with intrathoracic anastomosis (Ivor-Lewis). Differences in outcomes between McKeown and Ivor-Lewis esophagectomies for patients with this history remain unclear.

Patients and Methods

We retrospectively reviewed 36 patients with a history of TPL who underwent oncologic esophagectomy and compared the clinical outcomes between the procedures.

Results

Twelve (33.3%) and 24 (66.7%) patients underwent McKeown and Ivor-Lewis esophagectomies, respectively. McKeown esophagectomy was more frequently performed for the supracarinal tumors (P = 0.002). Other baseline characteristics, including the history of radiation therapy, were comparable between the groups. Postoperatively, the incidences of pneumonia and anastomotic leakage were higher in the McKeown group than in the Ivor-Lewis group (P = 0.029 and P < 0.001, respectively). Neither tracheal necrosis nor remnant esophageal necrosis was observed. The overall and recurrence-free survival rates were comparable between the groups (P = 0.494 and P = 0.813, respectively).

Conclusion

When performing esophagectomy for patients with a history of TPL, if it is oncologically acceptable and technically available, Ivor-Lewis is preferable over McKeown esophagectomy for avoiding postoperative complications.
749. GENDER DIFFERENCE IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Hashimoto Naoki
Published: September 2024

In Japan, esophageal cancer is often more common in men, with a lower incidence in women than in men, accounting for 12% of the total number of cancers. In Japan and the West, SCC is involved in alcohol and tobacco. These habits are characteristically more common among men. Women are more likely to be diagnosed at an earlier stage than men. Therefore, we examined the prognosis, stage, and pathology of 145 men and 30 women who underwent radical surgery for esophageal cancer over the past 5 years. (Result) p stage is male: stage 0:7(5%), stage 1:35(25%), stage II: 58(40%), stage III:35(25%), stage IV:10(7%) female: Stage 0: 2 (7%), Stage 1: 12 (40%), Stage II: 6 (20%), Stage III: 9 (30%), Stage IV: 1 (3%). Significantly more men had advanced cancer. No difference was observed regarding Ly and V. Although there were no differences in location and histology, depth of invasion and lympho node metastasis were significantly enhanced in males. (table 1) Kaplanmier survival rate after 5 years was significantly better for women than for men. (Fig 1).(Conclusion) Compared to men, women had less advanced cancer at the time of discovery and a better 5-year survival rate.
759. P02.04 PARAVERTEBRAL VERSUS EPIDURAL ANALGESIA IN MINIMALLY INVASIVE ESOPHAGEAL RESECTION (PEPMEN): A RANDOMIZED CONTROLLED MULTICENTER TRIAL
Authors: Feenstra Minke , Kooij Cezanne , Eshuis Wietse , de Groot Eline , Hermanides Jeroen , Kingma B Feike , Gisbertz Suzanne , Ruurda Jelle , Daams Freek , Marsman Marije , van den Bosch Oscar , ten Hoope Werner , Goense Lucas , Luyer Misha , Nieuwenhuijzen Grard , Scholten Harm , Buise Marc , van Det Marc , Kouwenhoven Ewout , van der Meer Franciscus , Frederix Geert , Hollmann Markus , Cheong Edward , van Berge Henegouwen Mark , van Hillegersberg Richard
Published: September 2024

Background

Thoracic epidural analgesia has been the mainstay for pain control in esophageal cancer patients undergoing minimally invasive esophagectomy (MIE). Although effective epidural analgesia potentially contributes to achieving enhanced recovery after surgery (ERAS) goals in patients undergoing MIE, it can have counterproductive side effects such as hypotension, urinary retention and reduced mobility. Paravertebral analgesia may be a promising alternative to epidural analgesia, avoiding potential side effects and improving postoperative recovery.

Methods

This open randomized controlled superiority trial was conducted across four Dutch centers. A total of 192 patients with esophageal cancer, scheduled for elective transthoracic MIE with intrathoracic anastomosis, were included and randomized to receive either epidural analgesia or paravertebral analgesia. The primary outcome was Quality of Recovery (QoR-40) on the third postoperative day (POD). Secondary outcomes included the quality of life, postoperative pain, opioid consumption, need for inotropic/vasopressor medication, duration of admission, mobilization, complications, readmission, and mortality.

Results

From December 2019 to February 2023, 94 patients were assigned to epidural and 98 to paravertebral analgesia. QoR-40 score on POD3 did not differ between groups (mean difference 3.7; P=.268). The epidural group had higher QoR-40 scores on POD1 and 2 (mean difference 7.7; P=.018, mean difference 7.3; P=.020) and lower pain scores (1 versus 2; P=<.001, 1 versus 2; P=.033). More patients in the epidural group required vasopressor-medication on POD1 (38.3% versus 13.3%; P<.001). In the paravertebral group, the urinary catheter was removed one day earlier (P=<.001). No significant differences in complications or length of stay were observed.

Conclusion

This multicenter randomized controlled clinical trial did not show superiority of paravertebral analgesia over epidural analgesia in quality of recovery on the third day after minimally invasive esophagectomy. These results, however, support the safety of paravertebral analgesia as a viable alternative to epidural analgesia, enabling the provision of both techniques to patients in clinical practice.
766. LASTING SYMPTOMS AFTER OESOPHAGEAL RESECTIONAL SURGERY (LASORS): MULTICENTRE VALIDATION COHORT STUDY
Authors: Paine Heidi , Chidambaram Swathikan , Dawas Khaled , Mohammadi Borzoueh , Qureshi Yassar , O'Neill Robert , Dai Nick , Alkhaffaf Bilal , Vohra Ravinder , Markar Sheraz Rehan
Published: September 2024

Background

As outcomes following curative-intent oesophageal cancer treatment improve, more patients are living with the long-term morbidity of cancer therapies, the symptoms of which are poorly recognised and understood. Existing symptomatology and quality-of-life tools are cumbersome and moreover are not designed specifically for evaluation of post-treatment survivorship.

The LASER study and subsequent consultation process identified six key symptoms thought to predict poor health-related quality-of-life (HRQoL) as measured by validated European Organisation for Research and Treatment of Cancer (EORTC) tools. The current study aimed to validate this six-symptom LAsting Symptoms after Oesophageal Resection (LASOR) clinical tool, and assess its clinical utility.

Methods

In this multi-centre cohort study, patients who underwent oesophagectomy between January 2015 and June 2019 across the United Kingdom, and were disease-free at least one-year post-treatment, were asked to complete LASOR, EORTC-QLQ-C30 and QLQ-OG25 questionnaires. LASOR symptoms (low mood, reduced energy, thoracotomy pain, heartburn, diarrhoea, and bloating after eating) were evaluated using composite scores based on frequency and quality of life impact, and correlated with EORTC HRQoL scores. The ability of the LASOR tool to predict patients with poor HRQoL was validated using receiver operating characteristic (ROC) curve analysis. Patient acceptability of the tool was assessed using a separate questionnaire.

Results

263 participants were included. 192 (73%) were males. Surgical technique included open (61%), hybrid (18%), and minimally-invasive (21%). 203 patients (77%) received neoadjuvant chemotherapy or chemoradiotherapy. 148 patients (56%) experienced a post-operative complication. Four LASOR symptoms were associated with significantly lower HRQoL: reduced energy (OR=2.13; 95% CI 1.20-2.87), low mood (OR=1.86; 95% CI 1.45–3.12), diarrhoea (OR=1.48; 95% CI 1.06–2.06), and bloating (OR=1.35; 95%CI 1.03-1.77). In combination, the LASOR symptoms produced an area under the ROC curve of 0.85 (sensitivity = 0.82, specificity = 0.73).

Conclusion

The six-symptom LASOR tool generated a reliable model for identification of patients with a poor HRQoL, with an overall diagnostic accuracy of over 80%. This is the first clinical symptom tool to be validated in the post-curative-treatment setting for patients with oesophageal cancer. The LASOR tool is straightforward to administer and highly acceptable to patients, and can be used to identify those at risk of high morbidity and poor quality of life in surveillance programmes. In turn, evidence-based survivorship services can be integrated into patient follow-up to alleviate the burden of cancer treatment on oesophagectomy patients.
772. EVALUATING OUTCOMES OF LES OBSTRUCTION AND REFLUX IN PATIENTS UNDERGOING PERORAL ENDOSCOPIC MYOTOMY GUIDED BY THE 16CM IMPEDANCE PLANIMETRY CATHETER
Authors: Nguyen Anh , Podgaetz Eitan , Sampson-Ansah Mahalia , Bhatt Anjali , Mendoza Roseann , Ellison Ashton , Reddy Chanakyaram A , Spechler Stuart J , Konda Vani JA
Published: September 2024

Background

Peroral endoscopic myotomy (POEM) is a standard treatment option in achalasia. The endoluminal functional lumen imaging probe (FLIP) system utilizes impedance planimetry to measure diameter and distensibility at the esophagogastric junction (EGJ) in real-time. Most reports of the intraoperative FLIP experience focus on the 8 cm balloon, but the 16 cm balloon catheter also provides topographical assessments in addition to EGJ metrics. The aim of this study is to determine the clinical outcomes after a tailored myotomy using the 16 cm balloon during POEM.

Methods

We conducted a retrospective review of consecutive patients who underwent POEM with intraoperative FLIP with the 16 cm balloon catheter between January 2020 and September 2023. Operative reports were reviewed, and data including FLIP metrics and topographical assessments and myotomy length, which was guided by FLIP panometry, were recorded. Clinical parameters for lower esophageal sphincter (LES) obstruction (defined by FLIP-EGJ metrics, BEDQ/Eckardt scores and/or need for LES re-intervention) and reflux (defined by GERD-HRQL/RSI scores, +pH testing, LA B/C/D reflux esophagitis, PPI use and/or need for anti-reflux surgery) were collected during the 6-36 month follow up time period.

Results

Of 100 patients (57 female, mean 56.1y), 82 had Achalasia, 15 EGJOO, and 3 hypercontractile esophagus. Myotomy length was tailored (mean 8.2cm, range 3 – 15) by FLIP, and 10% had a short myotomy (≤4cm). Among 16 patients with previous Heller, the myotomy targeted contractile activity proximal to the previous myotomy in 10 cases. On follow up of 71 patients (median time 14mo), clinical outcomes are noted in Table 1. Obstructive symptoms and FLIP metrics showed significant improvement. Repeat myotomy was required in 5.6%. While reflux symptom scores improved, 37.5% had abnormal %AET, 4.7% had reflux esophagitis, and 7.0% required anti-reflux surgery.

Conclusion

A tailored myotomy with guidance of a 16 cm FLIP catheter to assess EGJ metrics and topographical assessments during POEM appears to be safe and effective at 6-36 month follow up. A tailored myotomy allows for a shorter myotomy than traditional surgical lengths and can be extended to capture residual disease noted with the 16 cm FLIP catheter in patients with previous surgery. Use of the 16 cm balloon during POEM results in overall low rates of LES re-intervention and post-myotomy reflux.
777. COMBINED OESOPHAGEAL AND AIRWAY STENTING FOR MALIGNANT OESOPHAGEAL STRICTURES: THE UK’S LARGEST TERTIARY CENTRE EXPERIENCE AND DEVELOPMENT OF A NOVEL ALGORITHM
Authors: Gertner Julian , Mullin Monica , Shea Ms Rosalind , Aslam Nasar , Banks Matthew , Ahmad Omer , Sweis Rami , Graham David , Navani Neal , Thakrar Ricky , Sehgal Vinay
Published: September 2024

Background

Malignant oesophageal strictures can cause airway compromise and fistula formation. Combined oesophageal and airway stenting is a potential treatment yet no guidelines exist. This study aims to describe the outcomes of same-session oesophageal and airway endoscopic stenting for malignant strictures and propose an algorithm for intervention.

Methods

A retrospective study on patients undergoing same-session gastroenterology (GI) and respiratory endoscopy at University College London Hospital, 2019-2023. All procedures were with anaesthetic-led propofol sedation. Endoscopic decision making was based on pre-procedure multidisciplinary team meeting (MDM) and intra-procedure clinical assessment. Data collected included malignancy type, luminal narrowing, complications, and mortality.

Results

26 patients were identified. Mean age was 63 years. Cancer type was oesophageal (81%) or lung (19%). The most common referral indication was dysphagia (42%); airway compromise was often seen on imaging (65%). Stent insertion was oesophageal only (35%), airway only (19%) and dual (27%). Airway stenting was common (80%) if airway stenosis was >50%. No airway stenting occurred if stenosis was <50%. After oesophageal stenting, repeat bronchoscopy showed increased airway stenosis in 4 patients (25%). The only intraoperative complication was one oesophageal perforation. New tracheooesophageal fistula was the most common post-intervention complication (15%). Median time from malignancy diagnosis to death was 7.9 weeks.

Conclusion

We present the first algorithm (Figure 1) for endoscopic stenting in patients with malignant oesophageal stricture and airway involvement. We suggest upper GI and respiratory MDM to plan same-session endoscopy with decision-making framed by patient-centred goals given their poor prognosis.
778. ROBOTIC-ASSISTED EPIPHRENIC DIVERTICULECTOMY: 9 YEAR EXPERIENCE OF A TERTIARY CENTER
Authors: Cuce Federica , Pallabazzer Giovanni , Belluomini Mario Antonio , Gennai Andrea , Solito Biagio , Marini Paola , Santi Stefani
Published: September 2024

Background

Epiphrenic esophageal diverticula are rare and often associated with esophageal motor disorders. Surgery is reserved for larger diverticula with symptoms that significantly impair quality of life. When possible, a transhiatal approach can reduce pulmonary complications by preserving pleural integrity; more proximal diverticular openings require a combined transthoracic and abdominal approach to achieve complete excision.

Robotic surgery assists in precise dissection and preservation of delicate mediastinal structures. Currently, few reports are available on larger patient cohorts of robotic diverticulectomy.

We describe all consecutive cases of robotic-assisted epiphrenic diverticulectomy performed at a high-volume tertiary center, since robotic surgery became available in 2015.

Methods

A retrospective chart review was conducted and, for all consecutive diverticulectomy cases, surgical techniques, patient characteristics and short and long-term outcomes were recorded. All patients underwent preoperative EGDS and esophagogram.

Diverticulectomy was always accompanied by esophagogastric Heller myotomy (>7 cm) and Dor fundoplication with the Xi DaVinci system was performed. One to two SIGNA linear stapler firings were used for diverticular resection.

Symptoms, demographic data, and short and long-term surgical outcomes were recorded, including morbidity and mortality and post-operative symptoms.

Results

Four cases required both an abdominal and intrathoracic approach, none was converted. Intraoperative complications included one occurrence of splenic bleeding controlled by hemostatic. Intraoperative blood loss was negligible. In two cases an esophageal leiomyoma was found incidentally and excised. The only postoperative complication was trocar-related abdominal wall bleeding that led to reintervention for cauterization; mortality was zero. All patients underwent a post-op esophagogram, negative for leaks or strictures, and resumed soft feeding within 7 days.

All reported substantial symptom relief at six months. At one year, one patient reported reflux, and two reported dysphagia recurrence without evident structures or recurrences.

Conclusion

Robotic-assisted diverticulectomy is safe and effective for epiphrenic diverticula.

The abdominal approach allows for a thorough esophageal myotomy associated with a For antireflux procedure to reduce recurrences of the disease and long-term dysphagia. In some cases a transthoracic approach is also needed, when employed by experienced upper GI surgeons it doesn't significantly affect surgical outcomes. Quality of life improves after surgery, although symptomatic reflux might occur. Further prospective or experimental studies are needed to evaluate short and long-term outcomes of the robotic approach compared to other surgical approaches.
784. NO SUPPORT FOR IMMEDIATE POSTOPERATIVE REMOVAL OF NASOGASTRIC TUBE AFTER ESOPHAGECTOMY, RESULTS FROM A NORDIC MULTICENTER RANDOMIZED CONTROLLED TRIAL
Authors: Hedberg Jakob , Kauppila Joonas , Aahlin Eirik Kjus , Edholm David , Johnsen Gjermund , Johansson Jan , Lagergren Pernilla , Lindblad Mats , Lindberg Fredrik , Helminen Olli , Löfdahl Per , Førland Dag Tidemann , Vikhammer Mads , Svendsen Lars Bo , Sundbom Magnus , Szabo Eva , Åkesson Oscar , Nilsson Magnus , Achiam Michael , Mala Tom
Published: September 2024

Background

Esophagectomy is central in curative treatment of esophageal and gastroesophageal junctional cancer. Postoperative nasogastric (NG) tube for drainage of the gastric conduit is routine in most centers. The NG tube is typically associated with significant discomfort for the patients and may have risks of its own. Immediate postoperative removal of the NG tube has been suggested and deemed safe in several smaller trials. We hypothesized that immediate postoperative removal of the NG tube is non-inferior to keeping the NG-tube in place for 5 days postoperatively, with regard to anastomotic leak and other early outcomes.

Methods

Esophagectomy patients with a gastric conduit reconstruction were included in a multicenter, randomized controlled trial between February 2022 and March 2024. A 1:1 randomization stratified for center, age and anastomotic site (thorax/neck) was performed between immediate postoperative removal of NG tube (intervention) and 5 days of NG tube use (control). All patients underwent chest CT postoperative day 7. Anastomotic leak was the primary endpoint and a non-inferiority threshold of -9% difference in proportion of anastomotic leak, including 95% confidence interval, was set. Secondary endpoints included overall complications, pneumonia, length of stay as well as days in high dependency ward.

Results

Intention to treat analyses were performed on 444 patients whereof 215 were randomized to immediate NG-tube removal and 229 to control. Mean age was 67 years and neck anastomosis was performed in 78 patients (18%). 47 patients (22 %) had leak in the no NG tube group compared to 35 (15%) in the control group. Non-inferiority could not be established with a difference leak proportion to the advantage of NG tube use of 6.6% (95% CI: 13.8%-(-0.7%)). Overall complications (Clavien-Dindo >2) occurred in 94 patients (44%) in the experimental group and 91 patients (40%) in the control group. Overall 30d mortality was 1.1%.

Conclusion

In this randomized controlled multicenter trial, the by far largest to be performed so far, we could not establish non-inferiority for abstaining from postoperative NG tube use after esophagectomy with regards to anastomotic leak, and therefore support NG tube use. The somewhat high proportion of leak could be partly due to meticulous complication registration, including CT with peroral contrast on day seven in all patients. Use of postoperative decompression of the gastric conduit with an NG tube should be encouraged.
785. MANAGEMENT OF ESOPHAGEAL CANCER WITH CONCURRENT CERVICAL NODE METASTASIS: A NATIONWIDE POPULATION-BASED COHORT STUDY
Authors: Sanders Maxime , van der Horst Sylvia , Weijs Teus , Mook Stella , Mohammad Nadia Haj , Freund Jan Erik , Elliot Jessie , van Berge Henegouwen Mark , Gisbertz Suzanne , van Rossum Peter , van Laarhoven Hanneke , Luyer Misha , Nieuwenhuijzen Grard , Wijnhoven Bas , Mostert Bianca , Verhoeven Rob , Ruurda Jelle , van Hillegersberg Richard
Published: September 2024

Background

In the Netherlands, the standard treatment of locally advanced, resectable esophageal cancer without metastasis is neoadjuvant chemoradiotherapy followed by esophagectomy. There is a small subset of patients that present with concurrent cervical lymph node metastasis (LNM). Historically this was seen as distant metastasis and surgical intervention has usually not been an option for these patients. The contemporary TNM classification now categorizes these lymph node stations as locoregional disease. Our current study aims to describe current treatment paradigms in the Netherlands for patients presenting with esophageal cancer and concurrent cervical LNM.

Methods

This population-based cohort study utilized data from the Netherlands Cancer Registry (NCR), encompassing patients with locally advanced thoracic esophageal or gastroesophageal junction cancer and concurrent cervical lymph node metastasis. Treatment modalities were categorized into five options: neoadjuvant therapy followed by surgery (Neo + S), definitive chemoradiotherapy (dCRT), chemotherapy with or without radiotherapy < 30 Gray (CT), radiotherapy (RT), and best supportive care (BSC).

Overall survival (OS) was assessed using the Kaplan-Meier method and compared via the log-rank test. Hazard rates were computed using Cox proportional hazards regression, with adjustment for confounding achieved through inverse probability of treatment weighting (IPTW).

Results

Between 2015 and 2021, a cohort of 412 patients was identified from the NCR database. Median survival durations were observed as follows: 24.2 months for Neo + S, 18.0 months for dCRT, 14.5 months for CT, 7.0 months for RT, and 3.2 months for BSC (Figure). A comparison between the Neo + S group and dCRT demonstrated a significant improvement in survival (p=0.02). Further subdivision of the surgical group into neoadjuvant CRT or chemotherapy did not reveal a significant difference in survival (p=0.6). Utilizing IPTW to adjust for confounding factors, Neo + S maintained its survival advantage.

Conclusion

The retrospective cohort findings suggest that neoadjuvant therapy followed by surgery may represent the optimal approach for managing esophageal cancer patients with cervical LNMs Yet, it's vital to recognize the influence of confounding by indication, which statistical adjustments may not entirely rectify. Furthermore, immortal time bias notably skews results favorably toward surgery. Nevertheless, the results emphasize the importance of considering surgery as a viable option for these patients. These limitations underscore the critical need for a prospective study, prompting the launch of the NODE-II trial.
786. ANATOMICAL DISTRIBUTION OF HUMAN PAPILLOMAVIRUS INFECTION IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Jiang Kai-Yuan , Ishida Hirotaka , Taniyama Yusuke , Sato Chiaki , Okamoto Hiroshi , Ozawa Yohei , Kamei Takashi
Published: September 2024

Background

Human Papillomavirus (HPV) infection is a high-risk factor for many types of cancer development. The reported infectious rate in esophageal squamous cell carcinoma (ESCC) varies widely, ranging from 0% to 88.9%. It may be caused due to geographical location, sample size, and detection methods. In general, p16 expression is considered as a biomarker for HPV infection. However, the correlation between the p16 expression and HPV infectious status has been controversial.

Methods

Patients with ESCC underwent esophagectomy without neoadjuvant chemotherapy (NAC) from 2007 to 2021 were included. Three formalin-fixed paraffin-embedded blocks (oral side, tumor, and esophagogastric junction (EGJ)) from each surgical resected specimen were collected. p16 expression was examined by immunohistochemistry (labeling index ≥ 10% is defined as positive expression). The presence of HPV DNA was investigated by polymerase chain reaction. In addition, the anatomical distribution of HPV infection was investigated.

Results

A total of 158 patients with 417 samples were included. The positive expression rate of p16 was 3.6% (5/137), 19.2% (30/156) and 2.1% (3/146) in oral side, tumor, and EGJ, respectively. The HPV infectious rate was 7% (11/158), and six cases were detected in tumor site and the other 5 cases were detected in oral side or EGJ. In tumor tissue, HPV positive cases showed p16 positive, and the sensitivity and specificity for detecting HPV DNA by IHC of p16 were 100% and 84%, respectively. The HPV infection in ESCC specimens appears to be irregular.

Conclusion

This study is the largest sample size in Japan, demonstrating the p16 positive rate of 19.2% and HPV infectious rate of 7% in ESCC patients without NAC. IHC of p16 can be used as a screening examination for predicting HPV infection in ESCC because the false negative rate was 0%. In addition, we firstly reported the HPV infectious mapping in ESCC specimens, and it appears irregular and random.
788. LAPAROSCOPIC TOUPET FUNDOPLICATION - PERSONAL EXPERIENCE 174 CASES REPORT
Authors: Lisboa Fernando , Silva Pedro Arthur , Ferreira Luis Fernando , Diniz Gabriel
Published: September 2024

Background

Gastroesophageal Reflux Disease (GERD) is one of the most important disorders of the gastrointestinal system, affecting 20% t o 40% of the population of the United States of America, and 12% on the world. There are several surgical techniques for treating this disease, including the Toupet Fundoplication technique, which reduce the postoperative complications, like dysphagia, Gas Bloating Syndrome and incapacity to belch.

Methods

Prospective cohort study with 174 patients in two hospitals, one public and the other private, in the city of Natal, Brazil. All patients were evaluated postoperative as the following: 1) first week after the surgery were interviewed by the master surgeon; 2) fifty days after surgery were submitted to a Barium Swallow; 3) three months after the surgery the endoscopy was performed. The follow-up was carried out in relation to the symptom of postoperative dysphagia, ability to belch, feeling of fullness and gastroesophageal reflux.

Results

A total of 174 patients were observed, who were submitted for the Toupet

Fundoplication procedure. Of this total, 145 patients were followed-up. 143 patients had improvement of symptoms related to esophageal disease and are clinically satisfied. One patients had recurrence of reflux symptoms. One patient had Gas

Bloating Syndrome.

Conclusion

Toupet Fundoplication was a standard procedure in the study and achieved good results in 98,62% of the cases followed during follow-up of GERD control and relief symptoms with a minimal rate of adverse effects in the postoperative period.
798. FEASIBILITY AND EFFICACY OF CISPLATIN, PACLITAXEL AND IMMUNE CHECKPOINT INHIBITORS AS CONVERSION THERAPY FOR LOCOREGIONALLY UNRESECTABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA
Authors: Zhang Hanlu , Wang Wen-Ping , Wang Yun , Chen Long-Qi
Published: September 2024

Background

Induction therapy followed by conversion surgery is potentially curative for locoregionally unresectable esophageal squamous cell carcinoma (ESCC). However, the optimal induction treatment strategy is unclear. The study aimed to evaluate the feasibility and efficacy of cisplatin, paclitaxel and immune checkpoint inhibitors as conversion therapy for locoregionally unresectable ESCC.

Methods

Clinicopathological variables of cT4b ESCC patients who received neoadjuvant chemoimmunotherapy were retrieved from the prospective database of the Surgical Esophageal Cancer Patient Registry in West China Hospital, Sichuan University. Enhanced computed tomography, ultrasonography and bronchoscopy were routinely used for the diagnosis. The treatment protocol of neoadjuvant chemoimmunotherapy included 2 cycles of immunotherapy plus chemotherapy with the interval of 3 weeks among each cycle. All patients received 2 cycles of Pembrolizumab (200 mg, D1), Sintilimab (200 mg, D1), Tislelizumab (200 mg, D1) or Camrelizumab (200 mg, D1) intravenously. Concurrently all patients received 2 cycles of cisplatin (75 mg/m2 of body-surface area, D1) and paclitaxel (175 mg/m2 body-surface area, D1) intravenously. The perioperative parameters and short-term surgical outcomes were presented (Table).

Results

Between January 2020 and December 2022, a total of 317 ESCC patients who underwent neoadjuvant chemoimmunotherapy followed by surgery were screened. Twenty cT4b patients with middle or upper thoracic ESCC were finally enrolled in this study. Pretreatment tumor invades the trachea (4, 20%), left main bronchus (16, 80%), and aorta (6, 30%), respectively. All the patients were successfully performed by McKeown minimally invasive esophagectomy except for one patient conversion to thoracotomy. R0 resection was achieved in 15 patients, 4 patients underwent R1 resection and 1 patient underwent R2 resection. Mean operation duration was 290.4 ± 57.5 min. Mean estimated blood loss was 94.4 ± 108.8 ml. Three patients had postoperative pneumonia, two patients had postoperative pleural effusion and one patient had postoperative recurrent laryngeal nerve paralysis. No patient had postoperative anastomotic leak. No postoperative reoperation was needed and there was no perioperative mortality. Mean length of hospital stay was 10.9±1.4 days. 90-day mortality occurred in one patient with postoperative multiple systemic metastasis. Fifteen patients are alive with a median follow up of 18 months. One patient died with regional lymph node recurrence and three patients died with hematogenous dissemination.

Conclusion

Multimodal treatment strategy combining immunotherapy and chemotherapy may convert unresectable tumors into potentially operable ones, and achieved favorable survival. Longer follow-up and larger sample size are needed to verify our preliminary results.
806. MINIMALLY INVASIVE REVISION FUNDOPLICATION, IS IT SAFE AND FEASIBLE? SINGLE CENTER EXPERIENCE
Authors: Vijaya Kumar K , Parthasarathi Ramakrishnan , Ramesh N , Palanivelu C
Published: September 2024

Introduction

Laparoscopic fundoplication has become standard of care for patients with refractory gastroesophageal reflux disease, large and symptomatic hiatal hernia. Failure rate for laparoscopic fundoplication was between 2 to 17%. Doing Revisional Antireflux surgery is technically difficult. Our aim is to analyse symptomatic improvement post surgery, safety and durability of procedure in patients who underwent revision fundoplication at our centre

Patients and Methods

22 patients underwent Minimally invasive revision fundoplication between January 2019 to January 2022 were taken into study, of them 12 gentlemen and 10 women were noted. Modified DeMeester score was calculated in all patients preoperatively and on 6 months follow up.

Results

All patients underwent primary surgery laparoscopically. 14 patients (63.6%)had recurrent reflux symptoms and 8 patients (36.3%) had severe dysphagia. Revision fundoplication was done laparoscopically in 20 patients and 2 patients Robotic surgery was done. Intraoperatively 11 patients had wrap migration, 8 patients had tight wrap, 3 patients had twist of wrap. In the re-do anti-reflux surgery (ARS) procedure, floppy Nissen fundoplication was performed in 86.4% of the patients, which amounts to 19 patients., and 3 patient underwent a 270-degree Toupet fundoplication. In 2 patients, additional composite mesh reinforcement was employed. 13.6 % of patients had intraoperative complications, 9.09 % of patients had pleural injury, 4.7 % had intraoperative bleeding, 9.09% of patients had gallstone disease, for which cholecystectomy was done. All patients anterior and posterior vagus identified and preserved. On follow up 80% of patients had resolution of symptoms, 18% needed intermittent PPI. At a median follow up of 18 months, no surgical failure was noted in endoscopy.

Conclusion

Laparoscopic revision fundoplication is a safe procedure when operated in a high volume centre by an expert surgeon.