bluuebunny/crossref_metadata_2025 huggingface dataset:
PS01.089: A DIFFERENT FIXATION METHOD TO PREVENT STENT MIGRATION IN ESOPHAGEAL FISTULAS AND PERFORATIONS
Authors: Eroglu Atila , Aydin Yener , Ulas Ali , Yilmaz Omer
Published: September 2018

Background

Esophageal perforation is an emergency condition characterized by high morbidity and mortality. The removable esophageal stent is an effective method of treatment in cases with esophageal perforation as they allow minimal invasive and rapid nutrition. Stent migration is an important problem in perforations and fistulas where there is no obstruction in the esophageal lumen. Several methods are used to prevent stent migration, including different stent types and endoscopic suture technique. In this study, we aimed to present a method that we use in our clinic to prevent stent migration.

Methods

We retrospectively evaluated 12 consecutive patients who underwent stent placement and were fixed for migration prevention for esophageal fistula or perforation between January 2013 and February 2018 in our clinic. All of the cases were self-expandable metallic stents. The stent was removed from the delivery catheter without insertion and the suture material was passed through the head and reattached to the catheter. The stent was placed using flexible endoscopy. The suture material placed on the upper part of the stent was taken out of the mouth of the patient. After the stent is inserted and the delivery catheter is removed, the nasal catheter (aspiration catheter) was inserted and removed from the mouth. The suture material in the mouth was connected to the tip of the aspiration catheter. The aspiration catheter was withdrawn. The suture material removed from the patient's nose was fixed like a nasogastric catheter. After 3 or 4 days from the procedure, the suture was cut. Migration of the stent was followed by direct radiography.

Results

Seven cases were female and five cases were male. The mean age was 51.1 ± 12.7 years (range 20–72 years). No migrations were observed in any of the cases. After a mean of 19.5 days (range 11–23 days), the stent was removed endoscopically. In all cases, perforation and fistula improved.

Conclusion

We think that the esophageal stent fixation method is a simple and effective method to prevent migration.

Disclosure

All authors have declared no conflicts of interest.
PS01.092: FOKER GROWTH INDUCTION FOR LONG GAP ESOPHAGEAL ATRESIA: WHAT WE HAVE LEARNED
Authors: Jo Svetanoff Wendy , Bairdain Sigrid , Zurakowski David , Hamilton Thomas , Clark Susannah , Ngo Peter , Manfredi Michael , Jennings Russell , Gallagher Dorothy , Smithers C
Published: September 2018

Background

The Foker process is used in patients with long-gap esophageal atresia (LGEA) to maintain the native esophagus; however, chemical paralysis, used to ‘protect’ the esophagus, is associated with complications and longer hospital stays. The purpose of this study was to identify changes in practice patterns with increased Foker experience, and to review the relationship of paralysis time with the incidence of esophageal leaks and need for stricture resections.

Methods

A retrospective review of LGEA patients from January 2006 to December 2016 was performed. Patients were excluded if they had previous attempts elsewhere. Patients were initially divided into two groups: early group (surgery before 2013) and late group (2013–2016) to assess outcomes. All patients, irrespective of surgery date, were then divided into three subgroups based on esophageal anastomotic tension. Logistic regression with odds ratio (OR) and 95% confidence interval (CI) was used to assess risk of leaks and need for stricture resection.

Results

Fifty-eight patients met criteria, and demographics were similar between groups. The late group required significantly fewer surgeries between Foker I and Foker II and had shorter ICU length of stay (LOS). Variables that trended towards statistical significance included total length of paralysis, time between Foker I and Foker II, and total hospital LOS. Overall, 18 patients developed a leak, and 13 required stricture resections. There was no correlation between paralysis time or anastomotic tension with incidence of leak or stricture resection. Multivariable analysis indicated that the occurrence of a leak (OR 5.7, 95% CI: 1.4–27.3, P = 0.025) and need for > 8 dilations (OR 11.0, 95% CI: 2.3–53.4, P = 0.002) were significant predictors of need for stricture resection.

Conclusion

As our experience has grown, the need for multiple procedures between Foker I and Foker II has decreased, leading to less paralytic exposure, shorter ICU LOS, and trending toward decreased hospital LOS. By verifying that specified paralysis times are not required, we can continue to mitigate complications associated with lengthy paralysis times and longer hospital admissions without risking esophageal health.

Disclosure

All authors have declared no conflicts of interest.
PS01.093: REPEAT ESOPHAGEAL STRICTURE RESECTION: WHAT FACTORS ARE MOST INFLUENTIAL?
Authors: Jo Svetanoff Wendy , Bairdain Sigrid , Zurakowski David , Hamilton Thomas , Smithers C , Jennings Russell
Published: September 2018

Background

The objective of this study was to identify whether paralysis time following stricture resection and tension applied at the anastomosis influenced leak rate, need for repeat stricture resection (SR), or need for an interposition graft.

Methods

A retrospective chart review was performed of patients undergoing esophageal stricture resection and anastomosis from October 2007 to July 2017 (IRB# P00004344). Patients who required an interposition as their primary surgery were excluded. Leak rates following stricture resection and the need for further esophageal surgery was identified. Tension groups were also delineated into mild, moderate, and high anastomotic tension. Anastomotic tension and paralysis times were analyzed by multivariable logistic regression and area under the curve (AUC) to determine factors associated with development of leaks and an increased risk of repeat SR.

Results

Ninety-four patients were identified; 45 were males and mean gestational age was 35 weeks. Fifty-one patients were categorized with mild tension, 35 with moderate, and 8 with high tension. Four of the 51 patients (8%) with low tension and 15/43 (35%) with moderate or high tension developed leaks (P = 0.002). Seventeen patients overall required repeat SR (18%), including 3/51 with low tension (6%) versus 14/43 (33%) with moderate or high tension (P < 0.001). Additionally, 12/17 (71%) patients requiring repeat operations initially had a Foker process for their esophageal atresia. Multivariable analysis indicated that moderate/high tension (P = 0.006) and longer paralysis time (p 0.04) were predictive of a leak after initial SR (AUC = 0.720). Paralysis time of 7 + days (P = 0.05), moderate/high tension (P = 0.05) and occurrence of a leak (P = 0.002) were independent risk factors for the need for repeat SR (AUC = 0.861, 95% CI: 0.772–0.949). Of the 17 patients with repeat SR, 10 (59%) underwent a jejunal interposition.

Conclusion

Tension, paralysis time, and presence of a leak are independent risk factors for repeat SR. Low tension anastomoses had a significantly small incidence of repeat surgery. Esophageal replacement shoudl be considered earlier among patients who originally undergo a Foker procedure for esophageal continuity and for those whose stricture repair is placed under moderate or high tension.

Disclosure

All authors have declared no conflicts of interest.
PS01.094: PREDICTING FACTOR OF FAILURE OF CONSERVATIVE TREATMENT AND OUTCOME IN PATIENTS WITH ACUTE CAUSTIC FOREGUT INJURY
Authors: Athigakunagorn Jadsada , Sukpan Panupong , Jiravongbunrod Teerasak
Published: September 2018

Background

Most of the patients with caustic injury can be successfully manage with conservative treatment. However, some patients with high severity required surgery. In this study, we assess failure rate, outcome and predictors of failure of conservative treatment in patients with acute caustic foregut injuries.

Methods

We retrospectively reviewed clinical records of patients with acute caustic foregut injuries who were hospitalized and treated at the Bhumibol Adulyadej Hospital from January2008 – December 2015. Analysis the data included the clinical factor, laboratory result, failure rate and outcome of management.

Results

Out of the 190 patients with caustic foregut injuries, 7.4%(14 patients) were failed to treat with conservative treatment and underwent to emergency surgery. 2 deaths were found in this study. Factors that associated with failure of conservative treatment were epigastrium tenderness (OR 22.2, 2.8–173.6 95% CI), Heart rate > 100 (OR 7, 2.2- 22.6 95% CI), WBC count > 10,000 (OR 4.9, 1.3–18.3 95% CI), Band form positive (OR 9.2, 2.6–32.7 95% CI), Blood PH < 7.2 (OR 16, 3.6–70.9 95% CI).

Conclusion

We consider epigastrium tenderness, Heart rate > 100 bpm, WBC count > 10,000 cell/ul, positive band form and blood pH < 7.2 to be the significant factor associating with failure of conservative management in patients with acute caustic foregut injuries. Intensive evaluation and early surgery should be considered in this group of patients.

Disclosure

All authors have declared no conflicts of interest.
PS01.097: A CASE OF IGG4-RELATED SCLEROSING ESOPHAGITIS
Authors: Miki Hirokazu , Michiura Taku , Mukaide Hiromi , Inoue Kentaro , Yamamichi Keigo , Hamada Madoka
Published: September 2018

Background

IgG4-related disease (IgG4-RD) is a systemic disease characterized by fibrosing inflammation with an abundance of IgG4-positive plasma cells. IgG4-RD has been found to affect various organs. Many cases of IgG4-RD affecting the extrapancreatic organs have been reported in patients without pancreatic lesions.

Methods

Sclerosing esophagitis with IgG4-positive plasma cell infiltration is very rare disease. We report a case of esophageal benign stricture that was difficult to diagonose.

Results

A 76-year-old woman had been experiencing slight difficulty in swallowing in the 3 years prior to this presentation. Her dysphagia had progressed and she began to vomit frequently after meals and lost weight while hospitalized after surgery for cervical cancer. Esophagogastroduodenoscopy and an esophagram showed circumferential erosion and a stricture of the thoracic esophagus. No malignant cells were identified. However, because it was difficult to exclude a malignant tumor, she underwent esophageal resection. The resected specimen showed stricture with mucosal erosion and transmural wall hypertrophy. On histological examination, transmural hyperplasia consisting of inflammatory granulation tissue with abundant infiltration of IgG4-positive plasma cells and lymphocytes was observed.

Conclusion

A probable diagnosis of IgG4-related disease was made because comprehensive diagnostic criteria for this condition were met. IgG4-related esophageal disease presenting as esophageal lesions alone is very rare.

Disclosure

All authors have declared no conflicts of interest.
PS01.098: EMERGENCY COMPUTED TOPMOGRAPHY PREDICTS CAUSTIC ESOPHAGEAL STRICTURE FORMATION
Authors: Chirica Mircea , Bruzzi Matthieu , Resche Rigon Matthieu , Corte Helene , Voron Thibault , Sarfati Emile , Marie Zagdanski Anne , Cattan Pierre
Published: September 2018

Background

Endoscopy is the best predictor of stricture formation after caustic ingestion. Our aim was to compare the accuracy of emergency CT and endoscopy in predicting risks of esophageal stricture.

Methods

We describe a CT classification of esophageal caustic injuries: Grade I show normal esophagus; Grade IIa display internal enhancement of the esophageal mucosa and enhancement of the outer wall conferring a ‘target’ aspect; Grade IIb present as a fine rim of external esophageal wall enhancement. In 152 patients (56 males, median age 45) who underwent esophageal preservation after caustic ingestion we compared the accuracy of the CT and endoscopic (Zargar) classifications in predicting esophageal stricture.

Results

On endoscopy esophageal injuries were classified as grade 1(n = 50; 33%), grade 2a n = 11; 7%), grade 2b (n = 19; 13%), grade 3a (n = 14; 9%) and grade 3b (n = 58; 38%). On CT, 47 (31%) patients had grade I, 47 (31%) had grade IIa and 58 (38%) had grade IIb esophageal injuries. Fifty-six (37%) patients developed esophageal strictures. The risk of esophageal stricture formation was 0%, 17% and 83%, for grade I, IIa and IIb CT injuries and 0%, 0%, 28%, 50% and 76% for endoscopic grade 1, 2a, 2b, and 3a and 3b injuries, respectively. ROC curve analysis at 120 days after ingestion showed that CT outperformed endoscopy in predicting stricture formation (P = 0.047) and did just as well as a combined CT-endoscopy algorithm (P = 0.73).

Conclusion

Emergency CT outperforms endoscopy in predicting esophageal stricture formation after caustic ingestion. Emergency endoscopy evaluation after caustic ingestion is not indispensable.

Disclosure

All authors have declared no conflicts of interest.
PS01.102: MINIMALLY INVASIVE ENUCLEATION OF ESOPHAGEAL LEIOMYOMA: COMPARISON OF DIFFERENT TECHNIQUES WITH FOCUS ON QUALITY OF LIFE AND GASTROESOPHAGEAL REFLUX
Authors: Milito Pamela , Aiolfi Alberto , Zanghi Simone , Siboni Stefano , Asti Emanuele , Bonavina Luigi
Published: September 2018

Background

Minimally invasive enucleation of esophageal leiomyoma may induce or aggravate gastroesophageal reflux disease, but scarce data are available in literature.

Methods

We conducted a retrospective, cross-sectional single-center study investigating long-term outcomes of laparoscopic, thoracoscopic, and endoscopic enucleation with focus on quality of life and gastroesophageal reflux. Postoperative clinical and endoscopic data were compared to baseline. All patients underwent barium swallow study, endoscopy and completed the GERD-HRQL questionnaire after a minimum 1-year follow-up.

Results

Thirty patients were included in the study. There were 19 females and 11 males, median age 48 years (range 28–67). Thirteen (43.3%) patients underwent laparoscopic enucleation plus fundoplication (9 Toupet, 3 Nissen, 1 Dor), 12 (40%) patients thoracoscopic enucleation, and 5 (16.7%) patients endoscopic enucleation. Mean operative time was 149.1 ± 62.6 min. Mean tumor diameter was 5.4 ± 3.2 cm. There was no operative mortality. Overall morbidity rate was 16.6%, and no mucosal perforations occurred. Mean hospital stay was 4.0 ± 1.8 days. The mean baseline GERD-HRQL score was 4.25 (range 0–21) in the laparoscopic group, 3.4 (range 0–12) in the thoracoscopic group, and 5.7 (range 0–13) in the endoscopic group. Preoperatively, hiatal hernia was present in 6 patients (46.1%) in the laparoscopic group, in 4 patients (33.3%) in the thoracoscopic group, and in 2 patients (40%) in the endoscopic group. The mean follow-up was 58 months (range 3–192) (Table 1).

Conclusion

GERD symptoms were more common in patients after endoscopic enucleation. Primary laparoscopic enucleation combined with fundoplication allows effective long-term reflux control.

Disclosure

All authors have declared no conflicts of interest.
PS01.107: INTERDISCIPLINARY MANAGEMENT OF AORTO-ESOPHAGEAL FISTULA: BETTER SAFE THAN SORRY
Authors: Gschwandtner Elisabeth , Fink-Neuböck Nicole , Lindenmann Jörg , Porubsky Christian , Maier Alfred , Portugaller Rupert , Oberwalder Peter , Deutschmann Hannes , Dapunt Otto , Smolle-Jüttner Freyja-Maria
Published: September 2018

Background

Aorto-esophageal fistula is a rare but life-threatening event evolving spontaneously or—more often—following therapeutic interventions at the esophagus or the aorta. Especially in presence of long-standing inflammation preceding the formation of the fistula, acute surgical closure of the aortic leakage is all but impossible and interdisciplinary treatment is mandatory.

Methods

Review of cases of aorto-esophageal fistula within the last 12 years.

Results

In our collective of patients undergoing esophagectomy since 2005 (N = 445) we observed 7 cases (1,5%) of aorto-esophageal fistula. In one case the fistula had developed spontaneously following aspergillosis, one patient had had aortic stenting 29 years before, another one had developed anastomotic dehiscence following intrathoracic esophago-jejunostomy and in 4 cases esophageal stenting had been done. 5 patients presented with slight to dramatic hematemesis which in 2 instances needed endoscopic intervention, 2 had no bleeding. Preoperative angio-CT confirmed aorto-esophageal fistula in 3 cases who underwent aortic stenting prior to the surgical intervention, in 3 patients the fistula was found intraoperatively (aortic replacement N = 1; suture followed by stenting N = 1; operation stopped; aortic stenting, operation the following day). All patients recovered from surgery. In one case inflammation had caused partial necrosis of the aortic wall causing fatal bleeding during operation. Retrospectively, the lesion of the aortic wall could be identified on CT in all but one patient.

Conclusion

By interdisciplinary management, involving preoperative stenting or aortic graft implantation in cases not amenable to stenting, patients with aorto-esophageal fistula can be saved and may undergo elective esophageal surgery.

Disclosure

All authors have declared no conflicts of interest.
PS01.108: SPONTANEOUS ESOPHAGOCUTANEOUS FISTULA IN KIKUCHI DISEASE
Authors: Voon Kelvin , Mohammed Taher Mustafa , Rajan Reynu , Ritza Kosai Nik
Published: September 2018

Background

Kikuchi disease is a rare, self-limiting condition that is characterized by histiocytic necrotizing lymphadenitis with unknown pathogenesis. Common presentation is cervical lymphadenopathy and fever in a previously well young female. Mediastinal lymph node involvement is uncommon.

Methods

We report a case of spontaneous esophagocutaneous fistula secondary to necrotizing mediastinal lymphadenopathy in a patient with Kikuchi disease.

Results

A 38-year-old lady presented with fever and right back pain of two weeks duration. She had background history of Kikuchi disease which was diagnosed 1 year ago. Examination revealed multiple enlarged left cervical lymph nodes and right back tenderness. CT scan showed an esophagocutaneous fistula with right paraspinal abscess and multiple enlarged cervical and mediastinal lymph nodes. OGDS revealed a 5mm fistula opening at right posterior wall of distal esophageal, 3cm proximal to esophagogastric junction. Rest of esophagus and stomach were normal. Tuberculosis and SLE workup were negative. Cervical lymph node biopsy was consistent with Kikuchi disease. She was treated as spontaneous esophagocutaneous fistula secondary to necrotizing mediastinal lymph node with underlying Kikuchi disease. Percutaneous drainage of paraspinal abscess was done and antibiotics were commenced. Laparoscopic feeding jejunostomy was done for feeding. Esophageal stenting and endoscopic clipping of fistula were attempted but the fistula tract persisted. She then underwent laparoscopic excision of esophageal fistula tract (LEEFT). Intraoperative findings were dense inflamed paraesophageal tissue with thickened fistula tract at right posterolateral wall of distal esophagus with multiple enlarged mediastinal lymph nodes. Fistula tract and the lymph nodes were excised via laparoscopic transhiatal approach. She had an uneventful recovery and was discharged on post-operative day 7.

Conclusion

Spontaneous esophageal fistula is rare and necrotizing mediastinal lymphadenopathy needs to be considered. Laparoscopic excision of esophageal fistula tract (LEEFT) is a novel transhiatal approach and it is feasible in distally located fistula.

Disclosure

All authors have declared no conflicts of interest.
PS01.112: ESOPHAGEAL AORTIC FISTULA TREATED BY ESOPHAGOSCOPY COMBINED WITH AORTIC ENDOVASCULAR GRAFT EXCLUSION
Authors: Tang Shoujun , Zhou Haining
Published: September 2018

Background

The esophageal aortic fistula is an uncommon disease caused by a foreign matter in the esophagus. This condition presents a high mortality, and inappropriate treatment can result in serious consequences.

Methods

A 66-year-old male patient was admitted to a hospital because of frequent dysphagia and severe chest pain after eating fishbone 5 days ago. In another hospital, the patient underwent gastroscopy, which revealed that a fishbone was incarcerated in the esophageal wall 23 cm away from the incisor and was causing active bleeding. The fishbone was not successfully removed in this hospital. A CT scan of the thorax performed in our department indicated an esophageal striped high-density shadow (below the aortic arch). The borders of the thoracic aortic wall were unclear. On the basis of these findings, the patient was diagnosed with esophageal aortic fistula. The doctors in the otolaryngology department failed to remove the fishbone by esophagoscopy because of jet-like bleeding. An esophageal gasbag was immediately used for hemostasis by compression. Afterward, thoracic surgeons performed ascending aorta angiography, which showed an approximately 1.0 cm anabrosis in the lesser curvature of the initial part of the descending aorta. The covered stent was placed, and the fishbone was removed successfully by esophagoscopy.

Results

The patient was able to eat normally after 7 days postoperatively. No significant abnormality was reported in the following 3 years.

Conclusion

An esophageal aortal fistula caused by a foreign matter should be operated on immediately if the physical condition of the patient permits. The location of the foreign matter and its relationship to the large blood vessels can be detected by high-resolution computed tomography and computed tomography angiography. Stent implantation reduces the risk of massive hemorrhage. Therefore, we recommend esophagoscopy combined with aortic endovascular graft exclusion as a safe alternative.

Disclosure

All authors have declared no conflicts of interest.
PS01.113: RISK FACTORS FOR ESOPHAGEAL STRICTURE IN GRADE 2B AND 3A CORROSIVE ESOPHAGEAL INJURIES
Authors: Mahawongkajit Prasit
Published: September 2018

Background

Ingestion of corrosive agents remains an important public health problem. Early endoscopic examination of post-corrosive esophageal injuries has an important role in management of the patient. Publications document the risk of developing esophageal stricture as a sequential complication of esophageal injury grades 2b and 3a. Although there are studies describing the risk factors of post-corrosive stricture, there is limited literature on these factors. The aim of this study was to evaluate the different factors with post-corrosive esophageal stricture and non-stricture groups in endoscopic grades 2b and 3a of corrosive esophageal injuries.

Methods

Data were retrospectively analyzed in the patients with esophageal injury grades 2b and 3a between January 2011 and December 2017.

Results

196 corrosive ingestion patients were admitted with 32 patients (15.8%) in grade 2b and 12 patients (6.1%) in grade 3a and stricture was developed in 19 patients (61.3%) with grade 2b and in 10 patients (83.3%) with grade 3a. Substances of alkaline reaction were predominant in stricture patients (68.4% in 2b Stricture group, 60% in 3a Stricture group). The patients’ height of non-stricture group was greater than that of stricture groups (2b Stricture group, 1.58 ± 0.08 m, 2b Non-stricture group, 1.66 ± 0.07 m, P < 0.004; 3a Stricture group, 1.52 ± 0.09 m, 3a Non-stricture group, 1.71 ± 0.02 m, P < 0.001). Omeprazole was more commonly used in non-stricture than stricture group (26.3% in 2b Stricture group, 69.2% in 2b Non-stricture group, P = 0.017; 50% in 3a Stricture group, 100% in 3a Non-stricture group, 1.71 ± 0.02 m, P = 0.015).

Conclusion

In this study, the corrosive esophageal injuries grades 2b and 3a are important groups of patients who are at risk of developing post-corrosive esophageal stricture. Alkaline substances play the major role in stricture sequelae. The height of patients and the prescription of omeprazole may help to minimize the risks of post-corrosive esophageal stricture.

Disclosure

All authors have declared no conflicts of interest.
PS01.115: ESOPHAGECTOMY FOR ACHALASIA CARDIA: A SINGLE TEAM EXPERIENCE
Authors: Chandramohan Servarayan , Manickavasagam Kanagavel , Chinnathambi Madeshwaran , Jebaraj Abishai , Chandramohan Apsara , Devygounder Kannan , Varadharajan Visvarath
Published: September 2018

Background

In the era of per oral endoscopic myotomy, advancement in manometry and laparoscopy the treatment for achalasia cardia is well defined. Oesophagectomy has only a limited role in rare patients with sigmoid esophagus, perforation during nonsurgical treatment and malignancy. This study is about the indications of esophagectomy for achalasia cardia from one of the high volume centers for upper gastrointestinal disorders in India

Methods

This study includes 10 patients (7 male, 3 female) between august 2010 to august 2016.They had symptoms like dyspnea, dysphagia, regurgitation, chest discomfort, weight loss and cough. The duration of symptoms range from 2–120 months. Seven patients underwent previous pneumatic dilatation, four underwent Laproscopic Hellers cardiomyotomy with fundoplication (dor 3, toupet 1) and one patient had both pneumatic dilatation and cardiomyotomy.

Results

The indications for esophagectomy were sigmoid esophagus, failed pneumatic dilatation and laproscopic hellers cardiomyotomy, perforation after pneumatic dilatation and malignancy. The procedures done were transhiatal esophagectomy with stomach pull-up in 8 patients, Transthoracic esophagectomy in one, Esophagogastrectomy with transabdominal intrathoracic esophagojejunal anastomosis in one patient. The follow-up range between 14–84 months. During follow-up one patient developed hepatocellular carcinoma right lobe and died.

Conclusion

In the era where nonresection treatment play a major role in the management of achalasia cardia, esophagectomy still has a role in select patients. The indications for esophagectomy in our series included failed endotherapy, failed Hellers cadiomyotomy, sigmoid esophagus and malignancy.

Disclosure

All authors have declared no conflicts of interest.
PS01.116: EXTRAMUCOSAL ENUCLEATION IS SAFE AND FEASIBLE IN ESOPHAGEAL LEIOMYOMA IRRESPECTIVE OF SIZE: SINGLE INSTITUTION EXPERIENCE
Authors: Perwaiz Azhar , Singh Amanjeet , Chaudhary Adarsh
Published: September 2018

Background

Esophageal leiomyoma (EL) is the most common benign lesion of esophagus. Extramucosal enucleation (EME) is the treatment of choice however esophageal resection have been favoured by some particularly when they attain large size citing risk of malignant transformation. We share our experience of EME over the last 7 years.

Methods

Prospectively collected database on consecutive cases of EL managed surgically between March 2010 and March 2017 were analysed retrospectively. Our department policy is to consider EME in all. Routine preoperative workup included baseline blood tests, contrast enhance computed tomography chest and upper abdomen and endoscopic ultrasound. All perioperative details were recorded prospectively. All patient underwent CT with oral contrast on day 1 of surgery to exclude leak. Final histopathology were recorded and all of them were followed 6 monthly.

Results

Mean age of the patients analysed (n = 21; male = 16, female = 5) were 42.7 ± 10.7 years (range 22 to 61) with mean tumor size of 8.4 ± 2.8cm (range 4.2 to 15). Commonest tumour location was thoracic esophagus (n = 16; 76.1%) followed by abdominal (n = 4; 19.2%) and cervical esophagus (n = 1; 4.7%). Most tumor were asymptomatic (n = 9/21; 42.8%) while dysphagia was commonest among those who had symptoms at presentation(7/21; 33.3%). Five (23.8%) of these were of size ≥ 10 cm (giant EL). All of them underwent EME as planned. Majority (n = 17; 81%) underwent minimally invasive enucleation (Thoracoscopic = 14, Laparoscopic = 3) while rest 4 (19%) underwent open enucleation due to large size in 1, cervical location in 1 and intolerance to minimally invasive procedure in 2. The mean operative blood loss were 72.5 ± 22 ml and none required blood transfusion. The mean duration of surgery were 122 ± 27 minutes. There were no postoperative complications that required intervention. No leak reported on postoperative day 1 scan. All patients got discharged by a mean of 5.2 ± 1.8 days. The final diagnosis were leiomyoma in all. At a mean follow up of 36 ± 17.2 months none had recurrence or any long term complication attributable to enucleation.

Conclusion

Extramucosal enucleation is safe in esophageal leiomyoma irrespective of size and majority of them can be managed with minimally invasive surgery.

Disclosure

All authors have declared no conflicts of interest.
PS01.125: SURGICAL APPROACH FOR THE ELDER ESOPHAGEAL CANCER
Authors: Tashiro Keitaro , Kawai Masaru , Lee Sang-Woong , Tanaka Ryo , Imai Yoshiro , Hiramatsu Masako , Uchiyama Kazuhisa
Published: September 2018

Background

Recently the number of elder patients who have esophageal cancer has been higher in Japan. Because the anesthesia and surgical technique are developing day by day, we can choose surgery as radical therapy for esophageal cancer in elder patients. But the percentage of complication after operation in elder person still should be higher compared to young person. We present the problems and the risks of surgery for elder esophageal cancer in our institution.

Methods

61 patients (over 75 years old) who had esophageal cancer underwent esophageal resection from 1998 to 2016 in Osaka Medical College, Japan. We divided these patients to 3 groups: open surgery; Group A, none open surgery (trans hiatal approach); Group B, VATS (Video-Assisted Thoracic Surgery); Group C, and assessed the amount of blood loss and surgical time during operation and the frequency of complication after operation.

Results

Average age of patient in Group B was significantly higher than other groups (Group A: 78.7 y. o., Group B: 81.3 y. o., Group C: 77.5 y. o.). Surgical time in Group C (526.5 ± 20.7min) was significantly longer than other groups (Group A: 385.5 ± 17.9min, Group B: 297.1 ± 27.4min). Blood loss during operation in Group B tended to be less than other groups (Group A: 575.4 ± 105.4mL, Group B: 320.4 ± 61.0mL, Group C: 317.6 ± 80.3mL). The complication after surgery occurred in 27 patients (44.3%) in whole groups, including pneumonia (48.8%), anastomotic leakage (18.6%), recurrent nerve paralysis (16.3%), empyema (7.0%), ischemia of gastric tube and/or small intestine (4.7%), deep venous thrombosis (4.7%). According to surgical approach, the occurring frequency of pneumonia (Clavien-Dindo classification Grade III and more) after operation in Group A (28.6%) was higher than other group (Group B: 8.3%, Group C: 9.5%), but more recurrent nerve paralysis was occurred in Group C (33.3%) compared to other groups.

Conclusion

Lung diseases including pneumonia, particularly in elder patient, are one of the most critical and sometimes become a fatal complication after esophageal cancer surgery. VATS seems to be more safe and useful approach in elder esophageal cancer resection, but needs to be care for recurrent nerve paralysis.

Disclosure

All authors have declared no conflicts of interest.
PS01.126: LYMPH NODE METASTASES AND NECK DISSECTION FOR THE PATIENTS WITH CERVICAL ESOPHAGEAL CANCER
Authors: Shiga Kiyoto , Katagiri Katsunori , Saito Daisuke
Published: September 2018

Background

Cervical esophageal cancer (CEC) is a relatively rare disease but the outcomes of the patients with CEC are often poor. Lymph node metastases in the neck sometimes play a crucial role to treat the patients. The aim of this study is to evaluate the lymph node metastases and neck dissection for the patients with CEC.

Methods

Retrospective review of the records of the patients. Five patients with CEC who underwent total pahryngo-laryngectomy plus cervical esophagectomy were enrolled in this study. We analyzed the places of lymph node metastases of the patients and the relationship of the patients’ outcome.

Results

Four of the patients underwent free jejunum flap reconstruction after total pahryngo-laryngectomy plus cervical esophagectomy and the other one underwent gastric tube plus free jejunum flap reconstruction after the pahryngo-laryngectomy plus total esophagectomy. All patients underwent bilateral neck dissection. One patient underwent chemoradiotherapy as an initial treatment and he had no lymph node metastasis by pathological examination. The other four patients had neck metastases to some extent. Three of them had bilateral lymph node metastases and the other had one metastatic lymph node. Especially one patient had left upper lateral neck metastasis and right Rouvier lymph node metastasis.

Conclusion

These results indicated that patients with CEC should undergo bilateral neck dissection and if possible, Rouvier lymph node should also be resected during radical surgery.

Disclosure

All authors have declared no conflicts of interest.
PS01.128: A PROPENSITY SCORE-MATCHED ANALYSIS OF CLINICAL SIGNIFICANCE OF THE SUPRACLAVICULAR LYMPHADENECTOMY FOR SQUAMOUS CELL CARCINOMA LOCATED IN MIDDLE THORACIC ESOPHAGUS
Authors: Tsunoda Shigeru , Obama Kazutaka , Hisamori Shigeo , Hashimoto Kyoichi , Itatani Yoshiro , Tashiro Naohiro , Nishigori Tatsuto , Sakai Yoshiharu
Published: September 2018

Background

Supraclavicular lymph nodes (No 104) were upgraded from group 3 to group 2, which needs to be dissected in D2 surgery, for tumors located in middle thoracic esophagus in the 11th edition of Japanese classification of esophageal cancer. However, it is not based on prospective study and the evidence level remains moderate. Current evidence regarding supraclavicular lymphadenectomy is mainly based on retrospective cohort study of efficacy index without proper control. The aim of this study is to retrospectively investigate the clinical impact of supraclavicular lymphadenectomy for middle esophageal cancer.

Methods

A total of 240 consecutive patients who underwent R0 esophageal resection for clinical Stage I, II, III (UICC 8th) primary esophageal squamous cell carcinoma from 2005 to 2017 in Kyoto University Hospital were investigated. Patients who underwent salvage surgery after definitive chemoradiotherapy were excluded. Among them, 99 patients had middle esophageal cancer. All patients underwent at least abdominal and mediastinal lymphadenectomy including cervical paraesophageal (No 101) and paratracheal (No 106rec) nodes. After propensity score matching, 42 patients (21 each for with (3F) and without (2F) supraclavicular lymphadenectomy) were selected for comparison.

Results

In the propensity-matched population (n = 42), the 5-year overall survival of clinical Stage I (n = 15)/II (n = 9)/III (n = 18) was 100%/52%/57%. Though cStage, neoadjuvant therapy, ASA-PS and date of surgery (early, middle and late period) were well matched, the 5-year overall survival in 2F and 3F were 82% and 68%. The hazard ratio (3F/2F) for overall death was 2.6 (95% CI, 0.79–9.97; P = 0.1178). In terms of short term outcomes, postoperative morbidity graded as Clavien-Dindo grade 2 or higher was 48% in the both group, while respiratory complication (Clavien-Dindo grade 2 or higher) was 14% in 2F and 29% in 3F, respectively. The odds ratio was 2.4 (95% CI, 0.51–11.3; P = 0.2593).

Conclusion

This observational study failed to show any clinical benefit of supraclavicular lymphadenectomy. Given the nature of retrospective study, there might be overlooked confounding factors to select 2F or 3F. Further prospective study is warranted.

Disclosure

All authors have declared no conflicts of interest.
PS01.133: ISCHEMIC CONDITIONING OF THE STOMACH PRIOR TO ESOPHAGECTOMY: TIMING AND TECHNIQUE MATTER
Authors: Carrott Philip , Shih Terry , Reddy Rishi , Erickson Crystal , Lagisetty Kiran , Lin Jules
Published: September 2018

Description

This video highlights one method of gastric ischemic conditioning prior to esophagectomy. Multiple reports of ischemic conditioning have not shown benefit, but these studies generally had a short time of ischemia (7–14 days), and did not have a consistent method of conditioning that includes both short gastric and left gastric vessels. Animal data shows that 30 days is likely the minimum timing needed for development of collateral blood flow through the body of the stomach. We have treated 13 patients with between 35 and 180 days of ischemic conditioning prior to esophagectomy, and none of these patients developed a leak, with only one requiring dilation of a benign anastomotic stricture. In these patients, 5 patients underwent a concominant feeding jejunostomy. In our experience, ligation of the arterial and venous blood supply is important, as is ligation of both short gastric and left gastric vessels. If the left gastric vessels cannot be seen, lesser curvature perforating vessels high on the proximal stomach may be ligated as well. We prefer to use the laparoscopic clips to ligate these vessels, while some groups use energy devices to divide the short gastric vessels and clips to occlude the left gastric vessels. This keeps the subsequent adhesive disease to a minimum, which is likely the major barrier to longer conditioning time. Indeed, the ideal timing of the ischemic conditioning procedure is prior to starting chemo-radio-therapy, giving 100 days or more of conditioning time. The video outlines a laparoscopic procedure that we feel is optimum for ischemic conditioning of the stomach. We believe this method has cracked the code of a very morbid procedure and made it into a slightly morbid procedure, which can still have complications, but the anastomotic complications are much less severe with improved perfusion to the gastric conduit. Leaks are less frequent and less severe, and symptomatic strictures are fewer in number. Future work in this area should focus on ischemic conditioning timing, as well as cancer-specific outcomes related to the conditioning procedure.

Disclosure

All authors have declared no conflicts of interest.
PS01.136: POSTOPERATIVE OUTCOMES OF THE DUTCH UPPER GASTROINTESTINAL CANCER AUDIT ACCORDING TO THE PLATFORM OF THE ESOPHAGEAL COMPLICATIONS CONSENSUS GROUP
Authors: Van Der Werf Leonie , Busweiler Linde , Van Sandick Johanna , Van Berge Henegouwen Mark I , Wijnhoven Bas P L
Published: September 2018

Background

To standardize outcome reporting in esophageal surgery, the Esophageal Complications Consensus Group (ECCG) developed a standardized platform. Recently, this group published outcomes of 2704 patients that underwent an esophagectomyin 24 high-volume hospitals in the period 2015–2016. The aim of this study was to report postoperative morbidity and mortality in the Netherlands using the definitions of the ECCG.

Methods

All patients who underwent esophagectomy for cancer of the esophagus or esophagogastric junction in the Netherlands in 2016 were selected from the Dutch Upper gastrointestinal Cancer Audit (DUCA). Patient outcomes including postoperative complications, 30-day/in-hospital mortality readmission rate were reported according to the definitions of the ECCG platform (Low et al. Ann Surg 2017). Outcomes of the DUCA were compared with the recently published outcomes of the ECCG with Chi-square analysis.

Results

Some 797 patients were included from 22 hospitals. In 1 patient, the postoperative outcome was unkown. In 17 patients readmission status was unknown. Some 168 (21%) patients had an ASA score of ≥ III and 250 (31%) patients a Charlson comorbidity score of ≥ 2. In total, 498 patients (63%) had at least one postoperative complication (versus ECCG: 57%, P = 0.07). The most common complications were pneumonia (21% DUCA versus 15% ECCG, P < 0.01), anastomotic/staple-line failure or localized conduit necrosis (18% DUCA versus 11% ECCG, P < 0.01) and atrial dysrhythmia requiring treatment (13% DUCA versus 15% ECCG, P = 0.28). Readmissions occurred in 105 of 780 patients (13% DUCA versus 11% ECCG, P = 0.13). The 30-day/in-hospital mortality was 2.5% for the DUCA group and 2.4% for the ECCG group (P = 0.88).

Conclusion

The registration of complications according to the ECCG platform in the national audit promotes the use of uniform definitions and allows international comparison of outcomes. The overall complication rate, readmission rate and mortality in the Netherlands were comparable with the outcomes of the ECGG. However, anastomotic leakage and pneumonia were more frequently reported in the Netherlands.

Disclosure

All authors have declared no conflicts of interest.
PS01.139: THE CLINIC DIAGNOSIS AND TREATMENT OF PRIMARY ESOPHAGEAL ADENOCARCINOMA: ANALYSIS OF 63 CASES
Authors: Wei Jin-Chang , Jiao Gen , Song Xiang , Wang Qing , Song He , Song Wei , Wang Peng , Li Lin , Li Yu , Xu Feng
Published: September 2018

Background

To summarize the clinic and pathological characteristics of the primary esophageal adenocarcinoma and to discuss the reasonable diagnosis and treatment, further improve the curative effect.

Methods

The clinical data and therapeutic effect of 63 cases of esophageal adenocarcinoma treated from February 1995 to December 2011 in our department were analyzed retrospectively.

Results

There were 63 cases of primary esophageal adenocarcinoma, accounting for 0.66% (63/9608) of esophageal malignant tumors. There were 47 males and 16 females, with a ratio of 4. 4: 1, which was higher than that of esophageal squamous cell carcinoma (1.8: 1) in same period. There are no special characteristics in clinic syndrome and imaging. There were 12 cases of adenocarcinoma located in the middle thoracic segment of esophagus (19 cases) and 51 cases of lower thoracic segment of esophagus (81 cases), which were significantly different from predilection site of esophageal squamous cell carcinoma. TNM staging included 3 patients with stage I and 16 patients with stage II b. There were 23 patients with stage III and 4 patients with stage Ia. There were 32 cases of medullary type, 9 cases of mushroom type, 19 cases of ulcer type and 3 cases of constriction type. The pathological types were simple adenocarcinoma in 22 cases (34.9%), adenosquamous carcinoma in 27 cases (42.9%), adeno-Spina carcinoma in 14 cases (22.2%). All patients underwent partial esophagogastrostomy and esophagogastrostomy. 51 cases above aortic arch, 12cases below aortic arch. The resection rate was 100%, radical resection was 93.7% in 59 cases, palliative resection in 4 cases (6.3%), and positive stump in 2 cases (3.2%). The lymph node metastasis rate was 65.1% (41/63), higher than that of 31.6% esophageal squamous cell carcinoma in same period. There was no operative death in this group. The 1-year, 3-year, 5-year survival rates were 81.4%, 46.2% and 27.8% respectively, which was lower than synchronizational ESCC (89.7%, 68.2%, 38.6%).

Conclusion

Primary esophageal adenocarcinoma is a rare esophageal malignant tumor with high malignancy, strong invasion and high lymph node metastasis. It is important to pay attention to early diagnosis and treatment, mainly by surgical operation and adjuvant chemotherapy after operation to improve its long-term effect.

Disclosure

All authors have declared no conflicts of interest.
PS01.144: LYMPH NODE YIELDS AFTER ESOPHAGECTOMY: IMPACT OF APPROACH TO SURGERY AND USE OF NEOADJUVANT THERAPIES
Authors: Marwah Anindita , Perez Castro Pablo , Carroll Paul , De Perrot Marc , Keshavjee Shaf , Waddell Thomas , Pierre Andrew , Ringash Jolie , Elimova Elena , Darling Gail , Yeung Jonathan
Published: September 2018

Background

Although the importance of lymph node (LN) harvest for the adequate staging of esophageal cancer has been well studied, lymph node yields in the literature remain highly variable. Moreover, the effect of modern treatments of esophageal cancer such as induction therapy and minimally invasive approaches on lymph node yield is incompletely understood.

Methods

A retrospective review of 307 patients who underwent esophagectomy for esophageal cancer between 2005–2013 at Toronto General Hospital was conducted. Early in this experience, thoracoabdominal, transhiatal, Ivor Lewis and Mckeown approaches were utilized with transition over time to fully minimally invasive Ivor Lewis and Mckeown operations. Induction chemoradiotherapy is now our standard for locally advanced esophageal cancer. Demographics, histology, type and approach to esophagectomy, use of induction therapy, lymph node yield, and number of positive lymph nodes were collected. Kruskal-Wallis test was utilized for significance between groups.

Results

Our population comprised of 239 (78%) males and 68 (22%) females. Adenocarcinoma was the predominant histology at 220 (72%) with 78 (25%) squamous cell carcinoma and 9 (3%) as other histology. 144 (47%) patients had surgery alone, 147 (48%) had induction chemoradiotherapy, and 16 (5%) had induction chemotherapy. The open approach was used in 178 (58%), hybrid minimally-invasive in 33 (11%), fully minimally-invasive in 58 (19%), and transhiatal in 38 (12%). Overall, a median of 24 [IQR17–33; min 3, max 92] nodes were obtained. Induction therapy did not lower our yield (no induction 23[16–32], induction chemotherapy 32.5[17–47], induction chemoradiotherapy 25[19–33], P = 0.07). Transition to a minimally invasive approach similarly did not lower our yield, with only the transhiatal approach showing lower lymph node yield (open 26[17–33], hybrid 33[23–39], fully minimally-invasive 25[19–36], transhiatal 16[11–22], P = 0.005).

Conclusion

Lymph node yields above 20 can be routinely achieved for adequate staging. Despite the increasing use of induction therapy and minimally-invasive approaches, similar lymph node yields can and should be achieved.

Disclosure

All authors have declared no conflicts of interest.
PS01.147: BODY MASS INDEX AND PERIOPERATIVE OUTCOMES AFTER ESOPHAGECTOMY: THORACOABDOMINAL APPROACH HAS EQUIVALENT RESULTS AS MINIMALLY INVASIVE ESOPHAGECTOMY
Authors: Kroese Tiuri , Sachdeva Uma , Morse Christopher
Published: September 2018

Background

A thoracoabdominal approach to esophagectomy provides excellent exposure to the lower esophagus and gastroesophageal junction, particularly in obese patients and in patients with prior chest or abdominal surgery. However, thoracoabdominal esophagectomy (TE) has been associated with higher rates of perioperative complications and limits to the extent of resection, which may have oncologic consequences. Selectively approaching most obese or re-operative patients with esophageal cancer following neoadjuvant therapy through an open thoracoabdominal incision, the aim of this study was to compare perioperative complications and short-term oncologic outcomes of TE with minimally invasive Ivor-Lewis esophagectomy (MIE).

Methods

All esophageal cancer patients who underwent neoadjuvant treatment followed by MIE or TE with curative intent at a tertiary referral center between 2008 and 2017 were identified using a prospectively maintained database. Primary outcomes were oncological adequacy, including extent of lymph node resection and R0 resection rates, and perioperative complications including pneumonia, anastomotic leakage and chylothorax. Secondary outcomes included length of stay and readmission rates.

Results

A total of 171 patients were included, of whom 139 patients underwent MIE and 32 patients TE. Patients who underwent TE had a significantly higher body mass index (BMI) (mean 30.6 vs 26.5, P = 0.001) and were more likely to have relevant surgical history (56% vs 1%, P = 0.001). R0 resection rates were the same regardless of operative approach. Pathologic N-stage was the same between groups, though total lymph node yield was higher with MIE (mean 15 vs 20, P = 0.006). The rate of postoperative complications was not increased with TE. Median length of stay was one day longer in the TE group (P = 0.007).

Conclusion

In patients with esophageal cancer, resection is often more challenging in the setting of obesity or prior surgery, particularly in patients treated with neoadjuvant therapy. By selectively employing a thoracoabdominal approach in these difficult cases equivalent oncologic outcomes can be achieved, with no significant increase in postoperative complications, as compared with MIE. This study demonstrates that patient-specific selection in surgical approach can lead to comparable postoperative results. Further studies are warranted to evaluate effects on long-term outcomes.

Disclosure

All authors have declared no conflicts of interest.