bluuebunny/crossref_metadata_2025 huggingface dataset:
P155 REAL-TIME EVALUATION OF THE GASTRIC CONDUIT BASED ON THE REGIONAL O2 SATURATION (%) AND TOTAL HEMOGLOBIN INDEX IN THORACIC ESOPHAGECTOMY
Authors: Takeo Fujita , Kazuma Sato , Yuki Hirano , Hisashi Fujiwara , Hiroyuki Daiko
Published: November 2019

Aim

Evaluation of blood supply of gastric conduit is one of the most importance parameter in thoracic esophagectomy. Evaluation with indocyanine green is the most popular evaluation method. However, indocyanine green does not objecctive values with

Herein we introduce the new evaluation method based on the regional SO2(%) and Total hemoglobin index in thoracic esophagectomy.

Background and methods: Between February to July 2018, we evaluated 56 patients underwent thoracic esophagectomy for esophageal cancer. Regional O2 saturation level (rSO%) and total hemoglobin indexes (T-HbI) of gastric conduit was evaluated using the ToccareTM (ASTEM Co. Ltd Tokyo, Japan) to determine the optimal site of anastomosis on gastric conduit.

Results

Fifty-two patients were eligible in this study. Mean value of the rSO2(%)/T-HbI were 57.6%/0.22 at the anal side of the gastric conduit where sufficient feeding arteries were existed from right gastroepiploic artery and vein. On the other hand, mean values of the rSO2(%)/T-HbI were 59.4%/0.28 (p<0.05) at the distal side of the gastric conduit where direct feeding artery from right gastroepiploic vessel was terminated. Then, mean values of rSO2(%)/T-HbI were 46.3%/0.34 (p<0.05) at the tip of the gastric conduit, which consisted to the gradual congestion was happened prior to the tissue oxygenation in the gastric conduit.

There were 1 patient which found anastomotic leakage (1.9%) among 56 patients.

Conclusion

Evaluation of the regional SO2(%) and total hemoglobin index of the gastric conduit was non-invasiveness procedure and useful to easily determine the optimal site of anastomotic level to minimize the incidence of anastomotic leakage in thoracic esophagectomy.
P156 ASSESSMENT OF HEALTH RELATED QUALITY OF LIFE AND DIGESTIVE SYMPTOMS IN LONG-TERM, DISEASE FREE SURVIVORS AFTER ESOPHAGECTOMY
Authors: Boshier P R , Klevebro F , Savva K V , Waller A , Hage L , Hanna G B , Low D E
Published: November 2019

Background

Esophagectomy has been associated with decreased health related quality of life (HRQOL) and persistent gastrointestinal symptoms. The aim of this study was to investigate HRQOL and symptom evolution in disease free patients up to 20 years following esophagectomy.

Methods

The study cohort was identified from prospective, IRB approved esophagectomy databases from two high volume centers for the management of esophageal cancer. Patients that were alive and without evidence of disease recurrence in April 2018 completed HRQOL and symptom questionnaires, including: Digestive Symptom Questionnaire, SF36, EORTC QLQ-C30, and EORTC QLQ-OG25. Patients were assessed in three cohorts: <2 year; 2 to 5 years, and; >5 years following surgery.

Results

In total 171 patients who underwent esophagectomy between 1995-2017, responded to the questionnaires, corresponding to a response rate of 81.3%. Median age was 66.2 years, and median time from operation to survey was 5.6 years (range 0.3-23.1). Early satiety was the most commonly reported symptom in all patients irrespective of timeframe (87.4%; range 82-92%). Dysphagia was seen to decrease over time (58% at <2yrs; 28% at 2-5yrs; 20% at >5 yrs. P=0.013). Weight loss scores demonstrated non-statistical improvement over time. All other symptom scores including heartburn, regurgitation, respiratory symptoms and pain scores remained constant over time. The average level of HRQOL did not improve from levels one year after surgery compared to patients up to 23 years following esophagectomy.

Conclusion

With the exception of dysphagia, which improved over time, esophagectomy was associated with decreased HRQOL and lasting gastrointestinal symptoms >20 years after surgery. In additional to oncological outcomes, the impact of esophagectomy on long-term HRQOL and associated functional disorders should be considered by all members of the multidisciplinary team when counseling and caring for patients undergoing esophagectomy
P169 COMPARISON OF LAPAROSCOPIC TOUPET FUNDOPLICATION AND MAGNETIC SPHINCTER AUGMENTATION IN PATIENTS WITH 3-5 CM HIATUS HERNIA
Authors: Lazzari V , Milito P , Scaramuzzo R , Asti E , Bonavina L
Published: November 2019

Aim

To compare quality of life in patients with large hiatus hernia undergoing laparoscopic Toupet fundoplication and magnetic sphincter augmentation.

Background and Methods

Laparoscopic Toupet fundoplication (LTF) and laparoscopic magnetic sphincter augmentation (MSA) have been compared in a previous retrospective study (Asti E et al, Medicine, 2016) in patients with small hiatal hernia (<3 cm). There is no universal consensus in the use of MSA in patients with large hiatus hernia.

This is an observational, retrospective, comparative cohort study. Patients with <3 cm or >5 cm hiatus hernia measured by endoscopy and barium swallow study and those with previous esophago-gastric surgery were excluded. The primary outcome was quality of life based on the Gastro-Esophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) questionnaire. Secondary outcomes were proton pump inhibitors (PPI) use, incidence of dysphagia and gas-related symptoms, and hiatus hernia recurrence rate.

Results

Between March 2007 and June 2018, 150 patients with GERD met the inclusion criteria; 88 underwent a LTF and 62 a MSA procedure. Both groups had similar preoperative features. The mean follow-up was 64 months and all patients were followed for at least one year after surgery. There was no statistically significant difference between LTF and MSA in GERD-HRQL scores (p=0.178), PPI use (p=0.327), gas-related symptoms (p=0.162), dysphagia (p=0.254), and reoperation rate (p=0.167).

Conclusion

Both LTF and MSA have similar safety profile and disease-specific quality of life in patients with large hiatal hernia.
P174 ESOPHAGEAL CANCER SURGERY: EXPERIENCES WITH ANASTOMOTIC LEAK TREATMENTS AT A HIGH-VOLUME CENTER
Authors: Emil Ainsworth Jochumsen , Michael Hareskov Larsen , Alan Patrick Ainsworth
Published: November 2019

Aim

To study treatments and interventions for anastomotic leak following esophagectomy at a high volume center.

Background and Methods

Anastomotic leak is a severe and common complication of esophagectomies. Anastomotic leak patients treated between Jan 1 2016 and Dec 31 2018 were retrospectively identified from an institutional database of patients undergoing esophagectomies and were further analyzed. The primary out- comes for the assessed interventions were success- rate of intervention and length-of-stay. The following anastomotic leak treatments were assessed by this study: Conservative treatment, esophageal stents, endoscopic vacuum assisted closure therapy (E-VAC) and surgically placed drains.

Results

The study population consisted of 223 patients, 28 (12.6%) of who suffered anastomotic leaks. The distribution of the interventions and conservative treatment is illustrated in Figure 1. The success-rate of E-VAC was 75.0% (n=8), compared to a rate of 25.0% for stents (n=4) and 59.1% for conservative treatment (n=13). Surgically placed drains had a success-rate of 100.0%, but were only performed on 3 patients in total.

Conclusion

E-VAC was the most effective non- surgical leak intervention in terms of success-rate. Due to the design of this study, the effectiveness of conservative treatment was likely under- estimated.
P175 TRANSLATION OF MINIMALLY INVASIVE ESOPHAGECTOMY FROM RANDOMIZED CONTROLLED TRIAL SETTING (TIME) TO NATIONAL PRACTICE (DUCA) IN NETHERLANDS
Authors: Sheraz R Markar , Melody Ni , Suzanne Gisbertz , Jennifer Straatman , Donald van der Peet , Miguel A Cuesta , George B Hanna , Mark I van Berge Henegouwen
Published: November 2019

Aims

The TIME trial showed reduced pulmonary complications from minimally invasive esophagectomy (MIE) over an open approach, and led to widespread adoption of MIE in the Netherlands. The aim of this study was to compare clinical outcomes from minimally invasive esophagectomy in the DUCA (national dataset) and the TIME trial (RCT) for transthoracic esophagectomy1.

Methods

Original patient data from the TIME trial1 was extracted along-with data from the Dutch National Cancer Audit (DUCA) (2011-2017). Initially univariate analysis was used to compare patient and tumor demographics and clinical and pathological outcomes from patients receiving MIE in the TIME trial and in the DUCA-dataset. Secondly multivariate analysis, with adjustment patient and tumor factors, was performed for the effect of MIE vs. Open esophagectomy on clinical outcomes in both datasets. Thirdly the datasets were combined and multivariate analysis, was performed for the effect of patient inclusion in TIME trial or DUCA-dataset.

Results

115 patients from TIME (59 MIE vs. 56 open) and 4605 patients from the DUCA-dataset (2652 MIE vs. 1953 open) were included. Univariate analysis showed, in TIME trial, MIE reduced postoperative complications and length of hospital stay. However in the DUCA-dataset, MIE increased postoperative complications, re-intervention rate and length of hospital stay, however pathological benefits included increased proportion of R0 margin and lymph nodes harvested.

Multivariate analysis confirmed the TIME data showed MIE reduced postoperative complications (OR=0.38, 95%CI 0.16–0.90). In the DUCA-dataset, MIE was associated with increased postoperative complications (OR=1.37, 95%CI 1.20–1.55), re-intervention (OR=1.84, 95%CI 1.57–2.14), and length of hospital stay (Coeff=1.57, 95%CI 0.06–3.08). Pathological benefits to MIE in the DUCA-dataset included a reduction in proportion of R1 margin, and increased lymph node harvest.

Multivariate analysis of the combined dataset, showed inclusion in the TIME trial was associated with a reduction in postoperative complications (OR=0.23, 95%CI 0.15–0.36) and reoperation rate (OR=0.34, 95%CI 0.17–0.66).

Conclusions

MIE when adopted nationally outside the TIME-trial, was associated with an increase in postoperative complications and reoperation rate, which may reflect surgeons on a national level going through their proficiency-gain curve in the technique and outside of expert MIE centers.
P177 REINFORCED CRURAL REPAIR FOR LARGE HIATUS HERNIA: PRELIMINARY RESULTS WITH PHASIX ST® MESH
Authors: Panici Tonucci T , Sironi A , Lazzari V , Riva C G , Milito P , Asti E , Bonavina L
Published: November 2019

Aim

The aim of the study was to assess safety, quality of life and recurrence rate after laparoscopic repair of hiatal hernia reinforced with a biosynthetic absorbable mesh (PHASIX ST®).

Background & Methods

Safety and effectiveness of absorbable meshes for laparoscopic hiatus hernia repair are still debated, with several studies reporting conflicting outcomes. This may be due to patient selection, technique of repair, type of mesh, definition of recurrent hernia and length of follow up. An observational, single-center study was conducted in patients undergoing laparoscopic crural repair reinforced with PHASIX ST®, a monofilament resorbable mesh (poly-4-hydroxybuterate) with a hydrogel barrier on one side. Data were extracted from hospital charts and a prospectively updated research database. The quality of life was assessed by the GastroEsophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire. Clinical evaluation, upper gastrointestinal endoscopy and/or barium swallow study were performed at 6 – 24 months of follow up. Recurrent hernia was defined as the maximum vertical height of stomach > 2 cm above diaphragm at endoscopy and/or barium swallow study.

Results

103 consecutive patients were implanted with PHASIX ST® mesh from January 2017 to May 2019. The overall postoperative morbidity rate was 2.9%. The average follow up was 13 months with 31 (30%) patients reaching 2-year. The mean postoperative GERD-HRQL score significantly improved compared to baseline (4.6 ± 3.9 vs 16.6 ± 4.1, p<0,001). Recurrent hernia was found in 3 of 79 (3.8%) patients followed for at least 6 months after surgery. None of the patients required reoperation for adverse events or symptomatic hernia recurrence.

Conclusion

The use of PHASIX ST® mesh to reinforce crural repair for large hiatus hernias is safe and seems to be effective in the short-term follow up.
P179 THORACOSCOPIC EXTENDED 2-FIELD LYMPH NODE DISSECTION FOR ESOPHAGEAL CANCER. IMPLEMENTATION AND SURGICAL TECHNIQUE
Authors: Kyros Eleandros , Zografos Konstantinos , Vagios Ilias , Hasemaki Natasha , Karydakis Lysandros , Skotsimara Antonia , Vergadis Chrysovalantis , Karavokyros Ioannis , Liakakos Theodore , Charalabopoulos Alexandros
Published: November 2019

Aim

Lymphadenectomy in minimally-invasive esophageal cancer surgery still remains challenging and standardization of surgical procedures is of extreme importance. The aim of this study is to present our safe and reproducible technique in thoracoscopic superior lymphadenectomy during esophagectomy for cancer.

Background & Methods

In esophageal cancer surgery, dissection of the superior mediastinal lymph-nodes is of high importance. For adequate mediastinal lymph-node dissection, an extensive operating field is required along with appropriate equipment and experience. Thoracoscopy in prone position provides excellent visualization of the operative field comparing to thoracotomic phase. A step-by-step explanation of our surgical technique during thoracoscopic superior lymphadenectomy is provided.

Results

All patients were placed in prone position. The entire posterior mediastinal pleura was incised; azygos arch was divided with clips, facilitating dissection of the left side of the posterior mediastinum. The descending thoracic aorta was freed anteriorly, separating the esophagus; the thoracic duct was dissected and divided with vascular clips. Esophageal hiatus was dissected circumferentially and the esophageal wall was freed from the pericardiumanteriorly. Subcarinal lymph-nodes were dissected en bloc. Upper thoracic esophagus was separated from the membranous part of the trachea. The right recurrent laryngeal nerve lymph nodes were dissected at the level of the right subclavian artery, with extreme caution to avoid nerveinjury. Left recurrent laryngeal nerve was identified by posterior traction of the esophagus using a full thickness transluminal suture;by pulling it through a separate skin incision, the relative lymph nodes were dissected.

Conclusion

It is interesting that, higher number of lymph-nodes are harvested with this procedure which may be the result of better visualization/access. Overall, our technique has been standardized, is safe and reproducible and could be adopted by specialized Upper GI Units.
O18 TREATMENT OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY (TENTACLE STUDY)
Authors: van Workum Frans , Verstegen Moniek , Klarenbeek Bastiaan , Siersema Peter , Schouten Jeroen , Hannink Gerjon , van Berge Henegouwen Mark , Daams Freek , Polat Fatih , Willem Haveman Jan , Heisterkamp Joos , Nieuwenhuijzen Grard , Wijnhoven Bas , van Det Marc , Singh Pritam , Kouwenhoven Ewout , Griffiths Ewen , Bouwense Stefan , Rosman Camiel
Published: November 2019

Aim

The aim of this study is to investigate which factors contribute to anastomotic leakage severity and to compose an evidence based anastomotic leakage severity score. Secondly, we aim to investigate which anastomotic leakage characteristics are associated with success of different anastomotic leakage treatments and to compare the effectiveness of different initial anastomotic leakage treatments for anastomotic leakage classified according to severity and leakage characteristics.

Background

Anastomotic leakage occurs in 0%-30% after esophagectomy for cancer. It is a severe complication with mortality rates approximately ranging from 2%-12%. In addition, it is associated with a prolonged ICU treatment and hospital stay. Anastomotic leakage severity is currently graded according to how it is treated (grade I: conservative treatment, grade II: endoscopic/radiologic intervention and grade III: surgical intervention). However, this scoring system cannot be used to guide decision making when anastomotic leakage is diagnosed in a clinical setting. Factors that may influence the severity of the anastomotic leakage are (amongst others) location of the anastomosis, estimated surface of the defect, estimated circumference of the defect, extent of contamination, degree of sepsis and time from diagnosis until therapy. However, little is known about to what extent these and other factors contribute to anastomotic leakage severity. In addition, there is a paucity of data on what leakage characteristics dictate the success of a specific treatment.

Methods

We will perform an international multicenter retrospective cohort study. All adult patients with anastomotic leakage according to the ECCG definition after esophagectomy and gastric conduit reconstruction for esophageal cancer are suitable for inclusion. We aim to include at least 1000 patients. The primary outcome parameter is 90-day mortality. Secondary outcome parameters are in-hospital mortality, 30-day mortality, 180-day mortality, comprehensive complications index, total number of reinterventions, hospital and ICU length of stay and hospital related costs.

Results

Data collection will take place from April 2019 until December 2019. Study results are expected in June 2020.

Conclusion

We hypothesize that we will be able to identify factors that influence the severity of the anastomotic leakage and to compose a leakage severity score. Furthermore, we expect to identify leakage characteristics dictating the success of a specific treatment.
P189 PREDICTORS OF BARRETT’S OESOPHAGUS PROGRESSION : WHERE ARE WE?
Authors: Sara Jamel* , Amy Thie , Karina Tukaniva , Sheraz R Markar , George B Hanna
Published: November 2019

Introduction

Barrett’s esophagus (BE) is a well-established precursor lesion for oesophageal adenocarcinoma, which carries an overall poor prognosis (1-2). Patients diagnosed with Barrett’s oesophagus therefore undergo regular endoscopic surveillance to detect neoplastic lesions at an early stage to allow curative treatments (3). The low incidence of esophageal adenocarcinoma (EAC) in Barrett’s oesophagus patients highlights the need for risk stratification tools of patients on surveillance. In this review, we present current potential biomarkers and their associated diagnostic accuracy for the prediction of progression in BE.

Materials and methods

We searched MEDLINE, EMBASE, Web of Science, CENTRAL and Pubmed publisher. All studies on factors of Be progression were included. Two authors independently assessed the trials and extracted data. Quality assessment of studies was performed using QUADAS scoring. Pooled analysis was performed through Medusa software.

Results

The inclusion criteria were met by 25 studies. All the studies evaluated diagnostic accuracy of the biomarker to detect progression of Barrett’s to high grade dysplasia (HGD) and EAC. The biomarkers were p53 mutation in 6 studies, Methylation in 4 studies, Clinical factors in 7 studies and genetic factors in 5 studies and other biomarkers in 7 studies.

The pooled sensitivity and specificity for BO were 83.4 % [95 % confidence interval (CI): 68-95 %] and 75.6 % (95 % CI: 68-88 %), respectively. In particular, the use of p53 and methylation in BO patients appeared to be associated with a good diagnostic accuracy to predict neoplastic progression in BE.

Therefore, further biomarker research may provide promising results in risk stratification and prediction of progression to HGD and oesophageal adenocarcinoma in context of BE.

Conclusions

The evidence from this systematic review is suggestive of a crucial role of biomarkers in prediction of BE progression. Further work in translating biomarkers for routine clinical use may eventually lead to accurate risk stratification.
P195 THE STRUCTURE OF A CONSULTATION HOUR FOR BENIGN DISEASES OF THE UPPER GASTROINTESTINAL TRACT AT A CENTRE OF EXCELLENCE FOR ESOPHAGEAL AND GASTRIC SURGERY
Authors: Knepper L , Müller D T , Fuchs H , Fuchs C , Brinkmann S , Schröder W , Bruns C J , Leers J M
Published: November 2019

Aim

The aim of the study is to analyze the structure and the patient population of a consultation hour for benign diseases of the upper gastrointestinal tract at a centre of excellence for esophageal and gastric surgery.

Background and Methods

The increasing specialization in visceral surgery leads to a higher number of special consultation hours, e.g. for benign diseases of the esophagus and stomach. In this study we examine both the reasons for an introduction at a specialized clinic and the therapy suggestions. The clinical and demographic data of all patients who visited an appointment for functional diseases of the upper gastrointestinal tract of the University Hospital Cologne during the entire year 2018 were collected prospectively for this study and evaluated at the end of the year.

Results

In 2018, a total of 412 patients attended the benign OGI consultation hour (54% male). 107 patients (26%) attended more than once. 293 patients attended the consultation hour for the first time. The following diagnoses most frequently led to the presentation in the special consultation hour: GERD (n=262, 63%), achalasia (n=52, 13%), upside-down-stomach (n=24, 6%), dysphagia of unknown genesis (n=15, 4%), and other motility disorders of the esophagus (n=14, 3%). 190 patients received an EGD because they had not received an endoscopic examination in the last year. Functional diagnostics were performed in almost all new presentations: High- resolution-manometry (n=243), 24h-pH-metry (n=199). Even though the surgical department led the consultation hour, a conservative approach was recommended to 231 patients (56%). Surgery was recommended to 156 patients (38%) and an endoscopic approach was recommended in 25 cases (6%). Overall, 101 patients (43%) received an operation during the observation period. Most common indication for surgery was GERD (n=63, 62%). Of those 63 patients, 42 received a laparoscopic Nissen fundoplication.

Conclusion

The demand for a specialized clinic for reflux treatment is significant and includes a high degree of diagnostics. A differentiation of the symptoms is decisive in order to select the right patients for surgical therapy. Only about every third patient is recommended for surgery.
P197 LONG-TERM HEALTH-RELATED QUALITY OF LIFE AFTER BENIGN ESOPHAGEAL PERFORATION
Authors: Laura Knepper , Sebastian Brinkmann , Hans F Fuchs , Arnulf H Hoelscher , Kathrin Kuhr , Seung Chon , Wolfgang Schroeder , Christiane J Bruns , Jessica M Leers
Published: November 2019

Aim

This study aims to evaluate long-term outcome and health related quality of life in patients with benign esophageal perforations.

Background and Methods

Esophageal perforation is associated with high morbidity and mortality. In addition to surgical treatment, endoscopic endoluminal stent placement and endoscopic vacuum therapy (EVT) are established methods in the management of this emergency condition. As health-related quality of life (HRQoL) is becoming a major issue in the evaluation of any therapeutic intervention not much is known about HRQoL, particular in the long-term follow-up of patients treated for benign esophageal perforation with different treatment strategies. Patients treated for benign esophageal perforation at the University Hospital Cologne from January 2003 to December 2014 were therefore investigated. Primary outcome and management of esophageal perforation were documented and long-term quality of life was assessed using the Gastrointestinal Quality of Life Index (GIQLI), the Health-Related Quality of Life Index (HRQL) for patients with gastroesophageal reflux disease (GERD) and the European Organization for Research and Treatment of Cancer (EORTC) questionnaires for general and esophageal cancer specific QoL (QLQ-C30 and QLQ-OES18).

Results

Patients were divided based on primary treatment into an endoscopic (46.5%), surgical (34.5%) and conservative treatment group (19%). Short- and long-term outcome, as well as quality of life were compared. HRQoL was measured after a median follow-up of 49 months. HRQoL was generally reduced in patients with benign esophageal perforation. Endoscopically treated patients showed the highest GIQLI overall score and highest EORTC general health status, followed by the conservative and the surgical group.

Conclusion

HRQoL in patients with benign esophageal perforation is reduced even in the long-term follow-up. Temporary stent or EVT is effective and provides a good alternative to surgery not only in the short-term but also in the long-term follow-up.
P20 MINIMALLY INVASIVE TRATMENT OF CHYLE LEAK AFTER ESOPHAGECTOMY USING INDOCYANINE GREEN (ICG) ENHANCED FLUORESCENCE.
Authors: Alberti L , De Pasqual C A , Weindelmayer J , La Mendola R , Gervasi M C , Ridolfi C , Giacopuzzi S , de Manzoni G
Published: November 2019

Background

Chyle leak is a rare but life-threatening complication after esophagectomy. In Literature is reported a mortality rate up to 40% in case chyle leak after esophageal surgery. In case of re-operation, ligature of the chyle duct is mandatory. However, chyle duct identification can be difficult. To our knowledge, in Literature are reported only two cases of chyle duct identification through ICG visualization.

We present the case of a 66 years old male patient who underwent to a totally mini-invasive McKeown esophagectomy for a locally advanced esophageal adenocarcinoma, after neoadjuvant chemo-radiotherapy. In 2nd post-operative day (POD) we observed a chylous debt from the thoracic drain, sign of chyle leak. A first conservative approach was tempted, with a nihil-per-os regimen and total parenteral nutrition, with a significant reduction in drain output. However, at the resumption of oral intake, we observed a new increase of drain output. We therefore decided to re-operate the patient to seal the leak. On POD 15 the patient was submitted to a new thoracoscopy, with previous inguinal green indocyanine infiltration. During the thoracoscopy, the ICG allowed to safely identify the chyle duct and to proceed to its selective ligation. During the following days the patient’s clinical state progressively improved, allowing to restore oral feeding in POD3. No chyle debt was attested from the drainage, removed in POD 5. The patients was dismissed the next day.

In our opinion, this is a promising application for the ICG technique.
P201 LAPAROSCOPIC TRANSHIATAL OMENTAL REPAIR OF IATROGENIC ESOPHAGEAL PERFORATION IN ACHALASIA
Authors: Martina Nebbia , Pietro Riva , Anna Da Roit , Silvia Basato , Andrea Pansa , Damiano Gentile , Salvatore Marano , Carlo Castoro
Published: November 2019

Aim

Laparoscopic transhiatal omental patch repair(OPR) of esophageal perforation after pneumatic balloon dilatation(PBD) for achalasia.

Background&Methods

In August 2018 a 72yrs woman with a history of dysphagia for solids and liquids, nocturnal regurgitation and chest pain had a diagnosis of achalasia.

After inhalation during a barium swallow the patient developed fever, respiratory insufficiency and worsening of vital signs leading to ICU and intubation. She developed a right-pleural empyema, massive pneumothorax and right-upper lobe abscess, requiring thoracotomy and right-superior lobectomy.

She had been scheduled for a Per Oral Endoscopic Myotomy in November. After the submucosal tunnel, the procedure had been suspended due to presence of fibrosis.

In December the patient underwent a first PBD up to 30mm with symptoms resolution and 2kg weight regain.

In February, few hours after a second PBD up to 35mm, she complained mild pain at the left hemithorax and fever. 24hrs later a CTscan with water-soluble-contrast revealed a 3cm long esophageal perforation 5cm above the diaphragm and left paraesophageal mediastinal abscess without pleural involvement. Endoscopic treatment was excluded for significant dilatation of the esophagus and the fragile esophageal wall.

Because of the frailty status of the patient, the delayed diagnosis, the high risk of a direct suture of the esophageal wall through a left thoracotomy, the even higher risk of an emergency esophagectomy, we performed a laparoscopic approach. Limited dissection of the esophagogastric-junction and of the left diaphragmatic crura allowed access to the abscess cavity, no attempt to direct suture was done, a drain was placed, a pedicled omental flap was realized filling the cavity and repairing the esophageal defect. A jejunostomy was placed.

Results

The post-op period was uneventful; a CTscan with per-os contrast on POD3 and POD9 didn’t show any collection. The patient started an oral semisolid-diet on POD11. An EGDS on POD19 confirmed the presence of the OPR in the esophageal lumen and after 2-months showed a completely re-epithelialized esophagus.

Conclusions

Laparoscopic trans hiatal OPR of esophageal perforation in achalasia proved to be a minimally invasive and effective procedure in this patient due to its immunogenic and angiogenetic properties.
P202 ESOPHAGEAL VARICEAL BANDING LIGATION: SIX-YEAR EXPERIENCE OF A TERTIARY CENTER
Authors: Gkolfakis P , Miltiadou K , Gatos-Gatopoulos P , Grammatikos K , Koukoulioti E , Lazarides D Tziatzios G , Triantafyllou K , Papanikolaou I S
Published: November 2019

Aim

Esophageal variceal bleeding is a potentially lethal complication of portal hypertension. Endoscopic variceal band ligation (EVL) is the cornerstone of treatment for acute variceal bleeding, as well as its primary and secondary prophylaxis. Herein, we present our experience on EVL.

Materials and methods

Retrospective analysis of all cases subjected to EVL in our department from 01.01.2013 to 30.09.2018. Demographics, epidemiological data, outcomes -including number of sessions required to treat- and complications were recorded.

Results

One hundred and seventeen patients (males: 94=80.3%, mean age: 62.2±12.3 years), subjected to 224 sessions of EVL were recorded. The majority were cirrhotic (97.8%), mainly due to viral hepatitis (45.1%) and alcohol abuse (32.5%). Twenty patients (17.1%) had been previously subjected to EVL; fourty-five (39.1%) underwent EVL due to acute variceal bleeding, whereas 43 (36.7%) and 29 (25.2%) for primary and secondary prophylaxis, respectively. Variceal eradication was documented endoscopically in 49.7% of the patients treated with EVL.

Performing 2 sessions of EVL showed the best discriminative ability associated with variceal eradication [ΑUC(95%CI)=0.72(0.63-0.82), sensitivity 78%, specificity 72%]. Presence of cirrhosis, indication and endoscopic findings were not associated with success of variceal eradication (p=0.15, p=0.52 and p>0.68), whereas the etiology of cirrhosis was associated with successful eradication, as patients suffering of cirrhosis attributed to viral hepatitis had lower success rates (61% vs. 28.2%, p=0.01). In 14 (25%) patients, varices relapsed after successful eradication.

Twelve patients required rescue treatment (9 required TIPS and 3 Sensgstaken-Blakemore tube placement) to control bleeding. Complications related to EVL were documented in 13 (11.1%) patients, 69.2% of which was bleeding from post-EVL ulcers, for which however no further treatment was required.

Conclusion

In our series, 2 sessions of EVL are associated with the best therapeutic results with regards to variceal eradication, whilst patients with cirrhosis of viral etiology have lower eradication success rates.
P204 DETECTING PATHOLOGICAL COMPLETE RESPONSE IN ESOPHAGEAL CANCER AFTER NEOADJUVANT THERAPY BASED ON IMAGING TECHNIQUES: A DIAGNOSTIC SYSTEMATIC REVIEW AND META-ANALYSIS
Authors: de Gouw D J J M , Klarenbeek B R , Dressen M , Bouwense S A W , van Workum F , Fütterer J J , Rovers M M , ten Broek R P G , Rosman C
Published: November 2019

Background

Up to 32% of patients with esophageal cancer show a pathological complete response (ypCR) after neoadjuvant therapy. To prevent overtreatment, the indication to perform esophagectomy in these patients should be reconsidered. Implementing an organ-preserving strategy for patients with ypCR requires an accurate assessment of residual disease after neoadjuvant treatment. The aim of this study was to systematically review the effectiveness of imaging techniques used for detection of ypCR after neoadjuvant therapy but before resection in patients with esophageal cancer.

Methods

A systematic literature search of the Medline, Embase, and Cochrane Library databases was performed from January 1, 2000, to December 13, 2017. Eligible studies were diagnostic studies that compared results of imaging modalities after neoadjuvant therapy to histopathological findings in the resection specimen after esophagectomy. Methodological quality was assessed by the Cochrane Quality Assessment of Diagnostic Accuracy Studies, version 2, model. Primary outcome measures were true positive, false positive, false negative, and true negative values of imaging techniques predicting ypCR. A meta-analysis was performed by pooling sensitivities and specificities by using a bivariate model.

Results

A total of 4420 articles were identified. After exclusion of irrelevant titles and abstracts, 360 articles were reviewed in full text. In total, four imaging modalities (computed tomography [CT], positron emission tomography [PET-CT], endoscopic ultrasound [EUS], and magnetic resonance imaging [MRI]) were used for restaging. The meta-analysis was conducted with data from 56 studies involving 3625 patients. The pooled sensitivities of CT, PET-CT, EUS, and MRI for detecting ypCR were 0.35, 0.62, 0.01 and 0.80, respectively, whereas the pooled specificities were 0.83, 0.73, 0.99, and 0.83, respectively. The positive predictive value in detecting ypCR was 0.47 for CT, 0.41 for PET-CT, not applicable for EUS, and 0.61 for MRI.

Conclusions

Current imaging modalities such as CT, PET-CT, and EUS seem to be insufficiently accurate to identify complete responders. More accurate diagnostic tests are needed to improve restaging accuracy for patients with esophageal cancer.
P205 THREE YEARS EXPERIENCE OF THE FIRST SPECIALIZED ESOPHAGEAL CENTER IN EGYPT
Authors: Ezz R
Published: November 2019

Introduction

Subspecialty policy is increasing all over the world aiming to improve the results of heavy esophageal surgeries.

Aim

To define the impact of having surgical specialized esophageal unit on the volume of patients and the results.

Methodology

We reviewed all esophageal cases managed in our esophageal specialized department (from May 2016 to May 2019 Group A) and we compared the results to previous 3 years (from May 2013 to May 2016 Group B) and to the international results.

Results

Esophageal surgeries performed during this period was 394 cases in group A compared to 104 cases in group B. One hundred eighty operations were performed for Gastro esophageal reflux disease (GERD) in group a (45.7%) compared to 61 cases in group B (68.7%). Forty two (10.7%) modified Heller’s cardiomyotomy (Open and laparoscopic) for achalasia were performed in group A compared to 17 cases (16.3%) in group B. Surgeries for malignant lesions were performed for 122 cases (30.9%) in group A compared to 13 cases (12.5%) in group B. Other Esophageal operations were also done for 50 cases (12.7%) in group A compared to 13 cases (12.5%) in group B.

Mortalities in group A was 5 cases in benign diseases (1.8%) and 13 cases for malignant cases (10.7%) compared to 7 cases in benign diseases (7.7%) and 5 cases for malignant conditions (23%) in group B.

Morbidities in group A was 46 cases in benign diseases (16.9%) and 31cases for malignant cases (25.4%) Compared to 23 cases in the benign diseases (25.2%) and 5 cases for malignant conditions (38.5%) in group B. Our results in group A are comparable to Hospital mortality rates for patients in medium-volume centers (7.5%)(1).Also we approach the International results for morbidities of benign esophageal disease (5.7 to- 12.7%) for fundoplication (2).

Conclusion

Having a specialized esophageal unit resulted in increase of the volume of patients and improvement of the results.
P207 COMPARISON OF OPIOID vs OPIOID PLUS LOCAL ANESTHETIC EPIDURAL ADMINISTRATION IN IVOR LEWIS ESOPHAGECTOMY
Authors: Papaioannou E , Doka P , Koziakas E , Analyti A , Danassi D , Fotopoulou G , Lampadariou A
Published: November 2019

Aim

of the study was the comparison of single morphine vs morphine plus ropivacaine epidural administration for intraoperative pain management in Ivor Lewis esophagectomy.

Background & Methods

In a randomized prospective clinical trial, after informed consent, 20 patients were assigned to groups A (n=10): Morphine, and B (n=10=): Morphine and ropivacaine combination, according to the medication they were administered epidurally (ed), when submitted to Ivor Lewis esophagectomy. In both groups’ patients a thoracic epidural (T5-7) was inserted preoperative, and anesthetic protocol was the same, apart from opioid analgesics, that were titrated according to patients’ requirements. In group A morphine 1.5-3mg in 10-12ml normal saline volume, while in group B morphine 1.5-3mg plus ropivacaine 0.25% in a total volume of 10-12 ml were ed administered at least 20min before surgical incision. Opioids requirement, heart rate, arterial blood pressure, increments of muscle relaxant (rocuronium bromide) repetitive doses intraoperatively, and rescue analgesics need and side effects such as nausea, vomiting, drowsiness, respiratory depression and patients’distress in case of leg movement inability were recorded postoperatively.

Results

Patients’ demographics were similar in both groups. Intraoperatively, group A received significantly higher (p<0.001) fentanyl doses (4-6mcg/kg initially and 2hrs repetitive increments of 1-2mcg) vs group B (2-2.5mcg/kg initially, 4 (40%) patients didn’t require any supplementary dose and the rest 2-3mcg/kg in 1-2 increment doses until the end of operation). Vital signs were stable in both groups. Rocuronium requirement was significantly lower (p<0.001) in group B (apart from initial dose 1mg/kg, which was the same in both groups, group B demanded repetitive dose only before single to two-lumen endotracheal tube replacement, while group A required 0.2-0.3mg increment doses hourly). All patients were transferred awake postoperatively in ICU. None of any group patients demonstrated any side effects, but 3 (30%) group A patients required rescue analgesic (pain score > 4).

Conclusion

Morphine plus ropivacaine combination administered epidurally seems to provide lower pain scores and reduces the need for extra opioids intra- and postoperatively, and reduces muscle relaxants requirement during operation. Further studies are required to support these findings.
P209 OESOPHAGEAL DISRUPTIONS- A MULTIDISCIPLINARY ALGORITHMIC APPROACH
Authors: RM Koshy , J Wong , V Menon
Published: November 2019

Aim

We would like to reflect on our experience to propose a multidisciplinary algorithmic approach to manage both iatrogenic and spontaneous Oesophageal disruptions.

Background & Methods

Oesophageal disruptions, present to us a challenging group of critically unwell and compromised patients who need a long-term care plan. It is crucial to have a multidisciplinary approach, with the surgeon bringing together the interventional radiologists, endoscopists and nutritionists, to obtain the best outcome.

This retrospective cohort included 23 patients with both iatrogenic and spontaneous oesophageal disruptions managed at our centre between 2013 and 2019.

Results

There were 23 patient events with 14 anastomotic leaks (12 Oesophagectomies & 1 total Gastrectomy) and 10 perforations (7 iatrogenic & 3 spontaneous). Once diagnosed by contrast studies (CECT/swallow), they were started on broad spectrum IV antibiotics and antifungals. An urgent endoscopy followed with APC and clipping as adjuncts. With a median number of two stents used, their duration was 34 and 60.5 days in the leak and the perforation groups respectively.

About 40% needed image guided drains, with cultures that guided the antibiotic regimen. Nutrition in the cancer group was via jejunostomy feeds, while the perforation group had naso-jejunal tubes put during stenting and a small group needed TPN. Patients were allowed phased oral intake based on their clinical picture and contrast studies.

The median length of stay was 41.5 & 63 days, with a re-admission rate of 2 & 4 times amongst the leak and perforation groups.

Three patients developed Clavien-Dindo grade 3 complications needing further intervention, with two of them post leak and one post perforation. The former had 1 stent embedment with erosion and 1 stricture, while the later developed small bowel obstruction due to stent migration and needed an emergency laparotomy.

Though heterogeneous, the management of these groups share useful themes. The stents and adjuncts help with source control of sepsis (leak/perforation), facilitate healing and improve nutrition.

Conclusion

Oesophageal disruptions can be managed successfully with conservative measures, with a multidisciplinary approach. An algorithmic approach makes standard of care more uniform and brings better outcomes, with minimal morbidity. Team work is key.
P21 FEASIBILITY OF ENHANCED RECOVERY PROTOCOL AFTER ESOPHAGEAL SURGERY IN ELDERLY PATIENTS
Authors: De Pasqual C A , Weindelmayer J , La Mendola R , Alberti L , Ridolfi C , Gervasi M C , Giacopuzzi S , de Manzoni G
Published: November 2019

Background

In dedicated centres ERAS (Enhanced Recovery After Surgery) programs have been successfully applied after esophageal surgery. However, some concerns have been raised about the feasibility of these protocols in elderly patients.

Methods

We retrospective reviewed 72 patients submitted to Ivor-Lewis esophagectomy in our Institution, during the period 2015-2017. We divided the patients into two groups: 47 patients (65,3%) were <70 years old (Young Group, YG) while 25 patients (34,7%) were ≥70 years old (Elderly Group, EG). We compared post-operative outcomes and adherence to ERAS steps of the two groups.

Results

The two groups were not different in terms of overall morbidity rate (53,2% in YG vs 60,0% in EG p= 0,6) and pulmonary complications rate (70,2% in YG vs 72,0% in EG, p= 1). EG showed a higher cardiac complications rate (3,5% in YG vs 26,7% in EG, p=0,001). We did not report 90-days mortality. We did not observe differences in adherence to the following ERAS steps: pre-operative carbohydrate load administration (78,7% in YG vs 76,0% in EG, p=0,7), ward transfer on POD 0 (61,7% in YG vs 48,0% in EG, p=0,32), removal of naso-gastric tube on POD 1 (87,2% in YG vs 96,0% in EG, p=0,4), resume of liquid diet on POD 1 (55,3% in YG vs 56,0% in EG, p=1), urinary catheter removal on POD 2 (61,7% in YG vs 48,0% in EG, p=0,3), fully mobilization on POD 3 (63,8% in YG vs 52,0% in EG, p=0,4), resume of soft diet on POD 4 (72,3% in YG vs 68,0% in EG, p=0,7), discharge on POD 7 (48,9% in YG vs 40,0% in EG, p=0,6). Median day of discharge was POD 8 for both groups (p= 0,8).

Conclusions

In high-volume centres ERAS protocols can be safely applied to elderly patients undergoing esophagectomy.
P216 WHAT IS THE TIME BURDEN AND RESPONSE RATE ASSOCIATED WITH WRITTEN OR ONLINE COMPLETION OF HEALTH-RELATED QUALITY OF LIFE QUESTIONNAIRES AFTER CANCER TREATMENT?
Authors: Klevebro F , Boshier P , Jenq W , Low D
Published: November 2019

Background

Patient reported outcomes are increasingly important assessments to be applied in the follow-up of patients after cancer treatment. The primary aim of this study was to clarify the patient related time burden associated with completing these questionnaires. Secondary aims was to assess completion rates, and to investigate how symptomatic outcome differs according to the response time.

Method

Patients who had undergone surgical management of esophageal cancer (1991-2018) and were disease-free at the time of assessment were asked to complete a total of six questionnaires: SF36, EORTC-QLQ-C30, EORTC-QLQ-OG25, EuroQol 5D, Digestive Symptom Questionnaire, and Dumping Syndrome Rating Scale. Patients were offered either paper or online questionnaires that were completed consecutively allowing for accurate quantification of the time taken to complete each online questionnaire.

Results

In total, 117 of 147 eligible patients (79.6%) responded to the questionnaires. In the online group 60 (90.9%) responded compared to 57 (70.4%) in the paper group (P=0.002). The median age was 74.5 years in the online group compared to 70.9 years in the paper group (P=0.022). In the patients completing their questionnaires online, the six questionnaires took on average 26.4 (range 10-55) minutes to complete. The fastest quartile of patients completed the six questionnaires in 17 minutes or less (N=14). There was no significant association between time to complete the questionnaires and age, gender, time from surgery or health-related quality of life scores.

Conclusions

The results of the study demonstrates that online questionnaires in some ways might be superior to paper questionnaires, and that patients are willing and able to complete online questionnaires irrespective of age. Time to complete questionnaires was not associated with level of health-related quality of life.
P219 THE ROLE OF PET-CT IN THE EVALUATION OF LYMPH NODE INVOLVEMENT IN ESOPHAGEAL AND GASTROESOPHAGEAL JUNCTION CARCINOMA - A 5-YEAR SINGLE CENTER EXPERIENCE
Authors: Vergadis Chrysovalantis , Mpaili Eustratia , Syllaios Athanasios , Mpoura Maria , Michalinos Adamantios , Karavokyros Ioannis , Alexandrou Andreas , Charalabopoulos Alexandros , Schizas Dimitrios , Liakakos Theodore
Published: November 2019

Aim

To determine the efficacy of positron emission tomography-computed tomography (PET-CT) in the evaluation of lymph node status during preoperative staging on patients with esophageal and gastrοesophageal junction carcinoma compared to the final histopathological findings.

Background & Methods

Data on patients that underwent esophagectomy from 01/03/2014 to 01/03/2019 were prospectively collected and retrospectively reviewed. Based on the medical records, the following parameters were extracted and analyzed: patient demographics, histopathological parameters, surgical and oncological outcomes. All patients were staged according to the AJCC 8th edition.

Results

A total of 79 patients underwent Ivor Lewis or McKeown esophagectomy for either squamous cell carcinoma (n= 7 patients) or adenocarcinoma of esophagus or gastroesophageal junction (n= 72 patients). In 60 cases, clinical staging was conducted without performing PET- CT, while 19 cases underwent PET-CT. Among the 19 patients, 16 (84.2%) were men, and 3 (15.8 %) were women. Mean age was 62 years, (range 41- 72). Mean nodal harvest per patient was 30.6 lymph nodes. Twelve out of 19 patients (63.2%) revealed lymph node invasion, with a mean of 5.6 positive lymph nodes per patient. PET-CT identified the primary tumor in all 19 patients (100%). PET-CT demonstrated 100% compliance with the final histopathological reports regarding N status in only 5 out of 19 cases (26.3%). Four patients were staged as N0 both pre- and postoperatively, while one was deemed positive by PET-CT in right paracardial lymph nodes which was histopathologically confirmed. In other 4 patients (21.1%), PET-CT was 100% false negative, whereas in 3 patients (15.8%) PET-CT was 100% false positive. In the remaining 7 patients, PET-CT findings were in accordance with the pathology report in 7 out of 25 examined lymph node stations, false positive in 9 out of 25 and false negative in 9 out of 25.

Conclusion

PET-CT seems to have a considerable number of false positive and false negative results in esophageal cancer in our study as far as N-staging is concerned. Further studies with larger sample size are needed to reach more conclusive results.