bluuebunny/crossref_metadata_2025_split huggingface dataset:
P103 A HAND-SEWN INTRATHORACIC ANASTOMOSIS IN ROBOT-ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY (RAMIE): A DETAILED DESCRIPTION OF TECHNIQUE AND OUTCOMES
Authors: de Groot E M , Kingma B F , van Hillegersberg R , Ruurda J P 
Published: November 2019

Abstract

Aim
The aim of this study was to describe a technique that was developed and refined to construct a hand-sewn intrathoracic anastomosis during robot-assisted minimally invasive esophagectomy (RAMIE).

Background & Methods
Whilst some case series have reported promising results of a hand-sewn intrathoracic anastomosis during RAMIE, the exact techniques were often not described in detail. Therefore, the current single-center retrospective study was designed to provide a detailed and reproducible technical description of a hand-sewn, intrathoracic anastomosis that was developed and refined for patients who underwent RAMIE in a high volume center for esophageal cancer surgery (2016-2018). Video recordings were reviewed to evaluate technical details regarding the anastomosis, including number of sutures and distances between the anastomosis and the longitudinal staple line or gastric conduit tip. Technical details and distances were extracted and measured by using video analysis software. Moving average analyses were performed to evaluate whether the anastomotic leakage rate changed over the consecutive cases.

Results
A total of 68 patients were included in the study. For creation of the anastomosis, the gastric conduit was opened on a median distance of 19 millimeters (range 0-66) from the gastric conduit tip. After initially performing end-to-end anastomoses, a switch was made to an end-to-side anastomosis for the majority of 55 patients (81%). A median total of 27 sews (range 20-38) were required to close the anastomosis. In the last 22 patients of the cohort (32%), 4 tension release stitches were placed after circular suturing of the anastomosis. A re-inforcing omental wrap was positioned around the anastomosis in 64 patients (94%). The moving average curve for anastomotic leakage started at a rate of 40% (cases 1-10) and ended at 10% (cases 59-68).

Conclusion
This is the first study to report technical features and outcomes of a hand-sewn intrathoracic anastomosis during RAMIE in detail. Although an acceptable anastomotic leakage rate was observed in the final inclusion phase, a hand-sewn intrathoracic anastomosis during RAMIE may carry a substantial learning curve.
P104 SELECTIVE LYMPHATIC EMBOLIZATION TO MANAGE SEVERE POSTOPERATIVE LYMPHATIC LEAK
Authors: Gustav Linder , Pär Gerwins , Magnus Sundbom , Jakob Hedberg 
Published: November 2019

Abstract

Aim
To describe methods and clinical outcomes in a cohort of patients at Uppsala University Hospital who underwent selective lymphatic embolization due to severe lymphatic leak.

Background & Methods
Surgery for malignant disease with extensive lymph node dissection in the abdomen or thorax can be complicated by postoperative lymphatic leak. This is a relatively rare condition, associated with great morbidity and can be difficult to treat. Selective embolization of leaking lymphatic vessels is a recently introduced method for management of thoracic and abdominal lymphatic leaks.
Patients that had undergone treatment with selective embolization for severe lymphatic leaks were studied retrospectively. Lymphatic leaks were diagnosed with dynamic contrast enhanced magnetic resonance imaging (MRI)-lymphangiography and/or nodal lymphangiography utilizing Lipiodol. Selective embolization of leaking lymphatic vessels was performed in local anesthesia through transabdominal access, selective catheterization of lymphatic vessels with microcatheters, followed by occlusion of the vessel with coils and glue. Alternatively the leaking lymphatic vessel was occluded by injection of Lipiodol or Fibrovein via an adjacent lymph node. Data was analyzed with descriptive statistics.

Results
The study comprised 14 patients with severe postoperative lymphatic leak (six following transthoracic esophageal resection and eight following abdominal resections). Prior to intervention the average daily lymph output was 2092 ml and average serum albumin was 19 g/l (range 7-27). Median time from primary surgery to selective embolization was 73 days indicating that conservative treatment had previously been tried and failed. Selective embolization was successful in 93% (n=13) and in nine patients the lymphatic leak ceased instantly. A few patients needed more than one embolization procedure.
Median time in hospital care after embolization was two days. No procedure-related complications occurred and only one patient later needed open surgery due to persisting lymphatic leakage.

Conclusion
Selective lymphatic embolization appears to be a safe and effective method with potential to preclude open surgery in patients with persistent severe postoperative lymphatic leak. The procedure can be performed under local anesthesia but demands a highly skilled and dedicated interventional radiologist. The most detailed imaging to facilitate the procedure was achieved through dynamic contrast enhanced MRI-lymphangiography.
P105 MIRNA483-3P AND MIRNA221 DYSREGULATION AND CORRELATION WITH SURVIVAL IN ESOPHAGEAL ADENOCARCINOMA (EAC)
Authors: Isidori F , Bozzarelli I , Lugaresi M , Malvi D , Mastracci L , Hoefnagel S J M , Räsänen J , Söderström H , Raulli G , D’Errico A , Fiocca R , Seri M , Krishnadath K K , Bonora E , Mattioli S ,   EACSGE
Published: November 2019

Abstract

Aim
Our study aimed to characterize miR-221 and 483-3p dysregulation and to correlate their expression with clinical outcomes in patients submitted in first instance to surgical therapy (naïve patients) for esophageal adenocarcinoma (EAC).

Background & Methods
MicroRNA (miRNAs) are small, noncoding RNAs that play important roles in several biological processes by fine-tuning gene expression1. In a cohort of well-characterized EAC, we analyzed the expression of miRNAs. RNA was extracted from formalin-embedded (FFPE) surgical specimens of normal gastric tissues and EACs, classified according to BIM/GIM classification (BIM=Barrett’s intestinal metaplasia, GIM=Gastric intestinal metaplasia): 43 BIM-/GIM-, 32 BIM+/GIM-, 2 BIM+/GIM+, 9 BIM-/GIM+). Expression of 754 human miRNAs was profiled in 8 cases with TaqMan MicroRNA Array card A1.1/B3.0. miR-221 and 483-3p validation was performed with single TaqMan probes on all 85 FFPE samples. miR-221 and miR-483-3p were also analyzed in a cohort of 39 fresh-frozen biopsies (29 EAC and 10 normal esophageal tissues). In 3 EAC cell-lines (OE-19, OE-33, FLO-1)2 we tested the expression of miR-221 and miR-483-3p3 and of two major targets (PTEN and SMAD4, respectively). Correlations between miRNAs and clinical outcomes were calculated using Kruskal-Wallis, Mann-Whitney, t-Student’s and Kaplan-Meier tests.

Results
miR-221 and 483-3p resulted upregulated from the MicroRNA Array card analysis. This increase was confirmed in two independent cohorts (FFPE-cohort: miR-483-3p p=0.0065; fresh-frozen-cohort: miR-483-3p p<0.0001, miR-221 p=0.0062). Statistical analysis showed an upregulation of both miRNAs, in particular miR-483-3p (p<0.0001), in BIM-/GIM-, compared to BIM+/GIM-. miR-221 and 483-3p up- regulation correlated with reduced cancer-specific survival in FFPE samples (miR-483-3p p=0.053, miR-221 p=0.001). We demonstrated a significantly increase for miR-483-3p (p=0.01) with a trend toward reduction of SMAD4 expression in FLO-1 compared to other cell-lines.

Conclusions
We identified an up-regulation of miR-221 and miR-483-3p, which might contribute to cancer progression. In the most aggressive cell line, FLO-1, we observed an increased expression of miR-483-3p, with SMAD4 reduction. Further studies are warranted to elucidate in depth the role of miR-221 and miR-
483-3p in EAC.
P107 PREDICTION OF A POSITIVE CIRCUMFERENTIAL RESECTION MARGIN IN ADENOCARCINOMA OF THE ESOPHAGUS
Authors: William R C Knight , Connie Yip , Audrey Jacques , Nyree Griffin , Janine Zylstra , Wahyu Wulaningsih , Mieke Van Hemelrijck , Nick Maisey , DrAndrew Gaya , Cara R Baker , Mark Kelly , James A Gossage , Jesper Largergren , David Landau , Vicky Goh , Andrew R Davies 
Published: November 2019

Abstract

Aim
To determine if a positive circumferential resection margin (CRM) can be predicted in patients with esophageal adenocarcinoma undergoing neo-adjuvant chemotherapy prior to surgery

Methods
223 patients were included in this study. Multivariable analyses of clinico-pathological and computed tomography (CT) imaging predictors were performed to evaluate the likelihood of a positive CRM at initial staging and following neoadjuvant chemotherapy, with prediction models constructed. Area under curve (AUC) with 95% confidence interval (CI) from 1000 bootstrapping was assessed.

Results
Advanced clinical T-stage (T3-4) (odds ratio, OR 2.93 95%CI 1.03-9.48) and poor tumor differentiation (OR 2.84, 95%CI 1.39-6.01) were independently associated with an increased risk of a positive CRM. Non response to chemotherapy as estimated by CT independently corresponded with an increased risk of CRM positivity (OR 3.38 95% CI 1.43-8.50). Additional CT evidence of local invasion/pleural thickening and higher CT tumor volume (14cm3) improved the performance of a prediction model, including all above parameters; with AUC (c-index) of 0.76 (0.68-0.83).

Conclusion
Combining advanced clinical T-stage, poor tumor differentiation, CT non-response to chemotherapy, higher CT tumor volume and local invasion may be helpful in selecting patients for intensification of neo-adjuvant treatment prior to resection.
P109 GEOGRAPHICAL DIFFERENCES IN RESECTION RATES ASSOCIATED WITH SURVIVAL IN SWEDEN-IS SURGERY UNDERUSED?
Authors: Gustav Linder , Christine Jestin , Mats Lindblad , Jakob Hedberg 
Published: November 2019

Abstract

Aim
To investigate associations between resection rates and survival in esophageal and gastroesophageal junctional cancer.

Background & Methods
Surgical resection is the mainstay of curative treatment for cancer in the esophagus and the gastroesophageal junction. Merely about one third of these patients undergo resectional surgery although proportions vary. We set out to study differences in resection rates by county and their influence, if any, on survival.
A national cohort of patients with esophageal- and gastroesophageal junctional cancer, diagnosed 2006-2015, was set up by cross linking several national registries. The annual resection rate of each geographical county was calculated and divided into three groups (low, middle and high). Survival was analyzed with a Cox proportional hazards model including resection rate, sex, age, year of diagnosis, clinical TNM status, relevant comorbidities, neoadjuvant treatment as well as proportion intended curative oncological treatment.

Results
6532 patients were diagnosed during the study period whereof 1733 (26.3 %) underwent open or endoscopic resectional surgery. 860 (49.6%) patients received neoadjuvant treatment. In the studied decade, rates ranged from 21% to 33% in the 21 counties. Overall mean survival after diagnosis was 8.1, 9.9 and 12.1 months in the low, middle and high-resection rate groups respectively. In the multivariate Cox analysis, higher resection rate was associated with improved survival (HR 0.87, 95% CI 0.84-0.90, p<0.001).

Conclusion
In this national population-based cohort study, patients undergoing treatment in counties with higher resection rates had an associated improved survival. Local underuse of the surgical modality cannot be excluded.
P111 ROBOTIC-ASSISTED REPAIR OF IATROGENIC LEFT BRONCHUS PERFORATION DURING RAMIE – A CASE REPORT
Authors: Mann C , Lang H , Grimminger P P 
Published: November 2019

Abstract

Background
Iatrogenic bronchial injury during an esophageal surgery is a severe complication. Hence, immediate treatment is necessary to avoid further pulmonary complications and death. We present a case of an intraoperative bronchial injury caused by a bronchial tube cuff during a full robotic-assisted Ivor-Lewis esophagectomy (RAMIE).

Case report
A 64-year old patient with adenocarcinoma of the distal esophagus was planned for a RAMIE after completing neoadjuvant radiochemotherapy. Before beginning the thoracic phase, the anesthesist reported an airway leakage during the ventilation. During the transthoracic robotic assisted esophagectomy a perforation of the left main bronchus caused by the cuff of the double-lumen tube was found. Due to the diameter of the defect (1/2 inch) direct suturing was not possible. Therefore, we used a stalked pericardial patch to robotically oversew the perforation. The precise agility using the robotic DaVinci system was very useful treating this perforation minimally- invasively during the RAMIE without conversion. The rest of the surgery including the gastric pull-up and intrathoracic anastomosis was carried out without further complication.
The patient had a normal postoperative course and showed no signs of any pulmonary restrictions or any other morbidity. The patient was discharged fully enteralised and in good conditions at the 9th postoperative day. The histopathological stage was ypT3, N2(4/21), L0, V0, Pn0, R0 (stage IIIB in 7th UICC).

Conclusion
This case report points out the great possibilities of robotic surgery dealing with unexpected complications during complex operations. Robot-assisted complex suturing is a great advantage in robot-assisted minimally invasive surgery, especially during sewing a pericardium-flap onto the left bronchus perforation during an esophagectomy.
P115 TRANSITION FROM OESOPHAGECTOMY TO ENDOSCOPIC THERAPY FOR EARLY OESOPHAGEAL CANCER – A SINGLE CENTRE EXPERIENCE OF 251 CONSECUTIVE CASES
Authors: Reyhani A , J.M Dunn , Zylstra J , Santaolalla A , Gimson E , Baker C , Kelly M , Van Hemelrijck M , Zeki S S , Gossage J , Davies A 
Published: November 2019

Abstract

Aim
To compare Oesophagectomy and Endoscopic mucosal resection (EMR) short and long term outcomes of patients treated for early oesophageal cancer over a transition period in a single institution.

Background and Methods
Introduction of Endoscopic eradication therapy (EET) techniques in 2012 provided an alternative to oesophagectomy for high grade dysplasia (HGD) and early cancer. Historically the gold-standard treatment had been oesophagectomy, which is associated with significant post-operative morbidity and prolonged recovery, but offers a high chance of cure with additional benefit of regional lymphadenectomy. A single centre, contemporaneously maintained database of consecutive patients diagnosed with early oesophageal cancer and treated at a tertiary referral centre during 2000-2018 was analysed. Patients were discussed at MDT; histology was confirmed by 2 expert pathologists. Oesophagectomy was not preceded by neoadjuvant chemotherapy. Primary outcomes are overall and disease specific survival, secondary outcomes including hospital stay, complications and overall cost.

Results
113 patients underwent oesophagectomy and 138 underwent EMR +/- further EET. Mean age for oesophagectomy 64.6 vs. EMR 71.6 years (p=<.0001). Mean follow up for oesophagectomy was 5.6 vs 2.4 years after EET. The proportion of T1 tumours was (HGD 25% vs 39%, T1a 17% vs 34%, T1b 43% vs 16%, p<0.001), poor differentiation (23% vs 5%, p<0.001), lymphovascular invasion (19% vs 4%, p<0.001) and Inpatient hospital stay (median 14 vs 1.5 days EMR; p=<.0001) was significantly higher in oesophagectomy group. In-hospital and 30 day mortality was 0%. Surgical group suffered more complications (Clavien-dindo ≥ 3) 26% vs. EMR 1%, p=<.0001. Cancer recurrence after oesophagectomy was 18% (local 4%, systemic 9%, mixed 5%) vs. 5% following EET (local). Overall survival showed no difference between both groups (HR 1.157 95%CI 0.62-2.16). Stage matched survival in HGD; T1a and T1b sub-groups didn´t significantly differ.

Conclusion
In a large consecutive series of patients treated during a transition period, overall survival was similar in both groups. Surgery was associated with prolonged recovery and significant post-operative morbidity. EMR should be available for HGD and early cancer patients as gold standard of care although patients with adverse prognostic features may still benefit from oesophagectomy.
P116 A PILOT STUDY ON ENERGY INTAKE AND TOTAL ENERGY EXPENDITURE, USING A MULTI SENSOR DEVICE, IN OESOPHAGEAL CANCER PATIENTS DURING THE ENTIRE COURSE OF MODERN MULTIMODALITY TREATMENT
Authors: Ericson Jessica , Lundell Lars , Nilsson Magnus , Lindblad Mats , Klevebro Fredrik , Rouvelas Ioannis 
Published: November 2019

Abstract

Aim
The objective of the present pilot study was to address the feasibility and practical use of SenseWear Armband Mini® (SWA) as a possible valid method offering longitudinal, comprehensive and complete assessment of energy balance in oesophageal cancer patients submitted to modern multimodality therapy.

Background and methods
Assessment of malnutrition and its consequences are pivotal in the curative management of patients with oesophageal cancer. Twenty patients were recruited at diagnosis of oesophageal cancer, all amenable for curative treatment. The baseline measurement took place before start of neoadjuvant treatment and at three additional measurement periods: after the completion of neoadjuvant treatment, and at three and six months postoperatively. The patients carried the SWA for three consecutive days at each measurement period, allowing the measurement of free-living total energy expenditure (TEE) and physical activity level (PAL). Alongside, a three-day food diary was recorded, permitted the calculation of energy and protein intake. The body weigth was measured at all four occasions.

Results
Body weight steadily decreased during the preoperative phase. However, the greatest weight loss was observed during the first 3 months after surgery (mean=5.6 kg), where after it stabilised. The median energy intake of 1982 kcal (range: 910-3455) at baseline increased to 2210 kcal (range: 1718-3355, p=0.009) after the completion of the neoadjuvant treatment. At 3 months after oesophagectomy energy intake decreased to 1749 kcal (range: 1024-2707, p=0.101) and regained baseline levels first at 6 months postoperatively. The same trend was observed regarding protein intake. The TEE was 2262 kcal (range: 1595-3150) at baseline with no change after preoperative oncological treatment. A significant reduction in energy expenditure to 1975 kcal (range 1396-2336, p=0.005) was recorded at 3 months post oesophagectomy, which remained unchanged at six months after surgery.

Conclusion
There are significant obstacles in recording complete, comprehensive and repetitive data on energy balance during the entire course of modern multimodality treatment of oesophageal cancer patients.
With the objective to achieve and maintain positive energy balance focus must be on the patients’ energy intake already at the time of diagnosis, throughout the neoadjuvant therapy phase but particularly during the first 3 postoperative months.
P118 LOSS OF SMAD4 EXPRESSION IN ESOPHAGEAL ADENOCARCINOMA (EAC) IS CORRELATED TO POOR SURVIVAL
Authors: Mastracci L , Isidori F , Bozzarelli I , Lugaresi M , Malvi D , Hoefnagel S , Rasanen J , Soderstrom H , D'Errico A , Fiocca R , Seri M , Krishnadath K , Bonora E , Mattioli S 
Published: November 2019

Abstract

Aim
Our study is aimed to evaluate the impact of SMAD4 expression on the clinical outcome of therapy for esophageal adenocarcinoma (EAC).

Background & Methods
Esophageal adenocarcinoma is characterized by a high genetic heterogeneity and a low survival rate, despite the adoption of aggressive therapies. We evaluated the expression of SMAD4, a tumor suppressor gene frequently mutated in cancer. by immunohistochemistry in 67 formalin-embedded (FFPE) EAC surgical specimens (patients were primarily treated with surgical resection-naïve cases), 34 of which were analyzed for SMAD4 gene by Next Generation Sequencing (NGS) with a dedicated target panel. Loss of SMAD4 protein was defined by a complete loss of expression in least 30% of cancer cells. Survival curves were determined using Kaplan–Meier methods.

Results
Loss of SMAD4 immunoreactivity was found in 33 out of 67 EAC cases (49.3%). Among a subset of 34 cases assessed in NGS, SMAD4 mutations were found in 3 cases (8.8%), all associated with protein loss. Loss of SMAD4 expression was also found in several cases with no mutations in SMAD4 gene (17/34, 50%). Loss of SMAD4 immunoreactivity was associated with poor overall survival (p=0.013) and higher risk of recurrence (p=0.001).

Conclusion
Loss of SMAD4 expression was a recurrent event in EAC, linked with genetic mutations in few cases, whereas in the majority of cases it might be related to epigenetic mechanisms, such as promoter hypermethylation. SMAD4 loss was strongly associated with recurrence and poor survival in patients, suggesting SMAD4 expression as potential prognostic biomarker in EAC. Further studies are required to develop strategic therapeutic options directly targeting SMAD4 and/or its regulators.
P12 LONG-TERM QUALITY OF LIFE AFTER TOTAL GASTRECTOMY VERSUS IVOR LEWIS ESOPHAGECTOMY
Authors: Jezerskyte E , Saadeh L M , Hagens E R C , Sprangers M A G , Noteboom L , van Laarhoven H W M , Eshuis W J , van Berge Henegouwen M I , Gisbertz S S 
Published: November 2019

Abstract

Aim
The aim of this study was to investigate the difference in long-term health-related quality of life in patients undergoing total gastrectomy versus Ivor Lewis esophagectomy in a tertiary referral center.

Background & Methods
Surgical treatment for gastroesophageal junction (GEJ) cancers is challenging. Both a total gastrectomy and an esophagectomy can be performed. Which of the two should be preferred is unknown given the scarce evidence regarding effects on surgical morbidity, pathology, long-term survival and health-related quality of life (HR-QoL).
From 2014 to 2018, patients with a follow-up of > 1 year after either a total gastrectomy or an Ivor Lewis esophagectomy for GEJ or cardia carcinoma completed the EORTC QLQ-C30 and EORTC QLQ-OG25 questionnaires. Problems with eating, reflux and nausea and vomiting were chosen as the primary HR-QoL endpoints. The secondary endpoints were the remaining HR-QoL domains, postoperative complications and pathology results. Multivariable linear regression was applied taking confounders age, gender, ASA classification and neoadjuvant therapy into account.

Results
30 patients after gastrectomy and 71 after Ivor Lewis esophagectomy with a mean age of 63 years were included. Median follow-up was two years (range 12-84 months). Patients after total gastrectomy reported significantly less choking when swallowing and coughing (β=-5.952, 95% CI -9.437 – -2.466; β=-13.084, 95% CI -18.525 – -7.643). Problems with eating, reflux and nausea and vomiting were not significantly different between the two groups. No significant difference was found in postoperative complications or Clavien-Dindo grade. Significantly more lymph nodes were resected in esophagectomy group (p=0.008). No difference in number of positive lymph nodes or R0 resection was found.

Conclusion
After a follow-up of > 1 year choking when swallowing and coughing were less common after total gastrectomy. No significant difference was found in problems with eating, reflux or nausea and vomiting nor in postoperative complications or radicality of surgery. Based on this study no general preference can be given to either of the procedures for GEJ cancer. Patients may be informed about the HR-QoL domains that are likely to be affected by the different surgical procedures, which in turn may support shared decision making when a choice between the two treatment options is possible.