bluuebunny/crossref_metadata_2025_split huggingface dataset:
O190 THE EPIDEMIOLOGY OF ANTI-REFLUX SURGERY IN DENMARK 2000-2017: A NATIONWIDE REGISTRY-BASED POPULATION STUDY
Authors: Ljungdalh Jonas Sanberg , Durup Jesper , Houlind Kim Christian 
Published: November 2019

Abstract

Aim
The primary aim of this register-based study was to describe the utilization and development of anti-reflux surgery compared to use of proton-pump inhibitors from 2000-2017 in a nationwide population-based cohort.

Background & Methods
Treatment of GERD consists of anti-secretory drugs, mainly proton pump inhibitors (PPI), or anti-reflux surgery. Laparoscopic anti-reflux surgery is considered standard of care in surgical treatment of gastro-esophageal reflux disease1 and with careful patient selection based on thorough preoperative workup2 symptom control and patient satisfaction are high compared to medical therapy3–5.
In American studies, the rate of anti-reflux surgery peaked at 16.7 per 100.000 inhabitants in 2000 and then decreased to 6.1 per 100.000 inhabitants by 20106, 7. The only Danish study on the epidemiology of anti-reflux surgery, describes a reoperation rate of 5%, but only includes data from 1997-2005 and describes no rate of surgery compared to population size8. It is therefore unclear how the use of anti-reflux surgery has developed.
This register-based cohort study includes all patients who have undergone anti-reflux surgery in Denmark from 2000-2017. Data was retrieved from The National Danish Patient Registry and linked at an individual level using the unique civil registration number issued to all Danes. For the entire study period, rate of anti-reflux surgery, including primary and reoperative procedures, Charlson comorbidity index (CCI), 30- and 90-days perioperative mortality, use of laparoscopic technique and length of stay was calculated. Population-based rates of surgery was compared to rates of PPI-use.

Results
Rate of surgery peaked between 2000-2005 with >5.0 procedures per 100.000 inhabitants, but declined consistenly in the rest of the study period. Reoperations were an increasing percentage of the prodecures with up to 20% increasing from 7%. CCI increased during the study period with >25% having a CCI>0 at the end of the study. In the entire period, >98% of procedures were performed laparoscopically, mortality <1% and length of stay declined to median 1 day.

Conclusion
Anti-reflux surgery was utilized less, but mortality, conversion rates and length of hospital stay were consistently low, despite an increased burden of comorbidity and reoperations.
P192 CROSS REGIMEN FOR ADENOCARCINOMA OF THE ESOPHAGUS AND CARDIA: DOES PATHOLOGICAL RESPONSE INFLUENCE OVERALL AND DISEASE FREE SURVIVAL? MULTICENTER RETROSPECTIVE ANALYSIS
Authors: Stefano de Pascale , Paolo Parise , Michele Valmasoni , Jacopo Weindelmayer , Fabrizia Terraneo , Chiara Alessandra Cella , Simone Giacopuzzi , Andrea Cossu , Stefano Merigliano , Uberto Fumagalli Romario , Riccardo Rosati 
Published: November 2019

Abstract

Aim
Primary aim is to evaluate the relationship between pathological response after CROSS regimen for locally advanced esophageal adenocarcinomas and overall and disease-free survival. Secondary endpoint is to analyze the principal sites of relapse after surgery in this group of patients.

Background & Methods
The CROSS trial showed an improvement of overall survival after neoadjuvant chemoradiation and subsequent surgical resection compared to surgery alone for patients with esophageal cancer, representing the benchmark [1].
Patients submitted to CROSS regimen for adenocarcinoma of the esophagus and cardia followed by esophagectomy with a transthoracic extended lymphadenectomy were analyzed. The patients were treated in 4 centers part of Italian Group for the Study of Esophageal Diseases (SISME). Actuarial Overall survival (OS) and actuarial disease-free survival (DFS) were analyzed and stratified according to yp Stage (1 – stage I and II; 2 – stage IIIA and IIIB and 3 - stage IVA) as described in the 8th edition of TNM.
Kaplan-Meier method was used to estimate overall and progression-free survival, with the log-rank test to ascertain significance (p<0.05). Median and range were used. Statistical analysis was done with SPSS version 21.0.

Results
132 patients, from January 2014 to February 2019, were analyzed. Median age was 63 years (range 42-82). The site of the neoplasm was the distal esoghagus-EGJ in 127 cases and the middle esophagus in 5. Ivor Lewis was the procedure adopted. Fifty-month OS and DFS were respectively 42% and 6.7% respectively. No difference emerged when overall survival was analyzed according to yp Stages. Time to relapse is significantly longer for ypStage I and II. Recurrence occurred in 48 cases (36.3%) with 9 months as median time to relapse. Local and distal relapse were 10 (paratracheal nodes) and 38 respectively (7.5% and 28.7%, p<0.001).

Conclusion
Pathological response after CROSS regimen doesn’t relate to OS and DFS. Time to recurrence is significantly longer for yp Stage 1 e 2 rather than other ypStages. Chemoradiotherapy in a neoadjuvant setting may influence the site of relapse.
O193 ROLE OF MALNUTRITION IN 0ESOPHAGEAL SURGERY FOR CANCER
Authors: Alfieri R , Nardi M , Moretto V , Pinto E , Briarava M , Pomba L , Scarpa M , Pilati P L , Castoro C 
Published: November 2019

Abstract

Aim
To investigate whether preoperative malnutrition is associated with long term outcome and survival in patients undergoing radical oesophagectomy for oesophageal or oesophagogastric junction cancer.

Background & Methods
Dysphagia, weight loss, chemo-radiationtherapy frequently lead to malnutrition in patients with oesophageal or oesophagogastric junction cancer. Severe malnutrition is associated with higher risk of postoperative complications but little is known on the correlation with long term survival. We conducted a single center retrospective study on a prospectively collected database of patients undergoing oesophagectomy from 2008 and 2012 in order to evaluate the impact of preoperative malnutrition with postoperative outcome and long term survival. Preoperative malnutrition was classified as: prealbumin level less than 220 mg/dL (PL), MUST index (Malnutrition Universal Screeening Tool) >2 and weight loss >10%.

Results
177 consecutive patients were considered: due to incomplete data 60 were excluded from the analysis that was performed on 117 patients. PL was reported in 52 (44%) patients, MUST index was recorded in 62 (53%), 58 (49%) patients presented more than 10% weight loss at the preoperative evaluation. PL was associated with more postoperative Clavien-Dindo 1-2 complications (p=0.048, OR 2.35 95%IC 1.001-5.50), no differences were observed in mortality, anastomotic leak, major pulmonary complications. MUST index was not correlated with postoperative complications nor mortality but resulted worse in patients treated with chemo-radiotherapy (p=0.046, OR 1.92 95%CI 1.011-3.64). Weight loss >10% was not associated with postoperative complications or mortality. Overall 7 years survival rate was 69%. and DFS was 68%. Malnourished patients did not differ from non-malnourished regarding age, sex, tumor site, tumor stage and histology. No significant difference in 7 years survival rates was observed in patients with PL <220 mg/dL ( 55 % vs 67%), neither in patients with MUST score>2 (58% vs 72%), nor in patients with weight loss >10% (53% vs 70%).

Conclusions
Malnutrition is more common in patients treated with chemoradiation therapy and it is associated with postoperative complications. However, both long term and disease free survival are not affected by preoperative nutritional status. Larger patient population and data on long term postoperative nutritional status will be analyzed in further studies.
P198 SUPERIOR POLAR GASTRECTOMY ASSOCIATED WITH ANTI-REFLUX TECHNIQUE: CASE REPORT
Authors: Navío Seller A , Jiménez-Rosellón R , Bruna Esteban M , Vaqué Urbaneja J , Mingol Navarro F 
Published: November 2019

Abstract

Aim
To present a case report where Kamikawa’s technique1 was used, as well as the patient’s postoperative evolution and results.

Background and Methods
Superior polar gastrectomy remains an accepted surgical alternative for proximal gastric tumors, although this approach has higher rates of gastroesophageal reflux since the valvular mechanism of cardias disappears. Thus, an additional technique is needed to avoid its presence.
This is a description of surgical technique and short term results of superior polar gastrectomy associated to Kamikawa’s anti-reflux technique in a female patient with proximal gastric cancer.

Results
A 55 year-old female with no relevant medical history, diagnosed with diffuse signet ring cell gastric adenocarcinoma. The tumor was 3 cm long, extending from the esophago-gastric junction to the subcardial region (cT3 N1 M0). After presentation in a Multidisciplinary Group, the patient underwent perioperative chemotherapy according to the FLOT-4 protocol, presenting partial clinical response.
The surgical intervention took place 6 weeks after finishing chemotherapy, and a laparoscopic superior polar gastrectomy was performed, associating extended resection including 3-4 cm of distal esophagus and D1+ lymphadenectomy with periesophageal lymph node regions 110 and 111. Once the resection was finalized, an assistance laparotomy was made to externalize the surgical specimen. Saline solution was injected into submucosa of the cranial part of the gastric pouch and afterwards, two seromuscular flaps were dissected. Then, the gastric mucous membrane was opened in the inferior part of the flaps, constructing an esophagogastric end-to-side anastomosis made with 2 running sutures of V-lock 3/0. Finally, the previously prepared seromuscular flaps were sewn overlapping the esophagus and the esophago-gastric anastomosis in order to prevent reflux.
The patient presented a benign postoperative course, reintroducing oral intake and developing no heartburn, no dysphagia, nor vomiting and was discharged on the 9th postoperative day.
The postoperative barium swallow radiography showed no leak of contrast nor any regurgitation. The pathology report showed pT3N1 (2/17) and confirmed tumor free resection margins.

Conclusion
The procedure described here is feasible and performable, and achieves correct oncological results avoiding performing a total gastrectomy and improving the gastroesophageal reflux problems derived from a superior polar gastrectomy.
P199 IS ROUTINE ICU ADMISSION NECESSARY AFTER TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL AND ESOPHAGOGASTRIC JUNCTION CANCER?
Authors: Pansa Andrea , Da Roit Anna , Basato Silvia , Gentile Damiano , Riva Pietro , Marano Salvatore , Castoro Carlo 
Published: November 2019

Abstract

Aim
We evaluated short-term outcomes of esophagectomy for esophageal and esophagogastric carcinoma without routine postoperative admission to Intensive Care Unit (ICU).

Background & Methods
esophagectomy is subject to high rates of complications and mortality even when performed in high-volume centers and conventional postoperative management often involves routine ICU admission according to recent guidelines and recommendations1 .
From January 2018 to June 2019 a total of 112 esophagectomies were performed in the Upper GI Surgery division of Humanitas Research Hospital. We included the 83 patients that underwent transthoracic esophagectomy with a hybrid technique (laparoscopy + right thoracotomy) and high intrathoracic anastomosis for esophageal and esophagogastric junction cancer. Preoperative assessment included a prehabilitation program (nutritional evaluation, respiratory physiotherapy and adjustment of cardiologic therapy). Postoperatively, patients were managed by surgical team members. We retrospectively recorded data on necessity of ICU, operative times, complication rate (according to ECCG)2,3, length of hospital stay, in-hospital, 30-day and 90-day mortality.

Results
68 patients were males and 15 females. Mean age was 65 years old (range 29-82). 67 patients underwent neoadjuvant therapy (49 chemo-radiotherapy, 18 chemotherapy alone). Postoperative ICU admission was necessary in 6 patients (9,5%), reasons for admission were necessity of ventilatory weaning in 2 patients, high lactate levels in one patient, glottic oedema following oro-tracheal intubation in one patient, while in the other cases ICU admission was planned for severe comorbidities. Mean duration of prehabilitation was 20.3 days (1-107). Mean surgery duration was 452.4 minutes (337-549). Overall complication rate was 33.8%, with the most common complications being atrial fibrillation (50% of all complications) and urinary retention (20%). There were two type I anastomotic leaks. Median length of hospital stay was 11 days (range 8-29). All patients were alive at 30 and 90 days after surgery.

Conclusion
routine ICU admission is not necessary after transthoracic esophagectomy for cancer in over 90% of patients. Careful patients’ evaluation, stratification of the surgical risk and systematic use of a prehabilitation program, along with adequate peri-operative management, can narrow the need for postoperative ICU admission in the setting of a high-volume centre without any impact on short-term outcomes.
P203 PHARYNGOESOPHAGEAL RECONSTRUCTION AFTER LARYNGECTOMY AND RADIOTHERAPY
Authors: Maltzaris Nikolaos , Kotrotsiou Maria , Stavrianos Spyridon 
Published: November 2019

Abstract

Aim
The purpose of this presentation is to review our experience and evaluate our results in the treatment of patients with pharyngoesophageal fistula after laryngectomy and radiotherapy.

Background & Methods
10 patients were examined at the head and neck combined oncology clinic after previous laryngectomy and radiotherapy and pharyngocutaneous fistula with weakness to feed food as well frequent aspiration pneumonia. The interval between the effect of the laryngectomy varies between 3-5 years depending on the severity of the symptomatology and after the complete failure of the conservative methods of reconstruction.
Reconstruction was performed with musculocutaneous major pectoral flap in 8 patients, radial forearm flap and anterolateral thigh flap.

Results
The postoperative period was uncomplicated, and in all patients the feeding was held after barium swallow test, after 7-15 days with soft food. The gold standard treatment of pharyngoesophageal fistula after laryngectomy and radiotherapy is the musculocutaneous major pectoral flap and in severe radionecrosis of the neck with free tissue flap reconstruction.

Conclusion
Reconstruction with microsurgical techniques offer improved prognosis and quality of life of our patients.
P206 EVALUATION OF PREEMPTIVE MULTIMODAL ANALGESIA IN IVOR LEWIS ESOPHAGECTOMY
Authors: Papaioannou E , Doka P , Mavrommatis E , Danassi D , Kalogiannis E , Lampadariou A 
Published: November 2019

Abstract

Aim
of the study is the evaluation of preemptive multimodal analgesia vs established technique of single epidural, in Ivor Lewis esophagectomy, perioperatively.

Background & Methods
In a randomized prospective trial, 25 patients were randomly assigned to two groups (A=12: preemptive multimodal analgesia, and B=13: epidural analgesia) after informed consent. Patients with coagulative disorders, and renal or hepatic impairment were excluded from study. In all patients a thoracic epidural (T5 – T7) was placed before anesthesia induction. Anesthetic protocol was the same, according body weight, in both groups, apart from analgesic drugs. Group A patients received morphine 1.5-3mg and ropivacaine 0.25% 10-12 ml epidurally (ed), and paracetamol 1gr, parecoxib 40mg, clonidine 150mcg, dexamethasone 8mg, lidocaine 1mg/kg, and magnesium sulfate 25% 10 ml iv, at least 20 min before surgical incision, while in group B same doses of ed morphine and ropivacaine were administered post-incision and iv paracetamol and parecoxib were administered 1hr before end of surgery. Surgical incision infiltration in both wounds with ropivacaine 0.375% 20ml was performed jn both groups’ patients. Intraoperative opioid doses were titrated accordingly. Analgesic needs intra- and postoperatively, as well as vital signs stability and side effects such as postoperative nausea or vomiting (PONV), dizziness, sleepiness, and respiratory suppression were recorded.

Results
Group A patients received significantly lower opioid doses intraoperatively (p<0.001), 2 (17%) of them did not need extra opioids at all, and in 8 (67%), operation was completed with only one low dose of fentanyl (2-3mcg/kg) before abdominal surgical incision. Group A patients had stable heart rate (HR) and blood pressure (BP) during whole operation, while 11 (84.6%) from group B (p<0.001) demonstrated HR and BP raising in certain surgical times. All both groups’ patients were transferred to ICU awake. 5 (38.46%) group B patients (p>0.005) required rescue amalgesic post-awakening. None of both groups’patients demonstrated any drugs’ side effects.

Conclusion
Preemptive multimodal analgesia seems to be more efficient, reducing needs for opioids intraoperatively, rescue analgesics postoperatively and providing better hemodynamic stability, than single epidural. Further studies are needed to support this conclusion.
P208 PARAVERTEBRAL CATHETER ANALGESIA FOR MINIMALLY INVASIVE IVOR LEWIS OESOPHAGECTOMY
Authors: van den Berg J , Tabrett K , Cheong E 
Published: November 2019

Abstract

Background
Oesophagectomy is a major complex operation associated with significant morbidity and mortality. Epidural analgesia has long been the gold standard postoperative analgesia but is associated with side-effects like hypotension, epidural haematoma and infection. In an attempt to lower morbidity and enhance recovery postoperatively, we have adopted the use of paravertebral catheter analgesia (PVCA) for patients undergoing totally minimal invasive oesophagectomy (TMIO) .

Methods
Our objective was to review the current literature about the use of both PVCA and epidural analgesia. In addition, we evaluated the effect of PVCA in a large group of patients undergoing TMIO for cancer. We reviewed the records of 100 consecutive patients who had a TMIO with PVCA, spinal morphine, and PCA. Prospective independent scoring of postoperative pain, length of stay, HDU stay, PVCA failure, the use of patient-controlled analgesia (PCA), and the use of vasoconstrictor medication postoperatively was analysed.

Results
One hundred consecutive patients received PVCA with PCA after the TMIO. Catheter related failures occurred in 4 cases. The median pain score over each of the 5 days were 0. The average pain score was highest in the first 24 hours and decreased over the next 4 days postoperatively. The use of PCA was highest in the first 2 days and reduced daily over the subsequent 3 days. Seven patients required rescue analgesia in the form of intercostal nerve block. Spinal morphine was successful in 94% of cases. Vasoconstrictors were required in 19% on day 1 and 3% on day 2, postoperatively.

Conclusions
Intraoperative placement of PVCA results in good postoperative pain control after a TMIO. This technique is simple, safe, reproducible and with very low failure rates. Therefore, it should be used instead of epidural catheter analgesia.
P210 HYBRID LAPAROSCOPIC ROBOT-ASSISTED MINIMALLY-INVASIVE ESOPHAGECTOMY: A PROSPECTIVE EXPERIENCE IN A REFERRAL CENTER
Authors: Santi S , Belluomini M , D'Imporzano S , Pallabazzer G , Solito B , Bellomini M , Zenzaro M 
Published: November 2019

Abstract

Aim
To report the prospective experience in Hybrid Laparoscopic Robot-assisted Minimally-invasive Esophagectomy (HLRAMIE) in a referral Center.

Background & Methods
The minimally-invasive esophagectomy (MIE) is an attractive and established technique to improve the reduction of post-operative morbility with sound oncological results. The hybrid combination of laparoscopy and full robotic thoracic phase (HLRAMIE) is an approach aimed to be as effective as MIE to treat esophageal neoplasms.
Inclusion criteria: patients undergone to multimodal medical advice panel, affected from non-cT4, from mid thoracic to cardia, esophageal neoplasms, with and without neoadjuvant treatment, fit for minimally-invasive surgery. HLRAMIE: laparoscopic stage plus full robotic thoracic stage by Da Vinci Xi® (Intuitive Surgical, US), with gastric-pull first-choice conduit. Prospective, dedicated database.

Results
From October 2015 to April 2019, 33 patients underwent to HLRAMIE (site of neoplasm: 1 mid thoracic; 9 inferior; 23 cardia). 5 out 33 were converted to open. 27/28 underwent to a Ivor Lewis esophagectomy, 1/28 to McKeown procedure. The mean total surgical time was 517 minutes, mean robotic docking time 12 min with mean thoracic time 269 min (positive trend). Gastric pull-up was performed in 28/28. In 23/28 patients the esophago-gastric anastomosis was performed full robotic after the fashion of hand, in 5/28 was performed by circular stapler. The mean extubation time was 12 hours. The mean number of lymph node removed was: overall fields 32.4 (range 15-58), thorax 9.8 (3-27). The mean number of metastatic lymph node was 3.8 (0-18). 100% were R0 resections. The mean hospital-stay was 15 days. The perioperative mortality and 30-day mortality were both 0%. The overall post-operative morbility was 32.1%. 4/28 (14.2%) patients developed an anastomotic leakage, 75% were managed by endoscopy. 11/28 (39.2%) patients developed a late anastomotic stenosis (all in the hand made group).

Conclusion
In our experience, HLRAMIE is surgically reproducible with the principle of learning curve; oncologically adequate in relation to radical dissection; safe and effective in relation to post-operative early morbility and mortality. Long-term follow up and more powerful, randomized series are needed to establish the definitive clinical and oncological results of HLRAMIE.
P213 PROGNOSTIC SIGNIFICANCE OF CHANGES IN LYMPH NODE MORPHOLOGY ON SURVIVAL IN ESOPHAGEAL CANCER AFTER NEOADJUVANT THERAPY: A SYSTEMATIC REVIEW AND META-ANALYSES
Authors: Eliza Hagens , Karina Tukanova , Sara Jamel , Mark van Berge Henegouwen , George B Hanna , Suzanne Gisbertz , Sheraz R Markar 
Published: November 2019

Abstract

Aim
To assess the prognostic significance of lymph node regression or downstaging following neoadjuvant therapy for esophageal cancer.

Background and methods
The prognostic value of histomorphologic regression in the primary esophageal cancer has been established, whilst the impact of lymph node response on survival still remains unclear.
An electronic search was performed to identify articles evaluating lymph node regression or downstaging after neoadjuvant chemo- or chemoradiotherapy. Random effects meta-analyses were performed for regression and downstaging and primary outcome was the hazard ratio (HR) for overall mortality. Survival data were compared between patients with complete regression and those with partial or no response. Histopathological tumor regression in lymph nodes was defined by the absence of viable cells or degree of fibrosis. Furthermore, survival of patients with downstaged lymph nodes to N0 were compared to those with positive nodes following treatment.

Results
Eight articles were included, 4 of which assessed tumor regression (number of patients=789) and 4 assessing downstaging (number of patients=1937). Complete tumor regression (average rate of 30.0%) in the lymph nodes was associated with higher survival [HR= 0.63, 95% CI (confidence interval) = 0.43 – 0.92; p=0.017] (figure 1). Lymph nodes downstaging (average rate of 47.6%) had improved survival compared to node positivity (HR = 0.38, 95% CI = 0.29 – 0.50; p<0.0001) (figure 2).

Conclusion
A prognostic benefit was seen in patients with good lymph node response to neoadjuvant therapy, suggesting this should be used as an important additional prognostic marker in staging and in comparative evaluation of different neoadjuvant regimes.