bluuebunny/crossref_metadata_2025_split huggingface dataset:
P68 DEFINITIVE RESULTS OF THE HELLER MYOTOMY ASSOCIATED WITH THE DOR FUNDOPLICATION PERFORMED WITH INTRAOPERATIVE MANOMETRY FOR THE PRIMARY SURGICAL TREATMENT OF ESOPHAGEAL ACHALASIA: ONE CENTER EXPERIENCE
Authors: Valentina Tassi , Marialuisa Lugaresi , Benedetta Mattioli , Niccolò Daddi , Vladimiro Pilotti , Sandro Mattioli 
Published: November 2019

Abstract

Objective
In 1978 the Heller-Dor operation was proposed to accomplish new concepts of surgical pathophysiology: to abolish the lower esophageal sphincter with the division of the U-and sling fibers of the lesser gastric curvature, to prevent GER with an effective but not too effective partial fundoplication which protects the myotomy surface. Proponents performed this operation under intraoperative manometric control. We report on results we achieved in the period 1978-2016.

Methods
The Heller-Dor was performed in 367 patients (laparotomy 1978-1993, 209, 96 men; median age, 45 years; IQR 31.8–59.4 years, laparoscopy 1994-2016,158, 78 men; median age, 48 years; IQR 35.5–63.7 years; age p=0.166; gender p=0.346). Intraoperative manometry was performed and interpreted according to standard criteria. Follow-up consisted of periodical interview, endoscopy, barium swallow, which reports were graded in semiquantitative scales of evaluation.

Results
Mortality occurred in 1/209 (heart failure), 1/158 (coagulation disorder). Median follow-up was 193 months (IQR 137.1–273.4 months) in the laparotomy group, 95 months (IQR 71.1–140 months) in the laparoscopy group. Myotomy achieved the complete abolition of the high pressure zone in 100% of the patients in both groups. In the laparotomy group poor results were assessed in 22 (10.5%), for esophagitis in 15 and recurrent dysphagia in 7 with sigmoid achalasia. In the laparoscopy group poor results occurred in 7 (4.3%), 5 for esophagitis and 2 for recurrent dysphagia in sigmoid achalasia. In the second period the fundoplication was always sutured to the diaphragm to avoid slipping, the number of sigmoid esophagus cases decreased significantly. In the laparotomy group, gastroesophageal reflux and esophagitis appeared after a median period of 74.8 months since myotomy, recurrent dysphagia was evident shortly after surgery.

Conclusions
In light of the timing of appearance of causes of poor results assed in the laparotomy group, we consider the 95.7% of satisfactory results achieved with the laparoscopic Heller-Dor after 95 months median follow up, the indicator of potential of cure of this operation.
P69 INTRAOPERATIVE ENDOSCOPY IS OF A GREAT IMPORTANCE IN COMPLEX REVISIONAL UPPER GI SURGERY. CASE PRESENTATION OF RECURRENT ACHALASIA PREVIOUSLY TREATED WITH 3 LAPAROSCOPIC HELLERS CARDIOMYOTOMIES.
Authors: Vrakopoulou Gavriella-Zoi , Daniel Foley , Edel Smyth , Abraham Botha 
Published: November 2019

Abstract

Aim
To demonstrate the ability to perform increasingly complex revisional surgery utilising minimally invasive techniques and synchronous endoscopy for recurrent achalasia.

Background & Methods
We present a case of recurrent achalasia previously treated with 3 laparoscopic Hellers cardiomyotomies. Traditionally such a case would be considered for either open revisional surgery or oesophagectomy. In this case a fourth laparoscopic Hellers cardiomyotomy was succesfully performed using 3D laparoscopy combined with synchronous intraoperative endoscopy. The 3D video footage we present demonstrates the added safety provided by depth perception and high resolution imaging in revisional laparoscopic surgery. Synchronous endoscopy confirms altered anatomy, pathology and luminal change from extraluminal interventions resulting in prompt recognition of LES and subsequent efficient gastric myotomy.

Results
After a laborious adhesiolysis using the advantages of 3D imaging system we faced difficulties recognizing the exact LES location, in order to proceed with the gastric myotomy. In our opinion this could be the reason for previous treatment failures. At this point the use of synchronous flexible endoscopy enabled the recognition of cardia, so we could safely and efficiently complete a fourth laparoscopic Hellers cardiomyotomy including repair of a distal oesophageal diverticulum and a substantially lengthened gastric myotomy. This resulted in a substantial improvement in dysphagia symptoms with the patient resuming consumption of liquid and solid food as well.

Conclusion
Early adoption of technological advancements facilitates organ preserving revisional surgery and the avoidance of significant patient morbidity. These techniques radically increase the safety profile of minimally invasive surgery by facilitating anatomic recognition and provisioning for tailored intervention.
P70 SEVERE DUMPING SYMPTOMS ARE UNCOMMON FOLLOWING TRANSTHORACIC ESOPHAGECTOMY BUT SIGNIFICANTLY DECREASE HEALTH-RELATED QUALITY OF LIFE IN LONG-TERM, DISEASE FREE SURVIVORS
Authors: Klevebro F , Boshier P R , Savva K V , Waller A , Hage L , Hanna G B , Low D 
Published: November 2019

Abstract

Aim
The aim of the study was to increase the knowledge about dumping symptoms after esophagectomy and the association to health-related quality of life.

Background and Methods
High quality documentation of dumping symptoms after esophagectomy is currently limited. The aim of the study was to describe the incidence of symptoms associated with dumping syndrome and their relationship with health-related quality of life after esophagectomy.
The study cohort was identified from prospective IRB-approved databases from two high volume esophagectomy centers. Patients that were alive and without evidence of recurrence in April 2018 completed the validated Dumping Symptom Rating Scale and health-related quality of life questionnaires. Compound dumping symptom score was created by combining the individual scores for severity and frequency for each symptom.

Results
In total, 171 patients who underwent esophagectomy 1995-2017 responded to the questionnaires, corresponding to a response rate of 77.0%. Median age was 66 years and median time from operation to survey was 5.5 years. Absent or mild problems in all nine dumping symptoms were reported by 94 (59.5%) patients, 19 (12.0%) patients reported moderate or severe problems in at least three symptoms, the most common being “a need to lie down,” “diarrhea,” and “stomach cramps.” Increasing compound dumping symptom score was associated with significantly decreased function scores in all aspects of health-related quality of life except physical functioning (P<0.005).

Conclusions
Esophagectomy has the potential to change long-term eating patterns, however the majority of patients in the study did not have severe postoperative dumping symptoms. On the other hand moderate to severe dumping symptoms, which were reported by 12% of patients in this study were strongly associated with decreased health-related quality of life.
P72 IS OPEN LEFT THORACO-ABDOMINAL ESOPHAGECTOMY A VIABLE OPTION IN THE ERA OF MINIMALLY INVASIVE ESOPHAGECTOMY?
Authors: Klevebro F , Boshier P , Mueller C , Cools-Lartigue J , Ferri L , Low D 
Published: November 2019

Abstract

Aim
To evaluate short-term and oncological outcomes of left thoracoabdominal esophagectomy compared to minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction

Background and Methods
Left thoracoabdominal esophagectomy (LTE) facilitates complete resection of esophageal cancer particularly for bulky tumors, but there are concerns that this approach is associated with significant morbidity.
Prospectively entered esophagectomy databases from two high volume North American centers were reviewed for patients undergoing LTE or MIE in the 2012-2018. Patient demographics, tumour characteristics, operative outcomes, postoperative outcomes, and pathologic surrogates of oncologic efficacy (R0 resection rate, and number of resected lymph nodes) were compared.

Results
In total 247 patients were included in the study, LTE was applied in 170 (68.8%) patients, and MIE in 77 (31.2%) patients. LTE patients had more neoadjuvant treatment (LTE=78.2%, MIE=34.2%, P<0.001). There was no difference in overall postoperative complications (LTE=56.9%, MIE=55.0%, P=0.799), severe complications (Clavien Dindo>2 - LTE=26.1%, MIE17.0%, P=0.184), pulmonary complications (LTE=31.9%, MIE=20.0%, P=0.085), pneumonia (LTE=15.2%, MIE=13.6%, P=0.768), anastomotic leak (LTE=7%, MIE=10%, P=0.396), or postoperative mortality (LTE=0%, MIE=1.3%, P=0.140). Median length of stay was 7 days in both groups. R0 resection rate was 93.8% and 95.5% respectively (P=0.631). Median number of resected lymph nodes was 24 for LTE and 22 for MIE (P=0.226). LTE had more stage II-IV tumors (LTE=67.8%, MIE=40.7%, P<0.001), and more node positive resections (LTE=52.5%, MIE=31.4%, P=0.003).

Conclusion
LTE was used for larger tumors with greater lymph node burden in patients that were more likely to have received neoadjuvant treatment compared to MIE. Despite this the postoperative morbidity was equal to that of MIE, with no difference in short-term or oncological results in this cohort.
P79 CRITICAL APPRAISAL ON THE IMPACT OF SMOKING STATUS ON PERIOPERATIVE MORBIDITY, MORTALITY AND LONG-TERM SURVIVAL FOLLOWING OESOPHAGECTOMY FOR OESOPHAGEAL CANCERS: A TERTIARY UNIT ANALYSIS
Authors: Sivesh K Kamarajah , Maziar Navidi , Michael Griffin S , Alexander W Phillips 
Published: November 2019

Abstract

Aim
This study aimed to characterise morbidity and mortality profile by smoking status in patients undergoing oesophagectomy for oesophageal cancers.

Background
Oesophagectomy remains the mainstay for curative treatment of oesophageal cancer. Despite improvements in perioperative care, little is understood on the impact of smoking status on perioperative morbidity and mortality following oesophagectomy for oesophageal cancers.

Methods
Consecutive patients undergoing oesophagectomy cancer (adenocarcinoma or squamous cell carcinoma) between 1997 - 2016 at the Northern Oesophagogastric Unit were included from a contemporaneously maintained database. Primary outcome was overall survival. Secondary outcomes include overall complications, anastomotic leaks and pulmonary complications.

Results
During the study period, 1207 patients underwent oesophagectomy for cancer. Of these 1207 patients, most were current (74%) smokers with only 20% non-smokers. Median survival of current smokers was significantly shorter than ex-smokers and non-smokers (median: 35 vs 42 vs 44 months, p=0.031). On adjusted analysis, there were no significant difference in survival between non-smokers and ex-smokers with current smokers. Rates of overall complications were significantly higher with current smokers compared to ex-smokers or non-smokers (73% vs 66% vs 62%, p=0.015). There were no significant differences in anastomotic leaks and pulmonary complications between the groups.

Conclusion
In summary, this study demonstrated that current smokers have significantly reduced long-term survival compared to ex-smokers or never smokers, specifically patients undergoing surgery only or those with SCC. Future studies in patients with neoadjuvant therapy to further delineate genetic landscape of oesophageal cancers to identify high risk groups that may warrant further multimodality therapy.
P80 LONG-TERM OUTCOMES OF CLINICAL AND PATHOLOGICAL-STAGED T3N3 ESOPHAGEAL CANCER
Authors: Kamarajah S K , Newton N , Navidi M , Wahed S , Immanuel A , Hayes N , Griffin S M , Phillips A W 
Published: November 2019

Abstract

Objective
The aim of this study was to determine the outcomes of patients with T3N3 esophageal cancers and determine differences between the clinical stage and pathological stage.

Background
Locally advanced esophageal cancer is associated with poor long-term survival. Pre-treatment and post-treatment stage may differ due to the effect of neoadjuvant therapy and inaccuracies in staging. Multimodality staging followed by discussion at an MDT is considered the gold standard. Despite this, patients can be under-staged or over-staged leading to inadequate or unnecessary treatment associated with high levels of morbidity.

Methods
Consecutive patients from a single unit between 2010 - 2018 were included with either clinical (cT3N3) or pathological (pT3N3) esophageal cancer. Outcomes were compared between patients that underwent transthoracic esophagectomy and radical two field lymphadenectomy with or without neoadjuvant treatment and those patients staged cT3N3 treated non-surgically (NSR). Demographics, clinical and pathological stage, histological information and outcomes were recorded. Patients were staged using the TNM 8.

Results
This study included 156 patients, of which 63 had non-surgical treatment, only 3 of these had radical treatment. Of the remaining 93 patients who underwent esophagectomy, 34 were cT3N3, 54 were pT3N3 and five were unchanged before and after treatment. Median overall survival (OS) for surgical cT3N3 patients was significantly longer than pT3N3 and NSR (median: NR vs 19 vs 8 months, p<0.001). Twenty-seven patients with cT3N3 had lower staging following treatment whilst 3 had a higher stage.

Conclusion
T3N3 disease carries a poor prognosis. Within this cohort cT3N3 disease treated surgically has a high 5-year overall survival suggesting possible over-staging and stage migration due to neoadjuvant therapy. To contrast this those not having surgery have a dismal prognosis. The impact of neoadjuvant treatment cannot be predicted and, current staging modalities may be inaccurate. Clinical stage should be used with caution when counselling patients regarding management and prognosis.
P82 A PROPENSITY SCORE MATCHED COHORT STUDY TO EVALUATE THE ASSOCIATION OF LYMPH NODE RETRIEVAL WITH LONG-TERM OVERALL SURVIVAL IN PATIENTS WITH ESOPHAGEAL CANCER
Authors: Leonie R van der Werf, , Elske Marra, PhD , Suzanne S Gisbertz, PhD , Bas P L Wijnhoven, PhD , Mark I van Berge Henegouwen, PhD 
Published: November 2019

Abstract

Introduction
Previous studies evaluating the association of LN yield and survival presented conflicting results and many may be influenced by confounding and stage migration. This study aimed to evaluate whether the quality indicator ‘retrieval of at least 15 lymph nodes (LNs)’ is associated with better long-term survival and more accurate pathological staging in patients with esophageal cancer treated with neoadjuvant chemoradiotherapy and resection.

Methods
Data of esophageal cancer patients who underwent neoadjuvant chemoradiotherapy and surgery between 2011-2016 was retrieved from the Dutch Upper Gastrointestinal Cancer Audit. Patients with <15 LNs and ≥15 LNs were compared after propensity score matching based on patient and tumor characteristics. The primary endpoint was 3-year survival. To evaluate the effect of LN yield on the accuracy of pathological staging, pathological N-stage was evaluated and 3-year survival was analyzed in a subgroup of patients node-negative disease.

Results
In 2260 of 3281 patients (67%) ≥15 LNs were retrieved. In total, 992 patients with ≥15 LNs were matched to 992 patients with <15 LNs. The 3-year survival did not differ between the two groups (57% versus 54%, p=0.28). pN+ was scored in 41% of patients with ≥15 LNs versus 35% of patients with <15 LNs. For node-negative patients, the 3-year survival was significantly better for patients with ≥15 LNs (69% versus 61%, p=0.01).

Conclusions
In this propensity score matched cohort, 3-year survival was comparable for patients with ≥15 LNs, although increasing nodal yield was associated with more accurate staging. In node-negative patients, 3-year survival was higher for patients with ≥15 LNs.
P84 LOCALIZATION OF UNDETECTED RESIDUAL TUMOR AFTER NEOADJUVANT CHEMORADIOTHERAPY IN PATIENTS WITH ESOPHAGEAL CANCER
Authors: van der Wilk B J , Doukas M , Eyck B M , Spaander M C W , Schoon E J , Krishnadath K K , Oostenbrug L E , Lagarde S M , Wijnhoven B P L , Biermann K , van Lanschot J J B 
Published: November 2019

Abstract

Introduction
The preSANO-trial aimed to determine accuracy of clinical response evaluations (CREs) after neoadjuvant chemoradiotherapy (nCRT) in patients with locally-advanced esophageal cancer. After introduction of the ‘bite-on-bite’ biopsy-technique, most residual tumors were detected. Aim of this study was to determine the location of residual tumors that were not detected during CREs and whether or not endoscopic (bite-on-bite) biopsies had the theoretical potential to detect these tumors.

Methods
In this side-study of the prospective preSANO trial, biopsies and resection specimens were independently revised by two GI-pathologists. All patients were included that had residual tumor in the resection specimen that was not detected during two clinical response evaluations, 6 and 12 weeks after completion of nCRT. In the resection specimen, the tumor regression grade was defined for each esophageal wall layer. It was determined how often submucosal tumors under a tumor-free mucosal layer were missed during CREs. Biopsies taken during CREs were revised for the presence of submucosal tissue. This was defined as presence of submucosal structures, i.e. submucosal glands and/or thick-walled vessel-structures.

Results
Some 103 of 207 patients underwent CREs followed by surgery. Residual tumor was not detected during CREs in 33 patients. Resection specimens of 28 of these patients were available for revision. Missed residual tumors were located in the mucosal layer of the esophageal wall in 64% of these patients. Residual tumors were located in the submucosal layer, under a tumor-free mucosal layer, in 29% of patients. One patient still had tumor under a tumor-free mucosal- and submucosal layer. Submucosal structures were detected in two patients and it was uncertain whether submucosal tissue was present in six patients, while no specific submucosal structures were detected in 21 patients.

Conclusion
The majority of patients in whom residual tumor remained undetected during clinical response evaluations had tumor cells in the mucosal layer of the esophageal wall. Nearly one third of the patients had tumor in the submucosal layer under a tumor-free mucosa. Whether these submucosal tumors can be detected using endoscopic biopsies is uncertain. Further improvement of the accuracy of CREs should focus on sampling of larger mucosal areas, for example by using brush techniques.
P86 COMBINED ENDOSCOPIC AND SURGICAL PROCEDURE FOR EXCISION OF A GIANT FIBROVASCULAR POLYP
Authors: T Fraser , H Wadhawan , A Ariyarathenam , T Malik , T Wheatley , G Sanders , L Humphreys , R Berrisford 
Published: November 2019

Abstract

Aim
Giant fibrovascular polyp of the oesophagus is a rare benign condition.(1) We share our experience of removing a particularly large lesion and describe a combined endoscopic and surgical procedure used to remove it through only a cervical incision.

Background & Methods
A 53 year old year old female was referred to our department following endoscopy which demonstrated a giant fibrovascular polyp. A literature search was performed using EMBASE and Pubmed databases to identify any relevant case reports and articles. Written consent for presentation of the case and use of images was obtained from the patient.

Results
Surgery was carefully planned with thorough pre-operative assessment. Upper GI endoscopy was initially performed and a radio-opaque feeding tube was positioned around the base of the polyp and withdrawn proximally to delineate the proximal origin of the lesion in theatre with an image intensifier. A cervical oesophagotomy was performed under endoscopic guidance. The base of the polyp was divided with sharp dissection and transfixed. The polyp was then successfully delivered via the cervical oesophagotomy without causing any further trauma. The patient made a good recovery without any complications at follow-up.

Conclusion
Intraoperative endoscopy with a radio-opaque sling in these patients can direct the site of the cervical oesophagotomy, which can be guided to avoid the stalk of the lesion by an endoscope within the oesophagus.
P87 FLUORESCENCE ANGIOGRAPHY OF THE ANASTOMOTIC SITE DURING ESOPHAGECTOMY: TIME TO ENHANCEMENT AS QUANTITATIVE VALUE TO PREDICT ANASTOMOTIC LEAKAGE
Authors: Slooter¹ M D , de Bruin D M , Eshuis¹ W J , Gisbertz¹ S S , van Berge Henegouwen¹ M I 
Published: November 2019

Abstract

Aim
In this study we correlated time to fluorescent enhancement as a quantitative value of intraoperative fluorescence angiography (IFA) to anastomotic leakage (AL) after esophagectomy with gastric conduit reconstruction.

Background & Methods
IFA seems a helpful technique to visualize anastomotic perfusion after esophagectomy. However, IFA is interpreted subjectively. To evaluate fluorescence objectively and find a threshold to predict AL, we evaluated time to fluorescence enhancement.
All consecutive patients undergoing elective esophagectomy with gastric conduit reconstruction for a one-year period since the introduction of IFA in June 2018 were prospectively recorded. IFA was performed after injection of indocyanine green (ICG) before and/or after anastomotic reconstruction. During IFA, time to fluorescent enhancement was recorded (time points: ICG injection, enhancement in lung, base of gastric conduit, planned anastomotic site, tip of gastric conduit). The anastomotic site was changed according to subjective interpretation of IFA. AL was classified according to the ECCG classification.

Results
Sixty-five patients underwent esophagectomy with gastric conduit reconstruction for esophageal cancer. The anastomosis was either constructed in the cervical (13/65, 20%) or intrathoracic (52/65, 80%) region. The anastomotic site was adjusted due to IFA in 3/65 (4.6%) cases. AL occurred in 7/65 (10.8%) patients and in 1/3 (33.3%) after change of anastomotic site. Before anastomotic reconstruction, time between ICG injection and enhancement of the tip (injection-tip) and time between enhancement in the lung and base of the conduit (lung-conduit) were significantly correlated with AL (p=0.027 and p=0.042, respectively). ROC curve analysis revealed a cut-off value of 61 seconds for injection-tip with an area under the curve (AUC) of 0.91 and corresponding sensitivity 82.9% and specificity 100%. For lung-conduit a cut-off value of 11 seconds was found with an AUC of 0.71 and corresponding sensitivity 63% and specificity 83%.

Conclusion
In this study cut-off values for the time between injection-tip and lung-conduit were derived to predict AL after esophagectomy. Time to fluorescent enhancement is a quantitative fluorescent parameter, which is easy to implement, as no software is required. However, a larger cohort needs to be observed for potential significance of the difference between other time points and to confirm these thresholds.