bluuebunny/crossref_metadata_2025_split huggingface dataset:
O45 THE ASSOCIATION OF PERIOPERATIVE QUALITY-OF-CARE PARAMETERS (TEXTBOOK OUTCOME) WITH LONG TERM OUTCOME AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER
Authors: Kalff M C , Vesseur I , Eshuis W , Heineman D , Daams F , van der Peet D L , Gisbertz S S , van Berge Henegouwen M I 
Published: November 2019

Abstract

Aim
The objectives of this study were to confirm the association of textbook outcome (TO) and overall long-term survival after esophagectomy for esophageal cancer, to investigate the relationship of TO and recurrence rates and to identify clinicopathological predictors for not achieving TO.

Background & Methods
Despite current improvements in the multimodal treatment of esophageal cancer, surgery remains the key component. Therefore, it is essential to optimize the surgical procedure and to pursue the highest surgical quality. TO is a composite measure of ten perioperative parameters reflecting the quality of surgical care concerning esophagectomy.
All patients with esophageal cancer who underwent a transthoracic or transhiatal esophagectomy with curative intent in two tertiary referral centers in The Netherlands between 2007-2016 were included. Patients with a carcinoma in situ, patients undergoing salvage or emergency procedure and patients that applied for opt-out were excluded. Clinicopathological predictors for not achieving TO were identified using univariate and multivariate logistic regression. Survival was compared using Kaplan-Meier life-table estimates and cox regression.

Results
In total, 1057 patients were included. Over time, the percentage of patients who achieved TO increased from 28.9% in 2007 to 37.5% in 2016. BMI under 18.5, ASA score above one and age above 65 years were associated with a worse TO rate (OR 2.72 [1.02-7.24], ASA 2 OR 1.57 [1.13-2.17] and ASA 3+4 OR 2.33 [1.56-3.48], OR 1.387 [1.06-1.81], respectively), whereas neoadjuvant treatment predicted a better TO rate (OR 0.58 [0.41-0.81]). The median overall survival was 53 months (95% CI 42 – 63) for patients with TO and 35 months (95% CI 29 – 41) for patients without TO; resulting in an overall survival benefit of 18 months (HR 0.759, 95% CI 0.636 – 0.906, P = 0.002). The recurrence rates between TO and no-TO differed, but was not statistically significant (47.1% vs 42.8%, P = 0.177).

Conclusion
BMI less than 18.5, ASA-score higher than one and age older than 65 were characteristics associated with not achieving TO. Neoadjuvant therapy was associated with a better TO rate. Achieved TO resulted in a better overall five-year survival indicating the importance of pursuing TO.
P46 TRANSTHORACIC VERSUS TRANSHIATAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A NATION-WIDE PROPENSITY SCORE MATCHED COHORT ANALYSIS
Authors: MC Kalff , AC Mertens , WJ Eshuis , MI van Berge Henegouwen Prof , SS Gisbertz 
Published: November 2019

Abstract

Aim
The current study aims to compare transthoracic and transhiatal esophagectomy in a propensity score matched nation-wide cohort study.

Background & Methods
Chemoradiotherapy followed by resection is the standard therapy for resectable esophageal carcinoma in the Netherlands. The optimal surgical approach remains a matter of debate.
Data was acquired from the Dutch Upper-GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma from 2011-2016 were included. Patients with missing baseline data and patients undergoing emergency or hybrid surgery were excluded. Patients who underwent a transthoracic (TTE) or transhiatal (THE) esophagectomy were compared after propensity score matching.

Results
After propensity score matching, 1532 patients were included for analysis. The transthoracic approach yielded more lymph nodes (median 19 vs 14; p<0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher after TTE (p=0.044). The TTE group experienced more chyle leakage (9.7% vs 2.7%, p<0.001) and more pulmonary (35.5% vs 26.1%, p<0.001) and cardiac complications (15.4% vs 10.3%, p=0.003). The TTE group required a longer hospital stay (median 14 vs 11 days, p<0.001), ICU stay (median 3 vs 1 day, p<0.001) and had a higher early mortality rate (4.0% vs 1.7%, p=0.009). Subgroup analysis on anastomotic level showed that TTE with intrathoracic anastomosis (TTEi) had a significantly lower recurrent nerve lesion incidence (0.5%) compared to TTE with cervical anastomosis (TTEc) (7.4%, p=<0.001) and THE (5.9%, p=<0.001). There was no statistical difference in anastomotic leakage rates on anastomotic level, however incidence was lowest after TTEi (TTEc 21.5%, TTEi 15.1%, THE 19.5%). The higher early mortality rate after TTE was mainly caused by TTEc (4.6%), however, only the difference of early mortality between TTEc and THE (1.7%) reached statistical significance (p=0.006).

Conclusion
TTE provided a more extensive lymph node dissection which resulted in a higher N-stage, at the cost of increased morbidity and short-term mortality. Although results in high-volume centers are often superior, these data reflect nationwide results. Future research should investigate if a more extensive lymph node dissection leads to an improved long-term survival.
P47 A PREDICTION MODEL OF HOSPITAL STAY AFTER ESOPHAGECTOMY WITHIN AN ENHANCED RECOVERY AFTER SURGERY (ERAS) PATHWAY
Authors: Parise Paolo , Cossu Andrea , Puccetti Francesco , Palucci Marco , Cerchione Raffaele , Olivari Greta , Rosati Riccardo 
Published: November 2019

Abstract

Background and aims
ERAS principles have been applied even in oesophageal surgery, however low compliance and high rates of deviation from protocols are often reported. Aim of this study was to assess whether ERAS protocol deviation and other perioperative factors could be associated with a delayed discharge.

Methods
Patients who underwent esophagectomy at our Institution between 2014 and 2017 were included in the study. All patients were managed according to our perioperative ERAS protocol. In-hospital deaths were excluded. All data were prospectively entered in an electronic database. The 8th postoperative day (POD) was considered as the ideal day for discharge and therefore our outcome. A retrospective analysis of most relevant ERAS items and clinical features was conducted in order to identify variables positively or negatively associated to a delayed discharge. Variables associated with our outcome were exploited to build a score able to predict delayed discharge. An initial validation of the accuracy of the score was carried out on a separate patients’ sample. A χ2 test assessed association between outcome and categorical variables. Adapted standardized residuals of multilevel categorical variables allowed a dichotomous division. A new χ2 test confirmed the association. A ROC curve approach evaluated the role of continuous variables as markers of hospitalization longer than outcome. A χ2 test assessed the presence of association between the dichotomized variable and outcome. Backward logistic binary regression selected significant predictors with a selection criteria of p-value of <.05.

Results
286 esophagectomies were included in the study. ASA score *** 3, surgery duration *** 255 minutes and failure to mobilize within 24 hours were associated with a delayed discharge. “Hybrid” oesophagectomy was linked to a discharge within the target day. The logistic regression model was statistically significant (p < 0,001) and correctly classified 81,9% of cases. Sensitivity was 96,6%. Positive predictive value was 83,6% and negative 45,4%. The predictive score system, once applied to control population, correctly identified 100% of those discharged after 8th POD.

Conclusions
Our results seem to be clinically meaningful. All these parameters can be retrieved within the first 24 hours. The initial validation revealed good predictive properties.
P48 MEDIASTINOSCOPY-ASSISTED ESOPHAGECTOMY FOR AN UPPER THORACIC SQUAMOUS CELL CARCINOMA IN A PATIENT WITH LIVER CIRRHOSIS
Authors: Faiz Z , Rihuete-Caro C , Daiko H 
Published: November 2019

Abstract

Background
The standard treatment for T1a esophageal cancer (EC) is endoscopic submucosal dissection (ESD), whereas in T1b cancer is esophagostomy with lymph node dissection performed. The lesions infiltrated into the middle one-third (SM2) have in 36% of cases lymph node metastasis. Moreover, 41% of patients with SM2 cancer and lymphovascular invasion can develop recurrent cancer. Surgical resection is the recommended treatment. However, surgery could deteriorate the general condition and quality of life of patients with several chronic diseases. Hence, it is necessary to develop less invasive surgical approaches for this category of patients [1-2].

Methods
Mediastinoscopy-assisted esophagectomy (MAE) is one of the less invasive surgical approaches for EC patients with severe co-morbidities [3]. MAE facilitates direct visualization of the mediastinal organs and dissection of the mediastinal lymph nodes [3]. Thoracotomy could be avoided in MAE with less retention time and reduced volume of drainage in 24 h. However, MAE is still not widely performed because of the controversy about lymphadenectomy. This disadvantage could be covered by improving the surgical technique and instruments [4, 5].

Results
A 49-year-old man with Child Pugh Class A liver cirrhosis and portal hypertension underwent MAE with side to end anastomosis after ESD of an upper (23-30 cm) pT1b (SM2) well differentiated squamous cell carcinoma with lymphovascular invasion. The considerations for the mediastinoscopy-assisted esophagostomy were the presence of co-morbidities, not having lymph node metastasis in the clinical stage and the presence of lymphovascular invasion in the specimen. After esophagectomy, pathological investigation revealed squamous cell carcinoma in-situ (Tis, 12 x 8 mm) of the upper part of esophagus with no ductal involvement, absence of lymphovascular invasion and no lymph node metastasis (0/9). The patient had no postoperative complications.

Conclusion
MAE is a feasible and less invasive surgical approach in EC patients with severe co-morbidities, although there is a limitation in curative dissection of the mediastinal nodes. Direct vision of the mediastinal structures during MAE predicts organ injury and may affect postoperative morbidity and mortality.
P49 A HIATAL HERNIA >3CM IS ASSOCIATED WITH WORSE RESPONSE TO NEOADJUVANT TREATMENT IN ESOPHAGEAL CANCER PATIENTS
Authors: Styliani Mantziari , Penelope St-Amour , Michael Winiker , Clarisse Drmain , Sebastien Godat , Alain Schöpfer , Nicolas Demartines , Markus Schäfer 
Published: November 2019

Abstract

Aim
The aim of this study was to assess whether a preoperative HH≥3cm had an impact on histopathologic tumor response after neoadjuvant treatment, as well as on overall and disease-free survival.

Background & Methods
Hiatal hernia (HH) and long-term gastroesophageal reflux are known risk factors for esophageal cancer. Previous data suggest a negative impact of large hiatal hernias on survival after esophagectomy, as well as an increased toxicity after neoadjuvant treatment (1), although evidence remains scarce and the mechanism is not fully elucidated.
All consecutive patients who underwent surgical esophagectomy for adenocarcinoma or squamous cell cancer of the esophagus and gastro-esophageal junction from 2012-2018 were assessed. Baseline oesogastroduodenoscopy reports and CT-scan images were retrospectively reviewed to identify the presence of a HH of ≥3cm (2). Response to neoadjuvant treatment as assessed by the Mandard score (3), postoperative outcomes and survival were compared between HH and non-HH patients (defined as HH<3cm or no HH at all). Categorical variables were compared with the x2 or Fisher’s test, whereas continuous ones with the Mann-Whitney-U test. The Kaplan-Meier method and log-rank test were used for survival analyses.

Results
Among the 174 included patients, 44 (25.3%) had a HH≥3cm upon diagnosis. HH patients compared to the non-HH had significantly more Barrett’s metaplasia (52.3% vs 20%, p<0.001), although no differences in baseline stage were observed. HH patients presented a worse response to neoadjuvant treatment compared to non-HH patients (TRG 4-5 in 40.5% vs 21.3%, p=0.033). Among HH patients, perioperative chemotherapy compared to radiochemotherapy showed a trend to higher complete response rates (TRG 1 in 25% vs 11.5%, p=0.059). In the radiochemotherapy subgroup (n=112), HH patients had worse complete response rates than non-HH patients (TRG 1 in 11.5% vs 26.7% respectively, p=0.050). However, no differences in overall or disease-free survival were observed between HH and non-HH patients in the whole cohort or in subgroup analyses.

Conclusion
A HH≥3cm is frequently encountered in esophageal cancer patients. The presence of HH was associated with worse response to neoadjuvant treatment, especially radiochemotherapy. However, the presence HH did not have an impact on long-term survival and recurrence.
P51 NUTRITIONAL DEFICIENCY POST OESOPHAGO-GASTRIC SURGERY IN CANCER PATIENTS
Authors: Pushpa Veeralakshmanan Ji Chung Tham , Himanshu Wadhawan , Amy Wright , Marilyn Bolter , Richard Berrisford , Lee M Humphreys , Tim Wheatley , Grant Sanders , Arun Ariyarathenam 
Published: November 2019

Abstract

Aim
Postoperative nutritional status is an important prognostic factor in patients undergoing oesophagectomy or gastrectomy for malignant tumours. The deterioration in nutritional status post oesophagectomy is seen more profoundly after 6 months of surgery [1]. In our unit, we successfully implemented Allied Health Professionals (AHP) led clinics consisting of cancer nurse specialist and specialist dietician to conduct routine follow-up for 5 year duration post oesophago-gastric surgery to help identify and manage nutritional deficiencies.

Background & Methods
AHP led outpatient clinic was established in February 2017. Between February 2017 and February 2018, all patients who were eligible and who attended the AHP clinic at our tertiary unit were included in the study. All patients who attended the clinic, had micronutrient screening in particular ferritin, folate, vitamin B12 and vitamin D. Patients were screened for exocrine pancreatic insufficiency (EPI) through series of questions related to symptoms of EPI including steatorrhea, flatulence, loose stools and urgency to defecate. All patients included in the study were started on A-Z multivitamin tablets from their first visit. Patients reporting symptoms indicative of EPI were started on Creon. Patients found deficient in any micronutrients were invited for a follow-up measurement of the respective deficiency.

Results
A total of 52 patients were included in the study period with a median follow-up of 17 months post oesophago-gastric cancer surgery. Proportion of patients with deficiency in ferritin, folate, vitamin B12 and vitamin D were 51.92%, 11.54%, 7.69% and 42.31% respectively. Proportion of patients identified with symptoms indicative of EPI was 36.54%. At re-test follow-up, 64.71% patient noticed settlement of symptoms of EPI and 85.91% of patients improved their ferritin levels at retest. Folate, Vitamin B12 and D levels significantly improved post initial AHP follow-up (significance level p<0.05).

Conclusion
Despite the study’s limitation of a small sample size of 52, it highlights that nutritional deficiencies post oesophago-gastric surgeries are prevalent. AHP run follow-up clinics in our unit helps identify these deficiencies and manage them accordingly. Study shows statistically significant improvement in deficiencies thereby making AHP led follow-up clinics to be cost effective and improve patient outcome.
P52 LIVER REDUCTION DIET IN PATIENTS UNDERGOING GASTRO-OESOPHAGECTOMIES
Authors: Pushpa Veeralakshmanan , Himanshu Wadhawan , Grant Sanders , Lee M Humphreys , Richard Berrisford , Tim Wheatley , Arun Ariyarathenam 
Published: November 2019

Abstract

Aim
The prevalence of obesity has nearly doubled in the last 10 years and is a known risk factor for oesophageal adenocarcinoma [1]. There is an increasing popularity with minimally invasive esophagectomies employing laparoscopic and/or thoracoscopic approach [2]. Obesity can complicate technical aspects of surgery. There is increased risk of retraction trauma from fatty livers and the operative field of the gastro-oesophageal area is limited in obese patients. Pre-operative liver reduction diet (LRD) is a common practice in patients undergoing bariatric surgery. We propose a pre-operative LRD for obese patients undergoing oesophago-gastric surgery for cancer to be safe and can help with the overall complexity of the surgery.

Background & Methods
In our regional tertiary unit, we adopted a 2-week pre-operative LRD for patients undergoing oesophago-gastric surgery with BMI >30 Kg m-2. Data was collected prospectively from January 2017 to January 2019 for all patients undergoing oesophago-gastric surgery.

Results
142 patients underwent oesophago-gastric surgery in the study period, 31 with a BMI >30 Kg m-2. 20 of the 31 (64.5%) received and completed LRD prior to their operation. For 9 patients, no reason was documented for incompletion of diet and 2 were unable to manage the diet. For 75% (15/20) of these patients, surgery was randomized and completed using the hybrid approach (laparoscopic abdomen and open chest) and the rest undergoing open procedure, as per the ROMIO trial [3].
Although a small number of cases for comparison, there were no significant differences observed in length of stay (LOS), complications including pneumonia, chyle leak and anastomotic leak in our patient group receiving LRD compared to high BMI patients in the literature without LRD.

Conclusion
Oesophago-gastric surgeons in our unit find pre-operative LRD in obese patients leads to improved flexibility of the liver for easier retraction and a better exposure of the operating field, especially around the hiatus. Implementation of pre-operative LRD in obese patients undergoing oesophago-gastric cancer surgery has been shown to be safe. We aim to continue to record post-operative complications, peri-operative death and LOS and expand the sample size for our study.
P53 MINIMALLY INVASIVE TECHNIQUES FOR TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCERS: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS
Authors: Kwabena Siaw-Acheampong , Sivesh K Kamarajah , Rohan Gujjuri , James R Bundred , Pritam Singh , Ewen A Griffiths 
Published: November 2019

Abstract

Aim
To evaluate the clinical outcomes for open, minimally invasive and robotic esophagectomy techniques for esophageal cancers.

Background & Methods
Esophagectomy is a demanding operation which can be performed by employing different approaches including open surgery or a combination of minimal access techniques. Each approach has specific reported advantages and disadvantages. A systematic literature search was conducted for studies reporting open, laparoscopic hybrid esophagectomy (LHE), thoracoscopic hybrid esophagectomy (THE), totally minimally invasive esophagectomy (MIE) or robotic MIE (RoMIE) for esophagectomy. A network meta-analysis of intraoperative (operating time, blood loss), postoperative (overall complications, anastomotic leaks, chyle leak, length of hospital stay), oncological outcomes (R0 resection, lymphadenectomy) and survival were performed.

Results
Ninety-eight studies including 32,296 patients were included in the network meta-analysis, of which 55% (n=17824), 5% (n=1576), 7% (n=2421), 30% (n=9558) and 3% (n=917) were open, LHE, THE, MIE and RoMIE respectively. Both MIE and RoMIE were associated with less blood loss, significantly lower rates of pulmonary complications, shorter length of stay and higher lymph node yield. There were no significant differences between surgical techniques for surgical site infections, chyle leak, and 30-day and 90-day mortality. MIE and RoMIE had better 1-year and 5-year survival rates compared to open respectively.

Conclusion
Minimally invasive and robotic techniques for esophagectomy are associated with reduced perioperative morbidity and length of stay with no compromise on oncological outcomes but no improvement in perioperative mortality. There are suggestions of improved long-term survival with MIE and RoMIE but these associations are not consistent across 1-, 3- and 5-year survival.
P54 INCIDENCE AND OUTCOME OF HIATAL HERNIA AFTER OESOPHAGECTOMY: COMPARISON OF TRADITIONAL OPEN AND MINIMALLY INVASIVE APPROACH
Authors: Jonas Sanberg Ljungdalh , Nicolaj Markus Stilling , Alan Patrick Ainsworth , Michael Hareskov Larsen 
Published: November 2019

Abstract

Aim
The primary aim of this retrospective study is to evaluate the incidence of symptomatic and asymptomatic hiatal hernia (HH) in patients who have undergone intended curative open or minimally invasive oesophagectomy (MIO) for cancer of the oesophagus in a high-volume surgical centre. The secondary aim is to describe the treatment and outcome after HH treatment.

Background & Methods
MIO for the treatment of oesophageal cancer has emerged as an alternative to traditional open oesophagectomy without compromising disease free or overall survival1.
HH of abdominal viscera other than the gastric conduit is an infrequent but potentially life-threatening complication following oesophagectomy. HH may present with grievous complications, such as severe respiratory failure, intestinal ischemia with perforation, bowel obstruction, and strangulation leading to emergency surgery2,3. Surgical repair of these HHs is associated with a high morbidity rate and in the emergent setting even a high mortality4.
In meta-analysis, the pooled incidence of symptomatic HH after MIO was 4.5 %, compared to a pooled incidence of 1.0 % after open oesophagectomy5. However, studies on the subject, often do not describe whether patients are asymptomatic or simply have not been examined for the existence of HH. The actual HH incidence may therefore be underestimated and may be more sufficiently reported when including patient material with comprehensive follow-up.
This retrospective cohort study includes all patients (n≈455) who have undergone curative intended resection for malignant disease in the oesophagus at The Department of Surgery, Odense University Hospital, from 1th January 2012 – 31th December 2018. Patient demography, perioperative data including surgical approach and follow-up, including occurrence and treatment of hiatal hernia, mortality and recurrence of malignant disease will be extracted from complete electronic patient records. Follow-up ranges from 6-84 months. Primary outcome is occurrence of hiatal hernia after oesophagectomy determined by CT-scan or during surgery.

Results
As of abstract deadline for ESDE 2019, we have only just received permission for the study from The Danish Patient Safety Authority and can unfortunately not present our results yet. However, we expect that results are ready for presentation at ESDE 2019 and hope for your understanding.