bluuebunny/crossref_metadata_2025_split huggingface dataset:
373. FLIPPING THE SCRIPT: ENDOFLIPPING THROUGH ESOPHAGEAL CHALLENGES WITH A TWIST!
Authors: Gonçalves Ana Raquel , Cardoso Pedro , Peixoto Armando , Santos Ana Luísa , Macedo Guilherme 
Published: September 2024

Abstract

Background
High-resolution esophageal manometry (HRM) is the gold standard for studying esophageal motility disorders but isn't universally available, and it's also reported as invasive and uncomfortable. The EndoFLIP system offers a dynamic evaluation of the esophagogastric junction (EGJ), crucial for patients with inconclusive HRM or undergoing endoscopic or surgical therapy such as myotomy or fundoplication. EndoFLIP is a practical tool in patients with dysphagia with normal upper endoscopy, allowing diagnostic assessment during the same procedure, and better selecting patients for subsequent HRM.

Methods
We conducted a retrospective study where we analyzed EndoFLIP procedures performed at a tertiary center from January 2022 to February 2024, for multiple indications, including characterization of findings on HRM, primary investigation of patients with dysphagia undergoing diagnostic upper endoscopy, motility study in patients intolerant to HRM, and post-therapeutic endoscopic/surgical assessment.

Results
Sixty-nine patients submitted to EndoFLIP procedures were included (39.1% male; 60.9% female) with a median age of 62 years. The primary indication was dysphagia, with 17.3% of patients being intolerant or referred with inconclusive HRM. EndoFLIP enabled diagnosis in all patients, even with an inconclusive HRM. Endoflip was performed on patients with treated achalasia with recurrence of dysphagia (16%), of which 55% exhibited reduced distensibility of EGJ. The evidence of reduced distensibility allowed patient selection for further treatment.
Seven patients underwent EndoFLIP to characterize EGJOO. Comparing paired data from HRM and EndoFLIP, overall concordance was only 47,1%. Endoflip showed a large discordance for the EGJOO group, with 50% having normal findings and 20% confirming EGJOO. 43,8% of patients diagnosed with EGJOO confirmed by EndoFLIP underwent endoscopic therapy during the same procedure, allowing the diagnosis and treatment at the same time. Four patients with gastroesophageal reflux disease, intolerant to HRM and proposed for Nissen fundoplication, underwent EndoFLIP for EGJ and esophageal motility evaluation. Currently, they are proposed for surgery due to the normal findings on EndoFLIP.

Conclusion
The use of EndoFLIP in evaluating esophageal motility disorders presents a paradigm shift, overcoming the limitations of traditional methods like HRM. Our retrospective study demonstrates its pivotal role in diagnosing and managing patients with dysphagia submitted to diagnostic endoscopy, especially post-interventions like achalasia or Nissen fundoplication. With its ability to provide comprehensive assessments and guide tailored treatments, EndoFLIP emerges as a valuable tool in clinical practice. Its impact on patient management, evidenced by alterations in treatment strategies in over 80% of cases, underscores its significance.
374. INCIDENCE AND PREDICTORS OF STRICTURE DEVELOPMENT FOLLOWING ESOPHAGECTOMY: A RETROSPECTIVE ANALYSIS
Authors: AlQinai Shamlan , Crump Trafford , Mueller Carmen , Cools John , Spicer John , Ferri Lorenzo , Najmeh Sara 
Published: September 2024

Abstract

Objective
Anastomotic stricture (AS) is a well described complication after esophagectomy and not only affects nutritional status but also has a detrimental impact on long-term quality of life. This retrospective study explores the incidence of clinically relevant AS in patients undergoing esophagectomy for cancer and investigates the potentially reversible factors associated with AS.

Methods
A prospectively entered clinical database of consecutive patients undergoing esophagectomy at a high-volume referral center over a decade (1/2013-12/2022) was queried for the presence of post-operative clinically significant AS, defined as stricture requiring endoscopic dilation. Multiple variables encompassing patient-related risk factors, tumor pathology, prior treatment, operative factors, and post-op complications were included in logistic regression analyses to delineate predictors of stricture formation.

Results
Of 1015 patients in the database, 115 (11.3%) developed AS requiring at least 1 post-op dilation. Although higher American Society of Anesthesiologists (ASA) grading was associated with elevated AS rate impact with most patients being ASA 2 and 3; 24% and 49% respectfully (p &lt; 0.05). Specific patient factors/comorbidities such as age, peripheral or coronary vascular disease, and diabetes mellitus did not emerge as significant predictors. Surprisingly, neither histology, nor neoadjuvant therapy (chemo or chemoradiation) were associated with AS. Both a cervical anastomosis and a intra-operative pyloromyotomy had a higher AS rate than an intra-thoracic anastomosis (OR 13.3, p=0.006) and patients without a myotomy (p=&lt;0.006). Other operative factors including approach (open vs MIE) conduit type (stomach/jejunum/colon) or width (3/4/5/6 cm) did not impact AS rate. All patients had a hand-sewn anastomosis. No post-operative outcome measures (e.g. leak, epidural use, hypotension) was associated with the development of AS.

Conclusion
Our results highlight the interplay of patient-related risk factors, tumor pathology, prior treatment, and operative factors in the development of post esophagectomy strictures. Understanding these predictors could potentially influence risk stratification and may facilitate tailored postoperative care strategies for improved patient outcomes.
376. COMPARISON OF POST-SURGICAL NUTRITIONAL STATUS BETWEEN IVOR-LEWIS ESOPHAGECTOMY AND PROXIMAL GASTRECTOMY
Authors: Sunagawa Hideki , Okabe Hiroshi , Takabe Yuya 
Published: September 2024

Abstract

Background
In our institution, the surgical approach for esophagogastric junction cancer (EG) is determined based on the tumor location and the extent of esophageal invasion, opting for either Ivor-Lewis esophagectomy (IL) or proximal gastrectomy (PG). Both procedures necessitate the mitigation of postoperative weight loss, with nutritional therapy using Elemental diet 300 kcal/day initiated postoperatively and nutritional guidance provided by dietitians before discharge, and at 1, 3, 6, and 12 pos-operative months (POM). Additionally, quality of life (QOL) assessment using the PGSAS-37 questionnaire is conducted, and feedback is provided to patients.

Methods
The aim of this study is to compare the weight changes up to 12 POM and the temporal changes in PGSAS-37 scores following IL and PG procedures in our institution. We analyzed 45 cases who underwent IL or PG in our institution between January 2019 and December 2022, excluding cases of early recurrence within 12 months and those without questionnaire responses. Patient demographics, postoperative complications, anastomotic strictures, duration of Elemental intake (months), percentage of body weight loss (BWL) at 1, 3, 6, and 12 POM, and PGSAS-37 scores were extracted from electronic medical records.

Results
There were 27 IL cases and 18 PG cases. Postoperative complications of Grade 3 or higher were observed in 3 of IL group and 1 of PG group. Anastomotic strictures were observed in 1 of IL group and 6 of PG group. Duration of Elemental intake (months) was 4.5 (0-39) in IL group and 0 (0-8) in PG group (p=0.001). Median BWL (%) at 1/3/6/12 POM was IL: 4.5/8.3/10.3/13.8 and PG: 3.8/8.5/8.7/10.6. Temporal changes in total symptom score were similar in both IL and PG groups, but esophageal reflux subscale at 12 POM was significantly better in PG group (p=0.04).

Conclusion
The questionnaire response rates were approximately 80% at 12 months for both groups, but below 12 months ranged from 22.2% to 50%, indicating difficulty in assessing temporal changes in QOL. At 12 months, the IL group exhibited a greater percentage of weight loss than the PG group (p=0.027), but QOL evaluations, except for reflux symptoms SS, were comparable between the two groups. Both IL and PG groups experienced rapid weight loss up to 3 POM, with continued decline up to 12 months. However, improving questionnaire response rates is deemed necessary for investigating the relationship with QOL.
379. SUCCESSFUL MANAGEMENT OF ANASTOMOTIC LEAKAGE FOLLOWING ESOPHAGECTOMY USING ENDO-VACUUM ASSISTED CLOSURE (EVAC) THERAPY: A CASE REPORT
Authors: Yang Jae Yeong , Park Ki Bum , Park Ji Yeon , Kwon Oh Kyoung 
Published: September 2024

Abstract

Background
Esophagectomy is a crucial curative treatment for potentially resectable esophageal cancer. However, anastomotic leakage poses a significant complication, with reported incidences ranging from 11.4% to 21.2% and mortality rates between 7.2% and 35%. Endoluminal or cavitary type of vacuum therapy (EVAC) represents a minimally invasive approach adapted from negative pressure wound closure techniques. Our case demonstrates the successful application of EVAC in managing a significant postoperative leak.

Methods
A 70-year-old male who underwent esophagectomy for early esophageal cancer. On postoperative day 23, a 20mm-sized large anastomotic leakage was detected, leading to the insertion of Endo-VAC for treatment. Endoscopically exchange was regularly.

Results
Endoscopically exchange was performed seven times, gradually reducing the size of the leakage hole. In the end, the anastomotic leakage was completely healed, and the patient was discharged on postoperative day 86. The patient id currently undergoing outpatient follow-up with no recurrence or metastasis of the disease confirmed.

Conclusion
Through our case, we highlight the potential suitability of EVAC therapy as a less invasive and effective treatment modality for anastomotic leakage following esophagectomy. This approach may be considered as a priority treatment for anastomotic leak.
381. MULTICENTER PAN-CANADIAN EXPERIENCE OF PER ORAL ENDOSCOPIC MYOTOMY (POEM) FOR THE TREATMENT OF ACHALASIA: A RETROSPECTIVE STUDY
Authors: Poole Meredith , Abbad Aghiles , Al-Shamali Hussain , Al-Faraj Zainab , Wen Chuck , Pescarus Radu , Bechara Robert , Hong Dennis 
Published: September 2024

Abstract

Background
Per oral endoscopic myotomy (POEM) has emerged as a modality for the surgical treatment of achalasia using a minimally invasive approach with similar clinical efficacy to laparoscopic Heller myotomy. Japanese, European, American and International clinical practice guidelines now cite POEM as a first line treatment for achalasia. In Canada, single-centre experiences with POEM have shown promising results. This study aims to capture the pan-Canadian national experience with POEM for the treatment of achalasia across multiple institutions.

Methods
This was a retrospective study of patients who underwent POEM for achalasia across four Canadian institutions (St. Joseph's Healthcare Hamilton, Kingston Health Sciences Centre, Surrey Memorial Hospital and Montreal Sacred Heart Hospital) between 2012 to 2022. Pre-operative, procedural and post-operative data was collected. Our primary outcome was the proportion of patients with normal Eckhardt score (≤ 3) at 4 weeks. Secondary outcomes included procedure related adverse events, length of stay in hospital, post-procedure lower esophageal sphincter pressures, post-procedure gastroesophageal reflux disease (GERD) and response rate at further timepoints. Outcomes are reported as either proportions (%) or medians (IQR).

Results
POEM was attempted in 369 patients with a success rate of 99%. The median duration of surgery was 64 (47 – 89) minutes and length of stay was ≤1 day in 88% of patients. Peri-operative complications occurred in 11% of patients, all of which were Clavien-Dindo Grade ≤III. The post-operative response rate (Eckhardt score ≤3) was 100%, 98% and 95% at 1, 6 and 12 months, respectively. Additional interventions for achalasia following POEM were required in 6% of patients. High DeMeester scores, endoscopic esophagitis and symptomatic GERD were reported in 36%, 43% and 44%, respectively. 93% of GERD was treated with PPI therapy.

Conclusions
POEM is safe and feasible in Canadian institutions with efficacy in keeping with current international literature.
383. LOSS OF PERISTALTIC RESERVE DETERMINED BY MULTIPLE RAPID SWALLOWS CORRELATES WITH DYSPHAGIA AND POOR BOLUS TRANSIT IN INEFFECTIVE ESOPHAGEAL MOTILITY
Authors: Sileno Sean M , Crowell Michael D , Vela Marcelo F 
Published: September 2024

Abstract

Introduction
Ineffective esophageal motility (IEM) is a common finding on high resolution esophageal manometry (HRM) and is often of unclear clinical significance as its impact on dysphagia and bolus transit is variable. Multiple rapid swallow (MRS) testing is a provocative maneuver performed during HRM that assesses peristaltic reserve, documented by the presence of contractile augmentation (defined by contractile vigor after MRS greater than that seen with single swallows). Lack of augmentation after MRS is associated with dysphagia after anti-reflux surgery. To date, no studies have evaluated the impact of peristaltic reserve on dysphagia and bolus transit in IEM patients.

Methods
Retrospective review of 159 patients with Chicago classification 4.0 IEM. 52 patients were excluded due to prior esophageal surgery, technically inadequate MRS, or concomitant esophagogastric junction outflow obstruction. Demographics and brief esophageal dysphagia questionnaire (BEDQ) results were obtained from a prospectively maintained database. MRS and bolus transit data were analyzed using a commercially available software. Impedance analysis documented complete versus incomplete bolus transit. Augmentation was defined as the ratio of post-MRS DCI to mean single swallow DCI &gt; 1. Fisher's exact test for continuous data and linear model ANOVA were used to assess for statistical significance.

Results
107 IEM patients were included, 46 of them had loss of peristaltic reserve (no augmentation on MRS). Compared to IEM patients with augmentation, those without augmentation had more severe dysphagia documented by higher mean BEDQ score (6.8 versus 4.8, p= 0.045), and increased rates of impaired bolus transit (73% versus 55%, p-= 0.013).

Discussion
IEM patients without augmentation on MRS have more severe dysphagia and more frequent incomplete bolus clearance. These findings support adding MRS response to the diagnosis of IEM or using it to describe a subset of patients with more severe disease.
385. TRANSLATING MOLECULAR-TARGETING FLUORESCENT PROBES IN OESOPHAGEAL CANCER PRE-CLINICAL MODELS
Authors: Bozin Mike , Edgington-Mitchell Laura , Clemons Nicholas , Wright Gavin , Phillips Wayne , Duong Cuong 
Published: September 2024

Abstract

Background
Intra-operative molecular imaging (IMI) is an emerging field that utilises tumour-targeting fluorescent probes to improve oncological outcomes. A novel class of probe known as quenched activity-based probes (qABP), developed to measure enzyme activity in-vitro, has been repurposed to target tumour-expressed proteases known as cathepsins. Unlike other tumour-targeting probes, fluorescence is inhibited up until the qABP covalently bonds to cathepsins, releasing an inhibitory quencher which results in fluorescence. This may improve the contrast between normal tissue and tumour. Our laboratory group sought to obtain pre-clinical evidence to eventually translate qABP’s into the operating room for oesophageal, junctional and gastric cancer.

Methods
Cathepsin activity was screened in cell lines from the normal oesophagus, Barrett’s metaplasia, oesophageal adenocarcinoma (OAC), squamous cell carcinoma (SCC) and gastric adenocarcinoma (GAC) with two qABP’s known as BMV109 and VGT309. We additionally screened patient biopsies from oesophageal, junctional and gastric cancers. Cell line and tissue samples were analysed using in-gel fluorescence (Amersham Typhoon®) and Western blot. In-vivo, cell line xenografts were established in NSG mice using subcutaneous and orthotopic models. Tumour-bearing mice were then injected with VGT-309 and then imaged at specific timepoints using the IVIS® spectrum imager.

Results
Cathepsin activity was found in all oesophago-gastric cell lines and selectivity proven with a cathepsin inhibitor. Matched biopsies were collected from patients prior before and after neoadjuvant chemo-radiotherapy. Baseline tumour biopsies exhibited significantly higher cathepsin activity than normal biopsies, with these differences preserved in biopsies collected after chemo-radiotherapy (p &lt;0.001). In-vivo, OAC and GAC xenografts were identified in NSG mice as early as 12 hours post injection of VGT-309, exhibiting a 2.5-fold increase in fluorescence compared to normal background stomach. Bio-distribution analysis demonstrated that VGT-309 accumulated in liver and kidney, but less so in the murine oesophagus and stomach.

Conclusion
Translating qABP’s into the operating room has the potential to detect early cancers in Barrett’s metaplasia, reduce positive margin rates and identify lymph node metastasis. Our research group continues to investigate qABP’s, including determining their sensitivity to detect lymph node metastasis with the aim of translating this technology into a phase 1 clinical trial.
410. THE RELATIONSHIP BETWEEN GASTRIC CONDUIT EMPTYING, FUNCTIONAL ANATOMY AND PERISTALSIS: A DETAILED ANALYSIS USING DYNAMIC MAGNETIC RESONANCE IMAGING
Authors: Lourensz Kaleb , Bigwood Shalini , Johari Yazmin , Wickremasinghe Ms Anagi , Beech Paul , Hebbard Geoffrey , Burton Paul , Brown Wendy 
Published: September 2024

Abstract

Background
Gastric conduit peristalsis post oesophagectomy is an important mediator of conduit emptying and consequently gastrointestinal symptoms and quality of life. The relationship between anatomical variations of the conduit, peristaltic function and transpyloric flow are incompletely defined. We aimed to analyse gastric conduit function using dynamic MRI to evaluate functional anatomy, quantify peristaltic function and measure emptying.

Methods
Eighteen patients with gastric conduit reconstruction post oesophagectomy and 12 controls with normal gastric anatomy were recruited. Dynamic and static sequences of MRI following ingestion of a semi solid meal were obtained. Peristalsis variables including Gastric Motor Index (GMI - Velocity x Amplitude) were measured at 4 time points throughout the MRI, and volume scans were taken at the beginning and end of the 20-minute scanning period. Nuclear Scintigraphy conduit emptying studies were obtained from 17/18 (94%) of patients. Quality of Life questionnaire data was collected.

Results
Nine (50%) conduits demonstrated coordinated peristalsis, 3(16.7%) had no measurable peristalsis and 6 (33.3%) had incoordinate peristalsis. Regarding conduits vs controls, there was no difference in peristaltic wave frequency (5 vs 5/90 seconds) or GMI (35.45 vs 36.5, p=0.61), but emptying was decreased (0.10% vs 15% p=0.01). Acute angulation of the conduit was associated with a slower emptying half time (444 vs 127 min, p=0.025). Conduit width and location of the pylorus relative to the hiatus made no significant difference to peristalsis or emptying. Quality of life scores were significantly better in controls compared with conduits.

Conclusion
Although coordinate peristalsis was present in many conduits, it did not appear to be a key mediator of conduit emptying. Conduit shape and location within the mediastinum significantly affected emptying. These data demonstrate that construction of the conduit at the index operation may be a key factor in long term function and reducing gastrointestinal symptoms. Dynamic MRI is a promising research and diagnostic tool to assess conduit function due to its capacity to accurately delineate the key elements of conduit function.
416. SUCCESSFUL TREATMENT OF ESOPHAGO-MEDIASTINAL FISTULA DUE TO ESOPHAGEAL CANCER WITH IMMUNE CHEMOPOINT INHIBITOR FOLLOWED BY ROBOTIC RADICAL ESOPHAGECTOMY
Authors: Kim Dong Jin 
Published: September 2024

Abstract

Background
Esophagomediastinal fistula caused by intrathoracic esophageal cancer perforation poses significant challenges in treatment. We present a case of such a patient successfully treated by achieving complete resolution through surgical resection following chemotherapy with 5-FU, cisplatin, and pembrolizumab.

Methods
Clinical and surgical findings of the patient were reviewed through chart analysis. A 46-year-old male presented to the emergency room with fever and cough. Computed tomography (CT) indicated esophageal-mediastinal fistula due to mid-thoracic esophageal cancer and perforation. Endoscopic examination revealed a 5cm circumferential mass 20cm from the upper incisors, along with perforation. Biopsy confirmed poorly differentiated squamous cell carcinoma, with a PD-L1 CPS score of 80. The patient received multidisciplinary treatment involving chemotherapy followed by planned surgical intervention.

Results
First of all, the patient underwent peroral endoscopic gastrostomy for dietary intake. After 3-weeks interval three cycles of 5-FU (800mg/BSA, Day1-5), cisplatin (80mg/BSA, Day1), and pembrolizumab (200mg, Day1), complete resolution of the abscess cavity and significant reduction in esophageal cancer lesions were observed. Robotic transthoracic esophagectomy and Mckeown operation were performed, achieving complete resection of the esophagus including the primary lesion. Pathological examination revealed complete remission of the primary lesion and absence of metastatic nodes among the 51 dissected lymph nodes. After subsequent additional three cycles of anticancer-immunotherapy combined therapy were done, no signs of recurrence were found on CT scan performed 3 months post-surgery.

Conclusion
We report a case of successful treatment of a patient with thoracic esophageal cancer complicated by difficult-to-treat esophago-mediastinal fistula, managed effectively with concurrent chemotherapy and surgical intervention.
421. MODIFIED DOR FUNDOPLICATION IN ACHALASIA PATIENTS: LONG-TERM OUTCOMES FROM A HIGH-VOLUME CENTRE
Authors: Saliaris Konstantinos , Triantafyllou Ms Alexandra , Kitsou Ms Eleni , Karikis Ioannis , Katsila Sofia , Kakounis Konstantinos , Theodorou Andreas , Xiromeritou Vasiliki , Triantafyllou Tania , Theodorou Dimitrios 
Published: September 2024

Abstract

Background
Heller myotomy combined with Dor fundoplication remains the gold standard in the treatment of achalasia. Dor fundoplication serves as a floppy partial fundoplication which, at the same time, prevents recurrence of dysphagia due to outflow obstruction to the myotomised esophagus. In this study, we propose a modified floppier anterior wrap and present our unit’s experience in a series of consecutive patients with achalasia.

Methods
The prospectively collected surgical achalasia database of our department was retrieved. All patients had manometric confirmation of the diagnosis and were operated by the same surgical team. Data regarding preoperative Eckardt, GERD and Quality of Life assessment scores were collected. Patients attended regular follow-up appointments. Those with abnormal Eckardt and GERD scores were subjected to objective testing using manometry and 24h impedance pHmetry.

Results
118 patients with achalasia were subjected to Heller myotomy and modified Dor fundoplication from 01/2014 to 12/2020. 97 patients completed the follow-up appointments. Median follow-up was 72 months (28-120 months). 97% of patients reported a positive influence in their quality of life and did not regret undergoing surgery. 7/97 (7.2%) presented with an abnormal Eckardt score and 5/97 (5.2%) patients demonstrated an abnormal GERD score. Objective testing results with manometry and pH-studies of patients with abnormal scores will be completed within the next two months.

Conclusion
Our modified Dor fundoplication after Heller myotomy is a safe and efficient surgical method for treating achalasia. Long-term follow-up suggests significant and long-lasting improvement in Quality of Life and very low incidence of symptom relapse.