bluuebunny/crossref_metadata_2025_split huggingface dataset:
331. CASE-MIX ADJUSTMENT IN BETWEEN-HOSPITAL COMPARISONS ON CLINICAL OUTCOMES IN ESOPHAGEAL AND GASTRIC CANCER SURGERY: A NATIONWIDE POPULATION-BASED COHORT STUDY
Authors: Visser Maurits , van der Linden Margrietha , Eijkenaar Frank , Voshaar Martijn Oude , van Hillegersberg Richard , van Sandick Johanna , van Berge Henegouwen Mark , Wijnhoven Bas , Lingsma Hester 
Published: September 2024

Abstract

Background
Clinical outcomes of esophageal and gastric cancer surgery are used for internal and external benchmarking in clinical auditing. For true hospital comparisons, proper case-mix adjustment is required. This study aimed to develop distinct models that allow for case-mix adjusted quality assessment of esophageal and gastric cancer surgery separately and assessed the impact on between-hospital comparisons.

Methods
This study included all patients undergoing esophagogastric cancer surgery in the Netherlands between 2017-2022 registered in the Dutch Upper Gastrointestinal Cancer Audit. We developed distinct case-mix adjustment models for ten quality indicators (QIs) using backward selection. Model performance of each individual model was evaluated with area-under-the-receiving-operator-curve (AUC) statistics, representing the impact of case-mix on the QI scores. The impact on between-hospital comparisons was quantified using unadjusted and adjusted O/E ratios.

Results
A total of 4,354 esophageal cancer and 2,109 gastric cancer patients were included. The most frequently selected case-mix variables in the models for all QIs for esophageal cancer surgery were ASA-score, salvage surgery, peripheral vascular disease/aortic aneurysm, chronic lung disease, and tumor histology, whereas for gastric cancer these were age, preoperative weight loss, tumor location, and clinical M stage. The case-mix adjustment models for esophageal and gastric cancer surgery showed low to moderate performance, with internally validated AUCs of 0.58-0.73 and 0.58-0.74, respectively. Case-mix adjustment had low impact on between-hospital comparisons. For both types of cancer, case-mix adjustment had most pronounced impact on between-hospital comparisons for QIs 30-day/in-hospital mortality and failure-to-rescue.

Conclusion
This study showed that correct quality assessment requires different case-mix models per quality indicator for clinical outcomes of esophageal and gastric cancer surgery. The case-mix models had low to moderate performance scores, suggesting that case-mix has limited impact in between-hospital comparisons of oesopagogastric cancer surgery.
333. TECHNICAL CONSIDERATIONS IN UPPER-GI RECONSTRUCTION – A CASE SERIES
Authors: Aggarwal Shaurya , Bhuvanakrishna Thakshyanee , Hawlin John , Lorenzi Bruno 
Published: September 2024

Abstract

Background
Oesophageal reconstruction post-oesophagectomy is performed for both benign and malignant pathologies. Generally, the stomach is the conduit of choice due to its simplicity, requiring only one anastomosis. However, in some cases the stomach may not be a viable option immediately or at all, and alternatives must be considered. We describe a case where the stomach was not immediately viable and two cases where alternative conduits were sought. Furthermore, we discuss techniques such as ‘supercharging’ and ‘superdrainage’ which enhance arterial flow and venous drainage respectively, in order to prevent ischaemia and related complications of the anastomosis site.

Methods and Results
Case 1 presents a 72-year-old with an incarcerated para-oesophageal hernia leading to necrosis of the distal oesophagus and proximal stomach. After resection, a feeding jejunostomy and a loop oesophagostomy in the neck was created. Months later, the oesophagostomy was closed, and the residual stomach was carefully mobilised into the thorax while preserving the gastro-epiploic arcade, and oesophago-gastric anastomosis was performed.
Case 2 involves a 68-year-old female who had elective Nissen fundoplication for a hiatus hernia, which recurred early with strangulation of the distal oesophagus and proximal stomach requiring emergency oesophago-gastrectomy. She later underwent a colonic interposition using the left colon, with superdrainage through an anastomosis between a branch of the middle colic vein to the left external jugular vein.
Case 3 describes a 61-year-old male with a gastro-oesophageal adenocarcinoma treated with an Ivor-Lewis oesophagectomy. A year later, he suffered from a strangulated diaphragmatic hernia causing necrosis of the gastric conduit. This was replaced with an isoperistaltic colonic interposition using the transverse and left colon with super drainage. Unfortunately, three years later, this was again complicated with pancreatitis and perforated gall bladder with associated ischaemia of the colonic conduit. A re-do of the colonic interposition using the right colon was done with an arterial graft between the right transverse cervical artery and branch of ileal artery and super drainage via a branch of the ileal and right external jugular veins.

Conclusion
Primary and in particular secondary re-constructions of the UGI tract are complex procedures and individual approaches are needed as residual anatomy varies. Consequently, such cases require meticulous planning and a multidisciplinary approach involving the cardio-thoracic, plastic and vascular surgeons and adequate support by the anaesthetic and intensive care team. Although associated with significant morbidity and mortality, reestablishment of a swallowing passage is often desired by patients to maintain quality of life.
342. BILATERAL THORACOSCOPIC APPROACH FOR ADVANCED ESOPHAGEAL CANCER COMPLICATED WITH DOUBLE AORTIC ARCH (DAA)
Authors: Kamei Takashi , Taniyama Yusuke , Okamoto Hiroshi , Sato Chiaki , Ozawa Yohei , Ishida Hirotaka 
Published: September 2024

Abstract

Background
Double aortic arch (DAA) is a relatively rare vascular malformation that causes few problems in adults. However, the presence of DAA makes esophageal cancer surgery difficult, especially during upper mediastinal dissection. Here we report a bilateral thoracoscopic surgical technique in a patient with highly advanced esophageal cancer complicated with DAA.

Case
73-year-old male, cT3N4M0 stage III (UICC-TNM 7th) mid-thoracic esophageal cancer with DAA was diagnosed. After two courses of neoadjuvant chemotherapy, surgical treatment was planned. To develop a surgical strategy for esophagectomy for this complex malformation, we created a 3D printer model of the case. The results suggested that a bilateral thoracoscopic approach in the prone position was the ideal approach for upper mediastinal dissection. As expected, it was difficult to dissect the upper mediastinum using only a right-sided approach, especially on the esophagus oral side behind the right aortic arch (RAA), where dissection from the right side was impossible. By adding a left lateral approach, the oral side of the esophagus was pulled in from the left aortic arch (LAA) and was easily dissected. The operation was successful and the postoperative course was uneventful. In this presentation, we will demonstrate the technique of bilateral approach for advanced esophageal cancer complicated with DAA.

Discussion
The surgical strategy for patients with thoracic esophageal cancer and a coexisting complex vascular anomaly known as a double aortic arch (DAA) is a highlight. Typically, surgical approaches have been limited to either left or right thoracic access. However, through preoperative simulation using 3D printing, a bilateral approach was deemed safe and effective for these cases. The 3D printer models provided invaluable insights into the anatomical relationships of blood vessels, trachea, and heart, allowing for precise planning and execution of the surgery. Challenges such as the proximity of the descending aorta to the trachea and the optimal approach angle were successfully addressed through simulation, enhancing surgical outcomes. Furthermore, the bilateral thoracoscopic approach demonstrated potential benefits in preserving delicate structures like the recurrent laryngeal nerve. This innovative use of 3D printing technology in preoperative planning represents a significant advancement in the field of gastrointestinal surgery, offering improved safety and precision for patients with complex anatomical variations like DAA.

Conclusions
3D printer is useful for simulating thoracoscopic esophagectomy with macrovascular malformations. Bilateral approach is appropriate for surgery of esophageal cancer complicated with DAA and a 3D printer is a useful tool for simulating esophageal surgery.
349. CLINICAL CHARACTERISTICS AND PROGNOSTIC FACTORS OF ESOPHAGEAL SPINDLE CELL CARCINOMA
Authors: Zhong Chuan , Zhou Haining , Hu Jiewei 
Published: September 2024

Abstract

Background
Esophageal spindle cell carcinoma (ESpCC) is a malignant tumor composed of sarcomatous components. ESpCC is treated as a squamous cell carcinoma. However, because ESpCC is a rare tumor, little is known regarding its clinical characteristics and prognosis.

Objective
This article was to discuss the clinical characteristics, treatment and prognostic factors of ESpCC.

Methods
All the clinical and pathological data of 25 cases of ESpCC were retrospectively analyzed.

Results
The sex ratio of male vs female was 2.12:1. The male median age was 55 years, and the female median age was 62 years. A total of 25 cases were performed pathological biopsy and the accuracy was 48%. The most common site for ESpCC was the middle segment of the esophagus (60%). The most common gross tumor type of ESpCC was intraluminal type (40%). The local lymph node metastasis rate was 24%. Three-year and five-year survival rates after operation were 68% and 44%, respectively. Single factor analysis showed that the N stage, T stage, pTNM stage were the facors influencing the prognosis (P&lt;0.05).

Conclusion
ESpCC predominantly occurs in males and in the middle segment of the esophagus, and with a higher misdiagnosis before operation and good prognosis after operation. The intraluminal type is the most common gross tumor type. Radical operation is the preferred treatment for ESpCC.
Key words Esophagus, Spindle cell carcinoma, survival analysis
350. CONTINUOUS INTRAOPERATIVE NERVE MONITORING TO REDUCE THE LEFT RECURRENT LARYNGEAL NERVE PARALYSIS IN TRANSMEDIASTINAL ESOPHAGECTOMY
Authors: Inoue Hiroyuki , Fujiwara Hitoshi , Shiozaki Atsushi , Konishi Hirotaka , Nishibeppu Keiji , Ohashi Takuma , Shimizu Hiroki , Arita Tomohiro , Yamamoto Yusuke , Morimura Ryo , Kuriu Yoshiaki , Ikoma Hisashi , Kubota Takeshi , Otsuji Eigo 
Published: September 2024

Abstract

Introduction
Transmediastinal esophagectomy (TME) is a curative option for esophageal cancer, and can achieve total mediastinal lymph node dissection (LND) with transcervical and transhiatal procedures. With the transcervical procedure, the upper mediastinal LND is highly associated with the risk of causing recurrent laryngeal nerve paralysis (RLNP). Continuous intraoperative nerve monitoring (CIONM) can visualize the risk procedure in real time, which may result in reducing postoperative RLNP. The aim of this study was to clarify the usefulness of CIONM in reducing postoperative left RLNP with TME.

Material and methods
A total of 227 patients who underwent TME for esophageal cancer (EC) or esophagogastric junction cancer (EGJC) between October 2017 and July 2022 at our institution were included in this study. Patients who did not undergo the upper and middle mediastinal LND (33 patients) and could not undergo CIONM (34 patients) were excluded from these 227 patients. Finally, we analyzed data on 160 patients. The clinicopathological data were reviewed from the medical record database of our institution.

Results
The technical implementation rate of CIONM was 87.4%. The diagnostic performance for RLNP with amplitude&lt;100μV (LOS: loss of signal) at the end of transcervical procedure was as follows (sensitivity: 83.3%, specificity: 90.7%, positive diagnostic value: 88.8%). In the univariate analysis, the frequency of left RLNP was significantly higher in male, patients with primary tumor located at the upper thoracic esophagus, and patients with LOS (p&lt;0.001, respectively). Moreover, the multivariate analysis identified patients with tumor located at the upper thoracic esophagus and patients with LOS (p&lt;0.001) as independent risk factors for left RLNP.

Conclusion
In the present study, we showed the significant association between amplitude LOS and left RLNP. CIONM could contribute to reducing left RLNP by not only paying attention to amplitude reduction during surgery, but also learning the risk procedure that may cause nerve damage after surgery.
352. A RARE CASE OF ESOPHAGEAL EPIDERMOID METAPLASIA: A POTENTIAL PRECURSOR TO ESOPHAGEAL MALIGNANCY
Authors: Cardoso Pedro , Rodrigues-Pinto Eduardo , Garrido Isabel , Baptista Diana , Macedo Guilherme , Gonçalves Ana Raquel 
Published: September 2024

Abstract
A 62-year-old woman with medical history of fibromyalgia and depression was referred to the gastroenterology consultation due to dysphagia for solids for the past 3 months. She had previously performed an upper endoscopy which revealed an esophageal lesion, interpreted as a papillomatous lesion.
Upper endoscopy was repeated, showing a whitish, irregular, semi-elevated and hemi-circumferential lesion between 16 and 19cm from the incisors (Figure A and B). Biopsies were performed. Histology revealed a stratified squamous epithelium with mild inflammation, with spongiosis, hyperorthokeratosis and a prominent granular cell layer. This was consistent with esophageal epidermoid metaplasia (Figures C and D). No dysplasia or carcinoma was noted.
Esophageal epidermoid metaplasia is a rare condition described only in case reports and small series. It is thought that may be sporadically associated with esophageal squamous cell carcinoma. Endoscopically, this entity might have different appearances such as white plaques, altered texture, keratotic patches, sloughing, granularity, nodularity, furrows, decreased vascularity, and lacy appearance. We report this case to raise awareness for this entity and its association with dysplasia and esophageal cancer. Therefore, in the case of esophageal epidermoid metaplasia lesions a close follow-up or endoscopic treatment may be warranted.
Patient is currently on endoscopic surveillance every one year to screen for early dysplasia.
355. LONG-TERM RESULTS OF LAPAROSCOPIC HELLER-DOR FOR ESOPHAGO-GASTRIC JUNCTION OUTFLOW OBSTRUCTION: A PROSPECTIVE CONTROLLED TRIAL
Authors: Forattini Francesca , Provenzano Luca , Costantini Mario , Nezi Giulia , Capovilla Giovanni , Costantini Andrea , Moletta Lucia , Nicoletti Loredana , Valmasoni Michele , Salvador Renato 
Published: September 2024

Abstract

Background
The gold-standard treatment for esophago-gastric junction outflow obstruction (EGJOO) is still debated. Currently, the management of this motility disorder reflects the experience gained with esophageal achalasia, for which Laparoscopic Heller-Dor (LHD) has been proven to be an effective long-term treatment. However, prospective data comparing long-term results of LHD for these two motility disorders are still lacking. The aim of this prospective, controlled study was to assess the 5-year follow-up of laparoscopic Heller-Dor (LHD) in patients with EGJOO, compared with radiological stage I achalasia patients (ACH).

Methods
Patients with diagnosis of idiopathic EGJOO, referred for dysphagia or food regurgitation, and radiological stage I achalasia (subgrouped by manometric pattern I, II & III), treated with LHD, were enrolled to the study and then followed prospectively for 5 years.
During the follow-up patients were evaluated with Eckard score (ES), Barium-swallow X-ray, High Resolution Manometry (HRM), 24 hour pH-monitoring and Upper-Gastrointestinal endoscopy. The primary outcome was therapeutic success (presence of ES ≤3 or no additional treatment) at the 5-year follow-up assessment. The secondary outcomes included the postoperative IRP and the evidence of gastro-oesophageal reflux.

Results
The study involved 150 patients: 25 in the EGJOO group and 125 in the ACH group (25 pattern I, 74 pattern II, and 26 pattern III). The patients’ demographic and clinical parameters are summarized in Image. After 5 years, there was no significant difference in success rate: 92% in the EGJOO, 88% in achalasia pattern I, 91.9% in pattern II and 92.3% in pattern III (p=0.95). In the four groups, no differences were shown in the presence of postoperative esophagitis (p=0.08) and in the incidence of abnormal postoperative acid exposure (p=0.87) (Image).

Conclusion
This is the first long-term comparative study based on prospective data collection to assess the outcome of LHD in patients with EGJOO. After at least 5 years of follow-up, Laparoscopic Heller-Dor has a comparable success rate in both EGJOO and achalasia patients. Based on these data, we conclude that LHD can be proposed as a first-line treatment for symptomatic EGJOO, provided the diagnosis is accurate.
364. IMPROVING PERIOPERATIVE OESOPHAGECTOMY OUTCOMES WITH THE USE OF ROBOTIC SURGERY AT A HIGH VOLUME UK CENTRE
Authors: Rayner Charles , Paine Heidi , Luangsomboon Aphiwat , McGuire Ms Anna , Walker Robert , Madhavan Anantha , Singh Pritam , Abbassi-Ghadi Nima , Preston Shaun R 
Published: September 2024

Abstract

Background
There is a rapid movement towards adoption of robotically assisted minimally invasive oesophagectomy (RAMIO) in the United Kingdom. Transition from an open or laparoscopic oesophagectomy to a RAMIO programme, which carries considerable financial and training cost, must ensure parity of oncological and perioperative outcomes. We sought to compare our centre’s results as we performed the three standard approaches to two-phase oesophagectomy undertaken in the UK: Open/Open (Open); laparoscopic/robotic abdomen with open chest (Hybrid); and RAMIO.

Methods
This prospective cohort study investigated the experience of five surgeons in a single high-volume UK institution. We analysed all consecutive patients undergoing two-phase transthoracic oesophagectomy for oncological reasons between 2018 and 2023. The study period was divided into three cohorts: Open (2018-2020, n=61), Hybrid (2020-2023, n=82) and RAMIO (2023, n=61). Patient demographics, tumour characteristics, perioperative outcomes, and oncological data were compared. Data were analysed using Kruskal-Wallis and Chi-squared statistical tests.

Results
No significant differences were observed in patient demographics or tumour stage between the groups. Comparison of Open vs. Hybrid vs. RAMIO demonstrated a significant reduction of major complications (Clavien-Dindo ≥III), 34.4% vs. 23.2% vs. 19.7%, respectively (p=0.033); pulmonary complications, 36.1% vs. 25.4% vs. 16.4% (p=0.007); and median length of hospital stay, 14 vs. 12 vs. 9 days (p=0.001), all favouring the RAMIO group in sub-group analysis.
Comparison of Open vs. Hybrid vs. RAMIO demonstrated a non-significant reduction in anastomotic leak rate, 11.5% vs. 2.4% vs. 6.6%, respectively (p=0.112); and mortality, 4.9% vs. 1.2% vs. 0% (p=0.19), favouring the RAMIO group. Median lymph node yields were comparable across the groups, 49 vs. 43 vs. 44 (p=0.165).

Conclusions
This single-institution study demonstrates potential benefits of transitioning from open or hybrid to RAMIO for oesophagectomy. RAMIO was associated with significantly reduced pulmonary complications, major complications and a shorter length of hospital stay. Oncological outcomes remained on par across techniques. These findings have important patient, financial, and resource implications, and support the continued adoption of RAMIO in the UK.
386. SAFETY AND FEASIBILITY OF PERSONALIZED NEOANTIGEN DC VACCINES IN POSTOPERATIVE ESOPHAGUS SQUAMOUS CELL CARCINOMA: A PHASE 1B TRIAL
Authors: Chen Long-Qi , Liu Yixin , Yang YuShang , Chen Yueyun 
Published: September 2024

Abstract

Background
Immunotherapy, as a neoadjuvant treatment, currently stands at the forefront of esophageal squamous carcinoma research. Yet, the landscape of post-surgery adjuvant therapy remains largely unexplored, especially for patients who experience inadequate responses or develop resistance to initial immunotherapy. Addressing this gap, we have undertaken a single-center, single-arm, prospective, and exploratory clinical study. This study aims to evaluate the efficacy of a personalized neoantigen-loaded dendritic cell vaccine (Neo-DCVac) as a novel adjuvant treatment in ESCC patients who have previously undergone neoadjuvant immunochemotherapy (nICT).

Methods
Neo-DCVac was designed and administered to 12 ESCC patients undergoing radical mastectomy post-nICT. Tailored adjuvant therapy was based on tumor immune microenvironment (TIME) analysis, following Lam's Stratified Treatment Strategy. The immunization schedule included five doses at weeks 1, 2, 4, 6, and 8, with bi-monthly boosts during the consolidation phase, sustained over a year. Primary endpoints were safety and post-vaccination immune response. Secondary endpoints included 1- and 2-year overall survival (OS) and progression-free survival. T-cell response to neoantigen peptides was assessed using enzyme-linked immunospot (ELISPOT), flow cytometry, and enzyme-linked immunosorbent asssay (ELISA), alongside single-cell sequencing to explore the vaccine's efficacy mechanism.

Results
From April 2021 to October 2023, a total of 12 ESCC patients were enrolled. The occurrence of all-grade AEs was 38.5% (5/12), all of grade 1-2, with no dose-limiting toxicities. No treatment interruptions or treatment-related deaths were observed. Till October 27 2023, the median follow-up was 31.2 months. Survival analysis revealed 1-year and 2-year disease-free survival (DFS) and overall survival (OS) rates of 88.3%, 66.7%, and 100.0%, 91.7%, respectively. Patients with diver genes had a longer median DFS (not reached) compared with patients without diver genes (10.8 months, P = 0.001). Post-vaccine immunization, all patients showed a marked increase in peripheral blood T cell subtypes (CD3, CD4, CD8), with significant neoantigen peptide response in 75% (9/12) as evidenced by ELISPOT and ELISA tests. Single-cell sequencing coupled with CoNGA analysis revealed a distinct MAIT cell population, displaying 65 clonotypes and 146 cells with consistent GEX profiles and TCR sequences. GLIPH2 analysis on Neo-Vac immunotherapy patients identified shared peptide-MHC specificities, notably in patient ES0-01, and similar patterns in patients ES0-04 and ES0-07, suggesting T cell expansion and neoantigen-specific responses post-vaccination.

Conclusions
The neoantigen DC vaccine demonstrated favorable safety and exhibited notable efficacy in ESCC.