Anastomotic Leakage Research Articles

554. SHORT TERM OUTCOMES OF ESOPHAGECTOMY FROM LOW VOLUME CANCER CENTRE IN INDIA

Abstract This study evaluates short term outcomes of esophagectomy at a low volume cancer hospital in Visakhapatnam, India. Fifteen patients who underwent esophagectomy from 2020 to 2023 were analysed. The most common histology was squamous cell carcinoma. The mean age was 55 years and the majority were male. The common approaches used were open trans hiatal and transthoracic esophagectomy. The mean operative time was 9.5 hours and the mean hospital stay was 15.92 days. There were no perioperative deaths but complications included pulmonary issues, vocal cord paralysis, anastomotic leaks, chyle leaks and wound infections. Higher volume centres tend to have better outcomes after esophagectomy. However, factors other than volume like patient selection, ERAS (Enhanced Recovery After Surgery) protocols, specialized critical care and trained multidisciplinary teams also impact outcomes. At our centre, though a low volume hospital, proper patient selection, prehabilitation and a collaborative team approach helped achieve acceptable results. We recommend developing consensus on defining low and high-volume centres for esophagectomy in the Indian context, based on disease burden, resources and constraints. Overall, there is a lack of Indian data comparing outcomes between low and high-volume centres for esophagectomy.

564. PRONE POSITION THORACOSCOPIC HAND-SEWN ESOPHAGO-GASTRIC ANASTOMOSIS DURING 2-STAGE TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER. SURGICAL TECHNIQUE

Abstract Background Minimally invasive esophagectomy has been introduced in the 2000s in an effort to reduce post-operative pulmonary and cardiac complications. 2-stage totally minimally invasive esophagectomy combines laparoscopic abdominal phase followed by thoracoscopic thoracic phase. The rate limiting step of this approach is the construction of esophago-gastric anastomosis. Herein, we aim to present our anastomotic technique on hand-sewn esophago-gastric anastomosis in prone position, utilizing 3D-assisted thoracoscopy. Methods This is prospective analysis of consecutive patients that underwent 2-stage totally minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers from the same surgical team, over a period of 6 years and more than 250 consecutive esophagectomies. All operations were identical in terms of patient positioning, lymphadenectomy and type of anastomosis formed. The anastomosis was hand-sewn in prone position, in 2-layers, using barbed sutures, with utilization of 3D-assisted thoracoscopy. Thorough technique and key steps of this anastomotic technique are provided. Results Median operative time was 280 minutes while median suturing time for the esophago-gastric anastomosis was 45 minutes. Anastomosis was thoracoscopic, hand-sewn constructed in prone position in all cases. There was no conversion to open. Anastomotic leak complicated n=6 patients (2%); n=5 were type I anastomotic leaks, requiring no intervention and n=1 was type II, which was treated with thoracoscopic lavage and chest drains followed by endoVAC therapy. Conclusion Formation of the esophago-gastric anastomosis is the rate limiting step of 2-stage totally minimally invasive esophagectomy. Most surgeons prefer the construction utilizing mechanical staplers. Our anastomotic technique, present a safe and effective anastomosis, with favorable clinical outcomes. It can be reproduced safely and effectively, offering all the advantages of manual anastomosis and significant reduction of devastating post-operative anastomotic leakage. https://wetransfer.com/downloads/bdf3a3496197daf79ccf5b05f71ba64920240309175850/a4da3be742fd3199e102e553c8a4011e20240309175918/c14cc2

478. OVERVIEW ON USE OF THE TRANSCERVICAL MEDIASTINOSCOPIC APPROACH FOR MINIMALLY INVASIVE TREATMENT OF ESOPHAGEAL CANCER: ESTABLISHMENT OF INTERNATIONAL COLLABORATIVE GROUP

Abstract Background Minimally invasive esophagectomy has emerged as a promising alternative to open surgery, demonstrating reduced postoperative complications and comparable oncological outcomes. Despite advancements, pulmonary complications and anastomotic leakages remain concerns. Since 2015, a novel technique combining single-port transcervical and trans-hiatal laparoscopic mediastinal dissection for esophageal resection was introduced. This procedure exhibits lower pulmonary complication rates compared to traditional approaches. However, its global adoption is limited, necessitating collaborative efforts to standardize techniques and outcomes. Following the IDEAL framework stage 2B (exploration), an international collaborative group for transcervical esophagectomy has been established, aiming to exchange insights, experiences, and lessons learned. Methods A cross-sectional survey involving 13 surgeons currently practicing transcervical esophagectomy was conducted, revealing variations in surgical approaches, indications, and outcomes. Results Surgeons from China, Germany, Japan, and The Netherlands participated. Indications for surgery varied, with less selectivity in higher-volume centers. Large tumors near the carina, bulky primary lesions or T4 tumors were identified as contraindications. Different surgical approaches were reported, with the left transcervical and abdominal laparoscopic/robotic dissection being the most common. The mean operative time was about 382.2±117.9 minutes. The mean blood loss was of 100.2±71.1 milliliters. Surgeons reported high rates of R0 resection and lymph node harvesting, as well as low rates of pulmonary complications (8.6±3.7) and anastomotic leaks (10.1±5.2); however, concerns persist regarding recurrent laryngeal nerve injuries (27.2±18.2). Conclusion Transcervical esophagectomy is gradually gaining recognition, with varying adoption rates. The collaborative group aims to align techniques, share experiences, and standardize the procedure. Challenges include differences in indications, surgical approaches, and outcomes, highlighting the need for ongoing discussion and research. Despite concerns about recurrent laryngeal nerve injuries, the procedure shows promise in reducing pulmonary complications. The establishment this collaborative group signifies a crucial step toward global acceptance. By fostering collaboration, the group aims to enhance patient care, minimize learning-associated morbidity, and contribute to the continuous advancement of this surgical technique. Future efforts will focus on standardization, comparative studies, and training protocols.

340. THE IMPACT OF OBESITY ON SURGICAL OUTCOMES AFTER ESOPHAGECTOMY FOR CANCER IN SWEDEN

Abstract Background Global obesity rates continue to rise and are closely linked to an increase in esophageal adenocarcinoma. While obesity is associated with an increased risk of postoperative complications, its influence on long-term survival is less clear. Some studies suggest that obese patients have poorer outcomes due to higher comorbidity rates, while others indicate comparable or even better survival, possibly due to better nutritional reserves. This study aims to investigate whether obesity affects the survival and risk of postoperative complications in a national cohort of esophageal cancer patients. Methods This retrospective population-based register study included all individuals who underwent esophageal resection between 2006 and 2018 in Sweden. Data were extracted from the national quality registry for esophageal and gastric cancer (NREV). The cohort was grouped based on body mass index (BMI) into underweight (BMI < 20), normal (BMI 20-25), overweight (BMI 25-30), and obese (BMI > 30). Kaplan-Meier was used for survival analysis, and logistic regression and Cox regression were used for adjusted analyses (adjusting for sex, age, marital status, education level, Charlson comorbidity index score, histopathology, disease stage, and year of diagnosis). Results In total, 1742 individuals (79.9% males, mean age 66) were included, of whom 242 (13.9%) were obese. Obese individuals had more comorbidities at surgery, more commonly had adenocarcinoma, and underwent surgery more frequently in the later time period. The risk of surgical complications (e.g., anastomotic leak, bleeding) for obese individuals was not increased compared to those with normal weight (OR: 0.83 [0.56-1.21]), but an increased risk of non-surgical complications (e.g., pneumonia, cardiopulmonary events) was observed (OR: 1.78 [1.22-2.60]). The risk of death of any cause was decreased in obese individuals compared to those with normal weight (HR: 0.74 [0.58-0.95]), resulting in superior overall survival. Conclusion Despite the presence of more comorbidities among obese individuals undergoing esophagectomy, their risk of surgical complications remained comparable to those with normal weight. However, obese individuals exhibited a heightened susceptibility to other postoperative complications. Surprisingly, obese individuals demonstrated an improved overall survival at 5 years compared to those with normal weight.

770. CLOSURE OF OESOPHAGEAL DEFECTS USING THE VACSTENT DEVICE: INITIAL INSIGHTS FROM THE LARGEST UK CASE SERIES

Abstract Introduction Oesophageal defects are associated with poor morbidity and mortality and often require prolonged hospitalisation and artificial nutrition. Existing endoscopic treatment modalities exhibit limitations. Covered stents are associated with a migration rate of up to 50% and closure with endoscopic clips is limited to simple defects. Vacuum therapy is a well understood and established surgical therapy to promote wound healing. Endoscopic Vacuum Therapy (EVT) utilises these principles in the management of transmural oesophageal defects. The VACstent GITM (MicroTech) is a novel device which synergistically incorporates the advantages of a fully covered oesophageal stent while concurrently employing EVT. This approach seals the defect while mitigating against stent migration through the vacuum effect. Luminal patency is also maintained which helps to preserve nutritional independence. Accelerated healing and enhanced nutrition are thought to help reduce morbidity and enhance patient quality of life. Methods This single-centre prospective case series describes outcomes for patients with transmural oesophageal defects treated with the VACstent GITM device. All procedures were performed with propofol sedation and fluoroscopic guidance. The VACstent GITM was exchanged every 5-7 days until endoscopic closure. A contrast study was used to confirm closure after which oral nutrition was restarted. The primary outcome was clinical success, defined as the endoscopic and radiological evidence of defect closure. Secondary outcomes included number of stent exchanges, technical success, and the adverse event (AE) rate. Results The VACstent GITM device was used for seven patients between October 2023 and February 2024. Four patients had anastomotic leaks with three having iatrogenic perforations. The mean patient age was 60 (± 19.3) years with 57% of the patient cohort being male. The clinical success rate was 86% with a technical success rate of 100% and a median defect closure time of 13 (± 6.6) days. A median number of 1 stent exchanges was required. The median defect size was 8mm (± 6.2). There were no reported AEs. All patients were able to successfully come of artificial nutrition. Conclusion This case series illustrates the safety and efficacy of the VACstent for the treatment of a heterogenous group of oesophageal defects. To our knowledge this represents the largest series in a cohort of patients from the United Kingdom. Larger scale comparative studies incorporating a more diverse patient cohort will further clarify the potential of the VACstent device in reducing the necessity for major surgical interventions in this complex and challenging patient population. It will also help to refine future treatment algorithms for oesophageal defect management.

205. MINIMALLY INVASIVE IVOR LEWIS ESOPHAGECTOMY WITH TOTAL MEDIASTINAL LYMPHADENECTOMY FOR THORACIC ESOPHAGEAL CANCER: SHORT- AND LONG-TERM OUTCOMES IN 139 PATIENTS

Abstract Background The McKeown approach is a standard surgery for thoracic esophageal cancer in Japan, as lymph node dissection of upper mediastinum and neck is mandatory. The thoracoscopic approach allows access to the lymph node chain along the laryngeal nerves from the chest and led us to introduce minimally invasive Ivor Lewis esophagectomy (MIILE) with radical lymphadenectomy for middle and lower esophageal cancer. Although circular-stapled anastomosis is popular in MIILE, the frequency of anastomotic complications has been reported to be high. We introduced MIILE with linear-stapled anastomosis in 2010. Methods To evaluate the short- and long-term outcomes of MIILE with radial lymphadenectomy and linear stapled anastomosis, we performed a retrospective cohort study of 139 consecutive patients. The endpoints included overall complications, anastomotic leak rate, nutritional status at 12 months after MIILE, and 5-year overall survival, and disease-free survival. Surgical Procedure After laparoscopic gastric tube construction, thoracoscopic or robotic esophagectomy with total mediastinal lymphadenectomy was done in the prone position. ICG angiography was used to assess gastric tube viability and sacrifice the ischemic portion in recent cases. Esophago-gastric anastomosis was performed using a linear stapler. The opening was closed with interrupted sutures and covered with the omentum to secure the anastomosis. Results There was 122 male and 17 female patients with median age of 69 years. Preoperative diagnosis was stage I/II/III/IV in 44/46/37/12 patients. Pathology results were SCC in 108 cases. Tumor location was middle/lower/EGJ in 58/64/17 patients. Preoperative chemotherapy or CRT was administered in 77 patients. Median thoracic surgery time was 297 minutes and blood loss was 53 mL. Median hospital stay was 17 days. The short-term complication rate of grade IIIa or higher was 8.7%. Anastomotic leak occurred in 8 patients (5.8%), three of whom required intervention. No leakage occurred after introduction of intraoperative ICG angiography. 90-day mortality was 0.7%. With a median follow-up of 41 months, 5-year overall survival rate was 68.3% and disease-free survival rates was 56.7%. For the 65 SCC patients with clinical stage II/III disease, 5-year OS rate was 58.7%. During follow-up period, 2 patients (1.4%) required balloon dilatation due to anastomotic stenosis. At 12 months after MIILE, the mean weight loss was 11.6% and the mean albumin level was 3.9. Discussion Compared to benchmark complication rates reported by the international Esophagectomy Complication Consensus Group (ECCG), the overall complication rate (47% vs. 59%) was not significantly lower, but the anastomotic leak rate was significantly lower (5.8 vs. 11.4%). Overall survival, disease-free survival, and nutritional outcomes were similar to those reported in Japanese clinical trials. Conclusions MIILE with linear-stapled anastomosis is a safe procedure with a low rate of serious complications. Survival and nutritional outcomes were excellent. It may be recommended as a standard procedure for lower and middle esophageal cancer. https://www.dropbox.com/scl/fi/z6zyllnmie9qh3zhz2wd5/Okabe_ISDE.wmv?rlkey=4mig28fv5z2vhaui31tbk0mr9&dl=0

475. MINIMALLY INVASIVE IVOR -LEWIS ESOPHAGECTOMY - ANALYSIS OF PERIOPERATIVE ONCOLOGICAL AND SHORT TERM OUTCOMES

Abstract Background Trans thoracic Ivor-Lewis esophagectomy is the widely adopted procedure for gastroesophageal junction adenocarcinoma. Minimally invasive esophagectomy has been shown to be superior in comparison to the traditional open approach in terms of pulmonary complications and lymph node yield. We present our experience of minimally invasive Ivor-Lewis esophagectomy in this review. Methods A retrospective review of the patients who underwent minimally invasive Ivor-Lewis esophagectomy at a single center between September 2009 and April 2023 was performed. The perioperative and short term outcomes were analyzed. Results A total of 195 patients [147 males (75.38%)] underwent minimally invasive Ivor-Lewis esophagectomy during the study period. The median (range) age was 62 (48-77) years. The median operative time was 435 (310-530) minutes. The median estimated blood loss was 125 (80-250) ml. R0 resection was achieved in all the patients. The median lymph node yield, ICU stay and overall hospital stay were 22 (12-30), 3.5 (2-12) days and 10 (7-33) days respectively. Pulmonary complications were the most common seen in 24 (12.31%) patients. Anastomotic leak was noted in 5 (2.56%), chyle leak in 2 (1.02%), recurrent laryngeal nerve paresis in 12 (6.15%) patients. Anastomotic stricture was noted in 22 (11.28%) patients who were managed with endoscopic dilatation. Thirty day mortality was observed in 4 (2.05%) patients. Conclusion Minimally invasive Ivor-Lewis esophagectomy is associated with good perioperative oncological and short term outcomes when performed in a specialist esophageal center

581. SURGICAL TREATMENT OF ACUTE SYMPTOMATIC POST-ESOPHAGECTOMY DIAPHRAGMATIC HERNIA

Abstract Background Post esophagectomy diaphragmatic hernia (PEDH) is a rare, often asymptomatic condition, but it can also present as a life-threatening complication leading to emergency treatment. Acute onset of symptoms such as epigastric pain, shortness of breath and evidence of serious complications like strangulation, necrosis or perforation of the herniated organs represent an indication for emergency surgery. The aim of the present study is to report the experience of a tertiary care center for esophageal disease and to describe the clinical and surgical management of acute-onset PEDH treated in an emergency setting. Methods A retrospective analysis of a prospectively collected database of esophagectomies for cancer (hybrid, open, transhiatal or minimally invasive) performed at our Institution between January 2013 to June 2022 was performed. Early PEDH was defined as onset within 90 days from surgery. All patients with acute presentation of volvulus, ischemia, respiratory dysfunction or perforation were treated surgically by two expert surgeons. Results Among 357 patients, 10 had an urgent PEDH requiring surgery within 24 hours after onset of symptoms. Early PEDH was diagnosed in 5 patients (median time 4 days) and 3 of them had a concomitant diagnosis of anastomotic leak. Late hernia was treated at median time of 249 days. Organ resection was performed in 4 patients. Surgical access was laparoscopy in 8 patients, open and thoracotomy in 2. Cruroplasty was performed in 8 cases. Mortality was 0%. Recurrence was 10%. No preoperative risk factors for PEDH were identified (Table 1). Conclusions Diaphragmatic hernia could be a challenging complication after esophagectomy, that could present either as an early or late complication. Its early recognition is of paramount importance given its association with anastomotic leak or strangulation. Laparoscopic repair should be considered as the approach of choice in high-volume centers and cruroplasty with or without mesh positioning should be evaluated.

368. THE ROLE OF PG-SGA SCORE IN PREDICTING SHORT- TERM POSTOPERATIVE COMPLICATIONS IN ESOPHAGEAL CANCER SURGERY

Abstract Background The preoperative nutritional status is increasingly recognized as a determinant of postoperative outcomes in esophageal cancer patients. This study examines the relationship between preoperative nutritional scores, particularly the Patient-Generated Subjective Global Assessment (PG-SGA), and the incidence of short-term postoperative complications. Methods A prospective cohort study was conducted on patients undergoing surgery for esophageal cancer across two Surgical Departments at University Hospitals in Athens, Greece. Preoperative nutritional status was assessed using the PG-SGA score. Patients were categorized based on the PG-SGA score into low to medium risk with score of 8 or less, and high risk with score of 9 or higher. Postoperative complications were classified according to the Clavien-Dindo system, and their association with nutritional status was statistically assessed. Results This study included 59 consecutive patients who underwent surgery for esophageal cancer with female-to-male ratio of 1:4.9 and a median age of 65.4 ± 10.4 years, 43 (72.9%) of whom had received neoadjuvant chemotherapy. Notable postoperative complications (Clavien- Dindo classification ≥III) occurred in 14 cases, including evisceration (n=1), hemorrhage (n=1), chyle leakage (n=1), anastomotic leak (n=8), pleural effusion requiring radiological intervention (n=2), and a persistent pneumothorax necessitating additional thoracic tube insertion (n=1). A statistically significant association was found between malnutrition, as indicated by the PG-SGA≥9, and the development of severe postoperative complications (Clavien- Dindo classification ≥III) (p = 0.034). Conclusion This study suggests that preoperative PG-SGA score is potentially significant predictors of short- term postoperative complications in esophageal cancer surgeries. Incorporating nutritional assessments into the preoperative evaluation may help identify high-risk patients and tailor perioperative care to improve surgical outcomes.

Incisional hernia after major pancreatic resection: long term risk assessment from two distinct sources – A large multi-institutional network and a single high-volume center

BackgroundPost-operative incisional hernia (IH) is a common complication following abdominal surgery. Data regarding IH after major pancreatic surgery are limited. We aim to evaluate the long-term risk of IH following major pancreatic resection. MethodsA dual-approach study: a large multi-institutional research network (RN) was investigated for IH incidence and risk factors in propensity-score matched survivors after pancreaticoduodenectomy (PD) and distal pancreatectomy (DP), was complemented by a patient-reported questionnaire. ResultsRN analysis identified 22,113 patients that underwent pancreatic surgery. 11.0% of PD patients and 8.6% of DP patients developed IH (P < 0.0001). IH rates were higher with open surgery compared with minimally invasive approaches in PD (OR = 1.56, P = 0.03) and DP (OR = 1.94, P = 0.003). BMI>35 was found to correlate with increased IH rates for PD and DP (OR = 1.87, and OR = 1.86, respectively, P < 0.0001 each), as did postoperative intraabdominal infections (P < 0.0001). Patient-based survey of 104 patients, revealed that 16 patients (15%) reported post-operative IH during the follow-up period. BMI≥30, SSI and intra-abdominal abscesses were associated with increased IH risk (P < 0.05). ConclusionImproved survival after pancreatic resection has led to an increased prevalence of long-term surgical sequela. In this study, we demonstrate significant rates of IH among long-term survivors and assess potential risk factors.

198. IDENTIFYING THE OPTIMAL MANAGEMENT OF ESOPHAGEAL ANASTOMOTIC LEAKS. A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract Background There is currently no consensus as to how best to manage esophageal anastomotic leaks. Intervention with Endoscopic Vacuum Assisted Closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. Consequently, we aimed to conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. Methods A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. Results In total, 12 retrospective studies were included which included 511 patients. Of the 449 patients for whom data was available 371 (82.6%) were male, and 78 (17.4%) were female. The average age of patients was 62.6 years (Standard deviation (SD) 10.2). Overall, 94.5% of patients underwent initial esophagectomy for an underlying malignancy. The average Body Mass Index (BMI) reported was 25.9 kg/m2. The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The re-operation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (Odds ratio (OR) 0.23 95% confidence interval (CI) 0.09-0.58). EVAC had a significantly lower mortality rate than stenting (OR: 0.43, 95% CI 0.21; 0.87). Re-operation was used in significantly larger leaks than stenting (mean difference (MD) 14.66; 95%CI 4.61 24.70). Re-operation was also associated with a significantly increased mortality rate (OR: 2.66, 95% CI: 1.01-6.99.). Using stenting as a comparator, NMA failed to demonstrate a significant difference between interventions in terms of success rate. However, EVAC had the greatest difference in success rate (OR: 2.23, 95% CI 0.78-6.34). Conclusion The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. One aspect of EVT that was not examined in this study was the number of endoscopic interventions required. Sponge exchanges every 48 to 72 hours are necessary during EVT whereas stents may be left in place for 4-8 weeks. This may have significant implications for treatment choice in resource-limited settings and may have a profound impact on patient quality of life. Surgical management is often necessary for significantly larger leaks. Reoperation in the case of anastomotic leak is often the intervention of choice in systemically unwell patients and those with uncontained leaks. It therefore stands to reason that mortality rates are elevated among this patient cohort and differences in outcome are unlikely to be attributable to the modality of intervention alone.

389. WILL SYNCHRONOUS ESOPHAGEAL AND LUNG RESECTION INCREASE THE INCIDENCE OF ANASTOMOTIC LEAKS? A MULTICENTER RETROSPECTIVE STUDY

Abstract Background Reports on combined resection for synchronous lung lesions and esophageal cancer (CRLE) cases are rare and mostly individual cases. Furthermore, the feasibility of CRLE has always been a controversial topic. In the current study, we retrospectively analyzed the feasibility of CRLE and established an individualized prediction model for esophageal anastomotic leaks after CRLE by performing a multicenter retrospective study. Methods Patients who underwent esophagectomy between January 2009 and June 2021 were extracted from a 4-centre retrospectively maintained database, and those with CRLE at the same setting were matched in a 1:2 propensity score matched (PSM) ratio to esophagectomy alone (EA) patients. A nomogram was then established based on the variables involved in multivariate logistic regression analysis. Internal validation of the nomogram was conducted utilizing Bootstrap resampling. Decision and clinical impact curve analysis were computed to assess the practical clinical utility of the nomogram. A prognosis analysis for CRLE and EA patients by Kaplan-Meier curves was conducted. Results Of the 7152 esophagectomies, 216 cases of CRLE were eligible, and 1:2 ratio PSM EA patients were matched. The incidence of anastomotic leaks following CRLE increased significantly (P=0.035). The results of the multivariate analysis indicated the leaks varied according to the type of lung resection (anatomic &amp;gt; wedge resection, P=0.016) and site of resected lobe (upper &amp;gt; middle/low lobe; P=0.027), and a nomogram was established to predict the occurrence of leaks accurately (AUC=0.786). Although no statistically significant difference in overall survival (OS) was observed in the CRLE group (P=0.070), a trend toward lower survival rates was noted. Further analysis revealed that combined upper lobe anatomic resection was significantly associated with reduced OS (P=0.027). Conclusion Our study confirms that CRLE is feasible but comes with a significantly increased risk of anastomotic leaks and a concerning trend of reduced survival, particularly when upper lobe anatomic resections are performed. These findings highlight the need for careful patient selection and surgical planning when considering CRLE.

422. MANAGEMENT OF ANASTOMOTIC LEAK AFTER TOTAL GASTRECTOMY WITH THE “RENDEZ-VOUS” HYBRID TECHNIQUE: PRESENTATION OF OUR APPROACH AND RESULTS

Abstract Background Anastomotic dehiscence following total gastrectomy and Roux-en-Y reconstruction remains a demanding clinical scenario, associated with high morbidity and mortality rates. Management options focus on controlling systemic and local sepsis while allowing for proper anastomotic healing. Optimal treatment algorithm remains to be determined and therapeutic strategy is being individualized. The primary goal of the present study is to present the modified rendezvous stenting technique, a technique implemented in our department during reoperation for washout, in critically ill anastomotic leak patients. Methods We performed a retrospective descriptive analysis of severely ill patients suffering an anastomotic leak from an esophagojejunal anastomosis, who had been operated in our department during the last five years (01/2018-12/2023). All patients were operated on by the same surgical team and endoscopy was performed by the same endoscopist. Data regarding patients who had been subjected to the modified rendezvous technique were collected. Results Since 2018, five anastomotic leak patients underwent stenting over the anastomosis using the modified rendezvous technique during relaparotomy. Stenting was effective in controlling local contamination in 4 out of 5 patients (80%). One patient required repeat stent placement due to stent migration. Overall the 30 day mortality rate was 20% and no deaths directly attributed to the leak were observed. Stents remained in position for an average of 4.25 weeks. Conclusion Anastomotic stenting using the rendezvous technique is a safe and feasible technique. It can prove useful in controlling local abdominal contamination in severe anastomotic leak patients, while minimizing the risk of stent migration. Further implementation of the technique will allow for more reliable conclusions to be drawn, regarding the technique’s actual effectiveness.

Transcervical Endoscopic Esophageal Mobilization: An Approach to Transhiatal Esophagectomy

BackgroundTranscervical endoscopic esophageal mobilization (TEEM) is an approach to transhiatal esophagectomy that aims to minimize blood loss and decrease the operative time commonly associated with traditional transhiatal technique. MethodsA retrospective chart review was conducted on patients who underwent TEEM esophagectomy between 2009 and 2020. Baseline characteristics, perioperative outcomes, and postoperative complications were recorded. To report survival, a Kaplan-Meier survival plot was developed using SAS software (SAS Institute). ResultsA total of 241 patients underwent TEEM esophagectomy. The mean operative time was 185.1 ± 59.3 minutes, blood loss was 251.4 ± 212.3 mL, the number lymph nodes dissected was 13.6 ± 6.2, and the length of stay was 11.9 ± 8.5 days. In the postoperative setting, 68 (28.2%) patients experienced hoarseness, 62 (25.7%) had postoperative atrial fibrillation, 30 (12.4%) had an anastomotic leak, and 12 (4.6%) experienced chylothorax. The overall 30- and 90-day mortality rates were 2.1% (5 of 241) and 4.6% (11 of 241), respectively. The median overall survival was 2.36 years, with 60% 3-year survival and 40% 5-year survival. ConclusionsTEEM esophagectomy is a safe approach with acceptable postoperative morbidity and mortality and shorter operative times compared with historical norms.

550. INTRAOPERATIVE VOLUME STATUS DOES NOT AFFECT ERAS OUTCOMES OR COMPLICATION RATES IN HYBRID ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Intraoperative volume management in patients undergoing esophagectomy is nuanced. Data is conflicting in regards to the benefits of volume restrictive versus liberal approaches. Within a hybrid robotic assisted minimally invasive esophagectomy (hRAMIE) population undergoing oncologic resection there is a paucity of data regarding intraoperative volume status as it affects postoperative outcomes and no data regarding the impact on enhanced recovery after surgery (ERAS) outcomes. Methods Demographics, anthropometrics, cancer characteristics, and perioperative outcome data were gathered between January 2020 and December 2023 at a single, tertiary referral center in patients undergoing oncologic hRAMIE. Intraoperative volume status was defined, as in other reports, by identifying the median operative volume rate per hour and normalizing via the Du Bois body surface area; above or below 225 mL/hour/m2. ERAS outcomes were reported. Complications were stratified in accordance with the Esophagectomy Complications Consensus Group guidelines. Continuous variables were compared via Mann-Whitney U-Test; categorical via Fisher's Exact. Alpha set to 0.05. Results 96 patients (46 volume restrictive, 45 volume liberal) were identified. There were no differences in age, sex, body mass index, ASA class, Charlson Comorbidity Index, cancer histology, location, rate of neoadjuvant chemotherapy, or chemoradiotherapy. ERAS outcomes analysis reveals no statistical difference in ICU length of stay, mobilization times, return of bowel function, or length of stay (Table 1). Complications were reported in 45.8% of patients and did not differ between groups (p=0.8934). Pulmonary complications were most frequent (total 21.9%; restrictive 17.4%, liberal 28.9%, p=0.1422) followed by anastomotic leak (total 12.5%; restrictive 17.4%, liberal 8.9%, p=0.3681). Conclusion The current study demonstrates no impact of volume restriction on perioperative outcomes, ERAS benchmarks, or length of stay in patients undergoing hRAMIE for esophageal cancer. Data suggests that minimally invasive approaches may be associated with less total body and pleural inflammatory mediator generation, perhaps limiting susceptibility to variation in volume status. Highly powered, multicenter retrospective minimally invasive esophagectomy and volume status investigation is warranted prior to proceeding with controlled trial.

573. SHORT- AND LONG-TERM RESULTS OF RAMIE IN BORDERLINE CT3 /T4B ESOPHAGEAL CANCER AT INITIAL DIAGNOSIS: COMPARISON WITH CONVENTIONAL MIE

Abstract Background Conversion esophagectomy in patients with locally advanced esophageal cancer, initially deemed unresectable, but which has responded to prior therapy, remains unclear. Recently, the utility of RAMIE for locally advanced esophageal cancer has come under discussion. In this study, we first analyzed the short- and long-term outcomes of RAMIE, then investigated the outcomes of conversion RAMIE in cT3br/T4b patients, and compared them with those of conversion using conventional MIE. Methods Between January 2020 and August 2023, thirty-three patients with locally advanced esophageal cancer initially diagnosed as cT3br/T4b, who underwent RAMIE after prior treatment, were analyzed, and short-term and long-term postoperative outcomes were evaluated. Additionally, these 33 patients who underwent RAMIE for cT3br/T4b were compared to 48 patients with initial cT3br/T4b who underwent conventional MIE during the same period. Results The mean age of RAMIE patients with cT3br/T4b was 63.2 years, with a male-to-female ratio of 26:7, and a clinical stage III/IV distribution of 12/21. Nearly all patients received preoperative treatment with induction chemotherapy (e.g., induction-DCF) or definitive chemoradiation. Among these patients, three underwent R1 or R2 resection. Surgical complications included pneumonia in 18.1% of cases, recurrent nerve palsy in 12.1% (excluding complicated resection cases), and anastomotic leakage in 7.4%. Regarding long-term survival, the 3-year overall survival (3yOS) was 66.2%, and the 3-year disease-free survival (3yDFS) was 48.7% in patients who underwent RAMIE with initial cT3br/T4b. In the 48 patients who underwent esophagectomy with conventional MIE after pretreatment with cT4br/T4b status, the 3yOS was 52.7%, and the 3yDFS was 40.3%. These survival results for conventional MIE were lower than those for patients who underwent RAMIE (p=0.02). Conclusion The short- and long-term outcomes of RAMIE, including cases of T3br/T4 were described, and they were deemed acceptable. Regarding recurrence, local/regional disease control was considered relatively good.

400. MODIFICATION OF THE LESSER CURVATURE INCISION ENHANCES GASTRIC CONDUIT BLOOD FLOW AND DECREASE ANASTOMOTIC LEAKAGE RISK AFTER ESOPHAGECTOMY

Abstract Background We conducted this study to investigate the effectiveness of a modified incision line on the lesser curvature for gastric conduit formation during esophagectomy in enhancing the perfusion of the gastric conduit, as determined by indocyanine green (ICG) fluorescence imaging, and reducing the incidence of anastomotic leakage. Methods A total of 272 patients who underwent esophagectomy at our institution between June 2014 and August 2022 were enrolled in the study. The patients were divided into two groups in accordance with the type of cutline on the lesser curvature: the Conventional group, consisting of patients operated on until 2018 (Conventional group; n = 141), in which the traditional cutline (5.0 cm from the pylorus in routine) was adopted, and the Current group, consisting of patients operated on from 2019 until date (Current group; n = 131), in which a modified cutline on the lesser curvature was adopted, that allowed preservation of the entire right gastric artery was adopted (hereinafter, modified cutline) was adopted. Gastric conduit perfusion during the surgery was assessed by intraoperative ICG fluorescence imaging, and the clinical outcomes after esophagectomy were also evaluated. Results All patients underwent esophagectomy with regional lymph node dissection and gastric conduit reconstruction via the retrosternal route. The distance from the pylorus to the cutline was significantly longer in the Current group as compared with the Conv group (median: 9.0 cm vs. 5.0 cm, p &amp;lt; 0.001). The blood flow speed in the gastric conduit wall assessed by ICG fluorescence imaging was significantly higher in the Current group than that in the Conventional group (median: 2.81 cm/sec vs. 2.54 cm/sec, p = 0.001). Furthermore, the incidence of anastomotic leakage was significantly lower (p = 0.024) and the hospital stay significantly shorter (p &amp;lt; 0.001) in the Current group as compared with the Conventional group. Logistic regression analysis using the data of the entire cohort identified the blood flow velocity in the gastric conduit wall as the only variable that was significantly (negatively) associated with anastomotic leakage. Conclusions ICG fluorescence imaging is a feasible, reliable method for intraoperative assessment of gastric conduit perfusion. Use of the modified lesser curvature cutline could enhance gastric conduit perfusion, promote blood circulation around the anastomosis and ultimately reduce the risk of anastomotic leakage after esophagectomy.

261. CONVERSION ESOPHAGECTOMY FOR CT4B ESOPHAGEAL CANCER - MIE VS OPEN -

Abstract Background and Aims The standard treatment for locally advanced unresectable esophageal cancer is definitive chemoradiotherapy (dCRT), however, after induction chemotherapy with a triplet chemotherapy regimen (docetaxel, cisplatin, and 5-FU: DCF) or dCRT, conversion surgery could be performed if esophageal cancer is considered resectable. Furthermore, minimally invasive surgery such as robot-assisted or thoracoscopic procedures are expected to improve the outcome of patients with advanced esophageal cancer. We investigated the feasibility of minimally invasive esophagectomy (MIE) in conversion surgery. Materials and Methods Sixty-six patients who underwent conversion thoracic esophagectomy for cT4b esophageal cancer from 2007 to 2023 were included. The short-term outcomes of 25 open esophagectomy group and 41 MIE group (8 robot-assisted and 33 thoracoscopic) were compared. Results No differences in age, gender, PS, tumor location, histology, cN, or cM were observed between the two groups. cT4b organs tended to be in the airway in the MIE group (airway 70.7% vs 44%, major vessels 19.5% vs 24%, both 9.7% vs 32%, p=0.04) and DCF therapy was significantly performed in the MIE group for induction therapy (DCF 87.8% vs 56%, dCRT 12.2% vs 44%, p&amp;lt;0.001). On the other hand, salvage surgery was significantly associated with open esophagectomy (24.3% vs. 52%, p=0.003). There was no difference in surgical outcomes regarding thoracic operation time (157 min vs. 180 min, p=0.09), whereas the total operation time was significantly shorter in the MIE group (392 min vs. 439 min, p=0.02). Blood loss was significantly lower in the MIE group (79 ml vs. 470 ml, p&amp;lt;0.001), and R0 resection rate did not differ (82.9% vs. 72%, p=0.357). There were no significant differences in postoperative complications including pneumonia (26.8% vs. 44%, p=0.183) and recurrent nerve palsy (21.9% vs. 36%, p=0.260), but anastomotic leakage was significantly lower in the MIE group (4.8% vs. 24%, p=0.04). There was no difference in median postoperative hospital stay (16 [11-20] vs. 16 [14-29] days), however, median ICU stay (3 [3-4] vs. 4 [3-4] days, p=0.03) and readmission within 1 month after discharge (2.4% vs. 16%, p=0.04) were significantly lower in the MIE group. In-hospital mortality was observed in 1 case in the MIE group and 3 in the open esophagectomy group. Conclusion Despite the bias associated with the transition of treatment modalities and surgical techniques, MIE may contribute to improved short-term outcomes in conversion surgery.

534. EVALUATION OF SURGICAL OUTCOMES IN ROBOTIC-ASSISTED ESOPHAGECTOMY

Abstract Background The adoption of robotic surgery for the treatment of esophageal cancer is on the rise, with reports indicating favorable short-term outcomes. This study aims to evaluate the performance of robotic-assisted esophagectomies at our hospital. Methods We conducted a retrospective analysis of perioperative outcomes in patients who underwent robotic-assisted esophagectomies. Cases requiring a two-stage operation were excluded. Results A total of 64 cases were evaluated, with a median age of 72.0 years (range 46-83). Histological types included SCC/AC/ASC/Other: 49/10/1/4 cases. Clinical stages were 0/I/II/III/IVA/IVB: 1/20/11/27/4/1 cases, respectively. Postoperative complications, classified as Clavien-Dindo (CD) Grade II or higher, occurred in 24 cases (37.5%), which included respiratory complications (pneumonia, atelectasis, pneumothorax) in 7 cases (10.9%), anastomotic leakage in 7 cases (10.9%), recurrent laryngeal nerve palsy in 3 cases (4.7%), anastomotic stricture in 2 cases (3.1%), wound infection in 2 cases, gastric conduit necrosis in 1 case (1.5%), cervical lymphorrhea in 1 case, tracheoesophageal fistula in 1 case, and other complications in 3 cases. Conclusion Robotic-assisted esophagectomies have demonstrated favorable short-term outcomes when compared with prior reports. Further studies are warranted to elucidate the reduction of complications and to determine long-term outcomes.

505. USE OF INDOCYANINE GREEN FOR ASSESSMENT OF GASTROPLASTY VASCULARIZATION AFTER MCKEOWN ESOPHAGECTOMY

Abstract Background Anastomotic leakage is one of the most feared complications of esophagogastric surgery, conferring significant morbidity and mortality in these patients. It is known that inadequate vascularization of the gastroplasty is a major risk factor for anastomotic dehiscence. The aim of this study is to evaluate and demonstrate the utility of intraoperative use of indocyanine green (ICG) in patients undergoing esophagectomy and reconstruction with gastroplasty to assess the relationship between its vascularization and the presence of anastomotic leakage in the postoperative period. Methods Prospective, longitudinal, observational, and analytical study of 36 consecutive cases in which intraoperative ICG was used for patients undergoing McKeown esophagectomy and reconstruction with gastroplasty and cervical anastomosis from June 2021 to December 2023. The distance traveled by the ICG in a proximal direction from the pylorus at 30 and 90 seconds after its intravenous infusion was measured. An automatic baseline point or point of maximum fluorescence was also recorded and compared both in net value and in percentage at 30, 60, 90, and 120 seconds after the infusion of ICG with the theoretical zone of anastomosis construction (zone reaching the sternal manubrium after extending the graft over the sternum). Statistical analysis was performed using SPSS version 24.0. Results The rate of leaks and necrosis of the graft was 19.4% and 2.8%, respectively. There is a significant relationship (p&amp;lt;0.05) between the rate of anastomotic dehiscence and the net value and percentage compared with the automatic baseline point of ICG at the anastomosis site and at the apex of the gastroplasty at 30, 60, 90, and 120 seconds. Using a ROC curve (figure 1) that analyzed the time it takes for ICG to reach the anastomosis, a cutoff point of 19.5 seconds was established, which gives ICG greater profitability as a diagnostic test with an AUC of 0.821 (0.642-1). The positive predictive value of this test is 0.36, and the negative predictive value is 1. Conclusion The use of indocyanine green appears to be a good method for identifying those anastomoses and gastroplasties that present a high risk of dehiscence and/or necrosis. The time it takes for ICG to reach the anastomosis, the speed at which it does so, as well as the quantitative value provided by the platform used, seem to be valid parameters for identifying high-risk cases. This would allow for the performance of additional measures to reduce the risk of dehiscence and/or necrosis. Randomized prospective studies with a larger sample size would be necessary.