Anastomotic Recurrence Research Articles

The impact of anastomotic leakage on recurrence and long-term survival in patients with colonic cancer: A systematic review and meta-analysis

Background/ObjectiveAnastomotic leakage (AL) is one of the most severe complications following colorectal cancer surgery and is associated with increased short and long term mortality. The literature is conflicting regarding increased risk of recurrence after AL. The aim of this study was to systematically review the impact of anastomotic leakage on the risk of local or distant recurrence and overall survival, cancer specific survival, and disease-free survival. MethodsA systematic review and meta-analysis was conducted in accordance with the PRISMA guidelines. A systematic search in PubMed, EMBASE, CINHAL, and The Cochrane Library was performed and meta-analyses were performed on all outcomes including analysis based on time-to-event data. ResultsA total of eighteen cohort studies, including 69,047 patients whereof 2,555 patients had anastomotic leakage, were included. Meta-analysis demonstrated no significant effects of anastomotic leakage on local recurrence (RR 1.16, 95% CI 0.84–1.59) or distant recurrence (RR 1.44, 95% CI 0.52–3.96). Anastomotic leakage decreased overall survival (RR 0.85, 95% CI 0.77–0.94), disease free survival (RR 0.80, 95% CI 0.72–0.89), and cancer specific survival (RR 0.90, 95% CI 0.83–0.97). A time-to-event analysis was conducted on available data and the results were congruent with the frequency analyses. ConclusionAnastomotic leakage following colonic resections is significantly associated with impaired overall survival, disease free survival and cancer specific survival. The study did not show any statistically significant association between anastomotic leakage and recurrence.

Curative intent resection for loco-regionally recurrent colon cancer: Cleveland clinic experience

BackgroundLocoregional colon cancer recurrence occurs in around 10% of patients following initial curative intent primary resection. We hypothesized oncological results can vary based on the recurrence site. Our aim was to determine outcomes for patients undergoing resection with curative intent for locally recurrent colon cancer. MethodsPatients with locoregional recurrence after curative intent resection for colon cancer were identified (1999–2017). Demographics, operative details and outcome data were recorded. Kaplan-Meier method was used to compare survival differences. ResultsFifty-two patients (mean age, 62) were included. The most common recurrence site was primary anastomosis (48%). R0 resection was obtained in 68%. Major morbidity occurred in 37%. Patients with anastomotic recurrence had a statistically significant overall survival compared to other sites (71.6 vs. 40.8 months respectively with a P value of 0.05). ConclusionsExcellent outcomes are possible for curative intent recurrent colon cancer surgery. The site of loco-regional recurrence plays a significant role in outcomes.Table of Contents Summary: Colon cancer recurrence can be treated surgically with optimal outcomes. Anastomotic recurrence is associated with improved survival.

Systemic Immune Inflammation Index, Lowest Total Lymphocyte Count and Hemoglobin Level Are Prognostic Factors in Patients with Postoperative Recurrence of Esophageal Carcinoma Treated with Salvage Radiotherapy and Chemotherapy

To analyze the effects of clinical features, chemoradiotherapy related factors, hematological different nutritional indexes, and inflammatory indexes on the survival of postoperative recurrence of esophageal carcinoma treated with salvage chemoradiotherapy, and to explore the predictive factors of treatment-related toxic and side effects. A total of 242 postoperative esophageal carcinoma patients with local/regional recurrence during January 2008 to December 2016 treated with chemoradiotherapy were analyzed. Recurrence included anastomotic recurrence and regional lymph node metastasis (supraclavicular, mediastinal, and abdominal lymph node metastasis involved). The clinical features (sex, age, tumor location, T stage, N stage, TNM stage, regional recurrence site, number of recurrence areas, postoperative recurrence time), chemoradiotherapy related factors (post-recurrence treatment, radiotherapy target area, radiotherapy dose, chemotherapy regimen, chemotherapy cycle), hematological inflammation related indicators, including the absolute monocyte count (AMC), neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR), lymphocyte monocyte ratio (LMR), systemic immune-inflammation index (SII), systemic inflammation score (SIS), and hematological nutrition-related indicators, including total lymphocyte count (TLC), hemoglobin (HB), albumin (ALB), prognostic nutritional index (PNI)，body mass index (BMI) on survival, toxic and side effects were analyzed. The median survival time was 16.6 months, and the 1-, 2-, 3-and 5-year survival rates were 65.6%, 36.7%, 25.5% and 11.5%, respectively. Univariate analysis showed that T stage, N stage, TNM stage, chemotherapy cycle, NLR level, PLR level, LMR level, SII level, HB level, PNI level before chemoradiotherapy, and the minimum level of TLC during chemoradiotherapy were the influencing factors of OS. Multivariate analysis showed that the minimum level of TLC during chemoradiotherapy, SII and HB level before chemoradiotherapy were independent influencing factors of OS (P=0.001; P=0.009; P=0.009, respectively). AMC level, HB level and TLC minimum level were the main factors affecting hematological toxicity. The incidence of grade 2 hematological toxicity in the high AMC group was similar to that in the low AMC group, and the incidence of the non-anemia group and the G0-2 group in the lowest TLC was even lower than that in the corresponding group. No factors affecting hematological toxicity and radiation pneumonia were found in hematology. The minimum level of TLC during chemoradiotherapy, the level of SII and HB before chemoradiotherapy were the independent prognostic factors for postoperative esophageal carcinoma patients treated with salvage chemoradiotherapy.

Long-term efficacy of pure transanal total mesorectal excision for middle-low rectal cancer

Objective To investigate the long-term efficacy of pure transanal total mesorectal excision (PtaTME) for middle-low rectal cancer. Methods The retrospective descriptive study was conducted. The clinicopathological data of 18 patients with middle-low rectal cancer who were admitted to the Sixth Affiliated Hospital of Sun Yat-sen University from July 2014 to August 2016 were collected. There were 7 males and 11 females, aged (58±13) years, with a range from 40 to 84 years. The body mass index was (22±3)kg/m2. All the 18 patients underwent PtaTME. Observation indicators: (1) surgical and postoperative conditions; (2) postoperative pathological examination; (3) follow-up and survival. Follow-up using inpatient reexamination, outpatient examination, and telephone interview were performed to detect anastomotic complications, anal function, urinary retention, sexual dysfunction, survival and tumor recurrence and metastasis once every 3 months within postoperative 6 months, once every 6 months from 6 months to 3 years, and once a year after 3 years up to June 2019. The measurement data with normal distribution were represented as Mean±SD, and the measurement data with skewed distribution were represented as M (range). Count data were expressed as percentages. Survival rates were calculated by the Kaplan-Meier method. Results (1) Surgical and postoperative conditions: 18 patients successfully underwent PtaTME, without conversion to open surgery. The operation time, volume of intraoperative blood loss, distance between anastomosis and anal verge, time to first flatus, time to urinary catheter removal, and duration of postoperative hospital stay were (202±68)minutes, 50 mL (range, 20-400 mL), (4.5±2.0)cm, 2 days (range, 2-7 days), 3 days (range, 2-5 days), and 7 days (range, 5-10 days) in the 18 patients, respectively. There was no perioperative complication. Among 18 patients, 4 underwent preventive ileostomy. (2) Postoperative pathological examinations: the length of surgical specimens, the number of lymph node dissection, distance from tumor to the distal margin were (11.0±3.0)cm, 12±6, and 1.0 cm (range, 0.8-3.7 cm), respectively. The 18 patients had complete mesorectal membrane excision, with negative proximal margin, distal margin, and circumferential margin. Tumor pathological staging: there were 2 cases in Tis stage, 4 in T1 stage, 7 in T2 stage, and 5 in T3 stage; 16 in N0 stage, 1 in N1 stage, and 1 in N2 stage. Tumor histological classification: 2 patients had carcinoma in situ, 9 had moderately differentiated adenocarcinoma, and 7 had high-differentiated adenocarcinoma. (3) Follow-up and survival: 18 patients were followed up for 34.0-59.0 months, with a median follow-up time of 57.5 months. During the follow-up, 4 patients developed grade B anastomotic leakage and were cured after conservative treatment. One patient developed anastomotic recurrence at 2 years after surgery, and no recurrence was found after surgical resection of the recurrent lesion. Four patients with prophylactic ileostomy had the stoma closured, and the anus function was satisfactory after surgery. There was no urinary retention or sexual dysfunction in the 18 patients. Of the 18 patients, 17 had tumor free survival after surgery. The 3-year disease-free survival rate was 94.4%, and the 3-year overall survival rate was 100.0% in 18 patients. Conclusion PtaTME can achieve high quality of specimen, which is safe and feasible for the treatment of rectal cancer. Key words: Rectal neoplasms; Rectal cancer; Total mesorectal excision; Pure transanal total mesorectal excision; Long-term efficacy

Selective central vascular ligation (D3 lymphadenectomy) in patients undergoing minimally invasive complete mesocolic excision for colon cancer: optimizing the risk-benefit equation.

Complete mesocolic excision (CME) with central vascular ligation (CVL) has been advocated for right colon adenocarcinoma (RC), but the radicality of vascular dissection remains controversial. Our aim is to report outcomes of selective CVL (D3 lymphadenectomy) during minimally invasive CME for RC. A prospective database identified patients who were treated for RC between 2009 and 2016. Minimally invasive CME was standard. The radicality of lymphadenectomy was defined as high ligation (HL) versus CVL based on operative reports and videos. Two blinded radiologists independently evaluated the pre- and postoperative CT scans for radiographically abnormal nodes. Of 197 patients who underwent CME, HL was performed in 56 (28%) and CVL in 141 (72%). There were no baseline differences in age, sex, body mass index, American Society of Anesthesiologists score or pathological staging, and there were no major intra-operative complications in either group (including no major vascular injuries). The median total number of nodes retrieved was 27 and 31 (P=0.011) in HL and CVL groups, resepctively, with pathologically positive nodes identified in 33.9% and 39.8% (P=0.704), respectively. Preoperative imaging identified abnormal cN3 nodes in 1.5% of patients; all of whom underwent CVL. No abnormal cN2 or cN3 nodes remained on postoperative imaging. The 60-day mortality was 0.5%, and major morbidity was 4%. One patient (0.5%) had an anastomotic recurrence after a median follow-up of 22months. With imperfect preoperative clinical nodal staging, and in the absence of randomized data, the low morbidity and oncological outcomes observed support the approach of CME with HL as a minimum standard, with CVL (D3 lymphadenectomy) in selected cases.

Meta-analysis of Histological Margin Positivity in the Prediction of Recurrence After Crohn's Resection.

Despite significant advances in the medical management of Crohn's disease, many patients will require intestinal resection during their lifetime. It is disappointing that many will also develop disease recurrence. The current study utilizes meta-analytical techniques to determine the effect of positive histological margins at the time of index resection on disease recurrence. Embase, Medline, PubMed, PubMed Central, and Cochrane databases were searched using a Boolean search algorithm for articles published up to August 2017. Meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases were searched for studies reporting the outcomes for patients with Crohn's disease undergoing primary resection that correlated resection margin status with disease recurrence. Results were reported as pooled ORs with 95% CI. A total of 176 citations were reviewed; 18 studies comprising 1833 patients were ultimately included in the analysis, with a mean rate of histopathological margin positivity of 41.7 ± 17.4% and a pooled mean follow-up of 69 ± 39 months. Histopathological margin positivity was associated with a higher rate of overall recurrence (OR, 1.7; 95% CI, 1.3-2.1; p < 0.001), clinical recurrence (OR, 1.7; 95% CI, 1.0-2.8; p = 0.04), and anastomotic recurrence (OR, 1.6; 95% CI, 1.0-2.3; p = 0.03). In studies reporting plexitis specifically at the resection margin, there was an increase in recurrence (OR, 2.3; 95% CI, 1.1-4.9; p = 0.02). The definitions of histological margin positivity and postoperative recurrence vary between the studies and follow-up durations vary. The presence of involved histological margins at the time of index resection in Crohn's disease is associated with recurrence, and plexitis shows promise as a marker of more aggressive disease. Further studies with homogeneity of histopathological and recurrence reporting are required.

Recidiva anastomotică după neoplasm rectal 1/3 medie operat cu conservarea sfinterului anal

Recidiva anastomotică după neoplasm rectal 1/3 medie operat cu conservarea sfinterului anal

Colonoscopy Surveillance After Colorectal Cancer: the Optimal Interval for Follow-Up.

Patients who have undergone curative surgery for colorectal cancer are at risk of developing a metachronous colorectal tumour or anastomotic recurrence. The aim of this study was to determine the incidence of recurrent colorectal cancer in a cohort of patients who participated in a colonoscopy surveillance programme. This single-centre retrospective observational cohort study included patients who underwent curative surgery for colorectal cancer between 2005 and 2015. All reports of postoperative colonoscopies were retrieved to calculate the incidence rates of recurrence and metachronous colorectal cancer. Of 2420 patients, 1644 (67.9%) underwent at least one postoperative colonoscopy and 776 (32.1%) did not. In 1087 patients, colonoscopy was performed in the first 18months after surgery, which detected 34 (3.1%) instances of metachronous colorectal tumours or anastomotic recurrence. Thirty-three additional patients were also diagnosed with recurrent colorectal cancer, but the tumours were detected by other diagnostic modalities or detected perioperatively, rather than by colonoscopy. Patients with a history of colorectal cancer have an increased risk for a second colorectal tumour. Therefore, we recommend a colonoscopic surveillance programme with the first colonoscopy performed 1year after curative surgery, which is in accordance with national guidelines.

DOZ047.08: Endoscopic management of esophageal stenosis in patients with congenital esophageal atresia: experience of a single tertiary care center in Italy

Abstract Objective and Study Esophageal stenosis is the most common morbidity associated with congenital esophageal atresia (EA). There is no consensus regarding the endoscopic management of strictures in terms of timing and techniques of dilations. The aim of this study is to describe the endoscopic management of esophageal stenosis in children with EA admitted to our tertiary care center. Methods A retrospective descriptive single-center study was conducted. Data were collected of all patients diagnosed with EA admitted to the ‘Women's and Children's Hospital’ of Verona, Italy, between 2004 and 2017. Results Thirty-seven patients with EA were admitted to our center between 2004 and 2017. Twenty of them were excluded for insufficient data. All patients underwent surgical correction within 2 months of life. An endoscopic control with upper gastrointestinal endoscopy was performed in all of them. Eleven (65%) subjects had tracheoesophageal fistula. All of them had type C EA. Three (18%) had long-gap EA. Eleven patients (65%), 8 with Type C EA and 3 with Type A EA, underwent endoscopic dilation. Semirigid Savary-Giliard bougies were used in most of them. Pneumatic dilation with balloon was performed only in one case. Nine (81%) needed more than one dilation due to anastomotic stricture recurrence. In 3 of the 11 subjects (27%) more than 3 dilations were necessary. Two of them had long-gap EA. The median age of first endoscopic dilation was 3 months (range: 1–12 months). The median age of the last dilation was 6 months (range: 1–18 months). One of the 11 patients who underwent dilations (Type C EA with long gap) underwent surgical retreatment due to fistula recurrence. Six of the 17 subjects (35%) enrolled developed long-term complications. Conclusion Our data confirmed that anastomotic stricture is frequent in patients with EA who underwent surgical correction. Endoscopic management of stenosis is a safe and effective procedure that leads to a limited number of complications. Side effects are more likely to occur in patients with long-gap EA. Timing of dilations and endoscopic technique should be defined by international guidelines in order to improve patient's outcome.

What is the Meaning of an Early Anastomotic Recurrence after Curative Right Hemicolectomy? A Synchronous, Metachronous, or What Else?

What is the Meaning of an Early Anastomotic Recurrence after Curative Right Hemicolectomy? A Synchronous, Metachronous, or What Else?

Can rectal washout reduce anastomotic recurrence after anterior resection for rectal cancer? A review of the literature.

Local recurrence rates of rectal cancer after anterior resection remain high, despite the continued efforts of surgeons to devise preventive measures. Anastomotic recurrence, a form of local recurrence, may be caused by the implantation of exfoliated cancer cells during resection, and rectal stump washout has been proposed as a way to reduce the risk of this occurring. In this review article, we explore the mechanism of anastomotic recurrence after low anterior resection for rectal cancer, and examine the history and effectiveness of rectal washout on reducing recurrence rates, with a focus on washout solutions, procedures, and devices. Despite the lack of evidence from randomized trials, rectal washout with normal saline or diluted iodine is performed almost routinely during low anterior resection. Clamping is usually done using cross-clamps, linear staplers, tourniquets, and other devices. Although viable cancer cells may be shed into the rectal lumen during surgical resection, their impact on anastomotic recurrence remains uncertain. However, washout poses little or no harm to patients, and appears acceptable as a routine procedure. Randomized controlled trials or large observational studies may help to clarify the best practices for rectal washout.

Recurrence Following Anastomotic Leakage After Surgery for Carcinoma of the Distal Esophagus and Gastroesophageal Junction: A Systematic Review.

Esophageal cancer is the ninth most common cancer. The only potentially curative treatment is surgical resection, which unfortunately is still associated with major complications, the most important being anastomotic leakage, currently with an overall rate of up to 26% morbidity. The aim of this systematic review was to evaluate the relationship between anastomotic leakage and recurrence of disease. A literature search was systematically performed. Seven out of 312 articles dated between 2009 and 2018 fulfilled the selection for a total of 5,433 patients. The frequency of anastomotic leakage ranged from 7.2 to 11.2%. Patients affected by anastomotic leakage had a recurrence rate of 9-56%. Closer follow-up or even more aggressive oncological therapy should be considered for patients affected by anastomotic leakage after surgery for carcinoma of the distal esophagus and gastroesophageal junction.

Treatment: the role of contact X-ray brachytherapy (Papillon) in the management of early rectal cancer.

Treatment: the role of contact X-ray brachytherapy (Papillon) in the management of early rectal cancer.

Surgical Recurrence at Anastomotic Site After Bowel Resection in Crohn’s Disease: Comparison of Kono-S and End-to-end Anastomosis

BackgroundAnastomotic surgical recurrence after bowel resection in Crohn’s disease patients is problematic. This study was performed to evaluate the increased risk of anastomotic surgical recurrence. MethodsFrom 2006 to 2016, we performed anastomoses in 215 consecutive Crohn’s disease patients. The cohort was divided into two groups: Kono-S anastomosis (n = 117) and end-to-end anastomosis (n = 98). Multivariate analysis of predictors of anastomotic surgical recurrence and Kaplan–Meier analysis for the 5-year anastomotic surgical recurrence rate were evaluated. ResultsThe two groups showed no statistically significant differences in patient backgrounds. During a median follow-up of 54 months, 28 patients required anastomotic surgical recurrence [4 (3.4%) in the Kono-S group and 24 (24.4%) in the end-to-end group]. Six leaks (5.1%) were detected in the Kono-S group and 17 leaks (17.3%) in the end-to-end group; all were successfully treated conservatively. End-to-end anastomosis, leakage, age < 45 years, and body mass index of ≥ 18 kg/m2 at the first surgery had a higher risk of anastomotic surgical recurrence. Kono-S anastomosis significantly reduced the risk of anastomotic surgical recurrence after 1 year (odds ratio, 0.14). Anastomotic leakage influenced anastomotic surgical recurrence within 1 year (odds ratio, 4.84). The 5-year surgery-free survival rate at the anastomosis site with Kono-S anastomosis (95.0%) was significantly higher than that with end-to-end anastomosis (81.3%; P < 0.001). ConclusionsAnastomotic leakage after bowel resection in Crohn’s disease patients increased anastomotic surgical recurrence within 1 year, and Kono-S anastomosis is associated with a low risk of anastomotic surgical recurrence after > 1 year.

Failure Patterns after Radical Surgery of Thoracic Esophageal Squamous Carcinoma

Radiation therapy is an important cancer treatment modality in both adjuvant and definitive setting, however, the use of radiation therapy for elective treatment of regional lymph nodes is controversial for esophageal squamous cell carcinoma after radical surgery. This analysis aims to study the metastasis pattern through a pooled analysis of published results after radical tumor and lymph nodal resection with histological study in thoracic esophageal squamous cell carcinoma. Literature search using electronic databases of MEDLINE from May 1977 to April 2017 was performed, supplemented by review of references. Thirteen researches and 2531 thoracic esophageal squamous cell carcinoma patients underwent radical surgical resection were included. The probability of recurrence and metastasis in local (anastomotic and tumor bed included), lymph node and distal area was calculated. A chi-square test was used to investigate the difference by statistical software. The recurrent rate is 24.45% for locoregional, 13.23% for distal, 22.24% for lymph node, 2.44% for local. Lymph nodes is divided into cervical and supraclavicular with the recurrent rate of 12.27%, mediastinal with rate of 18.69%(upper 28.23%, middle 17.90% and lower 5.27%, respectively) and abdominal with rate of 6.10% (paraaortic 5.95% and upper abdominal 4.01% respectively). In upper thoracic esophageal squamous cell carcinoma, the order is as follows, cervical and supraclavicular with of 24.32%, mediastinal with rate of 14.86% (upper mediastinal 9.38%, middle mediastinal 3.131%, lower mediastinal 3.13%), abdominal with rate of 1.56%. In middle thoracic esophageal squamous cell carcinoma, the order is as follows, mediastinal with rate of 11.19%(upper mediastinal 7.36%, middle mediastinal 1.74%, lower mediastinal 1.74%), cervical and supraclavicular with rate of 7.12%, and abdominal with rate of 4.75%. In lower thoracic esophageal squamous cell carcinoma, the order is as follows, abdominal LN with rate of 14.85% (paraaortic 11.39% and upper abdominal 3.47%), mediastinal LN with rate of 6.93% (upper mediastinal LN 2.79%, middle mediastinal 1.68%, lower mediastinal LN 1.68%), and cervical and supraclavicular with rate of 3.47% The distal metastatic pattern is as follows, lung (7.04%), liver (6.79%), bone (4.99%), skin (2.28%), and brain (0.74%). Thoracic esophageal squamous cell carcinoma has a high propensity of lymphatic metastases but poor propensity of anastomotic and tumor bed recurrence. Cervical and supraclavicular, upper mediastinal should be delineated as the postoperative prophylactic irradiation target volume for upper, cervical and supraclavicular, upper mediastinal and abdominal lymph nodes especially paraaortic for middle, abdominal lymph nodes especially paraaortic and mediastinal lymph nodes should be delineated for lower as the postoperative prophylactic irradiation target volume.

Risk factors for anastomotic recurrence after primary ileocaecal resection in Crohn's disease.

Ileocaecal resection is the most common operation performed in Crohn's disease. Our study aimed to identify the risk factors for anastomotic recurrence following primary ileocaecal resection. We retrospectively analysed data from all Crohn's disease surgical patients in a single colorectal unit between 2006 and 2016, including all patients who underwent primary ileocaecal resection. We defined anastomotic recurrence as the postoperative need for endoscopic dilatation of the ileocolic anastomosis or neoterminal ileal resection, and used Cox regression to determine the risk factors for such recurrence. In total, 101 patients underwent primary ileocaecal resection during the study period. Nine (8.9%) patients were excluded because of follow-up less than 1 year and 12 (13.0%) patients had anastomotic recurrence. The median follow-up was 4.7 (1.3-10.8) years. At 3 years, 93.1% of patients required no neoterminal ileal resection or dilatation of the ileocolic anastomosis. Urgent primary ileocaecal resection [hazard ratio (HR)=4.98, 95% confidence interval (CI)=1.45-17.11, P=0.011], stapled anastomosis (HR=20.34, 95% CI=5.06-81.77, P<0.001) and need for postoperative corticosteroid treatment after the primary ileocaecal resection (HR=3.58, 95% CI=1.03-12.40, P=0.044) emerged as significant risk factors for anastomotic recurrence. Urgent surgery and postoperative corticosteroid need represented risk factors for anastomotic recurrence. Hand-sewn anastomosis with an opening of the bowel's antimesenteric border seems to be a safe choice for ileocaecal resection.

Post-Procedural Gain in Body Mass Index Is Associated With the Risk of Pouch Anastomotic Sinus Recurrences

Introduction: Excessive gain in body mass index (BMI) is associated with a poor pouch outcome. The aim of this study was to evaluate whether increase in BMI is associated with recurrences of chronic pouch sinus. Methods: All consecutive patients with a pouch sinus successfully treated with either endoscopic sinusotomy or redo surgery from 2006 to 2016 were identified from our IRB approved, prospectively maintained Pouch Registry and Colorectal Surgery Pouch Database. The excessive gain in BMI was defined as an increase in BMI≥10%. The primary outcomes were sinus recurrence. Sinus recurrence was defined as the diagnosis of sinus recurring after 6 months from the inception time. Results: This retrospective study included a total of 171 patients. Sinus recurrence was seen in 48 (28.1%) patients. A higher rate of BMI increase≥10% was found in patients with recurrence (22.9% vs. 8.9%, P=0.01). Consequently, patients with an excessive increase in BMI had a lover recurrence-free survival in Kaplan Meier analysis (P=0.10). In multivariate analysis, excessive BMI increase (odd ratio [OR]: 3.0, 95% confidence interval [CI]: 1.0-9.0) and Crohn's disease of pouch (OR: 2.9, 95% CI: 1.0-8.1) was independently related to sinus recurrence. In patients with a recurrent sinus, a similar healing rate was shared between those who had an excessive increase BMI and those who maintained a relatively stable weight (63.6% vs. 70.3%, P=0.81). However, the recurrent-sinus-related pouch failure rate was higher in patients with excessive weight gain (36.4% vs. 16.2%, P=0.31). Conclusion: Excessive gain in BMI after initial successful pouch sinus treatment is associated with an increased risk for sinus recurrence. Appropriate attention towards weight control may help decrease pouch sinus recurrence.802_A Figure 1. Patient and pouch sinus characteristics.802_B Figure 2. Multivariate analysis for risk factors associated with pouch sinus recurrence.802_C Figure 3. Kaplan Meier curve- recurrence-free survival for patients with and without an increase in body mass index≥10%.

P2.17-14 How Should Positive Margin for Bronchial Stumps (R1) Be Evaluated in Patients Undergoing Bronchoplasty for Lung Cancer?

Bronchoplasty for lung cancer is a surgical procedure aimed at respiratory function preservation and curability. And it may be performed for tumors exposed in the respiratory tract or tumors with lymph node extranodal invasion. "Surgical margin positive for bronchial stump" in bronchoplasty surgery has both out-of-wall and carcinoma in situ (CIS), but the difference is not detailed. In this study, we clarify how to evaluate bronchial stump in bronchoplasty. Of 2221 patients of resected lung cancer performed in our hospital from January 2002 to December 2015, 130 patients (5.8%) underwent pulmonary resection with bronchoplasty. The patient's background and its prognostic factors were examined by using Kaplan-Myer method. In addition, we examined details of microscopic residual disease (R1) of bronchial stump. There were 101 males and the median age of patients was 67 years old. 19 cases performed sleeve pneumonectomy and 18 cases performed extended sleeve lobectomy. There were 34 cases of pN0, 49 cases of N1 and 49 cases of N2. 30-day mortality was 2.3% (3cases) and 14 cases were R1 resection. 11 of which were positive for bronchial stump. pN2 and incomplete resection cases were significantly poor prognosis (p=0.03, p=0.009). 5 of the 11 microscopic bronchial stump positive cases were due to CIS and 6 were due to out-of-wall positives. However, among these 11 cases, there was only one case of anastomotic recurrence. And there were no statistical differences, but CIS was often found in long-term surviving cases. In cases of pulmonary resection with bronchoplasty, pN2 and incomplete resection are poor prognostic factors. Even in bronchial stump positive cases of incomplete resection, there was only one case of local recurrence. And long-term surviving cases were observed. There are some CISs for long-term survival, but there is no statistical difference because of small cases. Further examination is required.

Do dysplastic proximal resection margins predict the risk of anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma?

Positive proximal resection margins are strongly associated with anastomotic recurrence in esophageal cancer. However, the prognostic significance of dysplastic proximal resection margins remains unclear. The aim of this study is to investigate whether the dysplastic proximal resection margin can predict anastomotic recurrence and overall survival in patients with esophageal squamous cell carcinoma. Between 2000 and 2014, patients with esophageal squamous cell carcinoma who received a nonpalliative resection and survived the perioperative period were included. Two expert pathologists independently reviewed the proximal resection margin status, which was classified as negative, dysplastic, or positive. The kappa statistic was used to test interobserver reliability. Anastomotic recurrence and overall survival served as the main outcome measures. The study cohort consisted of 469 patients (445 males and 27 females). There was an excellent interobserver agreement for negative (kappa=0.88), dysplastic (kappa=0.88), and positive (kappa=1) proximal resection margins-which were identified in 418 (89.1%), 37 (7.9%), and 14 (3.0%) patients, respectively. After a median follow-up of 21.6 months, 30 (6.4%) patients developed an anastomotic recurrence. Compared with patients with negative proximal resection margins (24/418, 5.7%), the occurrence of anastomotic recurrence was more commonly observed in those with positive proximal resection margins (3/14, 21.4%, P=0.017) but not in those with dysplastic proximal resection margins (3/37, 8.1%, P=0.56). Multivariable Cox regression analysis identified positive proximal resection margins (hazard ratio: 5.93, P=0.010) and advanced clinical stage (hazard ratio: 12.04, P=0.023) as independent risk factors for anastomotic recurrence. Dysplastic proximal resection margins were not retained in the model as an independent predictor (hazard ratio: 1.38, P=0.602). The 5-year overall survival rates of patients with negative (38.2%) and dysplastic margins (27.0%) were similar (P=0.814), and significantly higher than that observed in those with positive proximal resection margins (9.5%, P=0.015). In conclusion, dysplastic proximal resection margins can be identified in at least 7.9% of patients with esophageal squamous cell carcinoma, but neither they are associated with an increased risk of anastomotic recurrence nor they portend a poor overall survival.

RA09.04: THE LYMPH NODE STATUS OF PT1 ESOPHAGOGASTRIC JUNCTIONAL ADENOCARCINOMA

Abstract Background There is no consensus regarding the optimal extent of lymphadenectomy for the esophagogastric junctional (EGJ) cancer. The Japanese esophagogastric cancer treatment guideline showed the tentative standard in the extent of lymphadenectomy based on the location, histology and T-categories. The purpose of this study is to identify the lymph node status in patients with pT1 EGJ adenocarcinoma. Methods From January 2000 to November 2016, we underwent radical resection with or without sentinel lymph node (SN) mapping for esophagogastric cancer at Keio University Hospital. We identified 38 patients with pT1 adenocarcinoma with its center located within 2cm of the junction. We then analyzed the lymph node status and SN distribution. Results The primary tumor that had their epicenter within the proximal of the cardia in 37%, that had their epicenter within the distal of the cardia in 63% of all patients (n = 12, 26). The surgical procedures were proximal gastrectomy (n = 30); subtotal esophagectomy (n = 4); and total gastrectomy(n = 4). Two patients (5%) had positive lymph node metastasis. Of the 2 patients with positive node, one patient had the metastatic lymph node along the short gastric vessels and the other patient had the metastatic lymph nodes along both the left gastric artery and the celiac artery. Those 2 patients with positive node had no recurrence. However, liver or local (anastomotic) recurrence occurred in 1 patients, respectively. SN was accomplished in all patients who underwent SN mapping and diagnostic accuracy based on the SN status was 100% (17/17). Conclusion Our results suggested that lower mediastinal lymphadenectomy was of limited significance in patients with pT1 EGJ adenocarcinoma. SN mapping may be contributory to the optimal extent of lymphadenectomy. Disclosure All authors have declared no conflicts of interest.