ChemInform Research Articles

765. PATTERNS, TIMING, AND SURVIVAL OF RECURRENCE FOLLOWING SURGERY FOR ESOPHAGEAL ADENOCARCINOMA IN THE EUROPEAN MULTICENTRE ENSURE STUDY

Abstract Background After surgery for esophageal cancer approximately half of patients will develop disease recurrence. A more accurate and detailed understanding of the pattern, timing, treatment and prognosis of initial recurrence sites can guide improvements in surveillance and therapy. Therefore, the aim of this study was to accurately describe the pattern and timing of esophageal cancer recurrence, and to assess the distinct survival patterns of these recurrence locations. Methods This study included all patients who underwent surgical resection for esophageal and junctional adenocarcinoma registered in the ENSURE study. ENSURE was an international multicenter study of consecutive patients undergoing surgery for esophageal and esophagogastric junction cancers between 2009 and 2015 across 20 centers in Europe and Canada (NCT03461341). The first recurrence site was recorded and recurrence-free survival (RFS) was estimated using Kaplan-Meier curves. Sites of first recurrence were stratified into different groups and survival outcomes post recurrence detection were estimated using Kaplan-Meier curves. Results Of 3397 eligible patients, 1310 patients had disease recurrence with comprehensive follow-up data available (median RFS of 12.1 months). First recurrence was detected at multiple distant sites (n=469; 37.3%) or at a single distant site (n=463; 33.7%), while isolated local recurrence occurred in 189 (14.4%) patients. Liver-only recurrence occurred significantly earlier (median 9.0 months), while lung-only (15.2 months) and local-only occurred later (17.8 months). Patients with multiple-sites and liver-only recurrence had significant worse median post recurrence survival (7.4 and 8.3 months, respectively) when compared with lung- or local-only recurrence (10.4 and 15.9 months, respectively). Conclusion This study demonstrates that specific recurrence locations of esophageal cancer possess distinct RFS curves. Furthermore, specific recurrence locations result in different post recurrence survival outcomes. This information can help guide improvements in surveillance after esophageal cancer surgery and decisions regarding treatment of esophageal cancer recurrence.

746. ESOPHAGECTOMY, WITH CHOLECYSTECTOMY HAS A HIGH INCIDENCE OF REFLUX ESOPHAGITIS AND GASTRIC TUBE ULCER

Abstract The surgical methods for thoracic esophageal cancer was subtotal esophagectomy, with gastric pull up via retrosternal route, and cervical anastomosis. However, some cases were complicated by acute cholecystitis in the early postoperative period, and cholecystectomy was performed intraoperatively to prevent postoperative cholecystitis in some cases. The disruption of normal anti-reflux mechanisms including the lower esophageal sphincter, angle of His, and diaphragmatic muscle and the denervation of the vagus nerve are generally thought to be the main factors that interfere with gastric motor function. Furthermore, the pressure difference between thoracic (negative) and abdominal cavity (positive) is another factor that promotes reflux across the anastomosis. Due to these factors, postoperative reflux esophagitis is frequently experienced. Furthermore, after cholecystectomy, due to loss of gallbladder reservoir function after cholecystectomy and decrease in antroduodenal motility, bile is not excreted by food intermittently but continuously, resulting in duodenogastric reflux. We investigated postoperative reflux esophagitis and gastric tube ulcers in cases with and without intraoperative cholecystectomy for the past three years. We investigated cholecystectomy with esophagectomy (n=65) and non-cholecystectomy with esophagectomy (n=101) in 166 cases of radical surgery for esophageal cancer in which 2-3 regions had been dissected in the past 3 years. As shown in Fig. 1, there are no differences in location, TNM, gender, and PPI administration .reflux esophagitis of the cervical esophagus is A:0 B:2 (3%), C:5 (8%), D:3 (5%) for chole(+), A:2 (2%), B:2 (2%), C:2 (2%), and D:2 (2%) for chole(-). Gastritis was Chole(+) superficial gastritis 14 (21%), metaplasia 4 (6%), chole(-) superficial gastritis 25 (25%), metaplasia 3 (2%). However, gastric tube ulcers occurred in 5 cases (7%) of Chole(+) and 1 case of perforation, while only 1 case (1%) of gastric tube ulcers occurred in Chole(-).. (Conclusion) Esophagectomy, gastric pull up with cholecystectomy has a high incidence of reflux esophagitis in the neck and can also cause ulcers in the gastric tube. Therefore, care should be taken in postoperative follow-up.

492. OUTCOMES OF ESOPHAGECTOMY IN THE ELDERLY- IS IT WORTH THE EFFORT?

Abstract Background Esophageal cancer is the sixth most common cancer in India and most patients are diagnosed at locally or loco-regionally advanced stages. Multimodal management offers the best chance of cure, with surgery being the cornerstone. With improved life expectancy, elderly patients with esophageal cancer are being referred for surgery more frequently. Although recent studies have shown encouraging outcomes, increased post-operative complications are common. The aim of our study was to evaluate morbidity and survival in patients above 70 years undergoing curative surgery for esophageal cancer from 2011 to 2021 at our centre. Methods Of 2291 patients undergoing esophagectomy, 122 were above 70 years, ten were inoperable. Mean age was 73.3 years (70-84 years), with 78% males and 83% squamous cell carcinoma, most common location being lower-third (63.6%). Of the 110 patients, 80 (72.7%) received neoadjuvant treatment, 68(61.8%) were ASA grade II or more. McKneown’s approach was common, utilized in 55%, of which minimally invasive in 53%, with Ivor- Lewis, left thoraco-abdominal and transhiatal approaches in the rest. Mean blood loss was 350 ml, with mean operative time of 270 minutes and circumferential positivity rate of 12.7%. Results The mean ICU stay was 1 day, with the mean hospital stay being 13 days. Almost half (49%) had Clavien-Dindo grade III or higher morbidity, with pulmonary complications seen in 27%. Anastomotic leakage was seen in 20/110 (18%), with only 2 patients needing an intervention. 30-day mortality was 8.2%. Recurrences were seen in 21 patients, anastomotic and regional recurrences in 6, distant in 6, regional with distant in 9. The median recurrence free survival was 26 months with 3-year RFS of 43.7%. With a median follow-up of 25 months, median overall survival was 30 months and 3-year OS was 45.3%. Conclusion Despite higher post-operative morbidity and mortality, elderly patients have reasonable recurrence free and overall survival outcomes with curative surgery. With continuing refinements in prehabilitation, operative techniques, wider adoption of minimally invasive surgery, intra-operative management and post-operative care, early post-operative outcomes are likely to improve further. Elderly patients with resectable esophageal cancer should not be denied surgery.

562. COMPARATIVE ANALYSIS OF THE OUTCOMES OF GASTRECTOMY VS. ENDOSCOPIC SUBMUCOSAL DISSECTION FOR THE TREATMENT OF GASTRIC TUBE CANCER AFTER ESOPHAGECTOMY

Abstract Background Although multimodal treatment and minimally invasive surgery for esophageal cancer have improved therapeutic outcomes for esophagectomy, this improvement has led to many reports of metachronous cancers following esophagectomy. After esophagectomy for esophageal cancer, the locations where metachronous cancers occur most frequently are the oropharynx, hypopharynx, and larynx, followed by the gastric tube. Due to a paucity of reports, much remains unknown about gastric tube cancer, such as the site of common occurrence, pattern of metastasis, treatment method. This study investigated the clinical characteristics of patients with gastric tube cancer and to examine the outcomes of gastrectomy versus endoscopic submucosal dissection. Methods Of 49 patients who underwent treatment for gastric tube cancer that developed 1 year or more after esophagectomy, 30 patients underwent subsequent gastrectomy (Group A), and 19 patients underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) (Group B). The characteristics and outcomes of these two groups were compared. Results The interval between esophagectomy and diagnosis of gastric tube cancer ranged from 1 to 30 years. The most common location was the lesser curvature of the lower gastric tube. When the cancer was detected early, EMR or ESD was performed, and the cancer did not recur. In advanced tumors, gastrectomy was performed but the gastric tube was difficult to approach and lymph node dissection was difficult; two patients died as a result of the gastrectomy. In Group A, recurrence occurred most often as axillary lymph node, bone, or liver metastases; in Group B, no recurrence or metastases were observed. Conclusion In addition to recurrence and metastasis, gastric tube cancer is often observed after esophagectomy. The present findings highlight the importance of early detection of gastric tube cancer after esophagectomy and that the EMR and ESD procedures are safe and have significantly fewer complications compared with gastrectomy. Follow-up examinations should be scheduled with consideration given to the most frequent sites of gastric tube cancer occurrence and the time elapsed since esophagectomy.

749. GENDER DIFFERENCE IN ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract In Japan, esophageal cancer is often more common in men, with a lower incidence in women than in men, accounting for 12% of the total number of cancers. In Japan and the West, SCC is involved in alcohol and tobacco. These habits are characteristically more common among men. Women are more likely to be diagnosed at an earlier stage than men. Therefore, we examined the prognosis, stage, and pathology of 145 men and 30 women who underwent radical surgery for esophageal cancer over the past 5 years. (Result) p stage is male: stage 0:7(5%), stage 1:35(25%), stage II: 58(40%), stage III:35(25%), stage IV:10(7%) female: Stage 0: 2 (7%), Stage 1: 12 (40%), Stage II: 6 (20%), Stage III: 9 (30%), Stage IV: 1 (3%). Significantly more men had advanced cancer. No difference was observed regarding Ly and V. Although there were no differences in location and histology, depth of invasion and lympho node metastasis were significantly enhanced in males. (table 1) Kaplanmier survival rate after 5 years was significantly better for women than for men. (Fig 1).(Conclusion) Compared to men, women had less advanced cancer at the time of discovery and a better 5-year survival rate.

Developing a comprehensive curriculum program for nurse practitioners delivering primary care in the long-term care setting.

In the Long-Term Care (LTC) setting, comprehensive primary care is often provided by Nurse Practitioners (NPs). NPs are uniquely positioned to meet the evolving primary care needs of LTC residents. However, caring for this population requires additional education and training due to its special considerations. To meet the learning needs of NPs entering the LTC workplace, a Certificate Program was designed to enhance primary care competencies within the LTC setting. The aim of the program is to increase knowledge, capacity, and confidence of NPs to deliver quality, evidence-based, integrated, and interprofessional primary care to LTC residents. This curriculum is anticipated to address the growing need for LTC services and improve the delivery of high-quality primary care.

Clinical characteristic, laboratory biomarkers, treatment regimen and psychiatry problems predictors of outcomes of alopecia areata: a prospective study

Background Alopecia areata (AA) has multiple aetiology such as genetic and environmental triggers. Aims To assess the recovery rate of AA and examine the associated psychiatric problems. Additionally, the relationship between clinical, psychiatric, and laboratory biomarkers and alopecia outcomes were investigated, along with potential risk factors that could aid in treating alopecia. Patients and methods A prospective cohort research included 42 AA patients and 45 healthy controls. Group A (active disease), group B (inactive disease), and group C (healthy control) were based on illness outcomes after 3 months of treatment. The Severity of Alopecia Tool (SALT), treatment regimens, laboratory investigation Interleukins 19 and 33 (IL-19 and IL-33), Symptom Checklist 90, and post-traumatic stress disorder Checklist for DSM-5 (PCL-5) were evaluated. Results After 3 months of therapy, the incidence of inactive AA was found to be 57.14%. Being females with family history of dermatitis were highly related with active illness, while smoking and unmarried patients were associated with inactive disease. After 3 months of treatment, active illness had the highest mean IL-33 and IL-19 levels. Conclusion The active disease group exhibited the highest mean IL-33 and IL-19 levels at baseline following three months of treatment. Our patients had 7.1% somatization, 7.1% obsessive-compulsive symptoms, 4.8% depression, 4.8% anxiety, 15.9% anger-hostility, 35.7% phobic-anxiety, 26.2% paranoid ideation, 4.8% psychoticism, and 61.9% post-traumatic stress disorder. AA outcomes were linked to females, a family history of dermatological disorders, smoking, being single, and higher mean IL-33 and IL-19 levels. Psychosis was highly linked with active AA. Only khellin and Ultraviolet A improved AA results.

High-flow nasal cannula in Spanish Pediatric Intensive Care Services: A national web survey about its use and indications

ObjectiveTo describe the high-flow nasal cannula (HFNC) indications in the Spanish pediatric critical care units (PICUs). DesignDescriptive cross-sectional observational study. SettingElectronic survey among members of the Spanish Society of Pediatric Intensive Care (SECIP). It was sent weekly from April 10, 2023, to May 21, 2023. ParticipantsAll SECIP members. InterventionsNone. Main variables of interestThe questions focused on workplace, years of experience, use or non-use of HFNC, justification and expectations regarding its application, starting point within each center, clinical criteria for indication, existence of clinical guidelines, evaluation during its use, and criteria and mode of withdrawal. ResultsTwo hundred and two participants, 176 were from Spain. Of these, 87/176 had over ten years of experience. One hundred sixty two use HFNC and 66/162 have HFNC clinical guidelines. Acute bronchiolitis (138/162) and respiratory assistance after extubation (106/56) are the two main indications. For 62/162 HFNC may reduce therapeutic escalation. Neuromuscular diseases (105/162) and anatomical airway diseases (135/162) are the two main contraindications. The reasons to do not use HFNC were the absence of evidence about it effectiveness (8/14) and its inadequate cost/effectiveness balance (8/14). ConclusionsA majority of Spanish pediatric intensivists use HFNC. Its application and withdrawal appears to be primarily based on clinical experience. Besides, those who use HFNC are aware of its limitations and the lack of evidence in some cases. It is necessary to develop single-center and multicenter studies to elucidate the effectiveness of this therapy in the context of critically ill children.

590. RESOLUTION OF SYMPTOMS AFTER OESOPHAGO-GASTRIC CANCER RESECTION (RESTORED)–STANDARDISING GASTROINTESTINAL SYMPTOMS AND CONDITIONS AFTER SURGERY: A MULTI-DISCIPLINARY EXPERT DELPHI STUDY

Abstract Background Oesophago-gastric cancer surgery negatively affects quality of life with a high post-operative symptom burden. Several conditions that may be diagnosed and treated after surgery are recognised. However, consensus regarding their definition and management is lacking. We aimed to develop consensus regarding the definition, investigation and management of the common symptoms and conditions, and triggers to consider disease recurrence, as a foundation for improving management and quality of life in these patients. Design Modified 2-round Delphi consensus study of a multidisciplinary expert panel. Results 86/127(67.7%) and 77/100(77.0%) responses were received in rounds 1 and 2. Consensus was achieved in defining 26 symptoms. For 10 conditions (anastomotic stricture, acid reflux, non-acid reflux, biliary gastritis, delayed gastric emptying, dumping syndrome, exocrine pancreatic insufficiency, bile acid diarrhoea, small intestinal bacterial overgrowth and carbohydrate malabsorption), definitions, diagnostic criteria, first and second-line investigation and first-line treatments were agreed. Consensus was not reached for third line investigation of some conditions, nor for second, third or fourth-line treatments for others. 12 of 14(85.7%) symptoms were agreed as triggers to consider cancer recurrence, during the early (< 1 year) and late (> 1 year) post-operative periods. Conclusion Expert consensus regarding symptoms, conditions and triggers to consider investigation for recurrence after oesophago-gastric cancer surgery was achieved. This will allow standardisation and timely diagnosis and treatment of post-operative conditions, reducing variation in care. It will facilitate comparative, prospective research to establish the incidence and response to treatment of these conditions, helping develop robust evidence to optimise patients’ quality of life.

315. SHORT-TERM RESULTS OF ROBOT-ASSISTED SURGERY FOR ESOPHAGEAL CANCER IN JAPAN 5 YEARS AFTER INSURANCE COVERAGE

Abstract Background In Japan, robot-assisted surgery (RAMIE) for esophageal cancer surgery was covered by insurance in 2018, and its introduction has been rapidly progressing since then. In our department, RAMIE has been introduced and performed in 250 cases so far. In the process, we have improved the short-term results by introducing the standardization and NIM (neuromonitoring) according to the characteristics of RAMIE. In addition, we have recently expanded the use of RAMIE in advanced cancer patients due to its usefulness in stable operation. In this meeting, we will review the short- and mid-term results and discuss current issues. Methods We analyzed the short-term results of all 213 RAMIE cases performed at our department, and compared them with the short-term results of 51 post-standardization (late) MIE cases previously reported. The mid-term results to date were also reviewed. Results A total of 213 patients were included. 211, 222 mins thoracic operation time. 235, 190 ml blood loss in comparison to MIE (vs. RAMIE). Postoperative outcomes were similar: overall complications (>Grade II) were 49, 54.9%, respiratory complications were 19.6, 23.9%, and recurrent nerve palsy was 15.7, 17.4%. Risk analysis demonstrated that paralysis in RAMIE was significantly related to prolonged thoracic operation time (p=0.021) and NIM (Odds=0.38, p=0.0447). In comparison between patients with early-stage and advanced cancer, pneumonia and anastomotic complications were not different. Prognosis was 81.7/64.2% (UICC 8th) for 3-year survival in cStage II/III patients. Conclusion RAMIE was considered to be highly useful for short-term and medium-term outcomes at this time.

645. CLINICAL SIGNIFICANCE OF LOCAL TREATMENT FOR RECURRENCE WITHIN THE SURGICAL FIELD AFTER RADICAL ESOPHAGECTOMY

Abstract Background In recent years, more aggressive multidisciplinary treatment and minimally invasive approaches with meticulous lymph node dissection have become the standard in esophageal cancer surgery, but recurrence cases within the surgical field after radical resection are unfortunately frequently observed. We will compare the clinicopathological characteristics of the cases of intra-sugical field recurrence with those of extra-surgical and both intra- and extra-surgical field recurrence and discuss their significance in light of the results of local treatment for intra-surgical field recurrence. Subjects The study included 130 cases of intra-surgical field recurrence among 490 esophageal cancer patients who underwent radical subtotal esophagectomy and cervical anastomosis (Mckeown-esophagectomy) with right thoracic approach between January 2013 and April 2019. Results The 130 cases of recurrence were categorized as intra-surgical field recurrence (Group I)/extra-surgical field (Group O)/intra- and extra-surgical field (Group I+O): 19/86/25. Preoperative factors: Tumor localization tended to be more common in Ut in group I (p=0.078), but there were no other differences such as cStage or preoperative treatment. Intraoperative/postoperative factors: I+O group had significantly more blood loss (p=0.045), but there were no other differences in the range of lymph node dissected field, number of dissected lymph nodes, combined resection of the thoracic duct, postoperative complications, hospital stay, or histological therapeutic effect. 19 patients in group I had 17 patients (89.5%) who received initial local treatment (surgery/CRT/RT: 4/7/6). The response rate (R0 resection or CR+PR) was 58.8%. Compared to cervical and upper mediastinal lymph node recurrence, the response rate to initial local treatment tended to be lower in patients with middle and lower mediastinal lymph node and anastomotic recurrence (80%/43%, p=0.145). Discussion Intra-surgical field recurrence after radical resection tended to be more common in the primary site of Ut. Recurrence in the upper mediastinal lymph nodes in the cervical region shows a relatively high response rate to local treatment, and long-term recurrence-free ("cure") is achieved. On the other hand, mid and lower mediastinal lymph node and anastomotic recurrences have a low response rate to local treatment and should be complemented with more systemic treatment, such as sequential ICI to initial treatment.

273. PERIOPERATIVE BLOOD TRANSFUSIONS AND SURVIVAL IN GASTROESOPHAGEAL CANCERS – A SWEDISH POPULATION-BASED STUDY

Abstract Background Blood transfusions have been associated with decreased long-term survival in cancer patients, possibly due to immunological factors. This cohort study aimed to investigate associations, if any, between perioperative transfusions and survival in gastroesophageal cancer patients. Methods A population-based cohort study was conducted based on the National Registry for Esophageal and Gastric cancer (NREV), which harbors clinical data including given transfusions. All patients resected for esophageal or gastric cancer in Sweden, between 2017 and 2022, were included and their survival was acquired from the Swedish Cause of Death Registry. Multivariable Cox regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CI), adjusted for confounders (age, American Society of Anesthesiologist class, access of surgery and pathological TNM stage) Results Of 1,368 patients, 227 patients (17%) received perioperative transfusions. Transfusion was associated with an increased risk of all-cause mortality within 3 years of surgery (HR 1.48 95% CI 1.17-1.91). Kaplan-Meier curves depicted worse crude survival in patients having received peroperative transfusion (Figure 1). To exclude the effects of surgery-related postoperative complications on short-term mortality, a sensitivity analysis was performed, excluding patients who died within 30 days of resection, and found that the impact of transfusions on survival remained. Conclusion Perioperative blood transfusions might have a negative impact on survival in patients who undergo gastroesophageal cancer surgery.

467. DISTRIBUTION OF LYMPH NODE INVOLVEMENT IN PATIENTS WITH GASTRO-ESOPHAGEAL JUNCTION ADENOCARCINOMA

Abstract Background Curative cancer surgery relies on understanding the lymphatic spread of the tumour to guide lymphadenectomy. The lymphatic involvement in patients with esophageal squamous cell carcinoma (SCC) has been evaluated extensively in large cohort studies from the East where SCC predominates, but the pattern of lymph node spread in gastro-esophageal junction (GEJ) adenocarcinoma is less clear. The primary aim of this study was to compare differences in the pattern of lymph node involvement according to the Siewert classification. Methods Consecutive patients who underwent curative resection for GEJ adenocarcinoma between February 2010 and April 2023 were analysed from a prospectively maintained database. Patient demographic data, neo-adjuvant treatment, operation type and histopathological report data were collected and analysed according to the pathological Siewert classification of GEJ cancer. Results 807 patients who underwent curative surgery for GEJ adenocarcinoma were analysed. The median lymph node yield was 26 (5-81). Comparing positive para-esophageal node yields, Type I and II tumours were similar but both significantly higher than Type III. For positive para-gastric nodes, Type 2 and 3 tumours were similar but both significantly higher than type 1. The significance of these comparisons is presented in table 1. There were no differences comparing other specific nodal groups. Evaluating the effect of node involvement on overall survival positive node status and positive hepatic artery nodes were found to be independent factors adversely affecting survival. Conclusion Siewert type I tumours have greater proximal lymph node involvement compared to type III tumours with higher proportions of positive para-esophageal nodes. Type III tumours on the other hand have higher proportions of para-gastric nodes. Type II tumours have similar para-esophageal node involvement to type 1 tumours and similar para-gastric involvement to type III tumours. Involvement of more specific nodal groups does not seem to vary between the sub types.

Postoperative Bowel Dysfunction in Patients with Rectal Cancer – Does a Minimally Invasive Surgical Approach Improve Outcomes?

IntroductionThe purpose of this study was to evaluate the association of MIS approaches for rectal cancer with long-term postoperative bowel dysfunction. Materials and MethodsThis was an Institutional Review Board-approved observational cohort study including consecutive patients with rectal or rectosigmoid cancer who underwent surgical resection between 2007 and 2017. The primary exposure was surgical approach, defined as open surgery or MIS (laparoscopy or robotic surgery). The primary outcome was major LARS, defined as a LARS score of ≥30. Subgroup analyses were performed by tumor height and type of MIS approach. ResultsAmong 749 potentially eligible patients, 514 (68.6%) responded to the survey and were included for analysis. In total, 195 (37.9%) patients underwent an MIS approach – 117 (60.0%) laparoscopic and 78 (40.0%) robotic. At a median follow-up of 6.1 (3.7-9.6) years from surgery, 222 patients (43.2%) had major LARS (MIS: 41.0% vs. open: 44.5%, p=0.44). On multivariable logistic regression, surgical approach had no association with major LARS (MIS, aOR: 1.21, 0.79-1.86). Older age (aOR: 1.03, 1.01-1.04), female sex (aOR: 1.75, 1.16-2.67), TME (aOR: 1.74, 1.01-3.02), diverting ileostomy (aOR: 2.74, 1.49-5.02) and radiation therapy (aOR: 2.63, 1.60-4.33) were all associated with major LARS. On subgroup analysis of patients with mid and low rectal cancers (n=197), there remained no association between surgical approach and major LARS (MIS, aOR: 1.50, 0.68-3.33). ConclusionsMIS approach to rectal cancer surgery was not associated with decreased risk of major LARS and should not be touted as a reason to offer MIS.

Avoiding the needle: A quality improvement program introducing apixaban for extended thromboprophylaxis after major gynecologic cancer surgery

ObjectivePatients undergoing gynecologic cancer surgery at our centre are recommended up to 28 days of enoxaparin for extended post-operative thromboprophylaxis (EP). Baseline survey revealed 92% patient adherence, but highlighted negative effects on patient experience due to the injectable route of administration. We aimed to improve patient experience by reducing pain and bruising by 50%, increasing adherence by 5%, and reducing out-of-pocket cost after introducing apixaban as an oral alternative for EP. MethodsIn this interrupted time series quality improvement study, gynecologic cancer patients were offered a choice between apixaban (2.5 mg orally twice daily) or enoxaparin (40 mg subcutaneously once daily) at time of discharge. A multidisciplinary team informed project design, implementation, and evaluation. Process interventions included standardized orders, patient and care team education programs. Telephone survey at 1 and 6 weeks and chart audit informed outcome, process, and balancing measures. ResultsFrom August to October 2022, 127 consecutive patients were included. Apixaban was chosen by 84%. Survey response rate was 74%. Patients who chose apixaban reported significantly reduced pain, bruising, increased confidence with administration, and less negative impact of the medication (p < 0.0001 for all). Adherence was unchanged (92%). The proportion of patients paying less than $125 (apixaban cost threshold) increased from 45% to 91%. There was no difference in bleeding and no VTE events. ConclusionsIntroduction of apixaban for EP was associated with significant improvement in patient-reported quality measures and reduced financial toxicity with no effect on adherence or balancing measures. Apixaban is the preferred anticoagulant for EP at our centre.

Effect of Perioperative Physical Activity on Skeletal Muscle Loss 6 Months After Esophageal Cancer Surgery

Background/Aim: Sarcopenia contributes to a poor prognosis in patients with esophageal cancer; thus, any clinical support that prevents loss of skeletal muscle mass preoperatively and postoperatively should be actively investigated. This study aimed to evaluate physical activity during the perioperative period and its impact on postoperative skeletal muscle mass. Patients and Methods: Sixty-two patients who underwent esophagostomy at the Hamamatsu University School of Medicine between 2019 and 2023 were evaluated. The physical activity (measured by the step count) of patients scheduled for esophagectomy was assessed preoperatively using a fitness tracker. The percentage change in skeletal muscle mass index (SMI) was calculated preoperatively and 6 months postoperatively. Factors associated with decreased SMI 6 months after esophagectomy were analyzed using multivariate analysis. Results: The median decrease in SMI was –6.2%. Multivariate analysis revealed that factors associated with the reduction of SMI were age &gt;69 years [odds ratio (OR)=7.21, 95% confidence interval (CI)=1.36-38.19, p=0.020], preoperative step count &lt;7,800 steps/day (OR=5.17, 95% CI=1.38-19.33, p=0.015), and postoperative step count &lt;2,400 steps/day (OR=3.55, 95% CI=1.01-12.45, p=0.048). Conclusion: A low perioperative step count and older age were significant risk factors for skeletal muscle loss in patients with esophageal cancer undergoing surgery. For patients with a low number of steps in the perioperative period or for older patients, interventions to increase the number of steps may prevent skeletal muscle loss.

539. ASSOCIATION BETWEEN WAITING PERIOD FOR RADICAL SURGERY AND POSTOPERATIVE RELAPSE IN CLINICAL STAGE I ESOPHAGEAL CANCER

Abstract Background Esophagectomy with locolegional lymphanedectomy based on potential lymph node metastatic risk is the current standard treatment for clinical Stage I thoracic esophageal cancer. Local excision by endoscopic submucosal dissection (ESD) is the standard treatment for clinical Stage 0, however surgery is considered as an additional treatment for pathological T1b cases due to potential metastatic risk. Cases of additional resection after ESD are those pathologically demonstrated to have a high risk of metastasis based on tumor depth and vascular invasion, etc. Compared to cases of surgery for clinical Stage I, many of these cases have a high risk of metastasis, and therefore a poor prognosis is generally expected. Addionally, the prolonged waiting time between initial diagnosis and radical surgery due to ESD may be a factor in poor prognosis, but there is currently no consensus on the risk. Therefore, we conducted a study to clarify the effect of waiting period before surgery (WP) on the risk of recurrence in clinical Stage I esophageal cancer surgery. Methods We retrospectively evaluated the association between WP and 3-year postoperative recurrence-free survival (3y-RFS) in 65 patients who underwent primary esophagectomy and gastric tube reconstruction for clinical Stage I esophageal cancer and 22 patients who underwent additional resection after ESD at our hospital. Results The WP of 87 patients was 2.12 ± 1.43 months (mean± SD), and 13 patients had postoperative recurrence (3y-RFS 85.1%). A 2-arm comparison of short or long WP with a cutoff value of 2.83 months (mean+0.5 SD) showed no clear association with 3y-RFS (100% vs 81.4%, p=0.071). A strong correlation was shown between WP and ESD (r=0.647, p&amp;lt;0.01). WP was 1.69±1.20 months (mean± SD) in 65 patients who underwent surgery as initial treatment, and 12 patients had postoperative recurrence (3y-RFS 81.5%). A 2-arm comparison of short or long WP with a cutoff value of 2.29 months (mean+0.5 SD) suggested an association with 3y-RFS (85.7% vs 55.6%, p=0.018). Conclusion Although this is a single-center, retrospective study of a small number of cases and only a univariate study due to the small number of events, it suggests that a longer waiting period before surgery may be a risk factor for postoperative recurrence.

585. COMPREHENSIVE RISK SCORE OF THE E-PASS SERVES A PROGNOSTIC INDICATOR FOR PATIENTS AFTER NEOADJUVANT THERAPY AND CURATIVE ESOPHAGEAL CANCER SURGERY

Abstract Background Neoadjuvant chemoradiotherapy (nCRT) and curative surgery have been recommended as the standard treatments for locally advanced esophageal cancer. In addition, the comprehensive risk score (CRS) of the physiological ability and surgical stress (E-PASS) scoring system, incorporating both clinical and surgical factors, has proven effective in predicting postoperative complications and mortality. However, the impact of E-PASS scoring system on the prognosis of esophageal cancer remains uncertain. This study aimed to evaluate the comprehensive risk score of E-PASS scoring system for predicting the short- and long-term outcomes of patients treated with nCRT and esophageal cancer surgery. Methods Patients with esophageal cancer who underwent curative resection between 2010 and 2022 were retrospectively enrolled in this study. The cohort was divided into the low and high CRS groups. The CRS cutoff value was determined using the Youden index applied to overall survival (OS) curves. Prognostic value was assessed through Cox regression and Kaplan–Meier analyses. Results In total, 814 patients were enrolled, including 556 and 258 patients with low and high CRS, respectively. ROC curve analysis determined that the CRS was a highly specific and sensitive predictive tool for postoperative complication occurrence and severity (AUC=0.889 and 0.838, respectively). When the cutoff value was established using the Youden index applied to overall OS curves, multivariate analysis demonstrated that the CRS was an independent prognostic factor for OS (HR: 1.48; 95% CI 1.14–1.92, P=0.003) and recurrence-free survival (HR: 1.44; 95% CI 1.13–1.82, P=0.002), irrespective of esophageal cancer stage and tumor regression scores. Conclusion The E-PASS scoring system emerges as a visible predictor of short- and long-term outcomes in patients with esophageal cancer undergoing nCRT and curative surgery.

The Effects of Aromatherapy Massage Given to Patients after Colorectal Cancer Surgery on Symptom Management: A Randomized Controlled Study

The Effects of Aromatherapy Massage Given to Patients after Colorectal Cancer Surgery on Symptom Management: A Randomized Controlled Study

454. QUALITY OF LIFE AFTER ESOPHAGECTOMY WITH INTRATHORACIC VS CERVICAL ANASTOMOSIS: A NATIONWIDE COHORT STUDY

Abstract Background Transthoracic esophagectomy with either intrathoracic or cervical anastomosis is considered standard of care in patients with mid to distal esophageal or gastroesophageal junction (GEJ) cancer. Patients after esophagectomy will experience a deterioration in health-related quality of life (HR-QoL) after esophageal cancer surgery. Whilst some reports describe long-lasting deterioration, other reports show recovery of HR-QoL comparable with the general population after 2 years. The aim of this study was to investigate the difference in HR-QoL in patients after a transthoracic esophagectomy with either intrathoracic- or cervical anastomosis in a nationwide database. Methods A nationwide cohort study was performed combining data from two registries: Netherlands Cancer Registry (NCR) and Prospective Observational Cohort Study of Esophageal-Gastric Cancer Patients (POCOP). All patients after esophagectomy for mid/distal esophageal or GEJ cancer between 2015 and 2022 were included. HR-QoL was measured at baseline, 3, 6, 9, 12, 18, and 24 months postoperatively using EORTC QLQ-C30 and OG-25 questionnaires. Linear mixed models were used to assess the mean score difference between patients with intrathoracic and cervical anastomosis. A difference of 10 points or more was considered clinically relevant. Adjustments were made for potential confounders (age, gender, ASA classification). Results Of the 4269 registered patients in the NCR, in 1274 patients at least one questionnaire was available. Of these patients 346 underwent an esophagectomy with cervical - and 928 with intrathoracic anastomosis. Patients after esophagectomy with cervical anastomosis reported statistically significant more problems in the following categories: dysphagia, couching, trouble eating with others and swallowing saliva during the first 3 months, choked when swallowing and trouble talking during the first 12 months postoperatively. In all other categories no significant difference was found. Only trouble talking at the 3-month time point was considered as a clinically relevant difference. Conclusion Although the intrathoracic anastomosis is associated with significantly better HR-QoL in several categories, only trouble talking at 3 months postoperatively was considered clinically relevant. Overall HR-QoL was comparable for esophageal cancer patients after an esophagectomy with either a cervical or intrathoracic anastomosis.