High-volume Centers Research Articles

490. THE IMPACT OF ONE-LUNG VENTILATION ON POSTOPERATIVE COMPLICATIONS AFTER IVOR LEWIS ESOPHAGECTOMY

Abstract Background One of the most common issue after Ivor Lewis esophagectomy are pulmonary complications, affecting up to 27% of patients, leading to longer hospital stay and higher healthcare costs. Traditionally, one-lung ventilation (OLV) with a double-lumen tube, is used during the thoracic phase of esophagectomy in order to provide a good surgical view by collapsing the right lung parenchyma. However, OLV has been proven to contribute to negative respiratory outcomes after surgery. On the other hand, a recent metanalysis showed that Two Lung Ventilation (TLV) is feasible throughout the two phases of the procedure, with good clinical, surgical and oncological results. Methods A consecutive series of patients undergoing minimally invasive Ivor Lewis esophagectomy (MIIL) between November 2022 and November 2023 in one high-volume center was retrospectively reviewed. Intraoperative ventilation characteristics were analyzed. Postoperative pulmonary complications were stratified according to Clavien Dindo classification and further divided into mild (<3a) and severe (>3b). Descriptive statistics was used to analyze the study sample. Data was expressed as median and interquartile range (IQR) for non-normally distributed variables and as proportions for binary variables. Categorical variables are expressed as frequencies and analyzed by chi-square (χ2) tests. P-values of < 0.05 defined statistical significance (two-sided). Results Of the 70 patients, 8 were excluded due to lack of data. 62 patients were further stratified into three groups considering the ratio between the durations of OLV and the thoracic phase (OLV/TP): group A less than 25% of OLV/TP, group B more than 25% but less than 75% and group C more than 75%. No difference between the three groups was found in terms of pulmonary complications (χ2=1.6248, p-value=0.4437) whilst patients with a shorter OLV/TP showed a significant reduction in the incidence of severe respiratory complications(χ2= 8.2974, p-value 0.015785, p < 0.05). Conclusion Taking into account the limits of the study (retrospective nature, single center study), our results show that the length of OLV may negatively affect postoperative pulmonary outcomes. These promising results justify the need to conduct a randomized controlled study that would be instrumental in reaching definitive conclusions.

179: Experience with Pediatric Extracorporeal Membrane Oxygenation (ECMO) Standby at Two High-Volume Centers

179: Experience with Pediatric Extracorporeal Membrane Oxygenation (ECMO) Standby at Two High-Volume Centers

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.

787. THE CHALLENGE OF GASTRO-ESOPHAGEAL ONCOLOGICAL SURGERY AFTER BARIATRIC PROCEDURES: EXPERIENCE OF A REFERRAL HIGH-VOLUME UPPER GI SURGICAL CENTER

Abstract Background The effectiveness of bariatric surgery for weight loss in morbidly obese patients has been well established and it's becoming more common as many surgeons are trained to perform them safely, even in older patients. Obesity is associated with reflux and hormonal imbalances that increase the risk of Barrett's esophagus, esophageal adenocarcinoma and gastric cancer. Bariatric procedures alter gastric anatomy, vascularization and lymphatic drainage and render subsequent upper gastrointestinal surgery for malignancies a technical challenge, that will present more and more in the future. We present laparoscopic sleeve gastrectomy, gastric bypass and gastric banding conversion to oncological respective surgeries. Methods We retrospectively reviewed the medical records of our referral high-volume center for upper gastrointestinal surgery and identified patients who underwent upper gastrointestinal oncologic surgery from January 1998 to May 2024. We selected all patients who had previously undergone bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic gastric bypass, gastric banding, or other less common procedures). Three patients met our criteria, and we recorded: demographic characteristics, surgical technique, oncologic surgical outcome, postoperative complications, long-term complications, and oncologic follow-up. Results A hybrid IvorLewis esophagectomy was performed years after a sleeve gastrectomy for distal esophageal adenocarcinoma. The sleeve was used for gastric pull-up, adequately vascularized by the right gastroepiploic artery as demonstrated by intraoperative indocyanine green. A patient developed adenocarcinoma of the cardia after Roux-en-Y gastric bypass, infiltrating the gastric pouch, the gastric remnant and liver S2. After neoadjuvant chemotherapy, an open Ivor-Lewis esophagectomy was performed using the gastric remnant for a pull-up. In a third patient, a locally advanced adenocarcinoma of the stomach developed after gastric banding. After neoadjuvant chemotherapy, an open total gastrectomy with Roux-en-Y esophagojejunostomy was performed. Conclusion We report three cases of successful esophago-gastric oncological surgery in patients with altered anatomy and vascularization due to previous bariatric surgery, without major postoperative complications or mortality. Oncologic benchmarks for both esophageal and gastric surgery were met as a high lymph node yield and oncologic margins were maintained. Our heterogeneous series suggests that sleeve gastrectomy, gastric bypass, and gastric banding surgery can be successfully converted to resective surgeries after a metachronous neoplasia diagnosis in high-volume upper gastrointestinal centers. These and similar modified reconstructive techniques are likely to be used in the future as metabolic surgery and esophago-gastric cancer are increasing.

Feasibility and safety of EUS-guided biliary drainage in inexperienced centers: a multicenter study in southwest Japan

Background and AimsEndoscopic ultrasound-guided biliary drainage (EUS-BD) has shown promising procedural outcomes in high-volume centers. While inferior procedural outcomes were reported in inexperienced centers during the early days of EUS-BD, the current outcomes are unknown. This study aimed to clarify the feasibility and safety of EUS-BD in centers that recently introduced EUS-BD. MethodsThis multicenter retrospective study was conducted at 22 centers that introduced EUS-BD between 2017 and 2022. A maximum of 20 initial EUS-BD cases at each center were evaluated. The clinical outcomes and experience of 84 endoscopists who performed these procedures were examined. The primary outcomes were the rate of technical success and adverse events (AEs). The secondary outcomes were risk factors associated with technical failure and procedure-related AEs. ResultsA total of 255 patients were enrolled. The technical success rate was 91.4% (233/255). Among technical failure cases (n=22), guidewire manipulation failure was the most common cause (n=12), followed by tract dilation failure (n=5). The AE rate was 10.2% (26/255). Multivariate analysis identified a puncture target diameter of <5 mm (odds ratio, 3.719; 95% confidence interval, 1.415-9.776; p=0.008) and moderate ascites extending to the liver surface (odds ratio, 3.25; 95% confidence interval, 1.195-8.653; p=0.021) as independent risk factors for technical failure and procedure-related AEs, respectively. Endoscopists’ procedural experience was not a risk factor for technical failure or procedure-related AEs. ConclusionsThe feasibility and safety of EUS-BD were maintained during the induction phase at inexperienced centers. These will be helpful in better understanding the current status of EUS-BD.

370. LOWER MEDIASTINUM DISSECTION IN THORACOSCOPIC ESOPHAGECTOMY

Abstract Background Thoracic esophagectomy is currently the preferred technique for the thoracic phase of transthoracic esophagectomy for esophageal cancer. Randomized controlled trials comparing this minimally invasive approach to the open one, demonstrated a lower rate of pulmonary complications rate, without worst long-term outcomes. Video-based learning of minimally invasive surgery is essential, especially in such a complex procedure like esophagectomy. However, resources are lacking. Therefore, we aim to conduct a video demonstration of lower mediastinum dissection of our standardized right thoracoscopy esophagectomy, in the prone position. Methods Surgery de-construction through video assessment is routinely performed in our upper gastrointestinal unit. It is fundamental for surgical training, as well as for technical skills improvement of experienced surgeons. Here we present a step-by-step approach of one of the key parts of our standardized thoracoscopic esophagectomy technique – the lower mediastinum dissection. Results Thoracoscopic esophagectomy is systematically performed in a prone position, using a bronchial blocker, 4 working ports and a pressure of 6 mmHg for pneumomediastinum. The first stage of thoracoscopic esophagectomy is the lower mediastinum dissection. Three main steps compose this procedure - posterior dissection, anterior dissection and main bronchus and carina dissection. This video offers a comprehensive overview of the key anatomical landmarks that require identification during the procedure, the sequential steps involved and the critical pitfalls. Conclusion Thoracoscopic esophagectomy for esophageal cancer should be performed in high-volume centers, in a standardized and systematic way. Video revision and procedure debriefing is essential not only for surgery learning and coaching, but also for outcome improvement. Sharing knowledge and experience through video-based presentations can contribute to development of this complex area of minimally invasive esophagectomy. https://drive.google.com/file/d/1vWJOTCey8wI6HQi0jAR8C_t3tUKVbrW1/view?usp=drive_link

Long-term clinical evaluation of a decade with peroral endoscopic myotomy at a single European tertiary center

Peroral endoscopic myotomy (POEM) is an established treatment for achalasia with compelling midterm efficacy. In this study, we analyzed the long-term efficacy, sought predictors of failure, and comprehensively assessed post-POEM reflux. We performed a retrospective analysis of a prospective database of patients undergoing POEM at a high-volume center from December 2012 to June 2023. Patients who had completed a 3-month follow-up were included. Efficacy was assessed at 3, 6, and 8 years using the Eckardt score (ES). An ES≤2 was considered treatment success. At 3 months, gastroscopy, manometry, 24-hour pH monitoring, and fluoroscopy were performed, and gastroscopy was repeated at 2 and 3 years. At each visit, patients were assessed for reflux symptoms and quality of life. From 496 included patients, 3-, 6-, and 8-year follow-ups were completed in 302, 115, and 40 patients, respectively. The treatment success rates at 3, 6, and 8 years according to the Kaplan-Meier analysis were 90.2% (95% confidence interval [CI], 87.2-93.3), 82.3% (95% CI, 77.3-87.6), and 73.5% (95% CI, 64.8-83.5), respectively. Year of procedure was the only predictor of outcome. Fifty-three patients (10.7%) encountered failure or recurrence. Treatment success of redo-POEM (n= 20) at 1 year was significantly lower (62.9% [95% CI, 44.3-89.2] vs 96.9% [95% CI, 95.3-98.5], P< .001). At 3 months, 40.4% of patients had reflux esophagitis (RE), 43.6% of patients had an acid exposure time >4.5%, 39.2% of patients were using proton pump inhibitors (PPIs), but only 24.2% had reflux symptoms. At 2 to 3 years, 50.8% of patients took PPIs, whereas 39.6% were symptomatic. RE decreased to 20.2% at 6 years. The treatment success of POEM declines over time but remains sufficiently high in the long term. Experience with the procedure improves the outcome. Gastroesophageal reflux affects almost half of patients early after POEM and decreases substantially over time together with a rise in PPI use.

Retroperitoneal vs transperitoneal approach for nonruptured open conversion after endovascular aneurysm repair

ObjectiveSeveral studies comparing the transperitoneal (TP) and retroperitoneal (RP) approach for abdominal aortic aneurysm (AAA) repair suggest that the RP approach may result in lower rates of perioperative mortality and morbidity. However, data comparing these approaches for open conversion are lacking. This study aims to evaluate the association between the type of approach and outcomes following open conversion after endovascular aneurysm repair (EVAR). MethodsWe included all patients who underwent open conversion after EVAR between 2010 and 2022 in the Vascular Quality Initiative. Patients presenting with rupture were excluded. The primary outcome was perioperative mortality. The secondary outcomes included perioperative complications and 5-year mortality. Inverse probability weighting was used to adjust for factors with statistical or clinical significance. Logistic regression was used to assess perioperative mortality and complications in the weighted cohort. The 5-year mortality was evaluated using Kaplan-Meier and Cox regression. ResultsWe identified 660 patients (39% RP) who underwent open conversion after EVAR. Compared with TP, RP patients were older (75 years [interquartile range, 70-79 years] vs 73.5 years [interquartile range, 68-79 years]; P < .001), and more frequently had prior myocardial infarction (33% vs 22%; P = .002). Compared with the TP approach, the RP approach was used less frequently in cases of associated iliac aneurysm (19% vs 27%; P = .026), but more frequently with associated renal bypass (7.8% vs 1.7%; P < .001) and by high-volume physicians (highest quintile, >7 AAA annually: 41% vs 17%; P < .001) and in high-volume centers (highest quintile, >35 AAA annually: 36% vs 20%; P < .001). RP patients, compared with TP patients, were less likely to have external iliac or femoral distal anastomosis (8.2% vs 21%; P < .001), and an infrarenal clamp (25% vs 36%; P < .001). Unadjusted perioperative mortality was not significantly different between approaches (RP vs TP: 3.8% vs 7.5%; P = .077). After risk adjustment, RP patients had similar odds of perioperative mortality (adjusted odds ratio [aOR], 0.49; 95% confidence interval [CI], 0.22-1.10; P = .082), and lower odds of intestinal ischemia (aOR, 0.26; 95% CI, 0.08-0.86; P = .028) and in-hospital reintervention (aOR, 0.43; 95% CI, 0.22-0.85; P = .015). No significant differences were found in the other perioperative complications or 5-year mortality (aHR, 0.79; 95% CI, 0.47-1.32; P = .37). ConclusionsOur findings suggest that the RP approach may be associated with a lower adjusted odds of perioperative complications compared with the TP approach. The RP approach should be considered for open conversion after EVAR when feasible.

Impact of hospital volume and facility characteristics on postoperative outcomes after hepatectomy: A mediation analysis

BackgroundThe impact of hospital procedural volume on outcomes after hepatectomy relative to other facility-related factors remains unclear. We sought to define the comparative impact of hospital volume compared with other facility-related factors on postoperative outcomes among Medicare beneficiaries undergoing hepatectomy. MethodsData on patients who underwent hepatectomy between 2013 and 2021 were collected from the Medicare Standard Analytic Files and linked with facility-level data from the American Hospital Association Survey databases. Hospital volume was stratified into high- (top 10%) and low-volume centers. Propensity score matching was used to account for variable imbalances in patient characteristics among high-compared with low-volume centers. Mediation analysis was employed to delineate facility-related factors responsible for the impact of hospital volume on outcomes with a specific focus on incidence of complications, in-hospital mortality, and failure to rescue. ResultsThe analytic cohort included 22,969 patients from 340 institutions. After propensity score matching, receipt of surgery at a high-volume center was associated with a lower likelihood of postoperative complications (39.9% vs 41.7%, P = .01), in-hospital mortality (2.2% vs 2.8%, P = .02), and failure to rescue (5.4% vs 6.5%, P = .04) versus low-volume centers. Mediation analysis revealed that hospital capacity (bed capacity and nurse-to-bed ratio) contributed the most to the variations in risk of complications and in-hospital mortality, whereas liver transplant program status had the largest impact on failure to rescue. ConclusionsHospital volume is a significant determinant of postoperative outcomes after hepatectomy, with hospital capacity and liver transplant program status being important mediators of this effect. Centralization and optimal resource distribution are important to achieve favorable outcomes following liver resection.

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.

Impact of routine extracorporeal cardiopulmonary resuscitation service on the availability of donor organs

In refractory cardiac arrest, extracorporeal cardiopulmonary resuscitation may increase the survival chance. However, in cases of unsuccessful treatment, extracorporeal cardiopulmonary resuscitation may additionally provide an important source of organ donors. Therefore, we hypothesized that implementing extracorporeal cardiopulmonary resuscitation service into a high-volume cardiac arrest center's routine would increases organ donors' availability. MethodsOur retrospective observational study analyzed out-of-hospital cardiac arrest patients admitted to the General University Hospital in Prague between 2007 and 2020.The following groups were analyzed regarding the recruitment of donors: before and after extracorporeal cardiopulmonary resuscitation implementation. We assessed the number of donors referred, the number of organs harvested, and the organ's survival. ResultsWe analyzed the results of 1158 patients after out-of-hospital cardiac arrest. In the conventional approach period, 11 donors were referred, of which seven were accepted. During the extracorporeal cardiopulmonary resuscitation period, the number of donors increased to 80, of whom 42 were accepted. The number of donated organs was 18 and 119 in the respective periods, corresponding to 3.6 vs. 13.2 (p = 0.033) harvested organs per year. One-year survival of transplanted organs was 94.4% vs. 99.2%, and five-year survival was 94.4% vs. 95.9% in relevant periods. Conventional and extracorporeal cardiopulmonary resuscitation did not affect donor organ survival. ConclusionEstablishing a high-volume cardiac arrest centre providing an extracorporeal cardiopulmonary resuscitation service may increase not only the number of prolonged cardiac arrest survivors but also the number of organ donors. In addition, the performances of donated organs were high and comparable between both treatment methods.

Impact of incidental dural tears on postoperative outcomes in patients undergoing cervical spine surgery: a multicenter retrospective cohort study

BACKGROUND CONTEXTIncidental dural tear (DT) during cervical spine surgery is a feared complication. However, its impact on patient-reported outcomes (PROs) remains unclear. PURPOSETo determine the influence of DTs on PROs 1 year after cervical spine surgery. STUDY DESIGNRetrospective cohort. PATIENT SAMPLEPatients undergoing elective cervical spine surgery for cervical spondylosis, ossification of the posterior longitudinal ligament (OPLL), and cervical disc herniation. OUTCOME MEASURESAnalysis included patients’ characteristics, perioperative complications, and PROs both preoperatively and at 1 year postoperatively. METHODSThis study enrolled consecutive patients who underwent elective cervical spine surgery at 13 high-volume spine centers. All patients were required to complete questionnaires both preoperatively and 1 year postoperatively, which included PROs such as numerical rating scales of pain or dysesthesia for each part of the body, Neck Disability Index NDI, and Core Outcome Measures Index. Patients were divided into 2 groups based on the presence (DT+) or absence (DT-) of dural injury. Comparisons were made regarding patient background, perioperative complications, and pre and postoperative PROs. Propensity score matching was also utilized to adjust for patient background, and further comparisons were made regarding complication rates and PROs. RESULTSOut of 2,704 patients, dural tears were identified in 97 (3.6%) cases. The DT+ group had a significantly higher proportion of fixation surgeries, upper cervical surgeries, OPLL, and revision surgeries. Perioperative complications were significantly higher in the DT+ group, including intraoperative nerve damage, postoperative paralysis, surgical site infections (SSI), and cerebrovascular complications. Outcomes collected from 2,163 patients (79.9%) revealed significantly more severe neck and upper limb pain in the DT+ group. After propensity score matching, significant differences persisted in postoperative paralysis and SSI in the DT+ group, but no significant differences were observed in PROs. CONCLUSIONSPatients with dural tears showed nearly equivalent postoperative outcomes at 1 year following cervical spine surgery compared to those without dural tears. However, the incidence of perioperative complications was higher, emphasizing the need for careful management.

PE014 Extraperitoneal robot-assisted radical prostatectomy with the Hugo™ RAS system: Initial experience at a high-volume robotic center

PE014 Extraperitoneal robot-assisted radical prostatectomy with the Hugo™ RAS system: Initial experience at a high-volume robotic center

Long-term Survival in Esophageal Cancer: Comparison of Minimally Invasive and Open Esophagectomy

BackgroundThoracoscopic esophagectomy is a less invasive surgical procedure; however, evidence of its effect on long-term survival is limited. We evaluated long-term survival after the procedure in patients with esophageal carcinoma. MethodsThis retrospective multicenter study involved 1559 consecutive patients with esophageal carcinoma who underwent thoracoscopic esophagectomy or open esophagectomy between 2012 and 2019 at 2 Japanese high-volume cancer centers. Propensity score matching analysis was performed to compare short- and long-term outcomes. In addition, stage-specific survival rates were compared between the groups. ResultsThere were 313 patients who were matched and analyzed. The 1-, 3-, and 5-year overall survival rates were 84.5%, 60.5%, and 52.1%, respectively, in the matched open esophagectomy group; and 87.2%, 68.6%, and 61.8%, respectively, in the matched thoracoscopic esophagectomy group. The weighted Cox regression model showed significantly better survival in the thoracoscopic esophagectomy group than in the open esophagectomy group (hazard ratio, 0.74; 95% CI, 0.582-0.941). Deaths from other causes occurred more frequently in the open esophagectomy group than in the thoracoscopic esophagectomy group. Stratified analysis showed no significant survival differences between clinical stage I or II and pathologic stage 0 or I subgroups. However, the thoracoscopic esophagectomy groups with clinical stage III or IV and pathologic stage II, III, or IV had significantly better overall survival. ConclusionsThis study demonstrated the survival benefits of thoracoscopic esophagectomy, particularly for highly advanced esophageal carcinoma.

403. ROBOTIC-ASSISTED IVOR LEWIS ESOPHAGECTOMY COMPARED TO CONVENTIONAL MINIMALLY INVASIVE ESOPHAGECTOMY: RESULTS FROM SEVEN HIGH VOLUME ITALIAN CENTERS

Abstract Background Over the past decade, minimally invasive esophagectomy has gained increasing attention, supported by numerous trials and retrospective series highlighting its advantages over the traditional open approach. In addition to the conventional minimally invasive surgery (CMIE), robotic assisted minimally invasive esophagectomy (RAMIE) has gained global popularity, due to its advantages in terms of 3D visualization and instrument stability. Methods This is a collaborative study involving seven high-volume Italian centers affiliated with the Italian Society for the Study of Esophageal Diseases (SISME). Patients who underwent Ivor Lewis esophagectomy for esophageal cancer between January 2015 and July 2022 were identified from seven institutional databases and divided in two groups according to the thoracic approach: CMIE versus RAMIE. Results We identified 316 patients in CMIE and 123 in RAMIE group. Operative time was significantly longer for RAMIE procedures (p&amp;lt;0.001). A borderline significant reduction in overall complication rate was observed (48% vs 59% in CMIE group, p=0.045), however there were no differences in severe (p=0.3) and pulmonary (p=0.13) complications rate. 90-day mortality (CMIE 3.2% vs RAMIE 0.8%, p=0.15) and readmission rate (CMIE 9.5% vs RAMIE 7.3%, p=0.47) were comparable. R0 rate was 94.9% in CMIE vs 92.7% in RAMIE (p=0.4). The most performed anastomosis was circular stapled anastomosis. Anastomotic leak rate was 13.9% for CMIE and 12.2% for RAMIE (p=0.6). Conclusion Minimally invasive Ivor Lewis esophagectomy has reached adequate surgical and oncological results with both conventional and robotic technique. Nowadays there is no clear superiority of one anastomotic technique.

Early Aseptic Tibial Loosening Is a Concern With a Modern Two-Peg Cementless Total Knee Arthroplasty Design

BackgroundWhile early generations of cementless total knee arthroplasty (TKA) had inferior outcomes compared to cemented TKA, modern cementless designs have offered excellent clinical results. The purpose of this study was to compare patient-reported outcome measures (PROMs) and early aseptic revision rates of a specific cementless TKA design featuring a two-pegged tibia to that of its cemented counterpart. MethodsA retrospective case series of all cementless and cemented TKAs utilizing a single design performed at a single, high-volume academic center was performed. Institutional review board approval was obtained. All cases were performed between November 2018 and March 2022. A minimum one-year follow-up was required. Demographics, complications, and reoperation/revision data were collected. Oxford Knee Score and Forgotten Joint Score were collected at one-year follow-up. Radiographic review was performed for cementless TKAs that were revised or had PROMs < one SD (“poor performers”) or had PROMs > one SD (“high performers”) below or above the mean, respectively. ResultsThere were 329 cementless and 349 cemented TKAs included. Mean follow-up was 1.9 and 2.6 years for cementless and cemented cohorts, respectively. There were no statistical PROM differences between the two cohorts. There was no statistical difference in aseptic revision rates between the cohorts (4.0% cementless versus 1.7% cemented, P = 0.078); however, there was a higher rate of tibial aseptic loosening in the cementless cohort (2.7% cementless versus 0% cemented, P = 0.002). The mean time to revision for aseptic tibial loosening was 17.6 months. There was no statistical difference in radiolucencies between “poor performers” and “high performers.” ConclusionsWhen compared to its cemented counterpart, the cementless TKA that was reintroduced in 2018 had similar one-year PROMs but a higher rate of early tibial loosening (2.7 versus 0.0%, P = 0.002). Level of evidenceIII.

283. MODIFIED FRAILTY INDEX AND CLINICAL FRAILTY SCALE TOOLS ARE NOT GOOD PREDICTORS OF SURVIVAL AFTER MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Assessing frailty in elderly patients is pivotal for preoperative risk stratification. Whilst the modified Frailty-Index (m-FI) and Clinical Frailty Scale (CFS) have been used to predict postoperative mortality and morbidity in various surgical contexts, their prognostic value for complications and overall survival following esophagectomy remains uncertain. Several studies have assessed pre-operative application of frailty indices and whether they have prognostic value for long-term postoperative outcomes, however, none have compared m-FI and CFS in patients undergoing esophagectomy. This study examines and compares m-FI and CFS with overall survival and post-operative complications in patients undergoing Minimally Invasive Esophagectomy (MIO). Methods We retrospectively analysed data from a prospectively maintained database, including patients aged ≥65 years undergoing MIO for esophageal cancer from January 2014 to December 2023, at a high-volume esophago-gastric tertiary centre. We compared the m-FI 11 and m-FI 5, CFS, all measuring frailty parameters in surgical patients. Frailty was defined as m-FI 11 ≥3, m-FI 5 ≥2, or CFS ≥4, based on the current literature evidence for application of these frailty assessment tools. Primary outcomes were 2- and 5-year all-cause mortality, with anastomotic leak, serious complications (Clavien-Dindo grade ≥IIIa) and average length of stay (LOS) as secondary outcomes. Results Among 174 patients (median age 72 years, range 65-85, male-to-female ratio 4:1), no significant associations were found between age, sex, TNM stage, and pre/post-op chemoradiotherapy within each scoring category. Neither tool showed significant associations for 2-, 5-year, and overall mortality (Table 1), nor for average length of stay. However, an m-FI 5 score ≥2 exhibited an odds ratio (OR) of 2.41 (95% CI 1.00–5.78, p = 0.049) for anastomotic leak, and a CFS score ≥4 had an OR of 2.46 (95% CI 1.02–5.90, p = 0.044) for serious complications. Conclusion In frail patients undergoing MIO, both the m-FI and CFS tools demonstrated no significant prognostic value for predicting overall survival. However, m-FI 5 ≥2 correlated significantly with anastomotic leaks, while CFS ≥4 correlated with serious complications. Relying on scoring tools for frailty assessment may inadvertently trivialise what is intended to be a multidimensional evaluation of health domains. Nevertheless, their utility in predicting complications should not be overlooked. We propose a more strategic use of frailty assessment tools to triage patients for comprehensive geriatric evaluation. This approach identifies patients at highest risk of complications and facilitates targeted prehabilitation for optimising outcomes.

561. COMMONALITY AND VARIATION IN PERIOPERATIVE ESOPHAGEAL CANCER MANAGEMENT IN HIGH VOLUME EUROPEAN CENTERS

Abstract Background Esophageal cancer is a leading cause of cancer related death worldwide. For patients with locally advanced, non-metastatic, esophageal cancer (EC), surgical resection remains an essential pillar. The multitude of surgical options have driven innovation, however, lack standardization and at times high-quality data-driven practices. A surgeon-level in-depth interview and questionnaire was created to understand the perioperative care pathways and intraoperative techniques used by high-volume European EC centres to gain insight into commonality and variation of current practice. Methods Eight (8) expert upper gastrointestinal surgeons were invited to participate in an in-depth interview and questionnaire. The focus included preoperative care pathways for esophageal adenocarcinoma of the distal esophagus/GE junction, technical aspects of esophageal resection (Ivor-Lewis) and postoperative pathways. The involvement of allied health, dedicated research programs, multidisciplinary cancer conference (MCC), follow up protocols and management of T4b EC was also assessed. Results The response rate was 100% (8/8). Majority of respondents indicated a country-level regionalization of EC care. The number of centres performing esophageal resection varied from 4 – &amp;gt;100. Average number of esophagectomies/year ranged from 60-150. All centres presented EC patients at MCC, had dedicated research programs, and participated in National and International EC databases. Chemoradiotherapy was the predominate neoadjuvant treatment for GEJ cancers. Pretreatment clinical staging varied, with all centres having different, but pre-defined, preoperative and postoperative pathways. Intraoperative techniques including conduit preparation, feeding tube use, pyloric intervention, thoracic duct ligation and anastomotic technique varied substantially. There was no consensus regarding follow up or management of T4b EC. Conclusion The perioperative pathways and technical aspects of esophageal resection shared some commonalities however also differed substantially across high-volume EC centres in Europe. Multicenter, pragmatic randomized controlled trials (RCTs) are needed to better delineate which techniques should be included as standard of care, and which should be abandoned.

374. INCIDENCE AND PREDICTORS OF STRICTURE DEVELOPMENT FOLLOWING ESOPHAGECTOMY: A RETROSPECTIVE ANALYSIS

Abstract Objective Anastomotic stricture (AS) is a well described complication after esophagectomy and not only affects nutritional status but also has a detrimental impact on long-term quality of life. This retrospective study explores the incidence of clinically relevant AS in patients undergoing esophagectomy for cancer and investigates the potentially reversible factors associated with AS. Methods A prospectively entered clinical database of consecutive patients undergoing esophagectomy at a high-volume referral center over a decade (1/2013-12/2022) was queried for the presence of post-operative clinically significant AS, defined as stricture requiring endoscopic dilation. Multiple variables encompassing patient-related risk factors, tumor pathology, prior treatment, operative factors, and post-op complications were included in logistic regression analyses to delineate predictors of stricture formation. Results Of 1015 patients in the database, 115 (11.3%) developed AS requiring at least 1 post-op dilation. Although higher American Society of Anesthesiologists (ASA) grading was associated with elevated AS rate impact with most patients being ASA 2 and 3; 24% and 49% respectfully (p &amp;lt; 0.05). Specific patient factors/comorbidities such as age, peripheral or coronary vascular disease, and diabetes mellitus did not emerge as significant predictors. Surprisingly, neither histology, nor neoadjuvant therapy (chemo or chemoradiation) were associated with AS. Both a cervical anastomosis and a intra-operative pyloromyotomy had a higher AS rate than an intra-thoracic anastomosis (OR 13.3, p=0.006) and patients without a myotomy (p=&amp;lt;0.006). Other operative factors including approach (open vs MIE) conduit type (stomach/jejunum/colon) or width (3/4/5/6 cm) did not impact AS rate. All patients had a hand-sewn anastomosis. No post-operative outcome measures (e.g. leak, epidural use, hypotension) was associated with the development of AS. Conclusion Our results highlight the interplay of patient-related risk factors, tumor pathology, prior treatment, and operative factors in the development of post esophagectomy strictures. Understanding these predictors could potentially influence risk stratification and may facilitate tailored postoperative care strategies for improved patient outcomes.

778. ROBOTIC-ASSISTED EPIPHRENIC DIVERTICULECTOMY: 9 YEAR EXPERIENCE OF A TERTIARY CENTER

Abstract Background Epiphrenic esophageal diverticula are rare and often associated with esophageal motor disorders. Surgery is reserved for larger diverticula with symptoms that significantly impair quality of life. When possible, a transhiatal approach can reduce pulmonary complications by preserving pleural integrity; more proximal diverticular openings require a combined transthoracic and abdominal approach to achieve complete excision. Robotic surgery assists in precise dissection and preservation of delicate mediastinal structures. Currently, few reports are available on larger patient cohorts of robotic diverticulectomy. We describe all consecutive cases of robotic-assisted epiphrenic diverticulectomy performed at a high-volume tertiary center, since robotic surgery became available in 2015. Methods A retrospective chart review was conducted and, for all consecutive diverticulectomy cases, surgical techniques, patient characteristics and short and long-term outcomes were recorded. All patients underwent preoperative EGDS and esophagogram. Diverticulectomy was always accompanied by esophagogastric Heller myotomy (&amp;gt;7 cm) and Dor fundoplication with the Xi DaVinci system was performed. One to two SIGNA linear stapler firings were used for diverticular resection. Symptoms, demographic data, and short and long-term surgical outcomes were recorded, including morbidity and mortality and post-operative symptoms. Results Four cases required both an abdominal and intrathoracic approach, none was converted. Intraoperative complications included one occurrence of splenic bleeding controlled by hemostatic. Intraoperative blood loss was negligible. In two cases an esophageal leiomyoma was found incidentally and excised. The only postoperative complication was trocar-related abdominal wall bleeding that led to reintervention for cauterization; mortality was zero. All patients underwent a post-op esophagogram, negative for leaks or strictures, and resumed soft feeding within 7 days. All reported substantial symptom relief at six months. At one year, one patient reported reflux, and two reported dysphagia recurrence without evident structures or recurrences. Conclusion Robotic-assisted diverticulectomy is safe and effective for epiphrenic diverticula. The abdominal approach allows for a thorough esophageal myotomy associated with a For antireflux procedure to reduce recurrences of the disease and long-term dysphagia. In some cases a transthoracic approach is also needed, when employed by experienced upper GI surgeons it doesn't significantly affect surgical outcomes. Quality of life improves after surgery, although symptomatic reflux might occur. Further prospective or experimental studies are needed to evaluate short and long-term outcomes of the robotic approach compared to other surgical approaches.