Ivor Lewis Operation Research Articles

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.

ASO Author Reflections: The Timeless Debate Between Ivor-Lewis or McKeown Esophagectomy.

Ivor-Lewis (IL) operation, esophagectomy and intrathoracic esophagogastrostomy and McKeown (MK) operation, esophagectomy, and cervical esophagogastrostomy are the most common procedures for esophageal cancer. The authors reported that the oncological outcomes and completeness of upper mediastinal dissection among esophageal squamous cell carcinoma patients undergoing the IL or MK operations were not different in previous paper. Whether the IL procedure can show equivalent oncologic outcomes as compared to the MK procedure in cases of upper esophageal cancer needs to be further studied in the future. In addition, a comparison of the functional outcomes and quality of life between patients who had undergone the IL and MK operations needs to be explored.

Short-term Outcomes of Minimally Invasive McKeown Procedure Versus Open Ivor-Lewis Procedure for Lower and Middle Esophageal Cancer

Short-term Outcomes of Minimally Invasive McKeown Procedure Versus Open Ivor-Lewis Procedure for Lower and Middle Esophageal Cancer

Long-term survival analysis of robotic esophagectomy for esophageal cancer.

Robotic esophagectomy has improved early outcomes and enhanced the quality of lymphadenectomy for esophageal cancer surgery. This study aimed to determine risk factors for long-term survival following robotic esophagectomy and the causes of long-term mortality. We included patients who underwent robotic esophagectomy at our institute between 2010 and 2022. Robotic esophagectomy was defined as a surgical procedure performed robotically in both the abdomen and thorax. Robotic esophagectomy was performed in patients at all stages, including advanced stages, even in patients with stage IV and supraclavicular lymph node metastasis. A total of 340 patients underwent robotic esophagectomy during the study period. Ivor-Lewis operation and McKeown operation were performed on 153 (45.0%) and 187 (55.0%) patients, respectively. The five-year survival rates based on clinical stages were as follows: 85.2% in stage I, 62.0% in stage II, 54.5% in stage III, and 40.3% in stage IV. Risk factors for long-term survival included body mass index, Charlson comorbidity index, clinical stages, and postoperative complications of grade 4 or higher. Among the cases of long-term mortality, recurrence accounted for 42 patients (61.7%), while non-cancer-related death occurred in 26 patients (38.2%). The most common cause of non-cancer-related death was malnutrition and poor general condition, observed in 11 patients (16.2%). Robotic esophagectomy has demonstrated the ability to achieve acceptable long-term survival rates, even in patients with cervical lymph node metastasis. However, addressing high-grade postoperative complications and long-term malnutrition remains crucial for further improving the long-term survival outcomes of patients with esophageal cancer.

Short term outcomes of robotic assisted minimally invasive oesophagectomy: A single institutional experience.

e16112 Background: With the aim to decrease the rate of pulmonary complications associated with thoracotomy, minimally invasive esophagectomy (MIE) was introduced. Our purpose is to see the feasibility, safety and short-term outcomes of Robot-Assisted MIE (RAMIE). Methods: Seventy-three patients of carcinoma oesophagus who underwent Robotic Esophagectomy from May 2018 to March 2023 were included. Demographic profiles, neoadjuvant therapy, and operative and postoperative outcomes were evaluated. Results: Fifty-three patients were male while 29 were female, with median age of 60 years. Four patients had a previous history of surgery for cancer, 2 had carcinoma colon, one had carcinoma breast and another had carcinoma thyroid. 71% of patients had clinical stage 3 disease and the most common location of the tumour was the middle third (62.7%). 85.3% of patients received neoadjuvant therapy. Eighty percent of our patients underwent Robotic Mc Keown’s Esophagectomy while 20% had Robotic Ivor-Lewis Operation. The thoracic part in 1 patient was converted to open due to extensive adhesions in the right hemithorax. Mean abdominal console time was 146 min (+ 32 min) and thoracic console time was 120 min (+ 39 min); with a total operative time of 314 min (+ 44 min). Intraoperative blood loss was 300 ml (+ 86 ml). Post-operative and short-term outcomes: Out of 75 patients, 74.7% patients recovered well without any major complications. The most common complications were pulmonary (16%). Anastomotic leakage was found in 8 patients of whom 4 patients were managed conservatively, 1 required oesophageal stenting, other 2 had bedside opening of neck wound and 1 required pectoralis major muscle flap cover. Clinically recurrent laryngeal nerve palsy was found in 2 patients while Chylothorax was found in 2 patients. The median ICU stay was 3 days (range 1-28 days), whereas the median hospital stay was 8 days (range 6-38 days). Our 30-day mortality was 1.3% and this patient died on POD8 due to sepsis and respiratory failure, while 90 day mortality was 4%. Oncological Outcomes: Pathological complete response was seen in 21.3% of patients and median lymph nodal yield was 21 nodes (range 9-68). There was one microscopic margin positivity. Conclusions: RAMIE is a technically feasible and safe procedure with good lymph node yield and R0 resections. Postoperative complications and short-term oncologic results are comparable to other high-volume centres.

OGC P25 Impact of minimally-invasive oesophagectomy on post-operative analgesia and surrogate outcomes

Abstract Background Minimally invasive oesophagectomy (MIO) via either two (MIO2) or three phases (MIO3) has been proposed to reduce post-operative pain and correspondingly improve patient recovery compared to open Ivor-lewis (ILO), Left thoracoabdominal oesophagectomy (LTA) or hybrid-ILO (lap abdomen, open thoracotomy). The primary aim of this study was to audit analgesia outcomes according to surgical approach via maximum daily pain score, daily and total post-operative opiate usage. Secondary outcomes included return of GI function, mobility, and rates of post-operative pneumonia, escalation in ward care or re-intubation due to respiratory failure. Methods Retrospective review of records from consecutive patients undergoing oesophagectomy at a single tertiary centre between January 2015 and December 2022. Post-operative analgesia consisted of thoracic epidural and patient controlled analgesia (PCA) for patients undergoing thoracotomy and PCA+/- paravertebral analgesia for those undergoing MIO. Patients remaining ventilated due to early post-operative complications were excluded from analysis. Opioid usage was converted to oral morphine equivalents for comparison. Patient mobility was prospectively recorded by a physiotherapist using the Manchester Mobility Score (MMS). Pneumonia was defined as either rising inflammatory makers or fever and any new respiratory symptom, oxygen requirement or pulmonary imaging changes. Results Of a total 328 eligible patients, 225 underwent open oesophagectomy, 80 MIO, and 23 hybrid-ILO. Pain scores were similar on post-operative day 0-5 across approaches. MIO was associated with a significantly lower median total opioid usage (MIO2-624mg, MIO3-720mg) compared to open (ILO-1608mg, LTA-1984mg ) and hybrid-ILO-1977mg (P<0.001). There was no significant difference in pneumonia, escalation or reintubation rates between the different approaches. MIO was associated with an earlier return of bowel function (P<0.001) and patients undergoing MIO achieved the maximum MMS score earlier than those undergoing thoracotomy (P<0.001). Conclusions Equivalent post-operative analgesia can be achieved between open and minimally invasive oesophagectomy when multimodal approaches including epidural anaesthesia are employed. MIO is however, associated with an approximately threefold reduction in opiate use with corresponding earlier return of gut function, and improved post-operative mobility compared to ILO, LTA or hybrid-ILO. Where feasible and can safely be employed, suitable patients may benefit from a minimally invasive oesophagectomy over open or hybrid approaches as part of an enhanced recovery pathway supported by a multidisciplinary team.

First Robot-Assisted Ivor Lewis Operation with Manual Intrapleural Anastomosis for Corrosive Esophageal Stricture

Introduction. Esophageal pathology constitutes a small share in general morbidity, however, it remains highly relevant due to its social and clinical significance. Corrosive strictures account for a large proportion among benign esophageal diseases. Treatment of the disease starts with intraluminal surgery. However, it provides only short-term effect due to the tendency of esophageal strictures to restenosis. In case of treatment failure, esophagoplasty is performed. The esophagoplasty according to Ivor Lewis with the formation of manual intrapleural anastomosis was performed in the BSMU Clinic. The abdominal and thoracic phases were performed using Da Vinci Si robotic surgical system. By the time of publication of this paper, the authors have gained experience of 15 successfully performed surgeries of this kind.Materials and methods. The paper presents a clinical case of robot-assisted esophagoplasty according to Ivor Lewis performed on patient Y., born in 1978, with the clinical diagnosis: corrosive strictures of the lower third of the esophagus with dysphagia of III–IV degree. The pathology developed as a result of surrogate alcohol consumption in September 2017. Since October 2017, the patient has been regularly treated in the Thoracic Surgery Unit of the BSMU Clinic, where she underwent a number of endoscopic surgeries, which appeared to provide a little effect. The patient underwent a subsequent surgical treatment including esophagoplasty according to Ivor Lewis with the formation of manual intrapleural anastomosis using Da Vinci Si robotic system.Results and discussion. First three days of the postoperative period, the patient remained in the Anaesthesiology and Intensive Care Unit. She received step-by-step parenteral and enteral nutrition. Control fl uoroscopic examinations revealed timely, disturbances-free evacuation and no contrast leakage from the formed anastomosis. The patient was discharged on day 11 in satisfactory condition.Conclusion. Using Da Vinci robot-assisted system in Lewis esophageal plastic surgery has a number of specific features. It provides more precise tissue extraction with preservation of stomach and esophageal vessels, moreover, mobility of the instruments enables the key phase to be performed, namely — manual suturing in the esophagoanastomosis. As a result, the risk of postoperative complications is reduced.

Surgical outcomes of 500 robot-assisted minimally invasive esophagectomies for esophageal carcinoma.

In 2003, robot-assisted minimally invasive esophagectomy (RAMIE) was first reported to overcome the technical limitations of minimally invasive esophagectomy. RAMIE requires repeated modifications to set up the robotic system, and sufficient experience is required to gain technical proficiency. This study aimed to identify the learning periods and the outcomes of RAMIE for esophageal carcinoma. We retrospectively reviewed 500 consecutive RAMIE cases for esophageal cancer from December 2008 to February 2021. The learning curve for RAMIE was identified using cumulative sum analysis. In a total of 500 RAMIE patients, the Ivor Lewis and McKeown operation were performed in 267 patients (53.4%) and 192 patients (38.4%), respectively. We classified learning periods into the learning phase (first 50 cases), the developing phase (51-150 case), and the stable phase (151-500 case). The rates of vocal cord palsy (42.0% vs. 28.4%) and anastomotic leakage (10.0% vs. 6.4%) were reduced after the learning phase. The mean total operative time (420 vs. 373 min), the mean length of stay (21.6 vs. 16.7 days), and the rate of anastomotic stricture (27.0% vs. 12.4%) were significantly reduced after reaching stable phase. In the stable phase, the proportion of the Ivor Lewis operation (26.0% vs. 67.1%), neoadjuvant chemoradiation therapy (14.0% vs. 25.7%), and bilateral cervical node dissection cases (12.0% vs. 22.0%) were significantly increased. Fifty procedures might be needed to achieve early proficiency, and extensive experience of more than 150 procedures is needed for quality stabilization.

433. INTRAOPERATIVE ICG-IMAGING AS A TOOL TO ASSESS PERFUSION IN THE GASTRIC CONDUIT

Abstract Background In curative surgery for esophageal cancer a gastric conduit is often used to replace the resected esophagus. Anastomotic leakage (AL) is a serious complication. Sufficient perfusion in the gastric conduit is critical for the anastomosis. The aim of this pilot study was to investigate the feasibility of intraoperative indocyanine green (ICG) and near-infrared fluorescent imaging as a tool to assess perfusion of the gastric conduit in order to prevent postoperative AL. Methods Patients undergoing esophageal resection at Umeå University Hospital were invited to participate in this prospective study during 2017–2022. The surgery performed was open Ivor-Lewis esophagectomy. ICG was administered intraoperatively and video footage of the near-infrared fluorescence was recorded. The time from injection until visualized fluorescence in the gastric conduit was measured, as well as the intensity of the fluorescence in the gastric conduit. A loop of jejunum was used as control and the quotient between the measurement in the jejunal loop and in the gastric conduit was used for objective assessment. Results 50 individuals were included. 46 patients had received neoadjuvant chemoradiotherapy and 3 had received chemotherapy only. 32 patients had video footages that were possible to assess as described above. Of these 11 had AL. No differences were demonstrated between patients with AL and those without, neither regarding time to fluorescence (p = 0.42), nor intensity (p = 0.72). Conclusion AL is a serious complication to esophageal surgery with a high incidence. Perfusion assessment of the gastric conduit using ICG has emerged as a promising technique to reduce AL. In this pilot study we developed two techniques to evaluate the perfusion in an objective manner, whilst none of these seem to be able to predict postoperative AL.

Thoracoscopic laparoscopy-assisted Ivor-Lewis resection of esophagogastric junction cancer

Objective: To investigate the outcome of patients with esophagogastric junction cancer undergoing thoracoscopic laparoscopy-assisted Ivor-Lewis resection. Methods: Eighty-four patients who were diagnosed with esophagogastric junction cancer and underwent Ivor-Lewis resection assisted by thoracoscopic laparoscopy at the National Cancer Center from October 2019 to April 2022 were collected. The neoadjuvant treatment mode, surgical safety and clinicopathological characteristics were analyzed. Results: Siewert type Ⅱ (92.8%) and adenocarcinoma (95.2%) were predominant in the cases. A total of 2 774 lymph nodes were dissected in 84 patients. The average number was 33 per case, and the median was 31. Lymph node metastasis was found in 45 patients, and the lymph node metastasis rate was 53.6% (45/84). The total number of lymph node metastasis was 294, and the degree of lymph node metastasis was 10.6%(294/2 774). Among them, abdominal lymph nodes (100%, 45/45) were more likely to metastasize than thoracic lymph nodes (13.3%, 6/45). Sixty-eight patients received neoadjuvant therapy before surgery, and nine patients achieved pathological complete remission (pCR) (13.2%, 9/68). Eighty-three patients had negative surgical margins and underwent R0 resection (98.8%, 83/84). One patient, the intraoperative frozen pathology suggested resection margin was negative, while vascular tumor thrombus was seen on the postoperative pathological margin, R1 resection was performed (1.2%, 1/84). The average operation time of the 84 patients was 234.5 (199.3, 275.0) minutes, and the intraoperative blood loss was 90 (80, 100) ml. One case of intraoperative blood transfusion, one case of postoperative transfer to ICU ward, two cases of postoperative anastomotic leakage, one case of pleural effusion requiring catheter drainage, one case of small intestinal hernia with 12mm poke hole, no postoperative intestinal obstruction, chyle leakage and other complications were observed. The number of deaths within 30 days after surgery was 0. Number of lymph nodes dissection, operation duration, and intraoperative blood loss were not related to whether neoadjuvant therapy was performed (P>0.05). Preoperative neoadjuvant chemotherapy combined with radiotherapy or immunotherapy was not related to whether postoperative pathology achieved pCR (P>0.05). Conclusion: Laparoscopic-assisted Ivor-Lewis surgery for esophagogastric junction cancer has a low incidence of intraoperative and postoperative complications, high safety, wide range of lymph node dissection, and sufficient margin length, which is worthy of clinical promotion.

Robotic versus open Ivor-Lewis esophagectomy: A more accurate lymph node dissection without burdening the leak rate.

Robotic-assisted minimally invasive esophagectomy (RAMIE) combines the beneficial effects of minimally invasive surgery on postoperative complications, especially on pulmonary ones, with the safety of the anastomosis performed in open surgery. Moreover, RAMIE could allow a more accurate lymphadenectomy. We reviewed our database to identify all patients with adenocarcinoma of the esophagus treated by Ivor-Lewis esophagectomy in the period January 2014 to June 2022. Patients were divided according to the thoracic approach into RAMIE and open esophagectomy (OE) groups. We compared the groups for early surgical outcomes, 90-day mortality as well as R0 rate, and the number of lymph nodes harvested. We identified 47 patients in RAMIE and 159 patients in theOE group. Baseline characteristics were comparable. Operative time was significantly longer for RAMIE procedures (p < 0.01); however, we did not observe the difference in overall (RAMIE 55.5% vs.OE 61%, p = 0.76) and severe complications rate (RAMIE 17% vs.OE 22.6%, p = 0.4). The anastomotic leak rate was 2.1% after RAMIE and 6.9% after OE (p = 0.56). We did not report the difference in 90-day mortality (RAMIE 2.1% vs.OE 1.9%, p = 0.65). In theRAMIE group, we observed a significantly higher number of thoracic lymph nodes harvested, with a median of 10 lymph nodes in theRAMIE group versus 8 in theOE group (p < 0.01). In our experience, RAMIE has morbimortality rates comparable to OE. Moreover, it allows a more accurate thoracic lymphadenectomy which results in a higher thoracic lymph nodes retrieval rate.

Overall morbidity after total minimally invasive keyhole oesophagectomy versus hybrid oesophagectomy (the MICkey trial): study protocol for a multicentre randomized controlled trial

BackgroundOesophageal cancer (EC) is the sixth leading cause of cancer death worldwide. Oesophageal resection is the only curative treatment option for EC which is frequently performed via an abdominal and right thoracic approach (Ivor-Lewis operation). This 2-cavity operation is associated with a high risk of major complications. To reduce postoperative morbidity, several minimally invasive techniques have been developed that can be broadly classified into either hybrid oesophagectomy (HYBRID-E) via laparoscopic/robotic abdominal and open thoracic surgery or total minimally invasive oesophagectomy (MIN-E). Both, HYBIRD-E and MIN-E, compare favourable to open oesophagectomy. However, there is still an evidence gap comparing HYBRID-E with MIN-E with regard to postoperative morbidity.MethodsThe MICkey trial is a multicentre randomized controlled superiority trial with two parallel study groups. A total of 152 patients with oesophageal cancer scheduled for elective oesophagectomy will be randomly assigned 1:1 to the control group (HYBRID-E) or to the intervention group (MIN-E). The primary endpoint will be overall postoperative morbidity assessed via the comprehensive complication index (CCI) within 30 days after surgery. Specific perioperative parameters, as well as patient-reported and oncological outcomes, will be analysed as secondary outcomes.DiscussionThe MICkey trial will address the yet unanswered question whether the total minimally invasive oesophagectomy (MIN-E) is superior to the HYBRID-E procedure regarding overall postoperative morbidity.Trial registrationDRKS00027927 U1111-1277-0214. Registered on 4th July 2022

A 25 mm Circular Stapler Anastomosis Is Associated with Higher Anastomotic Leakage Rates Following Minimally Invasive Ivor Lewis Operation.

(1) Background: Minimally invasive oesophagectomy (MIE) with intrathoracic anastomosis is increasingly used in treating patients with oesophageal cancer. Anastomotic leakage (AL) remains a critical perioperative complication, despite recent advances in surgical techniques. It remains unclear to what extent the size of the circular stapler (CS), a 25 mm CS or a bigger CS, may affect the incidence of AL. This study aimed to evaluate whether the CS size in oesophagogastrostomy affects the postoperative AL rates and related morbidity in MIE. (2) Methods: We conducted a retrospective review of consecutive patients who had undergone thoracic MIE between August 2014 and July 2019 using a CS oesophagogastric anastomosis at the level of the Vena azygos. The patients were grouped according to CS size (mm): small-sized (SS25) and large-sized (LS29). The patient demographics, data regarding morbidity, and clinical outcomes were compared. The primary outcome measure was the AL rate related to the stapler size. (3) Results: A total of 119 patients were included (SS25: n = 65; LS29: n = 54). Except for the distribution of squamous cell carcinoma, the demographics were similar in each group. The AL rate was 3.7% in the LS29 group and 18.5% in the SS25 group (p = 0.01). The major morbidity (CD ≥ 3a) was significantly more frequent in the SS25 group compared with the LS29 group (p = 0.02). CS size, pulmonary complications, and cardiovascular disease were independent risk factors for AL in the multivariate analysis. (4) Conclusions: A 29 mm CS is associated with significantly improved surgical outcomes following standard MIE at the level of the azygos vein and should be conducted whenever technically feasible.

386. SURGICAL SHORT-OUTCOMES IN ELDERLY PATIENTS WITH ESOPHAGEAL CANCER IN OUR INSTITUTION

Abstract With aging, patients with esophageal cancer would have several comobidity and decline of physiological function. It is difficult to fit the standerd treatment to the elderly patients with esopageal camcer. We review the data of elderly patients who underwent operation for esopageal cancer in our institution to evaluate the safety of surgery in this partucular population. During January 2017 and December 2021, twenty three patients over 75-year-old underwent the operation with right thoracotomy, that is McKeown’s or Ivor-Lewis operation, for esophageal cancer or esophago-gastric junction cancer in our institution. We retrospectively analyzed their preoperative assessment, concurrent disorders, surgical techniques used, postoperative course, and complications. Average age of the patients was 79.5 years, and over 80 year-old patients were nine. Preoperative chemotherapy was done in 12 cases. Only 3 patients underwent esophagectomy with right thoracotomy and three-field lymph node dissection. Postoperative complications occurred in 17 patients (74%). Mortality was one cases, because of severe respiratory failure. Anastomotic leakage was observed in nine patients. As other complications over Grade II in Clavien-Dindo (CD) classification, anastomotic stricture was 4, pneumonia was 3 cases. Recurrent nerve paralysis was observed in 6 patients in Grade I in CD classification. It is difficult to decide treatment for esophageal cancer only at age. In elderly cases, it would require more ingenuity for anastomosis after esophagectomy.

Role of intraoperative feeding jejunostomy in esophageal cancer surgery

BackgroundFeeding jejunostomy was routinely placed during esophagectomy to ensure postoperative enteral feeding. Improved anastomosis technique and early oral feeding strategy after esophagectomy has led to question the need for the routine placement of feeding jejunostomy. The aim of this study is to evaluate role of feeding jejunostomy during Ivor Lewis operation.MethodsWe retrospectively reviewed 414 patients who underwent the Ivor Lewis operations from January 2015 to December 2018.Results61 patients (14.7%) received jejunostomy insertion. The most common indication for jejunostomy was neoadjuvant concurrent chemoradiation therapy (CCRT). 48 patients (79%) had jejunostomy removed within 60 days after the surgery and the longest duration of jejunostomy inserted state was 121 days. About two-third of the patients with jejunostomy had never prescribed with an enteral feeding product. Among 353 patients without intraoperative feeding jejunostomy, 11(3.1%) received delayed jejunostomy insertion. Graft-related problems (6 patients), cancer progression (3 patients), acute lung injury (1 patient), and swallowing difficulty (1 patient) were reasons for delayed feeding jejunostomy insertion. Complication rate was relatively high as 24 patients (33.3%) out of 72 patients with jejunostomy insertion had complications and 7 patients (9.7%) visited ER more than twice with jejunostomy-related complications.ConclusionOnly 3.6% patients who underwent the Ivor Lewis operation during 4-year span had anastomosis leakage. Although one-third of the patients with jejunostomy were benefited with alternative method of feeding after discharge, high complication rate regarding jejunostomy should be also considered. We believe feeding jejunostomy should not be applied routinely with prophylactic measures and should be reserved to very carefully selected patients with multiple high-risk factors.

Clinicopathologic and survival differences between adenocarcinoma of the distal oesophagus and gastro-oesophageal junction.

The incidence of adenocarcinoma of the distal oesophagus (DO) and gastro-oesophageal junction (GOJ) are increasing. They may represent differing disease processes. This study aimed to assess clinicopathological and survival differences between patients with DO and GOJ adenocarcinomas. Data were extracted from a prospective single-surgeon database of consecutive patients undergoing an open Ivor-Lewis oesophagectomy for oesophageal adenocarcinoma (distal oesophagus, Siewert type I and II). Differences in clinicopathological characteristics and survival were evaluated and prognostic factors examined using univariate and multivariate survival analyses. The data were available for 234 patients who underwent an oesophagectomy between 1992 and 2019. DO tumours had higher rates of Barrett's oesophagus (P < 0.001), presented with lower tumour stage (P=0.02) and were more likely to be associated with fewer lymph nodes resected (P=0.003) than GOJ tumours. The median overall survival for distal oesophageal tumours was 29.2months, while gastro-oesophageal tumours was 38.6months. Kaplan Meier analysis did not show a difference in overall survival between the two groups (P=0.08). However, when adjusted for potential confounders, GOJ tumours were associated with a reduced adjusted hazard of death (adjusted HR 0.58, 95% CI 0.36-0.92, P=0.022) compared with DO tumours. This study suggests that GOJ cancers have different clinicopathological characteristics and improved survival compared to DO tumours.

201 POSTOPERATIVE OUTCOMES OF MINIMALLY INVASIVE ESOPHAGEAL SURGERY FOR ESOPHAGEAL CANCER IN A SINGLE CENTER

Abstract The aim if this study is to evaluate the safety and feasibility of minimally invasive esophageal surgery for esophageal cancer in a small volume center. Methods The medical records of patients who had undergone minimally invasive esophageal surgery (VATS Ivor Lewis operation with laparoscopic gastric mobilization) for their esophageal cancer between June 2017 and September 2019 in our institute were reviewed retrospectively. Perioperative outcomes including postoperative morbidities and mortalities were evaluated. Results A total of 31 patients were included in this study. The mean operation time for laparoscopic gastric mobilization were 111.3 minutes and those for VATS Ivor Lewis operation were 235.5 minutes. Seven patients underwent Neoadjuvant therapy. Half of the cases were stage I, however, operation could be performed in more advanced cases. There was no conversion to open procedure. Overall complication rates were 49.1%, and complication more than Grade III in Clavien-Dindo classification were 16.1%. Overall postoperative morality was 6.4%. Two patients died at 42 and 47 postoperative days due to acute respiratory failure, and one patient. Conclusion Minimally invasive esophageal surgery for esophageal cancer could be feasibly performed even in advanced cases. Postoperative pneumonia should be carefully managed to prevent postoperative mortality.

Lymph Node Involvement in Oesophageal Carcinoma: A Single-Centre Observational Study From Western India.

IntroductionLymph node involvement is the most important predictor of prognosis in oesophageal cancer. The present study describes our single-centre experience of lymphadenopathy in oesophageal carcinoma cases at a tertiary care centre in the Marathwada region of Maharashtra state in western India.MethodsThis descriptive study included 31 patients who were operated for oesophageal carcinoma at the State Cancer Hospital in Marathwada from August 2015 to September 2017. Thirty patients underwent three-field lymph node dissections, and one patient underwent Ivor Lewis surgery with two-field lymph node dissections. Three-field lymph node dissections were through a thoracotomy, followed by laparotomy and left cervical incision. The lymphatic metastases were categorised as (a) adjacent node metastases, (b) multiple levels of lymph node metastases, and (c) skip node metastases. The histopathological assessment of the removed specimen and lymph nodes was done. Pathologists evaluated the character and depth of the primary tumour and its invasion and node involvement. The location and numbers of positive and negative nodes were recorded.ResultsA total of 31 patients were included in the study, of which 17 had lymph node involvement. A total of 946 lymph nodes were dissected and examined, and the average number of lymph nodes removed per patient was 30.51. Among the 28 squamous cell carcinoma cases, lymph node involvement was found in 14 cases (50%) whereas, in adenocarcinoma, all the three cases showed lymph node involvement. In 11 cases of squamous cell carcinoma, thoracic lymph nodes were involved, whereas abdominal lymph nodes were involved in nine and cervical lymph nodes in two cases. Thoracic lymph nodes were involved in two cases of adenocarcinoma and abdominal lymph nodes were involved in one case of adenocarcinoma.ConclusionsSquamous cell carcinoma was the predominant type, and lymph node metastasis was observed in 50% of these cases. Thoracic lymph nodes were more commonly involved. Tumour staging T2 and T3 had an increasing percentage of lymph nodes involved. Lymph node involvement was more in moderately differentiated and undifferentiated oesophageal cancers.

Effects of enteral nutrition support combined with enhanced recovery after surgery on the nutritional status, immune function, and prognosis of patients with esophageal cancer after Ivor-Lewis operation.

BackgroundEsophageal cancer (EC) with a high incidence of malnutrition is a highly malignant digestive tract tumor. We investigated the effect of enteral nutrition (EN) support combined with enhanced recovery after surgery (ERAS) on the nutritional status, immune function, and prognosis of patients with EC after Ivor-Lewis operation.MethodsOne hundred patients were randomly divided into the observation group (n=42) and the control group (n=58). The patients in observation group were treated with EN combined with ERAS intervention after Ivor-Lewis operation, and the patients in control group were treated with conventional postoperative EN intervention. The situation of operation, nutritional status, immune function recovery and prognosis between the two groups were compared.ResultsThere was no statistically significant difference in operation time or intraoperative blood loss between the two groups (P>0.05). The chest tube removal time and oral feeding time of the observation group after operation were shorter than those of the control group (P<0.05). After intervention, serum albumin (ALB), transferrin (TF), pre-albumin (PA) and hemoglobin (Hb) levels in both groups were significantly decreased. These indexes were significantly higher in the observation group than in the control group (P<0.05). There were no significant changes in the levels of immunoglobulin (Ig) A, IgG, and IgM, or the numbers of CD3+, CD4+ and CD4+/CD8+ T cells in the observation group before and after intervention (P>0.05); however those indexes were significantly decreased in the control group after the intervention (P<0.05). Interestingly, the levels of IgA, IgM, IgG, CD3+ T cells, CD4+ T cells and CD4+/CD8+ T cells in the observation group were significantly higher than those in the control group after intervention (P<0.05). The incidence of pulmonary infection in the observation group was significantly lower than that in the control group. The postoperative exhaust time, postoperative defecation time and postoperative hospital stay were shorter in the observation group than in the control group (P<0.05). There was no significant difference in hospitalization cost between the two groups (P>0.05).ConclusionsEN combined with ERAS was more beneficial to the improvement of nutritional status and immune function recovery of patients with EC after Ivor-Lewis operation. It also shortened the length of hospital stay.

Analysis of the Value of Laparoscopy Combined with Right Thoracic Small Incision Ivor-Lewis in the Treatment of Cardia Cancer Under X-ray Biomedical Imaging

In order to explore the accuracy of image segmentation algorithm in the biological image segmentation of cardia cancer patients with X-ray barium meal imaging and the effect of laparoscopy combined with right thoracic small incision Ivor Lewis on the prognosis of patients with cardia cancer, 185 patients diagnosed with cardiac cancer in xxx hospital from June 2015 to December 2018 were taken as research objects. Based on X-ray barium meal images, the efficiency of manual segmentation and the proposed watershed based minimum error threshold algorithm for image segmentation was compared. Based on the segmentation results, 185 patients with cardiac cancer were divided into the control group (n = 105) and the test group (n = 80), and the control group received traditional Ivor Lewis surgery, while the test group received laparoscopic Ivor Lewis surgery combined with a small incision in the right chest. Postoperative comparison was made between the two groups of patients on the 3rd day after the operation in the number of lymph node dissection, the incidence of postoperative complications, and the pain score 24 h after the operation. The results showed that the minimum error threshold algorithm based on watershed presented in this study was significantly more accurate than manual segmentation in the segmentation of X-ray barium meal images of cardiac cancer patients. The intraoperative blood loss, postoperative out-of-bed activity time and hospitalization time of the experimental group were significantly lower than that of the control group, and the differences were statistically significant (P &lt; 0.05). The complication rates of postoperative chest drainage volume, postoperative 24 h pain score, postoperative pulmonary infection, bleeding and anastomotic fistula in the 2 d test group were all lower than those in the control group, and the differences were statistically significant (P &lt; 0.05), which indicated that the watershed based minimum error threshold algorithm proposed in this study can effectively achieve the segmentation of X-ray barium meal images of patients with cardiac cancer, while the laparoscopy combined with the right thoracic small incision Ivor Lewis can effectively improve the quality of life of patients.