Lower Esophageal Cancer Research Articles

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

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

Surgery Adherence and Survival Outcomes in Patients With Locally Advanced (IIA-IVA) Cancer of the Lower Esophagus: A SEER Database-Based Study.

Esophageal cancer is a prevalent malignant tumor of the upper gastrointestinal tract. The aim of this study was to examine the impact of surgical adherence on the prognosis of patients with locally advanced lower esophageal cancer and to analyze the factors that affect surgical adherence. Patients diagnosed with locally advanced (IIA-IVA) lower esophageal cancer between 2004 and 2015 were screened from the Surveillance, Epidemiology, and End Results (SEER) database. We utilized multifactorial logistic regression to analyze the correlates affecting surgical adherence. Furthermore, we employed Kaplan-Meier curves and Cox regression to determine the impact of surgical adherence on cancer-specific survival (CSS) and overall survival (OS). Of the 4922 patients screened, 2372 individuals were advised to undergo surgery, out of which 2025 ultimately underwent the procedure while the remaining 347 refused. Lower surgical adherence was associated with older age, unmarried, SEER classification of "distant," and squamous cell carcinoma. Adherence to surgery proved to be an independent factor affecting OS and CSS. The Cox regression analysis showed that patients who refused surgery had lower OS (OR: 1.657; 95% CI: 1.429∼1.927; P < .001) and CSS (OR: 1.487; 95% CI: 1.309∼1.690; P < .001) than those who underwent surgery. Kaplan-Meier curves showed that patients who underwent surgical treatment had a better prognosis. Good surgical adherence can improve the prognosis of patients with locally advanced (IIA-IVA) lower esophageal cancer, while poor surgical adherence is associated with older age, unmarried, SEER classification of "distant," and squamous cell carcinoma.

Abemaciclib in patients (pts) with esophageal cancer (EC) with CDKN2A loss or mutation (mut): Results from the Targeted Agent and Profiling Utilization Registry (TAPUR) study.

308 Background: TAPUR is a phase II basket study evaluating antitumor activity of commercially available targeted agents in pts with advanced cancers with specific genomic alterations. Results in a cohort of pts with EC with CDKN2A loss or mut treated with abemaciclib are reported. Methods: Eligible pts had measurable disease, ECOG performance status (PS) 0-2, adequate organ function, and no standard treatment (tx) options. Genomic testing was performed in CLIA-certified, CAP-accredited site selected labs. Pts received 200 mg (four 50 mg tablets) of abemaciclib twice daily for a total daily dose of 400 mg until disease progression. Primary endpoint was disease control (DC) per investigator defined as complete or partial (PR) response per RECIST v. 1.1, or stable disease of at least 16 weeks (wks) duration (SD16+). Simon 2-stage design tested the null DC rate of 15% vs. 35% (power = 0.85; α = 0.10). If ≥2 of 10 pts in stage 1 have DC, 18 more pts are enrolled; otherwise, the cohort is closed. If ≥7 of 28 pts have DC, the null DC rate is rejected. Secondary endpoints were objective response (OR), progression-free survival (PFS), overall survival (OS), duration of response (DOR) and safety. DOR is defined as time from pt’s first documented OR to progressive disease. Results: 10 pts with EC (8 adenocarcinoma, 2 squamous) and CDKN2A loss (n=5) or CDKN2A mut (n=5) were enrolled from Dec 2019 to June 2022. 6 pts had HER2 negative EC, 1 pt had HER2 low EC, 1 pt had HER2 positive EC, and 2 pts were not tested for HER2. All pts were evaluable for efficacy and toxicity. Table summarizes pt demographics and outcomes. 1 pt with CDKN2A loss had a 27-wk PR for a DC rate of 10% (1-sided 90% CI, 1% to 100%) and OR rate of 10% (95% CI, &lt;1% to 45%). The null DC rate was not rejected (p=0.80). Median PFS was 8 wks (95% CI, 2 to 13) and median OS was 17 wks (95% CI, 9 to 35). The pt with PR had HER2 negative adenocarcinoma, ECOG PS of 1 and 2 prior lines of therapy. 4 pts had 12 serious adverse events at least possibly related to tx, including anemia, atrial fibrillation, increased creatinine, dehydration, dyspnea, generalized muscle weakness, heart failure, lung infection, pericardial effusion and thrombocytopenia. 4 pts had a drug-related grade 3 AEs including anemia, increased bilirubin and thrombocytopenia. Conclusions: Abemaciclib monotherapy did not demonstrate sufficient clinical activity in pts with advanced EC with CDKN2A loss or mut for continued evaluation in this pt population. Other tx should be considered for these pts, including tx offered in clinical trials. Clinical trial information: NCT02693535 . [Table: see text]

Application of overlap anastomosis in digestive tract reconstruction during minimally invasive Ivor-Lewis esophagectomy.

This study aims to assess the feasibility of the Overlap anastomosis technique in minimally invasive Ivor-Lewis esophagectomy. An accompanying video presentation elucidates our surgical procedures. A retrospective review of 46 patients diagnosed with middle and lower esophageal cancer was conducted. These patients underwent minimally invasive Ivor-Lewis esophagectomy with Overlap anastomosis between January 2019 and December 2020. A consistent team of surgeons performed all procedures. The initial phase involved laparoscopic stomach mobilization, intra-abdominal lymphadenectomies, and preparation of the tubular stomach. Subsequently, with the patient in the left decubitus position, thoracoscopy was used to dissect the esophagus, excise the diseased segment, and conduct mediastinal lymph node dissection. The final stage encompassed the intrathoracic gastroesophageal anastomosis using the Overlap method. All surgeries were completed without converting to an open approach, achieving complete resection. There were no operative fatalities, with an average surgery duration of 259.4min. Average statistics included intraoperative blood loss of 92.3ml, 16.2 lymph nodes dissected, and a postoperative hospital stay of 10.3days. Postoperative complications comprised three instances of hoarseness due to recurrent laryngeal nerve palsy, two cases of aspiration pneumonia, one occurrence of chylothorax, and one gastric emptying disorder. Anastomotic technique-related complications were minimal, with only one patient experiencing an anastomotic leak that resolved spontaneously and two patients facing anastomotic stenosis, which was subsequently alleviated. Our findings posit that the Overlap anastomosis method is safe and efficient for minimally invasive Ivor-Lewis esophagectomy, marked by a notably low rate of anastomosis-related complications. Further evaluation of its long-term implications remains necessary.

Short-term outcome of totally minimally invasive versus hybrid minimally invasive Ivor-Lewis esophagectomy.

For resectable esophageal cancer, the choice of total minimally invasive esophagectomy (TMIE) or hybrid minimally invasive esophagectomy (HMIE) remains controversial. The purpose of this study was to evaluate the short-term clinical outcomes of TMIE and HMIE under the Ivor-Lewis procedure. The data of 145 patients diagnosed with middle or lower esophageal cancer who underwent radical Ivor-Lewis esophagectomy in the Affiliated Hospital of Qingdao University between January 2018 and December 2019 were retrospectively analyzed. The short-term outcomes such as complications during surgery or within 30 days after surgery and postoperative pain were analyzed. All patients were divided into TMIE group (75 patients) and HMIE group (70 patients). No significant difference was observed in the baseline characteristics of the two groups. TMIE was associated with less blood loss than the HMIE group (p<0.05). A total of 54 (37.2%) patients had postoperative complications. Although the two groups were statistically similar in the incidence of major complications, patients in the HMIE group were more likely to have pneumonia compared with those in the TMIE group. The numeric rating scale for pain was significantly higher in the HMIE group (p=0.002) and more patients required an additional opioid analgesia after esophagectomy (p=0.282). In conclusion, according to perioperative outcomes, TMIE can benefit patients better than HMIE.

Long-term esophageal cancer risk and distinct surveillance intervals after a single endoscopy screening: a multicentre population-based cohort study

Endoscopy surveillance is recommended for mild-moderate dysplasia and negative endoscopy findings every 3 years and 5 years, respectively, but evidence is limited. This study aimed to assess long-term esophageal cancer (EC) incidence and mortality after a single endoscopy screening. We included individuals at high risk of EC aged 40-69 years who underwent endoscopy screening in 2007-2012at six centres in rural China and had a baseline diagnosis of negative endoscopy findings, mild dysplasia, or moderate dysplasia. Participants were followed up for EC incidence and mortality. Cumulative incidence and mortality rates of EC were estimated by Kaplan-Meier analyses. Cox regression models were used to calculate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for associations between baseline endoscopy diagnosis and the risk of EC incidence and mortality. EC incidence and mortality after a single endoscopy screening were compared with those of the population in rural China by the standardized incidence ratio (SIR) and standardized mortality ratio (SMR). A total of 42,827 participants (40,977 with negative endoscopy findings, 1562 with mild dysplasia, and 288 with moderate dysplasia) were included; 268EC cases and 128EC deaths were identified during a median follow-up of 10.62 years. The cumulative EC incidence at 10 years was 0.45% (0.38-0.52) in the group with negative endoscopy findings, 2.39% (1.62-3.16) in the mild dysplasia group, and 8.90% (5.57-12.24) in the moderate dysplasia group, and the cumulative EC mortality at 10 years was 0.23% (0.18-0.27), 0.96% (0.46-1.46), and 2.50% (0.67-4.33), respectively. Compared with individuals with negative endoscopy findings, the HRs for EC incidence and mortality in the mild dysplasia group were 3.52 (2.49-4.97) and 2.43 (1.41-4.19), and those in the moderate dysplasia group were 13.18 (8.78-19.76) and 6.46 (3.13-13.29), respectively. The SIR was 0.53 (0.40-0.70) for the group with negative endoscopy findings, 1.95 (1.69-2.24) for the mild dysplasia group, and 6.75 (6.25-7.28) for the moderate dysplasia group, with the SMRs of 0.43 (0.31-0.58), 1.07 (0.88-1.29) and 2.67 (2.36-3.01), respectively. Individuals with negative endoscopy findings after a single endoscopy screening had a lower EC risk than the general population for up to 10.62 years, while those with mild-moderate dysplasia had an elevated risk. Our results support endoscopy surveillance for mild-moderate dysplasia every 3 years and suggest extending the interval to 10 years after a negative endoscopy finding. National Key R&D Programme of China, Special Project of Beijing-Tianjin-Hebei Basic Research Cooperation, and Sanming Project of Medicine in Shenzhen.

Novel simulation for dosimetry impact of diaphragm respiratory motion in four-dimensional volumetric modulated arc therapy for esophageal cancer

Background and purposeThe diaphragm respiratory motion (RM) could impact the target dose robustness in the lower esophageal cancer (EC). We aimed to develop a framework evaluating the impact of different RM patterns quantitatively in one patient, by creating virtual four-dimensional computed-tomography (v4DCT) images, which could lead to tailored treatment for the breathing pattern. We validated virtual 4D radiotherapy (v4DRT) along with exploring the acceptability of free-breathing volumetric modulated arc therapy (FB-VMAT). Methods and MaterialsWe assessed 10 patients with superficial EC through their real 4DCT (r4DCT) scans. v4DCT images were derived from the end-inhalation computed tomography (CT) image (reference CT) and the v4DRT dose was accumulated dose over all phases. r4DRT diaphragm shifts were applied with magnitudes derived from r4DCT scans; clinical target volume (CTV) dose of v4DRT was compared with that of r4DRT to validate v4DRT. CTV dosage modifications and planning organ at risk volume (PRV) margins of the spinal cord were examined with the diaphragm movement. The percentage dose differences (ΔDx) were determined between the v4DRT and the dose calculated on the reference CT image. ResultsThe CTV ΔDx between the r4DRT and v4DRT were within 1% in cases with RM ≦ 15 mm. The average ΔD100% and ΔDmean of the CTV ranging from 5 to 15 mm of diaphragm motion was 0.3% to 1.7% and 0.1% to 0.4%, respectively. All CTV index changes were within 3% and ΔD1cc and ΔD2cc of Cord PRV were within 1%. ConclusionWe postulate a novel method for evaluating the CTV robustness, comparable to the conventional r4DCT method under the diaphragm RM ≦ 15 mm permitting an impact of within 3% in FB-VMAT for EC on the CTV dose distribution.

Effect of Three Weeks of High-Intensity, Long-Term Preoperative Rehabilitation for Esophageal Cancer Patients with Stroke Sequelae Who Were Considered Unfit for Surgery Due to Low Activity: A Case Report

Treatment of esophageal cancer is based on tumor-node-metastasis (TNM) classification, and surgical treatment is chosen based on the patient's ability to tolerate surgery. Surgical endurance partly depends on activity status, with performance status (PS) generally used as an indicator. This report describes a 72-year-old man with lower esophageal cancer and an 8-year history of severe left hemiplegia. He had sequelae of cerebral infarction and a TNM classification of T3, N1, and M0, and was judged ineligible for surgery because his PS was grade three; he underwent preoperative rehabilitation with hospitalization for 3 weeks. He had been able to walk with a cane in the past, but once he was diagnosed with esophageal cancer, he began using a wheelchair and was dependent on assistance from his family in his daily life. Rehabilitation consisted of strength training, aerobic exercise, gait training, and activities of daily living (ADL) training for 5 h a day, according to the patient's condition. After 3 weeks of rehabilitation, his ADL ability and PS improved sufficiently for surgical indication. No complications occurred postoperatively, and he was discharged when his ADL ability was higher than that before preoperative rehabilitation. This case provides valuable information for the rehabilitation of patients with inactive esophageal cancer.

Comparison of lymph node metastasis pattern from esophagogastric junction adenocarcinoma versus very low thoracic esophageal squamous cancer: a propensity-matched analysis.

The anatomical locations of esophagogastric junction adenocarcinoma (AEG) and very low thoracic esophageal squamous cell carcinoma (ESCC) are similar. This study aimed to evaluate the difference in lymph node metastasis (LNM) distribution between AEG and very low thoracic ESCC. Data from 156 Siewert I-II AEG patients and 120 ESCC patients with proximal edges located within 5 cm of the esophagogastric junction (EGJ) and underwent curative surgery from 2010 to 2015 were retrospectively analyzed using propensity score matching (PSM). Five or six baseline variables were included in PSM separately. All patients underwent curative transthoracic surgery and systematic lymphadenectomy. After PSM, LNM rates of major stations were compared using the chi-squared test or Fisher's exact test. After PSM was performed with covariates (age, sex, T stage, grade, tumor length), 60 pairs of patients were included. The lower mediastinal and total thoracic LNM rates of ESCC were significantly higher than those of AEG (18.3% vs. 3.3%, P=0.019; 25% vs. 3.3%, P=0.002). After further addition of the N stage as a variant to the previous PSM model, we found that the paracardial LNM distribution was significantly different between ESCC and AEG patients (36.1% vs. 19.7%, P=0.043). Among all tumor characteristics, only the T stage was positively correlated with paracardial LNM in ESCC (P=0.010), but not in AEG. In AEG, the median survival was poor for patients with thoracic LNM. Patients with very low thoracic ESCC exhibit stronger metastatic ability in the lower mediastinal and paracardial nodes than Siewert I-II AEG. However, the pathological metastasis of AEG in thoracic nodes was associated with poor survival outcomes.

Evaluating Neoadjuvant Chemotherapy for Lower Esophageal Squamous Cell Carcinoma by Measuring Esophageal Wall Thickness.

The aim of this study was to evaluate the efficacy of preoperative chemotherapy for stage II-III esophageal squamous cell carcinoma based on an objective computed tomography method. A total of 82 patients who underwent preoperative chemotherapy followed by surgery for advanced esophageal squamous cell carcinoma from January 2006 to June 2019 were included. Treatment effect was evaluated by measuring the esophageal wall thickness before and after neoadjuvant chemotherapy using contrast-enhanced thoracoabdominal computed tomography. The percentage decrease in esophageal wall thickness was calculated using the following formula: reduction (%)=(wall thickness before preoperative chemotherapy - wall thickness after preoperative chemotherapy)/(wall thickness before preoperative chemotherapy)×100. We demonstrated the efficacy of this measurement method and then analyzed which patient factors might affect the treatment effect. Receiver operating characteristic analysis showed the percentage tumor reduction to be a good predictor of histological therapeutic effect (grade ≥2) (area under the curve=0.727). In the multivariate analysis, tumor location (lower versus upper esophagus) was identified as an independent factor associated with tumor reduction (odds ratio=0.15; 95% confidence interval=0.03-0.79; p=0.025). We demonstrated an association between the reduction of esophageal wall thickness in the tumoral area and the histological therapeutic effect of chemotherapy. Secondary analysis showed poorer tumor reduction in patients with lower esophageal cancer than in those with upper esophageal cancer.

362. CLINICAL VALUE AND EFFICACY INDEX OF LYMPHADENECTOMY FOR THORACIC ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Esophageal squamous cell carcinoma (ESCC) has high mortality in China. The cornerstone of treatment for resectable esophageal cancer is still surgery. It is vital to find the regularity of lymph node metastasis and the value of dissection for thoracic ESCC in China, to provide a basis for accurate staging and the relationship between overall survival (OS) and lymph node dissection. Cases were collected from 2957 patients in Sichuan Cancer Hospital &amp; Institute Esophageal Cancer Case Management Database (SCH-ECCM Database) from January 2010 to August 2017. The stations of lymph node were referenced according to CSCO diagnosis and treatment guidelines and JES, 11th Ed. According to the frequency and patient’s survival of metastases to each station of investigated tumor location were used to calculate the Efficacy Index (EI). EI was calculated by multiplying the frequency (%) and 5-year survival rate of metastases (%) in patients, and then dividing by the number of 100. The median follow-up time was 59.5 months. The EI was high in supraclavicular and mediastinal zones in patients with upper esophageal tumors, and the EI of 106recR was 13.72, which was the highest among lymph node stations. The EI was high in mediastinal zone followed by celiac and supraclavicular zones in patients with middle esophageal tumors, 104R with EI of 15.54 was the highest among lymph node stations. As for patients with lower esophageal tumors, the EI was high in celiac zone followed by mediastinal zones, the EI of left gastric artery was 10.86, over every lymph node stations. The EI of right recurrent nerve lymph nodes is the highest in upper esophageal cancer, as for middle esophageal cancer right supraclavicular lymph nodes had high metastasis rate and EI, but the left gastric lymph nodes had high metastasis rate and EI in the lower esophageal cancer. Although the lymph node metastasis rate of ESCC is still high, the more efficient lymphadenectomy should be considered based on further studies.

562. PROGNOSTIC IMPACT OF CLINICOPATHOLOGICAL FEATURES FOLLOWING METASTECTOMY FOR METACHRONOUS PULMONARY METASTASIS FROM ESOPHAGEAL CANCER: A SYSTEMATIC REVIEW AND META-ANALYSIS

Abstract Disease recurrence following treatment for esophageal cancer (EC) remains common despite incremental gains from receipt of neoadjuvant chemotherapy. The lung is a common site of distant metastasis following definitive EC treatment. Clinicopathological features of the primary EC tumour have implications on the development of metastatic disease and overall survival. This systematic review sought to identify the prognostic impact of clinicopathological features of the primary esophageal tumour following treatment of metachronous pulmonary metastasis from EC. A search of the major reference databases (PubMed, Medline, Cochrane) was performed with no time limits up to March 2022. Results were screened in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies reporting on the clinical and pathological features of the primary EC tumour among patients undergoing treatment for metachronous pulmonary metastasis were included. A random effects meta-analysis model was used to compare the impact of gender (male vs female), primary EC pathological T-stage (pT1/2 vs pT3/4) and pathological N-stage (N0 vs N1+), on 5-year survival following pulmonary metastectomy. Seven non-randomised studies comprising 110 patients undergoing pulmonary metastectomy for metastatic EC were included. Gender did not have an impact upon 5-year survival (Risk Ratio (RR) =0.65; 95% confidence interval (CI):0.37-1.15; p=0.14). A lower primary EC T-stage (T1/2) was associated with improved 5-year survival following pulmonary metastectomy compared to advanced T-stages (T3/4), though this did not reach statistical significance (RR= 1.76; 95% CI:0.96-3.20; p=0.07). The absence of nodal disease (N0) in the primary EC tumour did not confer a survival benefit over those patients with nodal involvement disease (N1+) proceeding to pulmonary metastectomy (RR= 1.45; 95% CI:0.86-2.46; p=0.18). Patient gender and pathological T- and n-stages of the primary tumour do not impact upon prognosis following metastectomy for metachronous pulmonary metastasis from EC. However, current evidence from smaller non-randomised studies remains weak owing to variation in the treatment of the primary EC, limiting outcome assessment.

Contribution of ZBTB20 Polymorphisms to Esophageal Cancer Risk Among the Chinese Han Population.

BackgroundZBTB20 was overexpressed in esophageal cancer (EC). The study aimed to identify genotypes of ZBTB20 polymorphisms and their correlation with EC occurrence in a Chinese Han population.MethodsFour single nucleotide polymorphisms (SNPs) in ZBTB20 were randomly selected for genotyping through Agena MassARRAY system among 525 EC patients and 522 healthy controls. Multiple genetic models were applied to assess the association of ZBTB20 polymorphisms with EC susceptibility by calculating odds ratios (ORs) with 95% confidence intervals (CIs).ResultsRs10934270 was associated with lower EC susceptibility (OR = 0.64, p = 0.004) with statistical power >90% in overall analysis. Specifically, the correlation of rs10934270 with EC susceptibility was found in subgroups including patients with esophageal squamous cell carcinoma (ESCC), males, subjects aged ≤65 years, subjects with BMI ≤ 24 kg/m2, and smokers. Rs9841504 might be a risk-increasing factor for ESCC. Moreover, rs9288999 in subjects aged ≤65 years and rs73230612 in females were related to lower EC risk.ConclusionOur research is the first to report that ZBTB20 rs10934270 is associated with reduced EC susceptibility in the Chinese Han population. These data provide a scientific basis for understanding the influence of the ZBTB20 gene on EC occurrence.

End-to-side circular stapled versus side-to-side linear stapled intrathoracic esophagogastric anastomosis following minimally invasive Ivor-Lewis esophagectomy: comparison of short-term outcomes.

The search for the optimal procedure for creation of a safe gastroesophageal intrathoracic anastomosis with a lower risk of leakage in totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is ongoing. In the present study, we compared the outcomes of end-to-side (with circular stapler [CS]) and side-to-side (with linear stapler [LS]) techniques for intrathoracic anastomosis during TMIIL performed in 2 European high-volume centers for upper gastrointestinal surgery. A propensity score method was used to compare the CS and LS groups. We retrospectively evaluated patients with lower esophageal cancer or Siewert type 1 or 2 esophagogastric junction carcinoma who underwent a planned TMIIL esophagectomy, performed from January 2017 to September 2020. The anastomosis was created by a semi-mechanical technique using a LS in one center and by a mechanical technique using a CS in the other center. General features, operative techniques, pathology data, and short-term outcomes were analyzed. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. The primary endpoint of the study was the rate of anastomotic leakage in the two groups. Secondary endpoints included rates of anastomotic stricture and overall postoperative complications. Considering the whole population, 256 patients were included; of those, 220 received the anastomosis with a circular stapler (CS group), and 36 received the anastomosis with a linear stapler (LS group). No significant differences by group in terms of sex, age, American Society of Anesthesiologists physical status classification, and type of neoplasm were showed. The rate of anastomotic leakage did not differ in the two groups (9.6% CS vs. 5.6% LS, p = 0.438), as well as the rate of anastomotic stricture in the 3-month follow-up (0.9% CS vs. 2.8% LS, p = 0.367). The rate of chyle leakage and of pulmonary, cardiac, and infective complications was not significantly different in the groups. After propensity score matching, 72 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups. The results of our study suggest that both techniques for esophagogastric anastomosis during TMIIL are feasible, safe, and effective, with comparable rates of postoperative anastomotic leakage and stricture.

Near-infrared fluorescence imaging-guided lymphatic mapping in thoracic esophageal cancer surgery

Identifying the lymphatic drainage pathway is important for accurate lymph node (LN) dissection in esophageal cancer (EC). This study aimed to assess lymphatic drainage mapping in thoracic EC using near-infrared fluorescent (NIRF) imaging with indocyanine green (ICG) and identify its feasibility for intraoperative LN drainage visualization and dissection. From November 2019 to August 2020, esophagectomy was performed using intraoperative NIRF navigation with ICG injected into the esophageal submucosa by endoscopy. All LNs were divided into four groups according to the NIRF status and presence of metastasis: NIRF+LN+, NIRF+LN-, NIRF-LN+, and NIRF-LN-. Regional LNs were detected in all 84 enrolled patients with thoracic EC. A total of 2164 LNs were removed, and the mean number of dissected LNs was 25.68 ± 12.00. NIRF+ LNs were observed in all patients and distributed at 19 LN stations, which formed lymphatic drainage maps. The top five LN stations of NIRF+ probability in upper thoracic EC were No. 7, 106ecR, 107, 1, and 106recL; in middle thoracic EC, they were No. 107, 7, 110, 1, and 105; and in lower thoracic EC, they were No. 107, 7, 110, 106recR, and 1. There were no cases of ICG-related adverse events or chylothorax. The 30-day mortality rate was 0%. Major complications included anastomotic fistula (7.14%), pneumonia (4.76%), pleural effusion (13.10%), atelectasis (3.75%), hoarseness (8.33%), and arrhythmia (4.76%). Regional LN mapping of thoracic EC was performed using ICG/NIRF imaging, which showed different preferred LN drainage stations in various anatomical locations of the thoracic esophagus. ICG/NIRF imaging is feasible for intraoperative LN drainage visualization and dissection. The clinical trial registration number is NCT04173676 ( http://www. gov/ ).

Anastomotic leakage after esophagectomy possibly caused by compression of the gastric conduit behind the sternoclavicular joint: a report of three cases

BackgroundThe narrowness of the thoracic inlet is often a problem in retrosternal reconstruction after esophagectomy. We report here three cases in which compression of the gastric conduit behind the sternoclavicular joint possibly caused anastomotic leakage.Case presentationsThe first case was a 71-year-old man who underwent subtotal esophagectomy for upper esophageal cancer followed by retrosternal reconstruction. On postoperative day 2, he developed septic shock and underwent reoperation because of a necrotic gastric conduit. The tip of the conduit above the manubrium was necrotic due to strangulation as a result of compression by the sternoclavicular joint. The second and third cases were a 50-year-old woman and a 71-year-old man who underwent subtotal esophagectomy for middle and lower esophageal cancer, respectively, followed by retrosternal reconstruction. Despite indocyanine green fluorescence imaging indicating adequate blood flow in both cases, the tip of the conduit appeared pale and congested because of compression by the sternoclavicular joint after anastomosis. Postoperatively, these two patients developed anastomotic leakage that was confirmed endoscopically on the ventral side of the gastric wall that had been pale intraoperatively.ConclusionsWhen performing reconstruction using the retrosternal route after esophagectomy, it is important to ensure that compression by the sternoclavicular joint does not have an adverse impact on blood flow at the tip of the gastric conduit.

Psychosocial risk factors associated with esophageal cancer in Chinese cohort: A systematic review and meta-analysis.

Previous studies were controversial about the role of psychosocial factors in the pathogenesis of esophageal cancer (EC). This study aimed to systematically evaluate the effect size of psychosocial risk factors for EC in Chinese cohort.A literature search was conducted in both English and Chinese databases, and odds ratios (OR) with the corresponding 95% confidence intervals (CI) were pooled using a random-effects model.28 studies were identified with a total of 6951 EC cases and 7469 controls. The meta-analysis indicated a higher risk of EC among the individuals with psychological trauma (OR: 2.36, 95% CI: 1.71–3.26), Type A behavior (OR: 1.40, 95% CI: 1.17–1.67), depression (OR: 4.00, 95% CI: 2.44–6.55), melancholy (OR: 2.06, 95% CI: 1.32–3.20), always in sulks (OR: 2.49, 95% CI: 1.21–5.12), and irritable personality (OR: 2.13, 95% CI: 1.58–2.89). A lower EC risk was found in the individuals with good interpersonal relationship (OR: 0.35, 95% CI: 0.17–0.70) and outgoing personality (OR: 0.39, 95% CI: 0.19–0.78).This meta-analysis suggested a potential association between psychosocial factors and EC risk. For the individuals with psychosocial risk factors, physicians should pay more attention to EC screening.

Minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy is a valuable approach for surgical treatment of esophageal cancer.

To compare the short-, mid-, and long-term outcomes in patients with esophageal cancer between minimally invasive esophagectomy via Sweet approach in combination with cervical mediastinoscopy (MIE-SM) and minimally invasive esophagectomy via McKeown approach (MIE-MC), and to evaluate the value of MIE-SM in the surgical treatment of esophageal cancer. A prospective, nonrandomized study was adopted. A total of 65 esophageal cancer patients after MIE-SM and MIE-MC from June 2014 to May 2016 were included. Among them, 33 patients underwent MIE-SM and 32 patients underwent MIE-MC. Short-term outcomes (including the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, postoperative hospital stay, reoperation, open surgery, number of dissected lymph nodes, and 30-day mortality), mid-term outcomes, [including Quality of Life Core Questionnaire (QLQ-C30) and the esophageal site-specific module (QLQ-OES18)], long-term outcomes [including overall survival and disease-free survival] were compared between the 2 groups. Radical resection (R0) were achieved in all patients. There were no significant differences in the duration of surgery, intraoperative blood loss volume, ICU stay time, postoperative complications, and postoperative hospital stay between the 2 groups (all P>0.05). More lymph nodes were dissected in the MIE-SM group (24.1±7.3) than those in the MIE-MC group (17.8±5.0, P<0.001). The emotional function, global health status scale scores in QLQ-C30 scale in the MIE-SM group were significantly higher than those in the MIE-MC group (P=0.025, P<0.001, respectively), and the pain score in the MIE-SM group was significantly lower than that in the MIE-MC group (P=0.013). QLQ-OES18 results showed that the pain score in the MIE-SM group was significantly lower than that in the MIE-MC group (P=0.021). Survival analysis showed that the overall survival and disease-free survival were similar between the 2 groups. MIE-SM appears to be a safe surgical approach, which may get better quality of life, suffer less pain, and can achieve the same therapeutic effect as MIE-MC. Therefore, MIE-SM should be considered as a valuable approach for the treatment of middle and lower esophageal cancer.

Covering the gastric tube with the mediastinal pleura during minimally invasive McKeown esophagectomy can reduce the incidence of anastomotic fistulae.

IntroductionThe rate of anastomotic leakage from intrathoracic esophagogastric anastomoses can be reduced by covering them with the mediastinal pleura. Whether anastomotic leakage can be reduced by covering the portion of the gastric tube in the upper mediastinum with the mediastinal pleura during minimally invasive McKeown esophagectomy (MIE McKeown) is unknown.AimTo evaluate the consequence of covering the mediastinal pleural during minimally invasive McKeown esophagectomy.Material and methodsConsecutive patients who underwent MIE McKeown between January 2015 and December 2019 were retrospectively analyzed. Participants for whom the portion of the gastric tube in the upper mediastinum was not covered with the mediastinal pleura were assigned to group A; otherwise, they were assigned to group B. Chi-square analysis and univariable and multivariable logistic analyses were used to compare the differences between the two groups and explore the risk factors for anastomotic fistulae.ResultsA total of 267 patients with middle and lower esophageal cancer were included in this study (131 in group A and 136 in group B). Anastomotic leakage occurred in 5 patients (5/136) in group B compared with 13 patients (13/131) in group A (p = 0.042). Univariable and multivariable logistic analyses identified a gastric tube not covered with the mediastinal pleura as a risk factor for significantly greater anastomotic leakage (p = 0.042), but it was not an independent prognostic factor for anastomotic leakage (odds ratio = 0.585, 95% confidence interval: lower bound: 0.069, upper bound, 1.122).ConclusionsThis study provides preliminary evidence that covering the gastric tube with the mediastinal pleura during MIE McKeown can decrease the incidence of anastomotic leakage.

OP270 Why The Haute Autorité de Santé Rejects the Widespread Use Of “Mini-Bypass”/One Anastomosis Gastric Bypass For Obesity In France

IntroductionOne anastomosis gastric bypass (OAGB) has become a widespread technique over the last few years in France, without any prior assessment and despite existing controversies among bariatric surgeons. An older bypass technique for treating obesity, the Roux-en-Y gastric bypass (RYGB), is available and reimbursed, having been assessed and approved for use in 2005. In 2019, the French Haute Autorité de Santé (HAS) assessed OAGB for the treatment of severe and massive obesity. This assessment, the first in the world, was undertaken for OAGBs carried out with a 200- or 150-centimeter biliopancreatic-limb (BP-limb) length.MethodsA systematic review (SR) of the literature and consultation of a working group consisting of both healthcare professionals (clinician and surgeons) and patients were carried out. The primary aim of our assessment was to determine whether the OAGB technique can replace RYGB. The efficacy and safety profile of OAGB was compared with RYGB in adult patients with massive, severe obesity. Complications and postoperative follow up specific to OAGB were identified.ResultsThe three selected randomized controlled trials (RCTs) could not confirm the superiority or the non-inferiority of OAGB, compared with RYGB, on the selected efficacy endpoints of weight loss, resolution of comorbidities, and quality of life. Adverse events reported for OAGB included severe nutritional complications and bile reflux that could potentially lead to lower esophageal cancer. In one RCT, the frequency of serious adverse events in the OAGB group was almost two times higher than in the RYGB group.ConclusionsHAS considered that OAGB carried out with a longer (200 centimeter) BP-limb is not a validated technique for the surgical treatment of massive, severe obesity. Thus, it cannot be considered an alternative to RYGB. There were insufficient data available on OAGB performed with a 150-centimeter BP-limb. Thus, HAS recommended undertaking a multicenter RCT to assess the efficacy and safety of OAGB. Patients who have already undergone OAGB should receive the same follow up as patients who have received RYGB, including close monitoring for nutritional complications and lower esophageal cancer and an endoscopic examination five years after surgery.