Minimally Invasive Esophagectomy Research Articles

Relationship between the severity of emphysematous change in the lung and morbidity after esophagectomy for esophageal cancer: A retrospective study on a novel strategy for risk prediction.

Chronic obstructive pulmonary disease (COPD) prevalence increases post-esophagectomy morbidity. However, the association between COPD severity and post-esophagectomy morbidity remains unclear because of the lack of an objective method to classify COPD severity. Low attenuation volume ratio (LAVR) estimated using Ziostation2 may reflect the extent of emphysematous changes in the lungs and COPD severity, thereby predicting post-esophagectomy morbidity. A total of 776 patients who underwent curative McKeown esophagectomy for esophageal cancer between April 2005 and June 2021 were included. The patients were divided into high and low preoperative LAVR groups. Short-term outcomes between the groups were compared for patients who underwent open esophagectomy (OE) and minimally invasive esophagectomy (MIE). A total of 219 (28%) patients were classified into the high LAVR group. High LAVR was significantly associated with disadvantageous patient characteristics such as advanced age, heavy smoking, and impaired respiratory function. Patients with high LAVR had a significantly higher incidence of severe morbidity and pneumonia after OE. High LAVR was an independent risk factor for severe morbidity (odds ratio [OR], 2.52; 95% confidence interval [CI]: 1.237-5.143; p = 0.011) and pneumonia (OR, 2.12; 95% CI: 1.003-4.493; p = 0.049) after OE. Meanwhile, LAVR was not correlated with the incidence of post-MIE morbidity. LAVR may reflect COPD severity and predict severe morbidity and pneumonia after OE, but not after MIE. Less invasiveness of MIE may alleviate the effects of various disadvantageous backgrounds associated with high LAVR on worse short-term outcomes.

Impact of perioperative decreased serum albumin level on anastomotic leakage in esophageal squamous cell carcinoma patients treated with neoadjuvant chemotherapy followed by minimally invasive esophagectomy

BackgroundAnastomotic leakage (AL) is a severe complication following esophagectomy with high mortality. Perioperative decreased serum albumin level is considered a predictive of AL, however, its impact on AL incidence in patients treated with neoadjuvant chemotherapy (NCT) followed by minimally invasive esophagectomy (MIE) is not well defined.MethodsThe data of 318 consecutive esophageal cancer patients who underwent MIE were collected retrospectively from January 2021 to December 2021. The perioperative level of albumin was detected and the baseline of altering levels for albumin was established. The incidence of postoperative complications and survival rate were analyzed between groups.ResultsAfter exclusion, 137 patients were enrolled and assigned to more decreased albumin (MA) and less decreased albumin (LA) groups. The levels of albumin descended significantly after MIE (p < 0.0001). There was no significant difference in the clinicopathologic characteristics or surgical outcomes between groups. The incidence of postoperative AL was 10.2% in MA group and 1.4% in LA group (p = 0.033). Three patients died due to AL in MA group, while no mortality was observed in LA group (p = 0.120). The rate of other postoperative complications was similar between groups. Progression-free survival (PFS) in LA group was a little higher than that in MA group, but it was no significant difference (p = 0.853). Similarly, no difference was observed in overall survival (OS) between groups (p = 0.277).ConclusionsSeverely deficient serum albumin after MIE was an indicator of AL in esophageal cancer patients treated with NCT.Trial registrationChinese clinical trial registry: ChiCTR2200066694, registered December14th,2022. https://www.chictr.org.cn/edit.aspx?pid=185067&htm=4.

The impact of hospital experience in bariatric surgery on short-term outcomes after minimally invasive esophagectomy: a nationwide analysis.

Minimally invasive esophagectomy (MIE) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIE. Data on esophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case mix. Of 3371 patients undergoing esophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIE. Bariatric hospitals (N = 6) accounted for 1057 (43.1%) MIE. Annual volume of bariatric procedures was median 523 and esophagectomies 42. In non-bariatric hospitals, volume of esophagectomies was median 52 (P = 0.145). Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P < 0.001). Bariatric hospitals were associated with a reduced risk of overall complications (aOR 0.76 [95% CI 0.62-0.92]), length of hospital (aOR 0.79 [95% CI 0.65-0.95]), and ICU stay (aOR 0.81 [95% CI 0.67-0.98]) after MIE. Surgical radicality (R0) did not differ. Lymph node yield (≥ 15) was lower in bariatric hospitals (90.0% vs. 94.7%, P < 0.001). Over the years, several short-term outcomes improved in bariatric hospitals compared to non-bariatric hospitals. In this nationwide analysis, there was an association between bariatric hospitals and improved short-term outcomes after MIE. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify.

Short-Term Outcomes and Quality of Life Following Minimally Invasive Esophagectomy in a Tertiary Care Center in Southern India.

With the advent of multimodality therapy and minimally invasive surgical approaches, patients suffering from carcinoma esophagus are showing promising outcomes. Hence, the frontier needs to be widened to assess the postoperative quality of life (QoL) of those surviving carcinoma esophagus. The objective of the study was to determine the short-term outcomes of minimally invasive esophagectomy (MIE) /hybrid esophagectomies in carcinoma esophagus and the organ-specific QoL in survivors of MIE for carcinoma esophagus, and to compare health-related QoL in patients following MIE for carcinoma esophagus with the general population. A longitudinal study design was used to evaluate the short-term postoperative outcomes of patients undergoing MIE for carcinoma esophagus between July 1, 2021, to July 15, 2022, and analyze the QoL of those patients who survived at one year without tumor recurrence. QoL was assessed using the European Organization for the Research and Treatment of Cancer (EORTC) QoL Questionnaire (EORTC QLQ-C30) and the EORTC QoL Questionnaire - Oesophageal Cancer Module (EORTC QLQ-OES18). A total of 15 patients who underwent minimal invasive/hybrid esophagectomy for esophageal carcinomawere included. Of these, 13 patients underwent hybrid esophagectomy while two patients underwent thoraco-laparoscopic esophagectomy. Squamous cell carcinoma was observed as the most common histological variant (60%) while 33% were adenocarcinoma and 6.7% lymphoma. The most common site of the tumor was the lower one-third esophagus (60%). Nine out of 15 patients developed postoperative complications needing prolonged ICU stay. One major anastomotic leak as well as one conduit necrosis was observed among 15 cases operated. Median length of hospital stay was 16 (IQR 12-24). QoL was assessed among 12 patients at the one-year follow-up excluding mortality cases and patients with tumor recurrence. The patients following MIE for carcinoma esophagus were observed to have low scores in physical functioning, role functioning, and social functionwhen compared with the general population. Cognitive functioning and emotional function were not found to be significantly different. No statistically significant difference was observed in the global health status among the two groups. There was no significant difference found in the general symptoms score comparison of the MIE patients with the general population. When it comes to organ-specific symptom scales, reflux was observed as a major issue among the patients who survived carcinoma esophagus after undergoing MIE. Dysphagia and dry mouth received low scores suggestive of minor issues. Though analysis of global health QoL scores of those with postoperative complications and those who had uneventful recovery at one year revealed a higher score for the latter, it was not statistically significant. Postoperative complications can prolong hospital stay, delay resuming normal work, and affect the global QoL of patients compared with those who recovered uneventfully. Physical and role functions were observed to be deficient among survived patients when compared with the normal population. Nutritional prehabilitation, cutting-edge surgical practice including minimally invasive techniques, minimizing deviation from normal postoperative recovery by high-quality ICU care, and postoperative rehabilitation are the cornerstones to ensure better QoL.

OGC P68 Surgical performance of Minimally Invasive Esophagectomy is associated with patient outcome on a national level - A video assessment study

Abstract Background It is highly likely that suboptimal surgical performance is associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association can lead to programs that promote better surgical performance of MIE and improve patient outcomes. Methods In this nationwide cohort study, 7 blinded expert MIE surgeons assessed performance of surgical videos of MIE performed in 2022, using a previously developed and validated competency assessment tool (CAT), the MIE-CAT. Hospitals were divided into quartiles based on their MIE-CAT score. Patient outcomes of 2021-2022 registered in the Dutch Upper-GI Clinical Audit were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Multilevel logistic regression, with clustering of patients within hospitals was used to analyze associations between performance and outcomes, and to correct for casemix. Primary outcome parameter was severe postoperative complications (Clavien-Dindo≥3) within 30 days after surgery. Results MIE-CAT scores ranged from range 93.9-118.8. In total, 970 patients were included. Severe postoperative complications occurred in 18.7% (n=41/219) in the highest performing quartile versus 39.2% (n=40/102) in the lowest performing quartile (RR=0.50, 95%CI 0.24-0.99). Moreover, there were less conversions (1.8% versus 8.9%, RR=0.21, 95%CI 0.21-0.21), less peroperative complications (2.7% versus 7.8%, RR=0.21, 95%CI 0.04-0.94) and overall less postoperative complications (46.1% versus 65.7%, RR=0.54, 95%CI 0.24-0.96). Oncological outcomes R0 resection and lymph node yield increased with oncologic specific-performance scores (e.g. hiatus dissection/thoracic esophagus dissection and abdominal/thoracic lymph node dissection respectively). ). A strong association between high anastomotic-phase score and a lower anastomotic leakage rate was observed (4.6% versus 17.7%, RR=0.14, 95%CI 0.06-0.31). Conclusions Better surgical performance was associated with decreased perioperative complications and better oncological outcome for esophageal cancer patients undergoing MIE. If surgical performance of MIE can be improved, significantly better patient outcomes may be possible.

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&amp;lt;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&amp;lt;0.001) and patients undergoing MIO achieved the maximum MMS score earlier than those undergoing thoracotomy (P&amp;lt;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.

OGC P23 Modified Frailty Index is not a good predictive tool of postoperative mortality following minimally invasive oesophagectomy

Abstract Background Evaluating frailty in the elderly population is crucial in preoperative assessment to identify high-risk patients. The modified frailty index (m-FI) is known to predict postoperative mortality in various surgical populations, but its predictive value in oesophagectomy patients' long-term mortality is unclear. No studies have specifically quantified frailty and its association with long-term postoperative mortality in oesophagectomy patients. This study investigates the association between m-FI score and long-term mortality in patients undergoing minimally invasive oesophagectomy (MIO). Methods The m-FI is a scoring tool of 11 parameters quantifies frailty in surgical patients. Retrospective analysis (1/1/2014-31/12/2023) of patients aged ≥75 years undergoing minimally invasive oesophagectomy procedures for cancer, at a single h[ka1] igh volume tertiary referral centre was carried out. Primary outcome was defined as 1-year all-cause mortality with overall length of survival as the secondary outcome. After sensitivity analyses m-fi score of less than 1 or greater than 2 were most predictive of mortality. Results Ninety-one patients (mean age 78 years, age range 75-88, male to female ratio of 4:1) were included, with a median m-FI score of 1 (range: 0-5). Patients with an m-FI score of ≥2 had a higher 1-year mortality rate (30% vs. 19%, p=0.195) and shorter overall median survival time (34 months vs. 47 months, p=0.399) compared to those with a score of ≤1. After adjusting for covariates, including preoperative chemotherapy, age, sex, and cancer staging, an m-FI score of ≥2 had a hazard ratio of 1.65 (95% CI: 0.68 to 3.98, p=0.267) for 1-year mortality compared to ≤1. Conclusions The m-FI tool can predict post operative mortality in a range of surgical specialities. The results of our study would suggest that higher m-FI score would correlate with worse long term mortality outcomes, however at this stage the m-FI tool cannot be applied in a clinical setting to accurately define elderly patient's probable outcome following MIO. Additional multicentre data is needed to establish its true predictive value in this patient cohort.

Major Intraoperative Complications During Minimally Invasive Esophagectomy

BackgroundStudies have shown minimally invasive esophagectomy (MIE) to be a feasible surgical technique in treating esophageal carcinoma. Postoperative complications have been extensively reviewed, but literature focusing on intraoperative complications is limited. The main objective of this study was to report major intraoperative complications and 90-day mortality during MIE for cancer.MethodsData were collected retrospectively from 10 European esophageal surgery centers. All intention-to-treat, minimally invasive laparoscopic/thoracoscopic esophagectomies with gastric conduit reconstruction for esophageal and GE junction cancers operated on between 2003 and 2019 were reviewed. Major intraoperative complications were defined as loss of conduit, erroneous transection of vascular structures, significant injury to other organs including bowel, heart, liver or lung, splenectomy, or other major complications including intubation injuries, arrhythmia, pulmonary embolism, and myocardial infarction.ResultsAmongst 2862 MIE cases we identified 98 patients with 101 intraoperative complications. Vascular injuries were the most prevalent, 41 during laparoscopy and 19 during thoracoscopy, with injuries to 18 different vessels. There were 24 splenic vascular or capsular injuries, 11 requiring splenectomies. Four losses of conduit due to gastroepiploic artery injury and six bowel injuries were reported. Eight tracheobronchial lesions needed repair, and 11 patients had significant lung parenchyma injuries. There were 2 on-table deaths. Ninety-day mortality was 9.2%.ConclusionsThis study offers an overview of the range of different intraoperative complications during minimally invasive esophagectomy. Mortality, especially from intrathoracic vascular injuries, appears significant.

Implementing the first program of minimally invasive esophagectomy for cancer in Israel: shifting the paradigm in a high-volume center - a cohort study.

Esophagectomy is associated with significant perioperative morbidity. Limited data are available on the process of implementation of minimally invasive techniques in esophagectomy and related outcomes. The authors sought to describe implementation processes and outcomes following the implementation of the first minimally invasive esophagectomy (MIE) program at a high-volume center in Israel under the mentorship of American early adopters. Patients who underwent esophagectomy for esophageal carcinoma 2011-2022 were included. Early and late cohorts were created for learning curve analysis. Secondary analysis included patients who underwent open esophagectomy 1997-2011. Overall, 300 patients underwent MIE: three-field MIE (3F-MIE) was performed in 242 (80.7%) patients, two-field MIE (2F-MIE) in 58 (19.3%) patients. Following program implementation in 2012, the number of MIE performed increased during the first 3 years ( n =33, 86.8% in 2015). Among 3F-MIE patients, a higher number of retrieved lymph nodes was reported during later cases (median, IQR1-3 17, 12-23 vs. 12, 8-12, P <0.001) while surgeries required a longer time (median, IQR1-3 300min, 261-355 vs. 262.5, 239-300, P <0.001). Among 2F-MIE patients, the late cohort had lower rates of prolonged ICU admissions than earlier counterparts ( n =2, 6.9% vs. n =9, 31%, P =0.041), overall and severe 30-day complications ( n =12, 41.4% vs. n =23, 79.3%, P <0.001 and n =7, 24.1% vs. n =23, 79.3%, P =0.003). MIE was safely implemented. Nodal yield was higher among MIE patients than open esophagectomy. During the study years, open approach was gradually abandoned in favor of 3F-MIE procedures, while 2F-MIE increased over the course of the last years.

219. ASSOCIATION BETWEEN VIDEO-BASED SURGICAL PERFORMANCE AND PATIENT OUTCOMES IN MINIMALLY INVASIVE ESOPHAGECTOMY IN THE NETHERLANDS

Abstract Background Increasing evidence shows substantial variation in surgical performance measured by a (video-based) competency assessment tool (CAT). Moreover, suboptimal surgical performance has been associated with less favorable patient outcomes in complex minimal invasive procedures. It is likely this also applies for minimally invasive esophagectomy (MIE). In a previous study a CAT for MIE (MIE-CAT) was developed and validated. The present study investigated the association between surgical performance and postoperative outcomes of MIE in the Netherlands. Methods A nationwide observational video analysis study was performed. All fifteen Dutch hospitals performing MIE voluntarily submitted all patient outcomes from the 2020–2021 Dutch Upper-GI Clinical Audit registry, and two representative surgical videos from 2022. Surgical performance was assessed by 7 blinded and independent expert MIE surgeons with the MIE-CAT. Hospitals were divided into quartiles based on their performance score. Multilevel logistic regression, with clustering of patients within hospitals, was used to study associations between surgical performance and patient outcomes. Primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Results Highest- (mean MIE-CAT 113.6, SD 5.5, n = 3) versus lowest-performance-quartile (mean 94.1, SD 5.9, n = 3) had more MIE experience (Pearson’s r = 0.74, 95%CI 0.32–0.92), larger volumes (Pearson’s r = 0.46, 95%CI -0.13-0.81) and favorable outcomes (Figure 1). Performance of highest- versus lowest-quartile was statically significantly associated with less complications (severe postoperative (RR, converted from OR, = 0.50, 95%CI 0.24–0.99), peroperative (RR = 0.21, 95%CI 0.04–0.94) and any postoperative (RR = 0.54, 95%CI 0.24–0.96)), less conversions (RR = 0.21, 95%CI 0.21–0.21) and a 11.5% absolute chance reduction of severe postoperative complications for an average patient. Increased anastomotic-phase performance was associated with less anastomotic leakage (RR = 0.14, 95%CI 0.06–0.31). Conclusion This Dutch nationwide study showed statistically significant and clinically relevant associations between surgical performance and outcomes of patients undergoing MIE. An average patient has a 11.5% absolute chance reduction of a severe postoperative complication when operated in a highest-performance quartile hospital, compared to a lowest-performance quartile hospital. These findings show that good surgical performance is an essential aspect for good clinical outcomes.

148. COMPARISON OF EARLY POSTOPERATIVE OUTCOME BETWEEN OPEN AND MINIMALLY INVASIVE TRANSTHORACIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A RETROSPECTIVE STUDY

Abstract Background Esophagectomy is a highly invasive surgical procedure for esophageal cancer, with open thoracotomy associated with a significant risk of pulmonary complications. Minimally invasive techniques, such as minimally invasive esophagectomy (MIE), are expected to reduce these complications and enhance postoperative recovery. This study aimed to compare the early postoperative outcomes of patients who underwent open esophagectomy versus MIE. Methods We conducted a retrospective study using a single-center database from January 1, 2010, to February 28, 2023, including patients aged 18–90 years with a resectable lesion of the esophagus or esophagogastric junction who underwent either open transthoracic esophagectomy or MIE (thoracoscopic/robotic-assisted). Patient data, surgical procedures, interventions, and early outcomes (within 30 days of operation) were collected and analyzed. The study included a total of 76 patients, with 50 patients in open esophagectomy group and 26 patients in MIE group. The primary outcome was the incidence of pulmonary complications during the hospital stay, and logistic regression was used for data analysis. Results The overall incidence of pulmonary complications was 37 cases (74%) in the open esophagectomy group and 14 cases (53.8%) in the MIE group, with the incidence of pulmonary infection occurring in 19 cases (38%) and 8 cases (30.8%), respectively. Perioperative mortality was 1 cases (2%) in the open esophagectomy group and 0 cases (0%) in the MIE group. After adjusting for age, sex, BMI, smoking, COPD, and operative time, the open esophagectomy group had a 4.29 times higher risk of pulmonary complications than the MIE group (odds ratio 4.29, 95% confidence interval 1.30–14.16; p = 0.017). Conclusion Our study demonstrates that MIE is associated with a lower incidence of pulmonary complications, reduced blood loss, and shorter ICU stays compared to open esophagectomy. Rates of anastomosis leakage, vocal cord paralysis, and hospital stays were comparable. These findings support the feasibility and safety of MIE, potentially improving surgical outcomes and enhancing postoperative recovery for the treatment of esophageal cancer.

330. PRE-EMPTIVE ENDOLUMINAL VACUUM THERAPY WITH A SURGICAL DRAIN FOR REDUCTION OF ANASTOMOTIC LEAK RATE FOLLOWING MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Background Endoluminal vacuum therapy (EVT) is an effective treatment for anastomotic leak (AL) following esophagectomy. A novel application of EVT is to utilise its effect to improve microcirculation and granulation at the anastomosis pre-emptively to reduce the risk of AL. We describe a unique method of positioning a fenestrated surgical drain with applied vacuum suction at the level of the anastomosis following minimally invasive esophagectomy (MIE), with the aim of reducing AL rate and postoperative morbidity. Methods A retrospective cohort comparison was performed on consecutive MIEs from 2019 to 2023. All operations were performed by experienced esophagogastric surgeons at a tertiary centre in the UK. Included patients were all adults undergoing MIE for esophageal cancer. Patients who underwent pre-emptive EVT (pEVT) with surgical drain following MIE were compared with a control group who underwent MIE alone. All patients followed the same enhanced recovery protocol with pEVT removed two to five days post-operatively. The primary outcome assessed was AL, secondary outcomes included: length of stay (LOS), readmission to Intensive care, complications (Clavien-Dindo) and 90-day mortality with minimum 90-days follow-up. Results 72 patients were included, 25 patients underwent MIE with pEVT compared with 47 in the control. The AL rate in the pEVT group was 8% compared with 21.3% in the control (RRR 62%, p = 0.13). All ALs following pEVT were managed successfully with EVT alone. There was a reduced risk of aspiration pneumonia (RR:0.37, p = 0.22) and readmission to ICU (RR:0.24, p = 0.049) following pEVT. There was 0%, 90-day mortality in both groups and no significant difference in median LOS (7 vs 9 days, p = 0.72 (pEVT vs Control)). However, a higher risk of stricturing following pEVT was noted (RR:3.76, p = 0.04). Conclusion Our data suggests pEVT with a surgical drain may be a safe and effective method of reducing AL rate following MIE. Additionally, it confers the benefit of being an effective treatment for AL should this complication arise. There was significant increase in benign stricturing requiring dilatation following pEVT, however, this may be attributable to other operative factors. Our results support the need for further prospective studies such as a randomised controlled trial.

231. ROBOT-ASSISTED TRANSMEDIASTINAL (TRANSCERVICAL &amp; TRANSHIATAL) ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background Esophagectomy is still main treatment mode for esophageal cancer, though it is known to be associated with severe surgical invasiveness resulting in high morbidity and mortality. Minimally invasive esophagectomy (MIE), which consisted of thoracoscopic and/or laparoscopic procedure, has been widely performed to diminish those disadvantages of open procedure. Recent reports, however, show insufficient effects of the conventional MIE. Therefore, additional improvements are needed to overcome those problems. Methods We developed the robot-assisted transmediastinal esophagectomy (RATME) in 2012 to prevent the postoperative complications. It is the combination of transcervical and transhiatal approach without one lung ventilation anesthesia and body change during surgery. Upper mediastinal lymphadenectomy along left recurrent laryngeal nerve (RLN) is perfomed by transcervical mediastinoscopic procedure under pneumo-mediastinum. Laparoscopic abdominal LN dissection is performed in parallel with the cervical procedure. Remnant lower and middle LN dissections, including subcarinal and main bronchus, are done using robotic procedure in which robotic arms are inserted through hiatus from abdomen. Finally, bilateral pleura can be preserved. Results To date, 275 RATMEs have been performed. Among them, post-operative pneumonia occurred in 33 cases (12%), and mortality is zero. Oncological outcomes, e.g., the numbers of harvested LNs, post-operative QOL, e.g., post-operative pulmonary function, were observed and reported to be better in RATME group as compared to open esophagectomy group. Survival after surgery is, also, not at all inferior. Conclusion RATME is a promising minimally invasive technique, overcoming the disadvantages of conventional procedures. For the patients with previous thoracic surgery, and/or impaired respiratory function who are unable to undergo transthoracic esophagectomy, RATME can offer a valuable alternative surgery as a radical treatment.

204. CORRELATION OF CIRCULATING T LYMPHOCYTES WITH RESPONSE TO NEOADJUVANT CHEMOIMMUNOTHERAPY IN OPERABLE ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Abstract Background There is growing evidence indicating that neoadjuvant chemotherapy combined immune-oncology therapy (neoCTIO) with anti-PD-1 antibodies is effective in esophageal squamous cell carcinoma (ESCC). However, the precise benefits remain unclear. This study aimed to explore whether the subsets and production of effector cytokines in circulating T lymphocytes were correlated with response to neoCTIO with toripalimab in operable ESCC. Methods ESCC patients staged cT2N1–2 M0 or cT3–4aN0-2 M0, with ECOG PS 0–1 status randomly received two cycles of different sequences of toripalimab plus chemotherapy (paclitaxel and carboplatin) on day 1 to 2 of each 21-day cycle. Minimally invasive esophagectomy (MIE) was performed 4–8 weeks after neoCTIO. Peripheral blood was collected before and after neoCTIO. Flow cytometry was used to detect the effector cytokines and subsets of CD8+ and CD4+ T lymphocytes. The primary endpoints were the advanced change of subsets, effector cytokines in T lymphocytes, and pathological complete response (pCR). The secondary endpoints included major pathological response (MPR) (NCT05044728). Results 96.7% (32/33) patients received MIE with R0 resection. 18.8% (6/32) patients achieved pCR and 31.3% (10/32) patients achieved MPR. In the responders, CD8+ T lymphocytes showed higher IFNγ and TNFα coexpression compared to non-responders before neoCTIO (P = 0.010). The responders had higher frequency of effector subsets (P = 0.029) and lower naive subsets (P = 0.006) of CD8+ T lymphocytes than the non-responders before neoCTIO. No difference was found in the cell frequency of CD4+ T lymphocyte subsets between the responders and non-responders. There was no correlation between the change of subsets, effector cytokines in T lymphocytes and the sequence of neoCTIO. Conclusion NeoCTIO with toripalimab is effective in the treatment of ESCC. The baseline frequency of effector subsets and coexpression of IFNγ and TNFα in circulating CD8+ T lymphocytes have positive predictive value while the baseline frequency of Naive subsets is a negative biomarker. CD4+ T cell subsets have no correlation with the treatment response. The change of circulating CD8+ T lymphocytes is not affected by the sequence of neoCTIO.

41. HIGH COMPREHENSIVE COMPLICATION INDEX AFTER MINIMALLY INVASIVE ESOPHAGECTOMY ASSOCIATED WITH POOR SHORT-TERM AND LONG-TERM OUTCOME: A PROPENSITY SCORE MATCHING ANALYSIS

Abstract Introduction The comprehensive complication index (CCI) is a new index to comprehensively and systematically evaluate complication severity. The objective of this study was to evaluate the predictive ability of CCI on short—and long-term overall survival(OS) in patients with esophageal squamous cell carcinoma (ESCC) undergoing minimally invasive esophagectomy (MIE) based on a propensity Score Matching (PSM) analysis. Methods A total of 356 patients treated with radical MIE from 2013 to 2017 were included, and the primary outcome was OS, and the secondary outcomes were postoperative hospital stay and hospital costs. Firstly, the optimla cut-off value of CCI was determined by X-tile. PSM was used to balance the baseline characteristics. Second, we compared postoperative hospital stay and hospital costs between high- and low-CCI group. Third, the Kaplan–Meier survival curve was used to analyze survival difference. Fourth, univariate and multivariate Cox analysis was used to explore the independent risk factors of OS. Results The CCI &amp;gt; 24.2 was defined as high-CCI group and CCI≦24.2 was defined as low-CCI group. The high-CCI group had more hospital costs and longer hospital stay than the low-CCI group both before and after PSM (p &amp;lt; 0.001). The K-M analysis indicated that patients with high CCI had worse prognosis both before and after PSM (before matching: P &amp;lt; 0.001; after matching: P = 0.04). CCI was determined as independent prognostic factor both before and after PSM (before PSM, P = 0.002; after PSM, P = 0.025). Conclusion The CCI could quantify postoperative complications after esophagectomy. High CCI is associated with longer hospital stay and hospitalization costs, and is an independent risk factor for poor OS.

345. ADJUVANT IMMUNOTHERAPY IN CURATIVE INTENT ESOPHAGEAL CANCER RESECTION PATIENTS

Abstract Background Despite ongoing therapeutic innovations, esophageal cancer remains a disease with one of the poorest survival rates with an overall 5 year survival of 20%. Recent clinical trials have demonstrated the role of adjuvant immunotherapy to improve patient survival. However, these therapies are often not completed in their entirety due to side effects or disease progression. We report our real world experience with immunotherapy and esophageal cancer within an integrated health care system. Methods All adult patients undergoing minimally invasive esophagectomy (MIE) in our large integrated health care system between September 1, 2017 and November 15, 2021 were reviewed. Patients with multiple cancers were excluded for a final patient cohort of 37 patients who received immunotherapy and 139 who did not. Patients who received immunotherapy were reviewed for the number of doses they received, if they were able to complete therapy, side effects, and disease progression. Baseline characteristics and outcomes, including 90 day and 1 year mortality, were compared between the two patient groups. Logistic regression was performed to identify factors that impacted survival. Results Of 37 patients who received immunotherapy, 17 received nivolumab, 17 received pembrolizumab, 11 received trastuzumab, 2 received ipilimumab, and 9 received combination. Only 5 patients successfully completed therapy. Therapy was terminated in 7 patients due to side effects, most commonly colitis. Furthermore, 18 patients stopped therapy due to disease progression, and 4 patients expired during treatment. There were no significant differences in 90 day or 1 year mortality between patients who received immunotherapy and those who did not. At a maximum of three year follow up, patients with late stage disease who received immunotherapy had a significantly worse survival. Conclusion Immunotherapy has been shown to have a promising impact on patient survival in esophageal cancer. However, outside of a clinical trial, there are numerous barriers to successful treatment in a real-world setting. At our regionalized center of excellence, we found that most patients are unable to complete immunotherapy treatment due to disease progression or side effects, and immunotherapy did not improve survival. Further work is required to tailor immunotherapy delivery to diverse patient populations.

281. TOTAL LAPAROSCOPIC VERSUS OPEN GASTRIC PULL-UP FOLLOWING MINIMALLY INVASIVE THORACOSCOPIC ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Backgroud The use of minimally invasive esophagectomy (MIE) as a treatment for patients with esophageal cancer has recently become more common worldwide. However, the laparoscopic approach for reconstruction and abdominal lymph node dissection has not fully investigated. The aim of the present study was to evaluate the technical feasibility of alimentary tract reconstruction with laparoscopically assisted gastric pull-up compared with open laparotomy gastric pull-up following minimally invasive thoracoscopic esophagectomy. Methods 63 esophageal cancer patients who underwent minimally invasive thoracoscopic esophagectomy between 2011 and 2020 were included in the present study. For reconstruction, 25 patients underwent open laparotomy gastric pull-up (OLG) while 38 patients underwent laparoscopically assisted gastric pull-up (LAG). We compared the outcomes between the two groups. Results No significant difference was observed in physical and tumor status between the two groups. The mean operative time was significantly longer in LAG group (549 vs 621 min, p = 0.010) and blood loss was significantly lower in LAG (561 vs 134 mL, p &amp;lt; 0.001). The mean number of harvested lymph nodes (47.2 vs 46.2, p = 0.840) were similar. The postoperative course showed lower incidences of overall complications (64% vs 32%, p = 0.011). No difference was observed in each complication between the two groups. Conclusions The findings suggest that laparoscopically assisted gastric pull-up is feasible and more effective in preventing postoperative complications.

Advantages of Totally Stapled Collard Over Circular Stapled Technique for Cervical Esophagectomy Anastomosis

BackgroundThe quality of life between the totally stapled Collard (TSC) and circular stapled (CS) techniques from the patient’s perspective has not been assessed. This longitudinal patient-reported outcome and objective data assessment study aimed to compare the effects of TSC vs CS for cervical anastomosis with minimally invasive esophagectomy (MIE) on the quality of life. MethodsThis single-center, retrospective study included patients with esophageal cancer who underwent MIE and cervical anastomosis between April 2019 and February 2021; of whom, 105 and 216 patients received TSC and CS anastomosis, respectively. The objective metrics were evaluated based on postoperative complications. Patient-reported outcomes instruments using the European Organization for Research and Treatment of Cancer modules were assessed preoperatively. The Quality of Life Questionnaire (QLQ) Core 30 and the QLQ-Oesophagus Module 18 assessed the quality of life. Mixed-effects models examined changes in questionnaire scores. ResultsThe stenosis rate in the TSC group was significantly lower than that in the CS group. There were no significant differences in other postoperative complications between the groups. In the QLQ Core 30 scale, the TSC group had better emotional function, less fatigue, less appetite loss, and better function than the CS group, with significant differences in different time points between the groups. QLQ-Oesophagus Module 18 revealed that the TSC group had significantly less appetite loss, dysphagia, dry mouth, pain, and obstruction, and better eating and speech than the CS group. ConclusionsTSC has significant advantages over the CS technique in lowering postoperative symptom burden and improving quality of life for cervical anastomosis on patient-reported outcomes.

Impact of minimally invasive total mesoesophageal excision and minimally invasive esophagectomy on failure patterns of locally advanced esophageal squamous cell carcinoma: a matched cohort study with long-term follow-up.

The effects of minimally invasive total mesoesophageal excision (MITME) on the long-term prognosis of locally advanced esophageal squamous cell carcinoma (ESCC) remain unknown. The objective of this study was to compare the static and dynamic failure patterns of MITME and minimally invasive esophagectomy (MIE) for locally advanced ESCC. We use propensity score matching (PSM) method to analyze the postoperative failure patterns of the two groups. Cumulative event curves were analyzed for cumulative incidence of failure between different groups, and independent prognostic factors were assessed using time-dependent multivariate analyses. The risk of dynamic failure calculated at 12-month intervals was compared between the two groups using the lifetime table. A total of 366 ESCC patients were studied by 1:1 PSM for T stage and TNM stage (MITME group, n = 183; MIE group, n = 183). In the matched cohort, there was significant differences between the MITME and MIE groups in the failure pattern of regional lymph node recurrence (0.5 vs 3.8%, P = 0.032) and non-tumor death (10.9 vs 31.7%, P < 0.001). The cumulative event curve found that the 5-year cumulative failure rate was lower in the MITME group than in the MIE group (3.3 vs 17.1%, P = 0.026) after 5years of survival. In addition, multivariate Cox regression analysis showed that MIE was an independent poor prognostic factor for a high cumulative failure rate in locally advanced ESCC patients at 5years after surgery (HR:4.110; 95% CI 1.047-16.135; P = 0.043). The dynamic risk curve showed that the MITME group had a lower risk of failure within 5years after surgery than the MIE group. Considering that MITME can significantly improve the postoperative failure pattern and the benefit lasts for at least 5years, it is feasible to use MITME as a treatment for locally advanced ESCC.

Long-term survival of esophageal squamous cell carcinoma after surgical treatment in a large-scale retrospective study from a single cancer center

PurposeTo analyze the long-term overall survival (OS) and influencing factors of patients with esophageal squamous cell cancer (ESCC) under surgical treatment.MethodWe collected patients with ESCC who received surgical treatment in Sichuan Cancer Hospital & institute from January 2010 to December 2017, and selected 2,766 patients with thoracic esophageal carcinoma with relatively complete follow-up results as the objects of this study. We analyzed the characteristics, postoperative complications and long-term OS results of those patients.ResultsOf the 2766 patients, 81.6% were male, midthoracic esophageal cancer accounted for 53.5%. McKeown was used in 72.0% of patients and Ivor-Lewis was used in 26.4% of patients. About 47.8% of patients received minimally invasive esophagectomy (MIE). The overall complication rate was 25.8%. The 1-year, 3-year and 5-year OS rates were 86.2%, 57.5% and 46.8%, respectively. McKeown had a better long-term OS rate than Ivor-Lewis (49.5% vs 41.2%, P < 0.001), and MIE is superior to open surgery (51.8% vs 42.5%, P < 0.001).ConclusionMcKeown has advantages over Ivor-Lewis. MIE results in better long-term survival outcomes for patients. But more prospective randomized controlled trials with large samples are needed.