Esophageal Resection Research Articles

ASO Author Reflections: Early Recurrence After Esophageal Cancer Resection Cannot be Predicted Preoperatively: A Call for More Reliable Biomarkers

ASO Author Reflections: Early Recurrence After Esophageal Cancer Resection Cannot be Predicted Preoperatively: A Call for More Reliable Biomarkers

A06 - OGC LAsting Symptoms after Oesophageal Resectional Surgery (LASORS): Multicentre validation cohort study

Abstract Background Patients are living longer with the long-term morbidity of oncological and surgical therapies as oesophageal cancer outcomes improve. Existing symptomatology and quality of life tools are cumbersome and moreover not designed for the post-treatment survivorship setting. The LASER study identified six key symptoms thought to predict poor health-related quality of life. The current study aimed to validate this six-symptom LAsting Symptoms after Oesophageal Resection (LASOR) clinical tool, and assess its clinical utility. Method Between 2015 and 2019, patients from UK centres who underwent curative-intent oesophageal cancer treatment, and were disease-free at least one year postoperatively, were asked to complete LASOR, EORTC QLQ-C30 and QLQ-OG25 questionnaires. LASOR symptoms (low mood, reduced energy, thoracotomy pain, heartburn, diarrhoea, and bloating after eating) were correlated with EORTC HRQOL scores. Multivariable regression analysis identified symptoms associated with poor HRQoL. Receiver operating characteristic curve analysis was used to validate the LASOR tool. Results 263 patients, spanning a combination of surgical approaches (two-stage, three-stage, left thoracoabdominal, transhiatal), techniques (open, minimally invasive, hybrid), and disease stage, completed the questionnaires. Four of the six LASOR symptoms were associated with poor HRQoL: reduced energy (OR 2.13; 95% CI 1.20-2.87), low mood (OR 1.86; 95% CI 1.4503.12), diarrhoea (OR 1.48; 95% CI 1.06-2.05), and bloating after eating (OR 1.35; 95% CI 1.03-1.77). The LASOR tool produced an area under the curve of 0.85. Conclusion The six-symptom LASOR tool generated a reliable model for identification of patients with a poor HRQOL, with an overall diagnostic accuracy of over 80%. This is the first clinical symptom and quality of life tool to be validated in esophageal cancer patients post-curative treatment. The LASOR tool is straightforward to administer and acceptable to patients. Clinical utility lies both in identifying patients at risk of poor HRQoL and in planning survivorship services.

OGC SO37 - Pyloric drainage interventions for delayed gastric conduit emptying after oesophagectomy: A single centre analysis

Abstract Background Oesophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for resectable oesophageal cancer. Delayed gastric emptying (DGE) is a common postoperative complication that results from the anatomical and physiological changes in the gastric conduit after an oesophageal resection. It is associated with an increased risk of pneumonia, anastomotic leak and prolonged hospital stay. Although several prophylactic pyloric drainage interventions have been postulated to mitigate the risk of DGE, the optimal modality remains debatable. This study aimed to define the incidence, evaluate prognostic factors, and characterise the management of DGE following oesophagectomy. Method Consecutive patients who underwent an oesophagectomy for oesophageal cancer between January 2022 and March 2024 were retrospectively identified from a hospital database. Pyloric drainage procedures consisted of expectant management, endoscopic/open pyloric Botox and pyloroplasty. Univariable and multivariable analyses were performed to define the incidence of DGE after each pyloric drainage modality, evaluate prognostic factors for DGE, and characterise the need for subsequent intervention in the management of DGE. Results The study cohort comprised 137 patients – mean age 66 years, male 78%. The incidence of DGE was 31%. Pyloroplasty had the lowest incidence of DGE (16%) followed by endoscopic botox (21%). Intra-operative pyloric drainage reduced the risk of DGE (p=0.03). The modality of prophylactic pyloric drainage used significantly influenced the risk of developing DGE (p=0.028). No significant differences were identified between patient demographics, operative approach, and oncological variables in the development of DGE. On multivariable analysis, pyloroplasty was associated with a reduced risk of DGE (OR 0.27, 95% CI 0.09 – 0.71). DGE did not influence overall survival. Conclusion DGE is a common postoperative complication which affects up to 39% of patients undergoing oesophagectomy. Patients who did not undergo a prophylactic pyloric drainage procedure during the index oesophagectomy were at an increased risk of developing DGE. Most patients with DGE (71%) require further intervention via endoscopy and botox injection. Pyloroplasty as a prophylactic drainage modality significantly reduced the risk of developing DGE compared to endoscopic botox. Further prospective randomised controlled trials are required to validate these findings.

A novel piglet model of esophageal stricture following variable segmental esophageal resection and re-anastomosis.

Esophageal strictures following esophageal atresia repair are a source of significant morbidity. To test new therapeutic approaches, we designed a piglet model of esophageal stricture by resecting variable lengths of esophagus with subsequent re-anastomosis. This study describes the model and validates its physiologic impact by blinded analysis of the weight gains of the piglets. A total of 24 two-week old Pietrain piglets had esophageal resections performed, ranging from 0 to 5 cm, with the goal of inducing postoperative esophageal strictures. Postoperative body-weights were evaluated by repeated analysis of variance followed by pairwise group-comparisons based on estimated marginal means. In addition, body weight was modeled by linear-mixed model regression. Different resection lengths were compared. The esophagi were evaluated postmortem for stricture. Of 24 operated piglets, 23 reached the endpoint, and 90% developed an esophageal stricture that was radiologically visible in a contrast study, as well as appreciable macroscopically in the necropsy. We found differences in pre- and postoperative body weights for all piglets (F (1, 18) = 298.54, p < 0.001), but no differences between resection lengths (F (4, 18) = 0.36, p = 0.837). Our model of postoperative esophageal stricture offers the opportunity to investigate potential treatments for strictures associated with esophageal atresia, since it reliably induces strictures and results in minimal loss of animals. The similar body weight gain in all groups indicates that stricture is mainly the result of esophageal resection and re-anastomosis, regardless of the length of the resected segment.

Risk of Financial Toxicity Among Adults Undergoing Lung and Esophageal Resections for Cancer

Although financial toxicity, defined as the harmful financial burden experienced by patients undergoing cancer treatment, has been of growing interest, data in thoracic oncology are lacking. We aimed to examine the risk of financial toxicity among patients undergoing surgical resection of thoracic malignancies. Adults undergoing lobectomy, pneumonectomy, or esophagectomy for cancer were identified in the 2012-2021 National Inpatient Sample (NIS). Risk of financial toxicity was defined as health expenditure (total hospitalization costs for the uninsured and maximum out-of-pocket costs for the insured) exceeding 40% of post-subsistence income. Multivariable logistic regressions were used to identify factors associated with financial toxicity risk. Of 384,340 patients, 69.5% had government-funded insurance, 27.2% private insurance, and 1.0% were uninsured. Compared to those with insurance, uninsured patients were more commonly Black and Hispanic and less commonly electively admitted. Mortality, complications, LOS, and costs were comparable regardless of insurance status. Approximately 68.9% of uninsured and 17.3% of insured patients were at risk of financial toxicity, and incidence of financial toxicity remained stable over time. After risk adjustment, complications were associated with over 2-fold increased risk of financial toxicity among uninsured (AOR 2.21, 95% CI 1.38-3.55). Among the insured, Black, Hispanic, and publicly insured patients demonstrated greater risk of financial toxicity, while minimally invasive operations and metropolitan hospitals exhibited lower risk of financial toxicity. Concordant with prior work examining financial toxicity in abdominal oncologic surgery, thoracic surgery demonstrates a comparable burden of financial toxicity. Referral policies and care subsidization may be considered in patients undergoing thoracic malignancy resections at risk for financial toxicity.

The role of computed tomography and esophageal ultrasonography in the preoperative evaluation of esophageal cancer resection

The role of computed tomography and esophageal ultrasonography in the preoperative evaluation of esophageal cancer resection

Effect of sprayable, highly adhesive hydrophobized gelatin microparticles on esophageal stenosis after endoscopic submucosal dissection: an experimental study in a swine model.

Esophageal mucosal resection for superficial esophageal cancer can lead to postoperative esophageal stricture, with current preventive measures being insufficient. Sprayable wound dressings containing hydrophobized microparticles exhibit strong adhesion. This study aimed to investigate the preventive effects of hydrophobized microparticles on esophageal stenosis following endoscopic submucosal dissection. Circumferential esophageal endoscopic submucosal dissection was performed on miniature swine (n = 6). Swine were categorized into two groups: those sprayed with hydrophobized microparticles (sprayed group) and those not sprayed (non-sprayed group). Hydrophobized microparticles were sprayed onto the sprayed group on Days 0, 3, and 7 of endoscopic submucosal dissection. The non-sprayed group underwent endoscopy on the same days. Esophageal stricture rate, submucosal inflammatory cell infiltration, submucosal fibrosis, and thickening of the muscular layer were compared between the groups on Day 14 of endoscopic submucosal dissection. Spraying of hydrophobized microparticles was easily performed using an existing endoscopic spraying device. The esophageal stricture rate was significantly lower in the sprayed group than in the non-sprayed group (76.1% versus 90.6%, p < 0.05). The sprayed group showed suppression of inflammatory cell infiltration in the submucosal layer (p < 0.01) and thickening of the muscular layer (p < 0.01). Sprayable tissue-adhesive hydrophobized microparticles reduce the stricture rate after esophageal ESD by inhibiting inflammatory cell infiltration, submucosal fibrosis, and thickening of the muscular layer. The use of hydrophobized microparticles for preventing post-endoscopic submucosal dissection esophageal stenosis offers a promising avenue for clinical applications in endoscopic procedures, potentially improving patient outcomes.

Evaluation of patient satisfaction with an enhanced recovery protocol for esophageal resections: a concurrent quantitative and qualitative analysis.

Patient satisfaction during hospitalization for esophagectomy has been little studied. The aim of this study was to evaluate patients' satisfaction with a newly introduced enhanced recovery protocol (ERP) for esophagectomy. At hospital discharge, patients were invited to complete a questionnaire. This pseudonymized questionnaire contained 5-point Likert scales regarding items on multidisciplinary care (n = 7), information/communication (n = 7), length of stay (n = 1), and specific adaptations of care in the ERP (n = 11). One open question asked for patient experiences and suggestions for improving the ERP. Between May 2017 and December 2021, 521 patients were included in the ERP after esophagectomy. Of them, 327 patients (63%) completed the questionnaire. Response rates were evenly distributed between genders and slightly higher in younger patients (<60years; 68%) as compared to elderly patients (>70years; 60%). Quantitative analysis revealed high satisfaction rates for multidisciplinary care (86.8%), information/communication (84.9%), and ERP adaptations (82.2%), and length of stay was considered optimal in 80%. There were no significant differences in satisfaction observed between gender nor age groups. For the qualitative analysis, there were 108 open answers, resulting in 268 statements. Sentiments expressed in these statements were evaluated as negative, positive, or unspecified. Negative sentiments were attributable to alimentation, organizational factors, and communication. Positive sentiments were attributed to interpersonal relations, multidisciplinary care, and ERP. Overall, patients are very satisfied with the ERP for esophagectomy during hospitalization. By incorporating qualitative data, the results of this quantitative analysis are expanded and elucidated, showing areas where improvements to our ERP are possible to increase patient satisfaction.

Surgical Technique and Implementation of Total Minimally Invasive (Laparo-Thoracoscopic) Ivor Lewis Esophagectomy for Cancer.

Esophagectomy represents a major oncological operation due to the surgical involvement of both the abdominal and thoracic cavities. The minimally invasive technique has been developed to minimize the operative impact on patients undergoing esophageal resections, often presenting with nutritional deterioration and poor functional reserves. The present article provides an illustrative description of the total minimally invasive (laparo-thoracoscopic) Ivor Lewis esophagectomy for cancer integrated with complementary components of perioperative clinical management. This standardized surgical technique of two-field esophagectomy (i.e., laparoscopy and thoracoscopy) was depicted based on the experience of a tertiary center for esophageal cancer care with more than 1500 cases operated on, and in accordance with the SUPER reporting guidelines. The accomplishment of the following descriptive and illustrative content allowed the development of remarks on the strengths and possible flaws of this specific procedure, providing a measurable opportunity to absorb technical details of the most widespread surgical resection for esophageal cancer worldwide.

Pancreatoduodenectomy after Ivor-Lewis Santi oesophagectomy with gastric tube reconstruction. An European multicentre experience

BackgroundPancreaticoduodenectomy (PD) is the standard surgery to treat tumors and other conditions affecting the head of the pancreas. PD involves the division of the gastroduodenal artery (GDA) and its branches, to allow for complete dissection of lymph nodes. However, PD in patients with prior esophageal resection presents challenges due to altered anatomy and risks compromising gastric tube vascularization. GDA preservation becomes crucial to avoid ischemia, although this may pose oncological risks by potentially leaving behind regional lymph nodes. This article reviews European surgical center experiences and techniques for PD in patients with prior esophageal surgery, focusing on short-term outcomes. MethodsWe have collected all the experiences carried out in European surgical centers and evaluated the techniques applied for PD in patients who had prior esophageal surgery while analyzing short-term outcomes. ResultsEight patients from 5 European centers were identified. Six patients were diagnosed with pancreatic adenocarcinoma, including one borderline case. Intraoperatively, the gastroduodenal artery (GDA) was preserved in all cases, with portal vein reconstruction required in only one instance due to tumor invasion. No ischemia or venous congestion of the gastric tube was observed during the surgical procedure. Post-operative complications that occurred included POPF type C in 1 (12.5 %), PPH type C in 1 (12.5 %). The median number of harvested lymph nodes was 21 [14–24]. with a median of 1.5 positive lymph nodes. R1 resection was present in 62.5 % of cases. ConclusionPerforming pancreaticoduodenectomy subsequent to Ivor Lewis esophagectomy is a technical challenge, but seems feasiable and safe in selected patients. GDA-preserving pancreaticoduodenectomy emerges as a valuable and time-efficient variation of the conventional procedure, it can be considered oncologically appropriate, but studies confirming its long-term impact on radicality are still needed.

Predictive factors for intrathoracic anastomotic leakage and postoperative mortality after esophageal cancer resection

BackgroundEsophageal cancer is currently one of the high-risk malignant tumors worldwide, posing a serious threat to human health. This study aimed to analyse the causes of postoperative mortality and intrathoracic anastomotic leakage(IAL) after esophagectomy.MethodsA retrospective analysis was conducted on 172 patients with esophageal cancer resection and focused on the preoperative and postoperative indicators. Cox regression analysis was performed to identify factors affected IAL and evaluated the potential factors on postoperative mortality. The Kaplan-Meier curve was applied to evaluate the effect of leakage on postoperative mortality after propensity score matching.ResultsUnivariable and multivariable Cox regression analysis showed that infection and high BMI were significant risk factors for IAL, patients with BMI over 24 kg/m2 in IAL group was two times higher than that of the group without IAL (95% CI = 1.01–6.38; P = 0.048). When patients were infected, the hazard ratios(HRs) of anastomotic leakage was twice that of patients without infection (95% CI = 1.22–4.70; P = 0.011). On the other hand, IAL was a significant cause of postoperative mortality, the 40-day postoperative mortality rate in the leakage group was significantly higher than the non leakage group (28.95% in leakage group vs. 7.46% in non leakage group, P<0.01). After propensity score matching, IAL still significantly affected postoperative mortality. The total length of hospital stay of the leakage group was inevitably longer than that of the non leakage group (22.19 ± 10.79 vs. 15.27 ± 8.59).ConclusionIAL was a significant cause of death in patients underwent esophageal cancer resection. Patients with high BMI over 24 kg/m2 and infection may be more prone to developing IAL after esophagectomy. IAL inevitably prolonged the length of hospital stay and increased postoperative mortality.

606. THE CHANGES OF THORACOSCOPIC OR LAPAROSCOPIC APPROACH FOR SPONTANEOUS ESOPHAGEAL RUPTURE IN JAPAN

Abstract Background The surgical treatment for esophageal rupture includes various approaches such as thoracotomy, laparotomy, thoracoscopy, and laparoscopy. These approaches aim to: Suture the perforation site, sealing it with omentum. or esophageal resection and reconstruction. Cleanse and drain the mediastinum or thoracic cavity. Adding gastrostomy or intestinal as needed. Many reports showed the usefulness of minimally invasive surgeries. In this study, we added our cases and discussed the surgical techniques and outcomes. Method I searched for reported cases in PubMed and the Journal of Health Care and Society and supplemented them with my experimental cases for analysis. All reports published between 2001 and the end of 2022 were included in this study. Results From 2001 to 2022, there have been 15 reports (16 cases) of idiopathic esophageal rupture using arthroscopic techniques, including our cases, 14 cases in men and 3 cases in women. The ages of the patients ranged from 39 to 78 years (mean 61 years, median 61 years), and the rupture sites were the lower esophagus in 15 cases (88%) and the middle part in 2 cases (12%). The time from onset of symptoms to surgery ranged from 4 to 77 hours. The approach method was thoracoscopy in 7 cases (41%), laparoscopy in 8 cases (47%), and a combination of thoracoscopic and laparoscopy in 2 cases (12%). Complications of Clavien-Dindo classification IIIa or higher were observed in 3 patients (18%). There were two cases each of thoracoscopic and laparoscopic complications in which complications were observed. The time from arthroscopic surgery to discharge was 12-120 days (mean 36.7 days, median 30.5 days). For cases with a thoracoscopic approach, the period from surgery to discharge is 23-120 days (average 50.1 days, median 39 days), and for cases with a laparoscopic approach, the period from surgery to discharge is 12-82 days (average 30 days). days, median 21 days). Discussion Spontaneous esophageal rupture develops various disease patterns such as mediastinum limited type with mild symptoms and intrathoracic rupture type. There are various treatment approaches, including conservative therapy, endoscopic closure, and surgery. The laparoscopic approach seemed to reduce the length of hospital stays. Conclusion The surgical approach for spontaneous esophageal rupture has been changed from thoracotomy to laparoscopic surgery. The trans hiatal procedure will increase among laparoscopic surgery. Spontaneous esophageal rupture is a remarkably highly invasive disease, and we thought that a less invasive and simpler treatment would be desirable.

766. LASTING SYMPTOMS AFTER OESOPHAGEAL RESECTIONAL SURGERY (LASORS): MULTICENTRE VALIDATION COHORT STUDY

Abstract Background As outcomes following curative-intent oesophageal cancer treatment improve, more patients are living with the long-term morbidity of cancer therapies, the symptoms of which are poorly recognised and understood. Existing symptomatology and quality-of-life tools are cumbersome and moreover are not designed specifically for evaluation of post-treatment survivorship. The LASER study and subsequent consultation process identified six key symptoms thought to predict poor health-related quality-of-life (HRQoL) as measured by validated European Organisation for Research and Treatment of Cancer (EORTC) tools. The current study aimed to validate this six-symptom LAsting Symptoms after Oesophageal Resection (LASOR) clinical tool, and assess its clinical utility. Methods In this multi-centre cohort study, patients who underwent oesophagectomy between January 2015 and June 2019 across the United Kingdom, and were disease-free at least one-year post-treatment, were asked to complete LASOR, EORTC-QLQ-C30 and QLQ-OG25 questionnaires. LASOR symptoms (low mood, reduced energy, thoracotomy pain, heartburn, diarrhoea, and bloating after eating) were evaluated using composite scores based on frequency and quality of life impact, and correlated with EORTC HRQoL scores. The ability of the LASOR tool to predict patients with poor HRQoL was validated using receiver operating characteristic (ROC) curve analysis. Patient acceptability of the tool was assessed using a separate questionnaire. Results 263 participants were included. 192 (73%) were males. Surgical technique included open (61%), hybrid (18%), and minimally-invasive (21%). 203 patients (77%) received neoadjuvant chemotherapy or chemoradiotherapy. 148 patients (56%) experienced a post-operative complication. Four LASOR symptoms were associated with significantly lower HRQoL: reduced energy (OR=2.13; 95% CI 1.20-2.87), low mood (OR=1.86; 95% CI 1.45–3.12), diarrhoea (OR=1.48; 95% CI 1.06–2.06), and bloating (OR=1.35; 95%CI 1.03-1.77). In combination, the LASOR symptoms produced an area under the ROC curve of 0.85 (sensitivity = 0.82, specificity = 0.73). Conclusion The six-symptom LASOR tool generated a reliable model for identification of patients with a poor HRQoL, with an overall diagnostic accuracy of over 80%. This is the first clinical symptom tool to be validated in the post-curative-treatment setting for patients with oesophageal cancer. The LASOR tool is straightforward to administer and highly acceptable to patients, and can be used to identify those at risk of high morbidity and poor quality of life in surveillance programmes. In turn, evidence-based survivorship services can be integrated into patient follow-up to alleviate the burden of cancer treatment on oesophagectomy patients.

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

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

509. DOES SARCOPENIA AFFECT THE OUTCOME OF PATIENTS WITH ESOPHAGEAL CARCINOMA AFTER ESOPHAGECTOMY?

Abstract Background Sarcopenia is increasingly recognized as an independent predictor of clinical outcomes of cancer patients such as post-operative complications and prolonged hospital stays. Additionally, sarcopenia can also negatively impact overall survival because of reduced ability to tolerate treatments like neoadjuvant therapy and surgery. At particular risk among cancer patients is the esophageal cancer population because of tumor stenosis leading to dysphagia and impossibility of oral feeding in many patients. The purpose of the current study was to investigate the effect of preoperative sarcopenia on postoperative complications in patients undergoing esophagectomy for esophageal cancer. Methods This retrospective study includes all patients who underwent full-robotic abdominothoracic esophageal resection because of esophageal cancer at our institution between 06/2020 and 12/2022. The skeletal muscle index (SMI) was assessed using the preoperative computed tomographic staging scans by measuring the cross-sectional muscle area at the third lumbar vertebral level. Following cut off SMI values were used to define sarcopenia: men: 52,4 cm2/m2, women: 38,5 cm2/m2 according to Prado et al (Lancet Oncol, 2008). Recorded parameters included demographic data, neo-adjuvant treatment, histologic findings, postoperative course and overall- and disease-free survival. Results A total of 113 cases were included in this preliminary analysis. 97 patients (86%) were classified as having sarcopenia. Of these, 38 patients (40%) had a preoperatively or during esophageal resection implemented percutaneous endoscopic jejunostomy (PEJ) tube to ensure enteral nutrition. Despite age, groups were comparable regarding neoadjuvant treatment and histologic findings (mean age sarcopenic patients: 66y vs. 61y non-sarcopenic patients, p = 0.03). There was no difference in the incidence of occurrence of anastomotic leakage, pulmonary complications, need for re-operation, length of (ICU) stay and overall- and disease-free survival between sarcopenic and non-sarcopenic patients. Conclusion Incidence of sarcopenia is very high among esophageal cancer patients. In our study population, however, preoperative sarcopenia failed to predict complications or long-term outcome after esophagectomy for esophageal cancer. 40% of the sarcopenic patients received a PEJ. This relatively high proportion of implemented PEJ could have contributed to the observed comparable outcomes between sarcopenic and non-sarcopenic patients. This observation underlines the importance of prehabilitation and nutritional support for patients with preoperative sarcopenia.

358. IMPLICATIONS ON OVERALL SURVIVAL FROM POSITIVE CIRCUMFERENTIAL RESECTION MARGINS IN OESOPHAGEAL CANCER PATIENTS AT A TERTIARY REFERRAL CENTRE IN ENGLAND

Abstract Background The oesophagogastric (OG) tertiary referral centre at our Trust was established in March 2009.It caters to a catchment population of approximately 1.6 million. Oesophageal cancer is a morbid disease contributing to 18% of cancer mortalities worldwide. Involvement of circumferential resection margin (CRM) is an indicator of poor prognosis. The aim was to calculate the microscopic positive resection rate in patients undergoing resections for oesophageal cancers, assess disease free survival (DFS) and overall survival (OS) in this cohort. Methods Patients undergoing oesophageal resections for cancer at our OG unit who satisfied the inclusion criteria - age&amp;gt;18, operation with curative intent, adenocarcinoma and squamous cell cancer with a microscopic positive resection margin (R1) were included. Data was collected from the electronic patient record (Quadramed). Retrospective analysis was performed using MS Excel and IBM SPSS statistics Ver 27. Results A total of 640 oesophageal cancer resections performed between April 2009 - March 2023, who satisfied the inclusion criteria were included. Median age at surgery was 66 years. The R1 rate was 40% in our cohort (R0:R1 =380:260). Male to female ratio in the R1 cohort was 4:1. 98% (255 patients) had T3/T4 disease. 47.7% (124 patients developed recurrence. Of these, 83.8% (104 patients) developed distant metastasis and 16.2 %(20 patients) had locoregional metastasis. Median time to recurrence was 12 months and disease-free survival was also12 months. The OS at one year of 81% (140/260) was comparable to national data. Conclusion We conclude that locally advanced tumour staged T3 and above is the most likely cause for higher rate of CRM positivity. Other factors that could contribute is the lack of serosal layer in the oesophagus and the practise of ex situ removal of nodes from the main specimen in theatre which could potentially lead to stripping of the adventitia thus making the CRM falsely R1 during pathological staging. The R1 status however does not seem to affect the overall survival rate.

808. ROUX-EN- Y GASTRIC BYPASS FOR REFRACTORY SEVERE GERD AFTER PROXIMAL GASTRECTOMY

Abstract Roux-en- Y gastric bypass for refractory severe GERD after proximal gastrectomy Category Gastro-esophageal reflux and hiatal hernia Background This is the case of a 27-year-old male diagnosed with achalasia. During dilation of the gastroesophageal junction a iatrogenic esophageal perforation occurred. Therefore, a polar gastrectomy with stapling of the lesser curvature and resection of the distal esophagus with esophagogastric anastomosis was performed. After the surgery the patient experienced symptoms of severe reflux unresponsive to PPI. Therefore, a subtotal gastrectomy with pouch construction and Roux-en-Y gastrojejunostomy was indicated. Methods We present an intraoperative video showing the surgical technique. Results The postoperative period was uneventful, with favorable response to gradual reintroduction of oral intake. The patient was discharged on the 9th POD. After a 12-month follow up the patient remains asymptomatic. Conclusions Surgery is currently the gold standard treatment for refractory reflux. In this case, the creation of a gastric pouch with Roux-en-Y bypass ensures the resolution of the symptoms of GERD as well as the gastric delay. Preservation of the gastroepiploic vessels to ensure an optimal gastric pouch perfusion is mandatory https://we.tl/t-kLUqi4AqqB

231. DESCRIBING THE LANDSCAPE OF ESOPHAGECTOMY BETWEEN EASTERN AND WESTERN ESOPHAGEAL SOCIETIES: COMPARATIVE STUDIES FROM THE JAPANESE NCD AND DUTCH DUCA

Abstract Objective Differences in clinicopathological characteristics of patients with esophageal cancer between countries may exist and impact on perioperative and surgical treatment as well as outcomes. Identification of these discrepancies may help the interpretation of present and future studies. Methods Data on patient demographics, comorbidity, pathology, surgical procedure, and short-term outcomes were retrieved, and compared between countries. Furthermore, we conducted a risk factor analysis focused on the major postoperative complications after esophagectomy to reveal the similarities and differences in risk factors. Results The mean annual number of resections for oesophageal cancer was 6673 in NCD (5.3 cases per 100,000 population) and 551 (3.1 cases per 100,000 population) in DUCA. Patients from the NCD were older and had a lower BMI. Complete minimally invasive esophagectomy was performed in 52.7% in NCD and 85% in DUCA. A cervical anastomosis was performed in 83.5% of patients in the NCD and in 33.8% in the DUCA likely reflecting differences in the location of primary tumors. Mortality within 30 days after surgery in the NCD and DUCA was 0.8% and 2.7%, respectively. Risk factors for postoperative major complications were similar between countries. Conclusions Although there were differences in patient variables, no significant differences were observed in short-term outcomes and risk factors of postoperative complications. The current results provide insight into contemporary demographics and outcomes of esophageal cancer resections from two an Asian and Western perspective.

478. OVERVIEW ON USE OF THE TRANSCERVICAL MEDIASTINOSCOPIC APPROACH FOR MINIMALLY INVASIVE TREATMENT OF ESOPHAGEAL CANCER: ESTABLISHMENT OF INTERNATIONAL COLLABORATIVE GROUP

Abstract Background Minimally invasive esophagectomy has emerged as a promising alternative to open surgery, demonstrating reduced postoperative complications and comparable oncological outcomes. Despite advancements, pulmonary complications and anastomotic leakages remain concerns. Since 2015, a novel technique combining single-port transcervical and trans-hiatal laparoscopic mediastinal dissection for esophageal resection was introduced. This procedure exhibits lower pulmonary complication rates compared to traditional approaches. However, its global adoption is limited, necessitating collaborative efforts to standardize techniques and outcomes. Following the IDEAL framework stage 2B (exploration), an international collaborative group for transcervical esophagectomy has been established, aiming to exchange insights, experiences, and lessons learned. Methods A cross-sectional survey involving 13 surgeons currently practicing transcervical esophagectomy was conducted, revealing variations in surgical approaches, indications, and outcomes. Results Surgeons from China, Germany, Japan, and The Netherlands participated. Indications for surgery varied, with less selectivity in higher-volume centers. Large tumors near the carina, bulky primary lesions or T4 tumors were identified as contraindications. Different surgical approaches were reported, with the left transcervical and abdominal laparoscopic/robotic dissection being the most common. The mean operative time was about 382.2±117.9 minutes. The mean blood loss was of 100.2±71.1 milliliters. Surgeons reported high rates of R0 resection and lymph node harvesting, as well as low rates of pulmonary complications (8.6±3.7) and anastomotic leaks (10.1±5.2); however, concerns persist regarding recurrent laryngeal nerve injuries (27.2±18.2). Conclusion Transcervical esophagectomy is gradually gaining recognition, with varying adoption rates. The collaborative group aims to align techniques, share experiences, and standardize the procedure. Challenges include differences in indications, surgical approaches, and outcomes, highlighting the need for ongoing discussion and research. Despite concerns about recurrent laryngeal nerve injuries, the procedure shows promise in reducing pulmonary complications. The establishment this collaborative group signifies a crucial step toward global acceptance. By fostering collaboration, the group aims to enhance patient care, minimize learning-associated morbidity, and contribute to the continuous advancement of this surgical technique. Future efforts will focus on standardization, comparative studies, and training protocols.

340. THE IMPACT OF OBESITY ON SURGICAL OUTCOMES AFTER ESOPHAGECTOMY FOR CANCER IN SWEDEN

Abstract Background Global obesity rates continue to rise and are closely linked to an increase in esophageal adenocarcinoma. While obesity is associated with an increased risk of postoperative complications, its influence on long-term survival is less clear. Some studies suggest that obese patients have poorer outcomes due to higher comorbidity rates, while others indicate comparable or even better survival, possibly due to better nutritional reserves. This study aims to investigate whether obesity affects the survival and risk of postoperative complications in a national cohort of esophageal cancer patients. Methods This retrospective population-based register study included all individuals who underwent esophageal resection between 2006 and 2018 in Sweden. Data were extracted from the national quality registry for esophageal and gastric cancer (NREV). The cohort was grouped based on body mass index (BMI) into underweight (BMI &amp;lt; 20), normal (BMI 20-25), overweight (BMI 25-30), and obese (BMI &amp;gt; 30). Kaplan-Meier was used for survival analysis, and logistic regression and Cox regression were used for adjusted analyses (adjusting for sex, age, marital status, education level, Charlson comorbidity index score, histopathology, disease stage, and year of diagnosis). Results In total, 1742 individuals (79.9% males, mean age 66) were included, of whom 242 (13.9%) were obese. Obese individuals had more comorbidities at surgery, more commonly had adenocarcinoma, and underwent surgery more frequently in the later time period. The risk of surgical complications (e.g., anastomotic leak, bleeding) for obese individuals was not increased compared to those with normal weight (OR: 0.83 [0.56-1.21]), but an increased risk of non-surgical complications (e.g., pneumonia, cardiopulmonary events) was observed (OR: 1.78 [1.22-2.60]). The risk of death of any cause was decreased in obese individuals compared to those with normal weight (HR: 0.74 [0.58-0.95]), resulting in superior overall survival. Conclusion Despite the presence of more comorbidities among obese individuals undergoing esophagectomy, their risk of surgical complications remained comparable to those with normal weight. However, obese individuals exhibited a heightened susceptibility to other postoperative complications. Surprisingly, obese individuals demonstrated an improved overall survival at 5 years compared to those with normal weight.