Esophageal Resection Research Articles

The relationship between preoperative anemia and length of hospital stay among patients undergoing radical surgery for esophageal carcinoma: a single-centre retrospective study

BackgroundAlthough it is unclear if preoperative anemia affects patients undergoing radical resection of esophageal cancer, it does increase the length of stay (LOS) for surgical patients. Accordingly, the purpose of this study was to investigate if, after adjusting for other covariates, anemia was independently associated with LOS in people undergoing radical resection of esophageal cancer.MethodsThe retrospective cohort study included 680 patients undergoing radical esophageal cancer surgery between January 2010 and December 2020. Preoperative anemia was the targeted independent variable, while LOS was the target independent variable. Demographics, comorbidities, laboratory tests, surgery and anesthesia, postoperative outcomes, and complications were collected. Multivariate linear analyses were performed for variables that might influence preoperative anemia and LOS selection. Subgroup analysis using hierarchical variables was then used to test the potential relationship.ResultsThe 647 individuals that were randomly chosen had an average age of 61.06 ± 8.16 years, and 77.43% of them were male. The prevalence of anemia was 36.6%. All patients recruited had an average length of stay (LOS) of 26.31 ± 13.19 days, 25.40 ± 11.44 days for patients who had no preoperative anemia, and 27.89 ± 15.66 days for patients who had preoperative anemia, p < 0.05. After adjusting for covariates, the results of fully adjusted linear regression revealed that preoperative anemia was significantly associated with LOS (β = 2.04, 95%CI (0.13, 3.96) ), p < 0.05. The results of the subgroup analysis were basically accurate and steady. Regardless of gender, same outcomes were seen when preoperative anemia was defined as a Hb level < 13 g/dL (β = 2.29, 95%CI (0.33, 4.25) ), p < 0.05. In addition, the LOS was shortened with the increase of preoperative hemoglobin (Hb) (β= -0.81, 95%CI (-1.46, -0.1) ), p < 0.05.ConclusionPreoperative anemia is typical in Chinese patients undergoing radical esophageal cancer resection and is independently associated with prolonged LOS.

Esophageal Cancer-Derived Organoids to Predict Patients' Treatment Response

The absolute 10-year overall survival of esophageal adenocarcinoma (EAC) has significantly increased from 26% to 36% due to neoadjuvant chemoradiotherapy (nCRT) with consecutive radical resection. However, 20-25% of EAC patients don't respond to nCRT and need alternative treatment, and 20-30% have a complete pathological response and may not need resection. Therefore, there is an urgent need for better models to accurately predict response of EAC to nCRT. Accumulating evidence indicates that patient-derived organoids (PDOs) may predict treatment responses, but the ability of PDOs to predict responses to chemoradiation in EAC patients remains unknown. Hence, we generated patient derived EAC cancer organoids (ec-PDOs) to examine their response to nCRT. The biopsies from treatment-naïve EAC patients after informed consent were used to establish ec-PDOs. Next, we investigated the response of ec-PDOs to the components of standard-of-care neoadjuvant treatment, including irradiation, carboplatin, and paclitaxel. Finally, the potential of ec-PDOs to reflect patients' response to nCRT before esophageal resection was evaluated. Mechanically and enzymatically dispersed patient derived EAC biopsies were cultured as ec-PDOs for up to 10 passages, indicating the self-renewal and expansion potential. These ec-PDOs expressed the EAC marker MUC5AC, indicating the EAC origin. Differences in growth kinetics and response to irradiation, carboplatin, and paclitaxel were observed between patients specific ec-PDOs. However, similar dose-response curves were seen within ec-PDOs from the same patient after different passages. This indicates that ec-PDOs exhibit interpatient response heterogeneity but have good reproducible responses within the same patient. Moreover, after combined treatment with irradiation (IR), carboplatin (Car), and paclitaxel (Pac) to mimic nCRT in EAC patients, the stem cell survival of ec-PDOs from patients with complete response (CR) and partial response (PR) are lower than that from those with progressive disease (PD). The preliminary findings in this study suggest a great potential of ec-PDOs to predict patient-specific responses to neoadjuvant treatment in EAC patients.

Factors Influencing Postoperative Complications Following Minimally Invasive Ivor Lewis Esophagectomy: A Retrospective Cohort Study.

Complications arising following minimally invasive Ivor Lewis esophagectomy often result from inadequate enteral nutrition, highlighting the need for proactive measures to prevent such issues. One approach involves identifying high-risk cases prone to complications and implementing percutaneous endoscopic jejunostomy (PEJ) tube placement during esophageal resection to ensure timely enteral nutrition. In this single-center, retrospective cohort study, we examined patients who underwent minimally invasive esophagectomy for esophageal cancer at a high-volume center. The dataset encompassed demographic information, comorbidities, laboratory parameters, and intraoperative details. Our center utilized the EndoVac system pre-emptively to safeguard the anastomosis from harmful secretions and to enhance local oxygen partial pressure. All patients received pre-emptive EndoVac therapy and underwent esophagogastroduodenoscopy in the early postoperative days. The need for multiple postoperative EndoVac cycles indicated complications, including anastomotic insufficiency and subsequent requirement for a PEJ. The primary objectives were identifying predictive factors for anastomotic insufficiency and the need for multi-cycle EndoVac therapy, quantifying their effects, and assessing the likelihood of postoperative complications. 149 patients who underwent minimally invasive or hybrid Ivor Lewis esophagectomy were analyzed and 21 perioperative and demographic features were evaluated. Postoperative complications were associated with the body mass index (BMI) category, the use of blood pressure medication, and surgery duration. Anastomotic insufficiency as a specific complication was correlated with BMI and the Charlson comorbidity index. The odds ratio of being in the high-risk group significantly increased with higher BMI (OR = 1.074, p = 0.048) and longer surgery duration (OR = 1.005, p = 0.004). Based on our findings, high BMI and longer surgery duration are potential risk factors for postoperative complications following minimally invasive esophagectomy. Identifying such factors can aid in pre-emptively addressing nutritional challenges and reducing the incidence of complications in high-risk patients.

33. QUALITY PERFORMANCE INDICATORS FOR THE SURGICAL TREATMENT OF OESOPHAGEAL CANCER- A SYSTEMATIC REVIEW

Abstract Background A systematic review was undertaken to identify existing quality performance indicators (QPI) for the surgical treatment of oesophageal cancer (OC) with the aim of defining a set of QPIs that can be used in accreditation and allowing comparison of treatment and outcomes across jurisdictions, and provide a basis to develop quality improvement programs. These QPIs capture key components of patient care that are fundamental to the overall outcomes. Methods A systematic literature review was conducted by searching MEDLINE, PubMed, EMBASE, and SCOPUS with all literature available until the date of 1st March 2022 included. Search terms utilised were Quality of health care OR Quality improvement OR Quality control OR Quality indicators OR Benchmark, AND Oesophagectomy OR Esophagectomy OR Oesophageal neoplasm OR Esophageal Neoplasm OR Adenocarcinoma OR Squamous Cell Cancer OR Oesophageal resection OR Esophageal Resection OR Oesophageal cancer OR Esophageal Cancer OR Ivor Lewis OR Oesophageal Surgery OR Esophageal Surgery. Results Twenty-five articles were included in the final analysis. The selected studies included editorials, retrospective review, prospective review, expert guidelines and consensus. For OC QPIs, process measures included multi-disciplinary meetings, access to perioperative multimodal diagnostic pathways, and surgical metrics (margin negative resections and adequate lymphadenectomy). Outcome measures included the RO resection rate, reoperation, readmission rate, and length of hospital stay. Conclusions This systematic review summarises QPIs for the surgical management of OC. The data from this review will form the basis of a project to develop internationally agreed QPIs for OC resections.

852 The Impact of Surgical Training on Clinical Outcomes After Oesophagectomy: A Systematic Review and Meta Analysis

Abstract Aim Surgical training, including in technical skills through theatre exposure, is integral to healthcare delivery and sustainability. We sought to investigate the impact of intraoperative trainee involvement during oesophageal resection on perioperative outcomes. Method A protocol was registered at PROSPERO (CRD42022330705). Seven databases were searched up to May 2022. Studies providing direct comparison between consultant- and trainee-performed oesophagectomies in adult patients were included. The co-primary outcomes were length of hospital stay and 30-day survival. Data was analysed in Stata SE v17. Log odds ratios (log OR) were calculated for dichotomous outcomes, whilst continuous variables were summarised as mean differences (MD). A random-effects model was employed. Heterogeneity was assessed using I2. Bias was assessed using ROBINS-I. Results 804 studies were screened, with 9 papers considered in the final quantitative synthesis. 3183 (72% male) patients, including 762 (24%) trainee-led cases, were included. There was a high risk of bias across included papers. Hospital stay was significantly shorter in the trainee group (MD -1.83 days: 95% CI [-2.88, -0.78], p&amp;lt;0.01). There was no difference in 30-day survival (p = 0.23), in-hospital survival (p = 0.92), anastomotic leak (p = 0.80), operative time (p = 0.63) or completeness of resection (p = 0.76) between groups. Conclusions Trainee involvement in oesophageal resections does not appear to have a detrimental impact on patient safety and outcomes. High-quality studies, with consistent outcome reporting and larger populations are needed to further inform this area of interest.

181. SAFETY AND TIME USAGE OF CIRCULAR STAPLED ANASTOMOSIS IN THE SHIFT FROM MIE TO RAMIE

Abstract Background Introducing new surgical techniques may increase the potential for adverse events. There is no consensus or evidence on the optimal anastomotic technique in esophageal resection. We used the circular stapled anastomosis (CSA) technique as standard in MIE, and continued this practice during the introduction of RAMIE. Here, we evaluate the early results of reconstruction during Iwor-Lewis esophagectomy using CSA after converting from MIE to RAMIE, with redspect to safety and time usage. Methods The first 27 RAMIEs were included, as well as an equal number of video recorded MIEs immediately preceeding the shift to RAMIE. Patient background and short-term outcomes were recorded prospectively. The duration of the reconstruction, i.e. the time from esophageal transection to transection of the blind limb of the gastric conduit was recorded from operative videos. Both MIE and RAMIE were performed in the prone position using single lumen tube intubation. The robot was not undocked during the reconstruction. Data was registered in a patient registry approved by the Institutional Data Protection Officer with written consent by all patients. Results 27 RAMIEs and 29 MIEs were included. Patient demographics, comorbidity and tumor disease stages were similar between the two groups. There were video recordings of 26 cases in each group. There were no conversions to thoracotomy in either group. All reconstructions were completed using CSA. The median duration of the reconstruction was 40 (range: 26–85) minutes in the MIE group and 46 (35–76) minutes in the RAMIE group (p = 0.02). There were three anastomotic leaks in each group (RAMIE 11% and MIE 10%). One patient died within 90 days of surgery in the MIE group. Conclusion In this study, the use of CSA during RAMIE for the reconstruction in Iwor-Lewis esophagectomy was feasible with comparable anastomotic leak rate as after MIE. The average duration of reconstruction was 6 minutes longer in the RAMIE group.

411. SINGLE-PORT THORACOSCOPIC RESECTION FOR THE SPINDLE CELL TUMOR OF ESOPHAGUS

Abstract Backgroud Single-port thoracoscopic for the huge spindle cell tumor of esophagusis is one of the most challenging surgeries. Here we reported a rare case of huge spindle cell tumor of esophagusis to explore the application of single-port thoracoscopic in esophageal resection. Methods A 61-year-old female was admitted due to swallow obstruction with breath tight for 1 month. The enhanced CT showed an irregular mass in the right posterior superior mediastinum close to the cephalic trunk, superior vena cava, right superior pulmonary artery and azygos vein, with tracheal and esophageal displacement. The differential diagnosis is potentially large, including lymphoma, lung cancer, bronchial cysts, esophageal tumors, etc. Ultimately we decided to use single-port thoracoscopic surgery for a biopsy or a complete resection of the tumor based on the intraoperative conditions. Results During the operation, we found that the tumor was located in the right posterior superior mediastinum and originated from the intrinsic muscular layer of the esophagus. The spindle cell tumor of esophagus resection by single-port thoracoscopic approach was carried out successfully. Pathological examination revealed esophageal leiomyoma. Conclusion The single-port thoracoscopic resection for the spindle cell tumor of esophagus is feasible and comprehensive.

197. FIBROSING MEDIASTINITIS CAUSING CONCOMITANT FOCAL STRICTURE AND TRACTION DIVERTICULA OF THE ESOPHAGUS

Abstract Background Fibrosing mediastinitis, also known as mediastinal fibrosis or sclerosing mediastinitis, is a rare condition caused by an excessive fibrosing reaction of the mediastinum. The clinical presentation of fibrosing mediastinitis varies based on the mediastinal structures involved, which can include the great vessels, airway, thoracic duct, phrenic nerve, or esophagus. We present a unique case of a patient with fibrosing mediastinitis causing dysphagia due to esophageal involvement with both focal esophageal stricture and multiple traction diverticula. Case Report: 82-year-old man with a past medical history of treated pulmonary tuberculosis in his 20s, Crohn’s colitis and gastroesophageal reflux disease presented to clinic with worsening dysphagia for the past few years with chronic dysphagia symptoms for the past 50 years. Barium esophagram demonstrated a stricture in the upper to mid esophagus and a corkscrew pattern of the mid-esophagus (Figure 1). Esophagogastroduodenoscopy demonstrated an esophageal stricture and multiple traction diverticula distal to the stricture. Computed tomography of the chest showed homogeneous soft tissue encasing the trachea and esophagus consistent with fibrosing mediastinitis. Serial dilation of the esophageal stricture was performed, but mucosal disruption was never achieved with no improvement in stricture diameter. The case was discussed in a multi-disciplinary conference where esophageal stenting was not felt to be feasible given multiple traction diverticula, and esophageal resection would be high risk given the fibrosing mediastinitis. Risks and benefits were discussed with the patient, and the patient opted to do dietary modifications as he did not have dysphagia on a pureed diet. Discussion Fibrosing mediastinitis is often idiopathic but can be due to infectious/inflammatory processes, sarcoidosis, or radiation exposure. The most common cause of fibrosing mediastinitis is prior infection with Histoplasma capsulatum. In this case, fibrosing mediastinitis from remote Mycobacterium tuberculosis infection resulted in a focal stricture and traction diverticula of the esophagus causing dysphagia. Barium esophagram revealed a corkscrew pattern of the esophagus, a pattern usually seen in diffuse esophageal spasm but was due to multiple traction diverticula. Fibrosing mediastinitis causing dysphagia is rare, and no prior reports in the literature describe a case causing concomitant esophageal stricture and traction diverticula in a patient.

447. PERIOPERATIVE OUTCOMES AFTER THORACOSCOPIC AND OPEN TRANSTHORACIC ESOPHAGECTOMY FOR CANCER

Abstract Background Surgery for esophageal cancer is complex and associated with considerable postoperative morbidity. Several strategies have been attempted to decrease morbidity after esophageal resection including enhanced recovery programmes, concentration of surgery in high-volume centres, and minimally invasive surgical approaches. Randomized trials showing superior perioperative outcomes with thoracoscopic esophagectomy have sometimes not been replicated in real-world studies. We compared our short-term outcomes including postoperative complications, morbidity and mortality after thoracoscopic and open transthoracic esophagectomy for cancer. Methods We performed a retrospective analysis of a prospectively maintained database of esophageal resections for cancer at a tertiary referral cancer centre between Oct 2003 and Dec 2022. Consecutive patients undergoing either thoracoscopic or open transthoracic esophagectomy (TTE) with a cervical anastomosis were included in the study. Operative time, blood loss, lymph node yield, postoperative morbidity and mortality after surgery were compared between the two groups. Categorical data were analysed using the chi square test and numeric data using the Student t test. A p value of 0.05 was considered statistically significant and no adjustment was made for multiple comparisons. Results A total of 3328 patients were operated for esophageal cancer between 1st October 2003 and 31st Dec 2022. 897 patients who underwent thoracoscopic and 1591 patients who underwent open TTE were included in the study. Comparison between the two groups on the different variables are shown in the table. On multivariable logistic regression analysis, extended radical lymphadenectomy, higher modified risk score and open thoracic approach were significantly associated with increased postoperative morbidity. Conclusion Our series of thoracoscopic esophagectomy, one of the largest in the world, validates the results of randomized trials in the real-world setting, with significant reductions in operative blood loss, ICU stay, postoperative pulmonary complications, wound infections, and major morbidity. Thoracoscopic approach remained an independent determinant of decreased postoperative morbidity.

491. VITAMIN B12 DEFICIENCY AFTER ONCOLOGICAL ESOPHAGECTOMY AND GASTRECTOMY

Abstract Vitamin B12 deficiency is common in patients with resections of the upper digestive tract and must be expected during follow-up examinations. While esophagectomy with gastric pull-ups preserve the duodenal passage and a large part of the stomach, (sub)total gastrectomies result in significant losses of gastric tissue and the common Y-Roux reconstruction bypasses the duodenal passage. This is a monocentric, retrospective, descriptive analysis of prospectively collected follow-up data. Between January 2015 and December 2019, 232 patients underwent an oncological (sub)total gastrectomy or esophagectomy. After applying the exclusion criteria (patient below 18, primary bone marrow disease, hereditary forms of anemia, postoperative tumor recurrence, R1/R2 situation), 157 patients remained for analysis: 103 patients (=66%) with esophagectomy (ER) and 54 (=34%) with (sub)total gastrectomy (SGE). Vitamin B12 levels were analyzed three, six, twelve, 18, and 24 months after the surgery. Prophylactic intramuscular vitamin B12 substitution (Erycytol 1 mg depot) was routinely prescribed quarterly only in patients with a total gastrectomy. After 3 postoperative months the incidence of vitamin B12 deficiency were 24% in the ER group vs. 5% (p = 0,064) in the SGE group; 17% vs. 10% (p = 0.4) after 6 months; 8% vs. 5% (p = 0.65) after 1 year; 10% vs. 10% (p = 0.83) after 18 months, and 12.5% vs. 39% (p = 0.022) after 2 years. The resulted incidence of hyperchromic macrocytic anemia is furtherly discussed in the abstract entitled ‘Types and incidence of postoperative anemia after oncological esophageal and gastric resections’. Comparing the total gastrectomy versus subtotal gastrectomy subgroups, patients with a subtotal gastrectomy have higher vitamin B12 deficiency incidences throughout the 24-month follow-up period. The human body physiologically provide a sufficient vitamin B12 storage for minimum 6–9 months. The high incidence of vitamin B12 deficiency in the ER group in the first 6 postoperative months might be due to a pre-existing vitamin B12 deficiency. After the 6th postoperative month there is an approximation between the Vitamin B12 deficiency incidences of ER and (S)GE patients. In the final 2-year follow-up, the incidence of vitamin B12 deficiency was significantly higher in the (S)GE group.

492. TYPES AND INCIDENCE OF POSTOPERATIVE ANEMIA AFTER ONCOLOGICAL ESOPHAGECTOMY AND GASTRECTOMY

Abstract According to current literature, anemias that develop after oncological esophageal and gastric resections are classified as deficiency anemias. Due to the surgery-related changes in the mechanical and biochemical conditions of the upper gastrointestinal tract, there is an alteration in the processing and absorption of hematopoietic-relevant vitamins and trace elements like iron, vitamin B6, vitamin B12, folic acid, copper and essential amino acids in the postoperative phase. Between January 2015 and December 2019, 232 patients underwent a (sub)total gastrectomy or esophagectomy at our center. In this monocentric retrospective analysis of prospectively collected follow-up data, 157 patients were included after applying the exclusion criteria: Age below 18, primary bone marrow disease, hereditary forms of anemia, postoperative tumor recurrence and R1/R2 situation. 103 patients (=66%) belonged to the esophagectomy group and 54 patients (=34%) to the (sub)total gastrectomy group. Preoperatively and three, six, twelve, 18, and 24 months postoperatively the following laboratory parameters were collected and descriptively analyzed: Hemoglobin, MCV, MCH, serum iron, ferritin, transferrin, and vitamin B12. Two years after the oncological resection 28% of patients with esophagectomy, EE, and 48% of patients with (sub)total gastric resection, (S)GE, show anemia. Normocytic anemia was the dominant type. The MCV distribution of anemic patients in the EE group was as follows: 3% microcytic, 77% normocytic, and 20% macrocytic. The anemic patients in the (S)GE group show the following MCV distribution: 16% microcytic, 81% normocytic, and 3% macrocytic. The (S)GE collective has more anemic patients in percentage terms than the EE collective throughout the whole follow-up period. This difference is significant at the 12th (p = 0.032) and 18th-month (p = 0.023) postoperative follow-up. A high percentage of patients with oncological resection of the upper gastrointestinal tract have a relevant postoperative anemia. The known postoperative iron and vitamin deficiencies, that would be associated with microcytic hypochromic and macrocytic hyperchromic anemia, are not the relevant causes for this anemia as it is predominantly a normocytic form. Normocytic anemia is an indication for an anemia of chronic disease. The reason for the predominance of normocytic anemia is not specifically known.

450. LINEAR STAPLED TECHNIQUE FOR ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY AND GASTRECTOMY: TECHNIQUE, STEPWISE INTRODUCTION, REPRODUCIBILITY AND OUTCOMES

Abstract Background Robotic-assisted surgery (RAS) for esophagectomy and gastrectomy is gaining in popularity. Compared to open oesophagectomy and conventional minimally invasive techniques, RAS is associated with decreased rates of complications, increased harvested lymph nodes and shorter length-of-stay. However, high anastomotic leak rates (20–27%) have been seen within randomised trials and case series, with up to 50% early in some published series. We present our technique and results of the staged introduction of a linear anastomosis. Methods The technique was initially developed by a single surgeon at open surgery; then adapted to thoracoscopic surgery and finally reproduced at RAS by several surgeons across two centres. Using a prospectively maintained database we reviewed the first forty-two cases utilising a modified linear anastomosis technique for oesophageal anastomosis. Outcomes, with particular focus on the anastomosis were reviewed. We also describe in detail the technical steps involved in our technique for a side-to-side linear semi-mechanical stapled anastomosis using a tri-stapler, with a 2-layer V-lock closure of the common enterotomy, during robotic surgery (video https://www.dropbox.com/s/ljf3zmuy68qry7b/Anastomosis%20technique_Short_Sound.mp4?dl=0). Results Forty patients had a two-stage esophagectomy, one with colonic reconstruction, and two, total gastrectomy. Median age was 62 (range 47–85). 93% (39/42) were adenocarcinomas, the remainder were squamous cell carcinomas. The anastomosis was performed via an open approach in the initial 11, thoracoscopically in 4, then robotically in 27 (including the two gastrectomies). The first 20 anastomoses were performed by one surgeon, who then taught four others. Two grade I anastomotic leaks occurred (4.7%), both were treated conservatively. There was no 30-, 90-day, or in hospital mortality. Non-anastomotic complications occurred in 14/42 (33.3%) of patients, most commonly respiratory (5/42, 11.9%). Conclusion We report a reproducible technique for semi-mechanical linear stapled anastomosis and its safe introduction into esophageal and gastric resections, including RAS. Anastomotic leak rates are below the internationally reported rates, even in the early phase of its introduction in open, thoracoscopic and RAS. With good training and mentorship this may help more centres safely introduce a RAS esophago-gastric programme, improve patient outcomes and reduce length of stay.

227. RELATIONSHIP BETWEEN 90-DAY PROGNOSIS NUTRITIONAL INDEX AND INFLAMMATORY RESPONSE MARKERS AND LONG-TERM SURVIVAL IN ESOPHAGEAL CANCER

Abstract Background The incidence rate of esophageal cancer in Asia is mainly squamous cell carcinoma, which is characterized by high mortality and poor prognosis. The prognosis of tumors is not only related to the biological characteristics of tumor cells, but also closely related to the nutritional status and inflammatory response of patients. The aim of this study is to investigate the relationship between nutritional index (PNI) and inflammatory response markers (NLR, LMR) at 90 days after surgery and long-term survival in patients with esophageal squamous cell carcinoma. To provide reference for accurately assessing the condition, identifying survival risks, and improving long-term prognosis. Methods The data of ESCC patients who underwent radical resection for esophageal cancer from April 2018 to November 2018 were extracted (n = 66). Calculate the prognostic nutritional index (PNI), neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR) and other indicators of patients at 90 days after operation. ROC was used to calculate the cut-off values of PNI, NLR, and LMR. KaplanMeier survival curve was used to analyze the relationship between different PNI, NLR, LMR levels and long-term survival of patients. All patients were followed up regularly after surgery, and the last follow-up time was April 2023. Results The best cut-off values of PNI, NLR, and LMR were 42.8, 3.27, and 4.76, respectively. Kaplan Meier survival analysis showed a correlation between postoperative PNI, NLR, LMR at 90 days and overall survival and disease-free survival. At 90 days after surgery, the OS (P = 0.007) and DFS (P = 0.038) of patients in the high PNI group (PNI ≥ 42.8) were better than those in the low PNI group; The OS (P = 0.002) and DFS (P = 0.048) of patients in the low NLR group (NLR &amp;lt; 3.27) were better than those in the high NLR group; The OS (P = 0.001) and DFS (P = 0.039) of patients in the high LMR group (LMR ≥ 4.76) were better than those in the low LMR group. Conclusions PNI, NLR, and LMR are important predictors of OS and DFS in patients with esophageal squamous cell carcinoma after radical resection of esophagus. Patients with PNI ≥ 42.8, NLR&amp;lt;3.27, and LMR ≥ 4.76 at 90 days after surgery have better OS and DFS.

471. MINIMALLY INVASIVE ESOPHAGECTOMY WITH RESECTION OF THE DESCENDING AORTA DUE TO SUSPECTED TUMOR INFILTRATION

Abstract Background Classically, esophageal neoplasms have had a poor survival, considering those T4b tumors that infiltrate the aorta, airways or vertebrae to be unresectable despite not having distant disease. With the advancement of surgical techniques, the improvement of neoadjuvant/adjuvant systemic treatments and the multidisciplinary approach to this pathology, these barriers of unresectability are gradually being broken. Methods This is a 68-year-old patient, a 1-pack-a-day smoker, who presented squamous cell carcinoma 30 cm from the dental arch treated with chemoradiotherapy according to the CROSS scheme. After surgery at another center, there is suspicion of infiltration of the descending aorta, for which he was referred to our center. The case is discussed in a multidisciplinary committee and a decision is made to place TEVAR in the first stage and surgical resection of the lesion in a second stage. Results The patient underwent surgery performing a three-stage esophagectomy (McKeown) using prone thoracoscopy without selective intubation, through which a regulated esophagectomy was performed with total lymphadenectomy and en bloc resection along with the anterior wall of the descending aorta where there was suspicion of tumor infiltration, exposing the aortic prosthesis (Photo 2). The prosthesis is covered to isolate it from possible sources of infection with a patch of pericardium fixed with loose sutures to the aortic wall and biological glue. It was reconstructed using a mediastinal gastroplasty with cervical circular mechanical anastomosis. Postoperative period marked by cervical leakage that was resolved by conservative treatment. Conclusion Resection using a minimally invasive approach of an aortic patch in cases of suspected tumor infiltration in esophageal neoplasms without systemic disease may be a safe therapeutic option as long as it is performed in centers specialized in complex esophageal resections and with a multidisciplinary team that also involves cardiac surgeons. The oncological prognosis must be evaluated in the long term, but achieving R0 resections should not be worse than in locally advanced resectable tumors.

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

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

Controversies in the surgical management of esophageal adenocarcinoma.

The incidence of esophageal adenocarcinoma (EAC) has risen dramatically over the last decade. Over this same period, our understanding and treatments have been revolutionized. Just over a decade ago, the majority of patients with locally advanced esophageal cancer went directly to surgery and our overall survival was bleak. Our current strategy for locally advanced esophageal adenocarcinoma is a multi-disciplinary approach. This approach consists of chemotherapy plus or minus radiation followed by surgical resection followed by adjuvant immunotherapy with the presence of any residual disease. Therefore, now more than ever, the goals of surgery are to minimize morbidity, provide aggressive local control and allow patients to receive to quickly recover so they can receive adjuvant systemic therapy. Surgery continues to play a crucial role in the multi-disciplinary approach to EAC. This review will highlight the on-going areas of controversy in surgical treatment. These controversies are around surgical selection, perioperative decision making and the role of surgery. Specifically, there are controversies in the type of surgical approach offered. This review will discuss the benefits of minimally invasive versus open esophagectomy. The indications for gastrectomy versus esophagectomy in patients with gastroesophageal junction EAC. Further, at the time of operation, there is still debate and on-going trials addressing the addition of a pyloric intervention. Lastly, as we push the limits of systemic therapy, there are those who may not even need a surgical resection. This review will cover the most recent data on selective esophageal resection and the concerns regarding this approach.

Skip metastasis at the esophageal resection margin in radical gastrectomy: clinical characteristics of 30 cases

Objective: To summarize the clinical characteristics of patients with skip metastasis at esophageal resection margin during radical gastrectomy. Methods: This is a descriptive study of case series. Relevant data from 2006 to 2022 were collected from two major gastric cancer consultation and treatment centers: Nanjing Drum Tower Hospital and Jinling Hospital.Characteristics, surgical approach, number of dissected lymph nodes, immunohistochemical staining, and pathological staging were summarized and analyzed. The distribution of residual tumor cells at the esophageal margins was further analyzed at the cellular and tissue levels. Skip metastasis at the esophageal resection margin was defined as a negative esophageal margin with a positive margin in the cephalad donut. Results: Thirty (0.33%, 30/8972) eligible patients, 24 (80.0%) of whom were male, were identified in the two centers. The mean age was 63.9±11.0 years. Seventeen (56.7%) of these patients had papillary or tubular adenocarcinomas, including 13 (43.3%) poorly- and four (13.3%) moderately-differentiated tumors; four (13.3%) had signet-ring cell carcinomas; four (13.3%) mucinous adenocarcinomas; three (10.0%) mixed adenocarcinomas, including two with poorly-differentiated tubular adenocarcinomas mixed with signet-ring cell carcinoma and mucinous adenocarcinoma; and one had a poorly differentiated tubular adenocarcinoma mixed with signet-ring cell carcinoma. Two patients (6.7%) had other types of cancer, namely adenosquamous carcinoma in one patient and undifferentiated carcinoma in the other one. The predominant tumor sites were the lesser curvature (n=26, 86.7%) and the cardia (n=24, 80.0%). The mean tumor diameter was 6.6 cm, mean distance between tumor and esophageal resection margin was 1.5 cm, and proportions of tumor invasion into the dentate line, nerves, and vessels were 80.0% (24/30), 86.7%(26/30), and 93.3% (28/30), respectively. The mean number of lymph nodes resected was 20.4±8.9. The pathological stage was mainly T4 (n=18, 60.0%) and N3 (n=21, 70.0%), the median Ki67 was 52.7%, and the rates of positivity for HER2, EGFR, VEGFR, E-cadherin and PD-L1 were 40.0% (12/30), 46.7% (14/30), 80.0% (24/30), 86.7% (26/30) and 16.7% (5/30), respectively. At the cellular level, cancer cells were mainly distributed in small focal areas, as cell masses, or as tumor thrombi; large numbers of widely distributed atypic cells were seldom observed. At the tissue level, cancer cells were located in the mucosal layer in seven patients (23.3%), in the submucosal layer in 18 (60.0%), and in the muscular layer in five (16.7%); no cancer cells were identified in the outer membrane. Five of the seven tumors were located in the lamina propria, two in the muscularis mucosae, and none in the mucosal epithelium. Conclusion: Patients with skip metastasis at the esophageal resection margin at radical gastrectomy have unfavorable tumor biology and a high proliferation index, are at a late pathological stage, and the residual cancer is mostly located in the submucosa.

Aggressive intraoperative warming and postoperative pulmonary complications in elderly patients recovering from esophageal cancer surgery: sub-analysis of a randomized trial.

Elderly patients having esophagectomies often become hypothermic which may promote complications. We tested the hypothesis that aggressive warming to a core temperature of 37°C reduces postoperative pulmonary complications (PPCs) in elderly patients having esophageal cancer resections. This study was a pre-defined sub-study of a multi-center, parallel group, superiority trial (PROTECT). Patients aged >65 years and having elective radical resection of esophageal cancer in a single center were randomly allocated into either aggressive warming group (target intraoperative core temperatures of 37°C) or routine thermal management group (target intraoperative core temperatures of 35.5°C). The primary endpoint was the incidence of PPCs. Secondary endpoints included duration of chest tube drainage and other postoperative complications. A total of 300 patients were included in the primary analysis. PPCs occurred in 27 (18%) of 150 patients in the aggressive warming group and 31 (21%) of 150 patients in the routine thermal management group. The relative risk (RR) of aggressive versus routine thermal management was 0.9 (95% CI: 0.5, 1.4; p = 0.56). The duration of chest drainage in patients assigned to aggressive warming was shorter than that assigned to routine thermal management: 4 (3, 5) days vs. 5 (4, 7) days; hazard ratio (HR) 1.4 [95% CI: 1.1, 1.7]; p = 0.001. Fewer aggressively warmed patients needed chest drainage for more than 5 days: 30/150 (20%) vs. 51/150 (34%); RR:0.6 (95% CI: 0.4, 0.9; p = 0.03). The incidence of other postoperative complications were similar between the two groups. Aggressive warming does not reduce the incidence of PPCs in elderly patients receiving esophagectomy. The duration of chest drainage was reduced by aggressive warming. But as a secondary analysis of a planned sub-group study, these results should be considered exploratory. https://www.chictr.org.cn/showproj.aspx?proj=37099, ChiCTR1900022257.

Esophageal reconstruction as the first step for treating secondary aortoesophageal fistula due to thoracic endovascular aortic stent infection

BackgroundThe surgical strategy for aortoesophageal fistula (AEF) depends on the experience of each surgeon, and there is no consensus on the strategy to be adopted. We propose our two-stage operation compromising esophagectomy and reconstruction as the first step and in situ aortic graft replacement as the second step after 7 days for treating AEF secondary to thoracic aortic stent graft infection.Case presentationA diagnosis of AEF was made in a 70-year-old man with a history of multiple aortic interventions. The patient underwent esophageal resection and reconstruction with a pedicled stomach roll endoscopically in the right thoracic cavity. Postoperatively, enteral feeding was resumed via a feeding tube placed in the jejunum to maintain adequate nutritional status. There was no evidence of either anastomotic leakage or necrosis. Seven days later, the patient underwent removal of the infected stent graft and in situ graft replacement via a redo left thoracotomy. After the surgery, the patient was able to start oral intake relatively early. Although more than 6 months has passed since the patient was discharged, no recurrence of infection has been observed.ConclusionsThe benefit of our strategy is the radical treatment for secondary AEF and the early resumption of oral intake.

18F-FDG-PET/CT to Detect Pathological Complete Response After Neoadjuvant Treatment in Patients with Cancer of the Esophagus or Gastroesophageal Junction: Accuracy and Long-Term Implications

Purpose The curative strategy for patients with esophageal cancer without distant metastases consists of esophagectomy with preceding chemo(radio)therapy (CRT). In 10–40% of patients treated with CRT, no viable tumor is detectable in the resection specimen (pathological complete response (pCR)). This study aims to define the clinical outcomes of patients with a pCR and to assess the accuracy of post-CRT FDG-PET/CT in the detection of a pCR.MethodsFour hundred sixty-three patients with cancer of the esophagus or gastroesophageal junction who underwent esophageal resection after CRT between 1994 and 2013 were included. Patients were categorized as pathological complete responders or noncomplete responders. Standardized uptake value (SUV) ratios of 135 post-CRT FDG-PET/CTs were calculated and compared with the pathological findings in the corresponding resection specimens.ResultsOf the 463 included patients, 85 (18.4%) patients had a pCR. During follow-up, 25 (29.4%) of these 85 patients developed recurrent disease. Both 5-year disease-free survival (5y-DFS) and 5-year overall survival (5y-OS) were significantly higher in complete responders compared to noncomplete responders (5y-DFS 69.6% vs. 44.2%; P = 0.001 and 5y-OS 66.5% vs. 43.7%; P = 0.001). Not pCR, but only pN0 was identified as an independent predictor of (disease-free) survival.ConclusionPatients with a pCR have a higher probability of survival compared to noncomplete responders. One third of patients with a pCR do develop recurrent disease, and pCR can therefore not be equated with cure. FDG-PET/CT was inaccurate to predict pCR and therefore cannot be used as a sole diagnostic tool to predict pCR after CRT for esophageal cancer.