Open Esophagectomy Research Articles

Continuous Epidural Versus Non-Epidural Pain Management After Minimally Invasive Esophagectomy: A Real-Life, High-Case-Load Center Experience.

Background/Objectives: Esophagectomy is a key component of esophageal cancer treatment, with minimally invasive esophagectomy (MIE) increasingly replacing open esophagectomy (OE). Effective postoperative pain management can be achieved through various analgesic modalities. This study compares the efficacy of thoracic epidural anesthesia (TEA) with non-TEA methods in managing postoperative pain following MIE. Methods: A retrospective review was conducted on 110 patients who underwent MIE between 2018 and 2023. 1. TEA vs. 2. intravenous patient-controlled analgesia (PCA) alone vs. 3. transversus abdominis plane (TAP) catheter with PCA vs. 4. single-shot TAP block with paravertebral catheter (PVB) in combination with PCA were compared. The primary outcome was postoperative pain within the first 72 h, assessed using the numeric rating scale. Secondary outcomes included postoperative surgical complications (Clavien-Dindo classification (CDC)), patient satisfaction, and duration of induction and emergence, among others. Results: The incidence of an NRS > 3 during movement was 47.1%, 51%, 60.1%, and 48.3% for TEA, PCA alone, TAP + PCA, and PVB + PCA, respectively. For pain at rest, the rates were 8.3%, 4.3%, 11.2%, and 5%, respectively. High surgical complication rates were observed across all groups (CDC IIIa-V 31.6% overall), with patient satisfaction similarly high, regardless of the analgesic modality used (85% satisfied or very satisfied). No differences in the other secondary outcomes were observed. Conclusions: PVB combined with PCA offered analgesic efficacy and patient satisfaction comparable to TEA in managing postoperative pain following MIE.

OGC SO17 - Right lateral approach to left gastric pedicle and Usage of articulated Signia Tri-stapler in Laparoscopic abdominal phase of a 2-stage Oesophagectomy

Abstract Background Advancements in oesophagectomy surgery over the past decade has seen an increase in minimally invasive oesophagectomies (MIE) being performed. Studies showed MIE had considerable advantages over open oesophagectomy by reducing intraoperative blood loss and post-operative complications while maintaining similar oncological outcomes1. In the abdominal phase of the Ivor-Lewis 2-stage oesophagectomy, a posterior approach is commonly used to dissect posterior gastric and left gastric vessels2. Method A 40-year-old patient with early malignant lesion underwent laparoscopic 2-stage oesophagectomy. In this video, we demonstrate using a right lateral approach to access and divide the left gastric vein and artery. Lymphadenectomy of stations 7 and 8a was also completed. A pyloroplasty is performed along with fashioning a gastric conduit using an articulated Signia tri-stapler, a smart stapler that adapts in real-time to tissue variability. Results The right lateral approach is superior to the more commonly used posterior lesser sac approach as it provides visuals of key vessel structures and spleen thereby reducing the risk of injury and bleeding. In the second stage, the Signia tri-stapler allows precise manoeuvres with fully powered articulation, rotation, and clamping, resulting in consistent staple lines and stronger staple lines. Conclusion Oesophagectomies remain a highly technical surgery with varied practices across centres and we would like to propose using a right lateral approach and articulated tri-stapler as a better technique that would reduce risk of bleeding and leaks.

MS O09 - OGC Long-term oncological outcomes following totally minimally invasive, hybrid and open oesophagectomy for cancer

Abstract Background There has been a significant shift in the surgical management of oesophageal cancer, with increased popularity of minimally invasive oesophagectomy in comparison to open approaches. Data thus far has largely focused on the peri-operative and short-term benefits with limited study on long-term oncological outcomes. This study aims to explore patterns of oesophageal cancer recurrence and survival following minimally invasive and open oesophagectomy. Method This was a retrospective review of consecutive patients who underwent open (OO), hybrid (HO) and minimally invasive (MIO) oesophagectomy for cancer at a regional oesophago-gastric centre in the UK between 2014-2023. Follow-up data was obtained from the centre’s established surgical database, in addition to the regional radiology, MDT and electronic patient records to record survival, recurrence, and patterns of recurrence (locoregional, haematological, distal nodal, peritoneal and number of recurrence sites). Results 437 patients (170 OO; 132 HO; 135 MIO) were included. There was no difference in baseline data between the groups. Overall survival rates at 1-, 3-, and 5-year were 88%, 64% and 54%. Recurrence rates at 1-, 3-, and 5-year were 17%, 35% and 41%. Haematological and locoregional recurrence made up 37% and 33% of all recurrence types. 52% of patients had one type of recurrence at diagnosis. After adjusting for disease stage, there was no significant difference between operative approaches with respect to survival and recurrence rates (at 1,3 and 5 years), time to recurrence, or patterns of recurrence. Conclusion This study found no significant difference in long-term oncological outcomes when comparing different minimally invasive and open surgical approaches to oesophagectomy. MIO can continue to be offered to patients as a safe alternative to open surgery. Further multi-centre prospective research is required to validate these results.

OGC SO46 - Improving outcomes after oesophagectomy: The benefits of full robotic-assisted minimally invasive oesophagectomy (RAMIO) demonstrated in the first 100 cases, at a high-volume UK unit

Abstract Background There is a rapid movement towards adoption of robotically assisted minimally invasive oesophagectomy (RAMIO) in the United Kingdom. Transition from an open or laparoscopic oesophagectomy to a RAMIO programme, which carries considerable financial and training cost, must ensure parity of oncological and perioperative outcomes. We sought to compare our centre’s results of the three standard approaches to two-phase oesophagectomy: Open/Open (Open); laparoscopic/robotic abdomen with open chest (Hybrid); and RAMIO. Method This prospective cohort study investigated the experience of five surgeons in a single high-volume UK institution. We analysed consecutive patients undergoing two-phase transthoracic oesophagectomy for oncological reasons between 2018 and 2024. The study period was divided into three cohorts: Open (2018-2020, n=61), Hybrid (2020-2023, n=82) and RAMIO (2023-2024, n=100). Patient demographics, tumour characteristics, perioperative outcomes, and oncological data were compared. Data were analysed using Kruskal-Wallis and Chi-squared statistical tests. Results No significant differences were observed in patient demographics or tumour stage between the groups. Comparison of Open vs. Hybrid vs. RAMIO demonstrated a significant reduction in major complications (Clavien-Dindo ≥III), 34.4% vs. 23.2% vs. 14% (p=0.0014); pulmonary complications, 36.1% vs. 25.4% vs. 13% (p=0.0004); anastomotic leak rate, 11.5% vs. 2.4% vs. 4.0%, (p=0.0370); median length of stay, 14 vs. 12 vs. 8 days (p=0.0001); and mortality, 4.9% vs. 1.2% vs. 0% (p=0.0133) all favouring the RAMIO group in sub-group analysis. Median lymph node yields were comparable across groups, 49 vs. 43 vs. 43 (p=0.0876). Conclusion This single-institution study demonstrates potential benefits of transitioning from open or hybrid to RAMIO for oesophagectomy. RAMIO was associated with significantly reduced pulmonary complications, major complications and a shorter length of hospital stay. Oncological outcomes were maintained across all 3 techniques. These findings have important patient, financial, and resource implications, and support the continued adoption of RAMIO in the UK.

Survival comparison between open and thoracoscopic esophagectomy for node-negative esophageal squamous cell cancer: an ambispective cohort study.

It is controversial whether there is a survival difference between open esophagectomy (OE) and thoracoscopic esophagectomy (TE) for esophageal cancer (EC). Therefore, this study aimed to compare the differences in survival and safety between two surgical approaches in patients with node-negative esophageal squamous cell carcinoma (ESCC). This ambispective cohort study included 1104 patients with node-negative ESCC who received OE or TE treatment at a Grate-A tertiary hospital in Henan Province between January 2015 and December 2016. The primary endpoint was 5-year overall survival (OS) and disease-free survival (DFS), and the secondary endpoint was surgical safety. Multivariable Cox regression analysis was used to analyze the effect of surgical approaches on OS and DFS, and propensity score matching (PSM) was performed to match confounding factors between two groups. Patients were followed up ranged from 1.03 to 91.60months, with a median follow-up time of 67.37months. Kaplan-Meier survival analysis showed statistically significant differences between OE and TE in OS (70.05% vs 83.73%, P < 0.001) and DFS (67.15% vs 77.76%, P < 0.001). Furthermore, multivariate Cox regression analysis also demonstrated significant differences in long-term survival between the two groups (OS, HR (95%CI): 0.54 (0.41,0.70); DFS, HR (95% CI): 0.68 (0.54, 0.86)). TE was associated with a reduction in intraoperative bleeding (median: 100ml vs. 200ml, P < 0.001), and an increase in the number of lymph nodes dissection (median: 23 vs. 28, P < 0.001). Similar results were found after PSM. In a selected cohort of patients with node-negative ESCC, TE surgical treatment was safer and had better long-term survival outcomes compared to OE. This provided corresponding clinical guidance to enhance survival benefits for patients. In the future, we hope to further explore the reasons for TE achieving higher survival rates.

Comparative Analysis of Surgical Outcomes in Hybrid and Open Esophagectomy for Esophageal Cancer: A Regional Russian Cancer Centre Experience.

Surgery is pivotal in treating esophageal cancer; hybrid esophagectomy, which combines minimally invasive and open techniques, shows promising outcomes. This historical cohort study compared the surgical outcomes of standard open esophagectomy with hybrid esophagectomy. Overall, 58 patients who underwent either hybrid or open esophagectomy at the Ulyanovsk Regional Clinical Oncology Clinic, Russia, from January 2015 to December 2023 were included. Data on demographics, surgical details, and postoperative outcomes were analyzed. The primary measures were overall complications and anastomotic leakage rates. Statistical analysis was performed using Pearson's Chi square test and t test via StatTech software (version 2.8.8). The number of removed lymph nodes was higher in the hybrid group (24±9) than in the open group (15±7) (P<0.001). In addition, the hybrid esophagectomy group showed significant reductions in operational time and blood loss (P<0.001 and P=0.014, respectively). The need for blood transfusion was higher in the open esophagectomy group (P=0.043). The postoperative length of stay in the hospital did not differ significantly between the two groups (open=20±8 days, hybrid=17±7 days, P=0.178). Cardiac complications were more frequent after an open esophagectomy (P=0.044). Hybrid esophagectomy reduced postoperative cardiac complications and other adverse events while maintaining satisfactory oncological outcomes. It had advantages over standard open esophagectomy in terms of lymphadenectomy, operative time, blood loss, and transfusion requirements, suggesting its efficacy for esophageal cancer patients.

The Prognostic Impact of Minimally Invasive Esophagectomy on Survival After Esophagectomy Following a Delayed Interval After Chemoradiotherapy: A Secondary Analysis of the DICE Study.

To evaluate prognostic differences between minimally invasive esophagectomy (MIE) and open esophagectomy (OE) in patients with surgery after a prolonged interval (>12wk) following chemoradiotherapy (CRT). Previously, we established that a prolonged interval after CRT before esophagectomy was associated with poorer long-term survival. This was an international multicenter cohort study involving 17 tertiary centers, including patients who received CRT followed by surgery between 2010 and 2020. Patients undergoing MIE were defined as thoracoscopic and laparoscopic approaches. A total of 428 patients (145 MIE and 283 OE) had surgery between 12 weeks and 2 years after CRT. Significant differences were observed in American Society of Anesthesiologists grade, radiation dose, clinical T stage, and histologic subtype. There were no significant differences between the groups in age, sex, body mass index, pathologic T or N stage, resection margin status, tumor location, surgical technique, or 90-day mortality. Survival analysis showed MIE was associated with improved survival in univariate ( P =0.014), multivariate analysis after adjustment for smoking, T and N stage, and histology (HR=1.69; 95% CI: 1.14-2.5) and propensity-matched analysis ( P =0.02). Further subgroup analyses by radiation dose and interval after CRT showed survival advantage for MIE in 40 to 50Gy dose groups (HR=1.9; 95% CI: 1.2-3.0) and in patients having surgery within 6 months of CRT (HR=1.6; 95% CI: 1.1-2.2). MIE was associated with improved overall survival compared with OE in patients with a prolonged interval from CRT to surgery. The mechanism for this observed improvement in survival remains unknown, with potential hypotheses including a reduction in complications and improved functional recovery after MIE.

471. MANAGEMENT OF EARLY ESOPHAGEAL CANCER - A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract Background and Objectives Optimal surgical management for early oesophageal cancer remains controversial. We aimed to perform a network meta-analysis (NMA) of studies comparing outcomes after open esophagectomy (OE), minimally invasive esophagectomy (MIE), endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for early oesophageal cancer. Methods A systematic search of electronic databases was undertaken. A network meta-analysis was performed as per PRISMA-NMA guidelines. Statistical analysis was performed using R and Shiny. Results 21 studies including 10,002 patients with stage Tis, T1a or T1b oesophageal carcinoma were included. Overall, 3,103 patients underwent ESD (31%, 3103/10,002), 6,191 underwent OE (61.9%, 6,191/10,002), 502 underwent EMR (5.2%, 502/10,002) and 206 underwent MIE (2.1%, 206/10,002). At NMA, at approximately 3.5 years follow up, there was a significant difference in recurrence rates of Tis, T1a or T1b disease following OE (odds ratio (OR): 0.32, 95% CI 0.12 – 0.83) as compared to EMR. Compared to ESD, estimated 5 year overall survival for Tis, T1a and T1b disease were equivocal following OE and EMR respectively (OR: 0.98, 95% CI 0.66 – 1.44), (OR: 0.88, 95% CI 0.38-2.04). When compared with ESD, superior resection rate was observed in OE (OR: 4.04 95% CI 2.56, 6.37) and MIE (OR: 16.49, 95% CI 2.19, 123.86). OE had the highest rate of pulmonary complications. Compared with ESD, pulmonary complications were significantly different to those who underwent OE (OR: 4.06, 95% CI 2.28 – 7.22). OE had the highest rate of recurrent laryngeal nerve injury, post operative ileus and procedure specific mortality as compared to ESD, EMR and MIE which was not found to be significantly different at NMA. ESD and EMR exhibited advantages over OE and MIE in certain procedural aspects including procedure duration, length of hospital stay and cost. Conclusions OE was associated with superior surgical outcomes compared to ESD. Disease recurrence was also higher in EMR compared to OE with improved cost-effectiveness for ESD and EMR. ESD demonstrated reduce morbidity as compared to OE. Considering these results, OE, MIE, ESR and EMR are all feasible options for primary early oesophageal cancer, contingent on surgeon and institutional expertise.

618. A COMPARISON OF HEALTH-RELATED QUALITY OF LIFE AT ONE YEAR FOLLOWING MINIMALLY INVASIVE VERSUS OPEN ESOPHAGECTOMY

Abstract Introduction Minimally invasive esophagectomy (MIE) is being increasingly adopted in the surgical management of esophagogastric cancer. While equivalent clinical and oncological outcomes have been demonstrated in comparison with open resections, differences in health-related quality of life (HR-QOL) between the 2 modalities into survivorship remains unclear. The aim of this study was to determine the differences in HR-QOL between MIE and open esophagectomies (OE) at 1 year post-resection. Methods Consecutive patients undergoing an esophagectomy at a single, U.K based tertiary referral centre for esophagogastric cancer between January 2018 – December 2022 were evaluated. MIE was defined as utilisation of laparoscopic, thoracoscopic or robotic access for at least one phase of an esophagectomy. HR-QOL at 1 year following surgery was measured using the validated European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ-C30) and esophagogastric cancer module (QLQ-OG25) and compared between groups. Results A total of 28 patients undergoing MIE and 25 patients undergoing OE were included. No statistical difference was noted in mean global HR-QOL between the OE and MIE cohorts at 1 year (69.33±19.50 vs 64.88±22.05; p=0.66). No statistically significant intergroup differences between OE versus MIE were observed at 1 year in physical functioning (82.67±16.89 vs 79.05±24.39; p=0.97) or role functioning (73.33±29.27 vs 67.86±32.37; p=0.60) domains. Similarly, no difference was observed in symptoms of nausea/vomiting (10.67±18.17 vs 8.93±14.69; p=0.56), pain (29.33±25.56 vs 26.79±33.44; p=0.26) or fatigue (29.78±25.40 vs 37.70±30.44; p=0.44). Conclusion HR-QOL remains comparable between MIE and OE at 1 year. Patient-reported outcomes must be assessed in the long-term to determine if minimally invasive approaches confer HR-QOL improvements well into survivorship.

Long-term Survival in Esophageal Cancer: Comparison of Minimally Invasive and Open Esophagectomy

BackgroundThoracoscopic esophagectomy is a less invasive surgical procedure; however, evidence of its effect on long-term survival is limited. We evaluated long-term survival after the procedure in patients with esophageal carcinoma. MethodsThis retrospective multicenter study involved 1559 consecutive patients with esophageal carcinoma who underwent thoracoscopic esophagectomy or open esophagectomy between 2012 and 2019 at 2 Japanese high-volume cancer centers. Propensity score matching analysis was performed to compare short- and long-term outcomes. In addition, stage-specific survival rates were compared between the groups. ResultsThere were 313 patients who were matched and analyzed. The 1-, 3-, and 5-year overall survival rates were 84.5%, 60.5%, and 52.1%, respectively, in the matched open esophagectomy group; and 87.2%, 68.6%, and 61.8%, respectively, in the matched thoracoscopic esophagectomy group. The weighted Cox regression model showed significantly better survival in the thoracoscopic esophagectomy group than in the open esophagectomy group (hazard ratio, 0.74; 95% CI, 0.582-0.941). Deaths from other causes occurred more frequently in the open esophagectomy group than in the thoracoscopic esophagectomy group. Stratified analysis showed no significant survival differences between clinical stage I or II and pathologic stage 0 or I subgroups. However, the thoracoscopic esophagectomy groups with clinical stage III or IV and pathologic stage II, III, or IV had significantly better overall survival. ConclusionsThis study demonstrated the survival benefits of thoracoscopic esophagectomy, particularly for highly advanced esophageal carcinoma.

258. SHORT-TERM OUTCOMES AFTER ESOPHAGECTOMY ANALYZED USING NATIONAL CLINICAL DATABASE IN JAPAN

Abstract Esophagectomy for esophageal cancer is a highly invasive procedure in gastrointestinal surgery. The National Clinical Database (NCD) of Japan starting data collection in 2011 has accumulated real world data of esophagectomy, one of the main nine gastroenterological surgeries for which detailed input items have been required for the evaluation of surgical mortality and postoperative complications. We herein reviewed the short-term outcomes after esophagectomy analyzed by Japanese nationwide big database. Many studies on esophagectomy, including investigations of quality indicators, feasibility of minimally invasive surgery, and various patients’ conditions, have been conducted using NCD. The validation of certification systems by the Japanese Society of Gastroenterological Surgery (JSGS) and the Japan Esophageal Society (JES) revealed that the institute’s certification had greater influence on short-term surgical outcomes than the operating surgeon’s certification. Minimally invasive esophagectomy (MIE) can replace open esophagectomy (OE). MIE performed with no preoperative treatment was associated with significantly less incidence of any pulmonary morbidities, prolonged ventilation 48hours, unplanned intubation, surgical site infection, and sepsis. The total surgery-related mortality rates of MIE and OE were 1.7% and 2.4%, respectively (P &amp;lt; 0.001). The operative mortality in the elderly group with residual tumors increased to more than twice than that in the non-elderly groups (15.9 vs. 5.5 or 6.5%) and was much higher than that in elderly patients without residual tumors (15.9 vs. 4.6%). Careful selection is important for the treatment of elderly patients with highly advanced tumors to avoid unfavorable short-term outcomes. Thus, the NCD has contributed to quality assessment and improvement of surgery by feedback of accurate data in Japan.

225. LONG-TERM ONCOLOGIC OUTCOMES OF ROBOT-ASSISTED VERSUS CONVENTIONAL OPEN ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: PROPENSITY-SCORE MATCHED ANAYLSIS

Abstract Background This study aimed to compare the long-term oncologic outcomes of robot-assisted minimally invasive esophagectomy (RAMIE) with those of conventional open esophagectomy (OE) for esophageal cancer. Methods Between January 2006 and December 2021, 1,745 consecutive patients underwent esophagectomy for esophageal cancer at our institution. Among them, we retrieved 1,133 patients (mean age 63.1±7.8 years, 86 [7.6%] women, 1,100 [97.1%] squamous cell carcinomas), who were operated by a single surgeon. These patients were categorized into following two groups based on their surgical approaches: RAMIE (n = 497) and OE (n = 636). The RAMIE and OE groups were matched in a 1:1 ratio using propensity scores. Results Median follow-up was 51.8 months. Five-year overall survival (OS, 70.7% vs. 55.0%) and recurrence-free survival (RFS, 63.3% vs. 50.1%) rates were significantly higher in RAMIE than in OE group (P &amp;lt; 0.01). Following propensity-score matching, 886 patients (443 pairs) were successfully matched, demonstrating no significant intergroup differences. The RAMIE group consistently demonstrated enhanced OS (70.4% vs. 61.8%, P &amp;lt; 0.01) and RFS (62.8% vs. 55.8%, P=0.04) after five years, even after adjustment (Figure). The rate of noncancer mortality was significantly higher in the OE group (P &amp;lt; 0.01), whereas the esophageal cancer-related mortality showed no significant differences (P = 0.25). Conclusions RAMIE could be a safer and more feasible option for patients compared with conventional open esophagectomy with favorable long-term oncologic outcomes.

261. CONVERSION ESOPHAGECTOMY FOR CT4B ESOPHAGEAL CANCER - MIE VS OPEN -

Abstract Background and Aims The standard treatment for locally advanced unresectable esophageal cancer is definitive chemoradiotherapy (dCRT), however, after induction chemotherapy with a triplet chemotherapy regimen (docetaxel, cisplatin, and 5-FU: DCF) or dCRT, conversion surgery could be performed if esophageal cancer is considered resectable. Furthermore, minimally invasive surgery such as robot-assisted or thoracoscopic procedures are expected to improve the outcome of patients with advanced esophageal cancer. We investigated the feasibility of minimally invasive esophagectomy (MIE) in conversion surgery. Materials and Methods Sixty-six patients who underwent conversion thoracic esophagectomy for cT4b esophageal cancer from 2007 to 2023 were included. The short-term outcomes of 25 open esophagectomy group and 41 MIE group (8 robot-assisted and 33 thoracoscopic) were compared. Results No differences in age, gender, PS, tumor location, histology, cN, or cM were observed between the two groups. cT4b organs tended to be in the airway in the MIE group (airway 70.7% vs 44%, major vessels 19.5% vs 24%, both 9.7% vs 32%, p=0.04) and DCF therapy was significantly performed in the MIE group for induction therapy (DCF 87.8% vs 56%, dCRT 12.2% vs 44%, p&amp;lt;0.001). On the other hand, salvage surgery was significantly associated with open esophagectomy (24.3% vs. 52%, p=0.003). There was no difference in surgical outcomes regarding thoracic operation time (157 min vs. 180 min, p=0.09), whereas the total operation time was significantly shorter in the MIE group (392 min vs. 439 min, p=0.02). Blood loss was significantly lower in the MIE group (79 ml vs. 470 ml, p&amp;lt;0.001), and R0 resection rate did not differ (82.9% vs. 72%, p=0.357). There were no significant differences in postoperative complications including pneumonia (26.8% vs. 44%, p=0.183) and recurrent nerve palsy (21.9% vs. 36%, p=0.260), but anastomotic leakage was significantly lower in the MIE group (4.8% vs. 24%, p=0.04). There was no difference in median postoperative hospital stay (16 [11-20] vs. 16 [14-29] days), however, median ICU stay (3 [3-4] vs. 4 [3-4] days, p=0.03) and readmission within 1 month after discharge (2.4% vs. 16%, p=0.04) were significantly lower in the MIE group. In-hospital mortality was observed in 1 case in the MIE group and 3 in the open esophagectomy group. Conclusion Despite the bias associated with the transition of treatment modalities and surgical techniques, MIE may contribute to improved short-term outcomes in conversion surgery.

294. LEARNING CURVE OF MINIMALLY INVASIVE ESOPHAGECTOMY: OUR SERIES, SYSTEMATIC REVIEW OF THE LITERATURE AND META-ANALYSIS

Abstract Background Minimally invasive esophagectomy has demonstrated non-inferiority in terms of surgical and oncologic outcomes compared with open esophagectomy, with better short-term outcomes. The learning curve of this procedure is protracted before a plateau of ideal results is reached. The purpose of this study is to evaluate the safety and efficacy of implementing a totally minimally invasive esophagectomy program for cancer in a high-volume center and the impact of the learning curve on perioperative and oncologic outcomes. Methods This is a retrospective non-randomized control study. The study includes 199 patients who underwent surgery from June 2018 to October 2022. Patients undergoing MIE were assigned to the “MIE group” (n=61), while those undergoing Open Esophagectomy to the “OE group” (n=138). By comparing the perioperative and oncological outcomes between the two groups, we assessed the safety and efficacy of the MIE. Subsequently, the MIE group was divided into two subgroups: Early Experience (“EE”) and Late Experience (“LE”) group. By comparing the perioperative surgical outcomes between these two groups we evaluated the presence and the impact of a learning curve. Results Although longer surgical duration (p&amp;lt;0.001), MIE did not compromise surgical radicality (same rate of R0, p=0.345 and higher number of lymph node yields p&amp;lt;0.001). We observed a learning curve effect on postoperative outcomes, with decreasing complication rates (61% vs. 36.7%, p=0.054), and shorter ICU stay (1.6 ± 2.4 vs. 0.6 ± 1.5, p=0.049) and faster recovery in the LE group (19.6 ± 19.8 vs. 12.2 ± 5.9, p=0.055). Analysis of CUSUM plots reveals a decrease in total ICU and recovery starting with patient number 25. A meta-analysis confirms a trend towards lower anastomotic leak rates as the learning curve progresses. Conclusion The findings of this study support the safety and efficacy of implementing a totally MIE program for cancer in a high-volume center. The outcomes are not impaired by the learning curve effect and meet current standards. Comparing the outcomes of the early experience with those of the late experience, we discovered improving trends in postoperative complication and recovery rates. In our high-volume center's experience, improving these outcomes has required 25 to 30 cases.

542. POST-ESOPHAGECTOMY PARACONDUIT HIATAL HERNIA DEVELOPMENT AND RECURRENCE

Abstract Background Hiatal hernia post esophagectomy is a delayed postoperative complication. Historically, in open surgery, the incidence is rare. The increased utilization of minimally invasive methods has increased the incidence of hiatal hernias. Current literature is limited to case series. There is even less on frequency and management of re-recurrent cases. Our objectives were to identify the incidence of hiatal hernia post esophagectomy and the outcomes of the recurrent cases. Methods A retrospective analysis of prospective data at a single center was conducted on esophagectomies performed 2017 to 2022. Non-gastric conduit reconstructions were excluded. Baseline patient demographics including comorbidities, type of tumor, neoadjuvant therapy, surgical approach (open versus minimally invasive [MIE]), and conduit construction were recorded. Radiographic presence of non-gastric conduit abdominal contents was defined as hiatal hernia. Time of hiatal hernia occurrence, details of the repair and timing re-recurrence was recorded. Associated factors described in literature including baseline demographics, neoadjuvant therapy, operative technique, conduit diameter and use of pexy techniques were analyzed with univariate analysis. P&amp;lt;0.05 was considered significant. Results A total of 565 esophagectomies met inclusion criteria, 78% (439/565) were MIE. Robotic-assisted comprised 33% (143/439) of the MIE cohort. A hiatal hernia was identified in 3% of patients (15/565). All had malignancy and were Ivor Lewis (11/15, 73%) or 3-hole (4/15, 27%). The majority had an MIE (13/15, 86%), one had open esophagectomy (6%), and one had hybrid (1/15, 6%). There was no difference in risk factors between the hernia and non-hernia groups. Median time to hernia was 5 months (IQR: 4, 12). All underwent repair. Recurrent hernia occurred in 33% of patients (5/15), all within the robotic-assisted MIE. Conclusion Hiatal hernia post esophagectomy occurred in 3% of cases, and most cases occurred within the MIE group. Recurrence of hernias occurred in robotic-assisted esophagectomy patients. Analysis of patient-specific factors such as prior hiatal hernia, body-mass index, neoadjuvant therapy, operative technique, conduit pexy technique all did not reveal significant correlation with hiatal hernia development. The recurrence of hiatal hernia all required redo repairs. Though we had no deaths in the hiatal hernia cohort, repeat surgeries affect morbidity in esophagectomy patients. Further analysis is needed to identify ways to minimize hernia recurrence in minimally invasive esophagectomy.

322. IMPACT OF POSTOPERATIVE NUTRITIONAL SUPPORT MODES ON CLINICAL AND PATIENT-REPORTED OUTCOMES IN ENHANCED RECOVERY AFTER ESOPHAGECTOMY FOR CANCER

Abstract Background Enhanced Recovery After Surgery (ERAS) for esophagectomy has been demonstrated to be safe and effective. However, there is significant variation in the nutritional support treatment modes during the perioperative period. We have recently developed a novel ERAS nutritional support mode. In this study, we compared this new mode with the previous ERAS nutritional support treatment mode to assess their impact on clinical and Patient-Reported Outcomes (PROs), aiming to develop an optimal approach. Methods We enrolled 357 patients who underwent esophagectomy for esophageal thoracic cancer or esophagogastric junction cancer from June 2021 to August 2023. Two different ERAS nutritional support treatment protocols were used postoperatively: the control group previously received enteral nutrition by nasojejunal tube + parenteral nutrition + early oral diet after surgery, while the study group currently received parenteral nutrition + early oral diet. We compared the two groups in terms of clinical observation indicators, hematological analysis, serum protein changes and clinical outcomes. The comparison of quality of life on PROs was assessed using the MD Anderson Symptom Inventory. Symptom changes were analyzed using a mixed-effects model. Results A total of 324 patients successfully completed the ERAS nutritional support protocols. The success rates were 91% in the control group and 90.2% in the study group, with no statistically significant difference (p&amp;gt;0.05). The incidence of complications did not significantly differ between the two groups (p&amp;gt;0.05). Compared to the control group (n=223), the study group (n=101) significantly shortened the chest drain time (6.2±2.6 days vs. 6.6±1.5 days, p&amp;lt;0.05) and elevated the levels of serum total protein and albumin on the 4th postoperative day (53±5 g/L vs. 51±4 g/L, 30±2 g/L vs. 28±2 g/L, p&amp;lt;0.05). There were no statistically significant differences in the first flatus time, first defecation time, infusion time and postoperative hospital stay between the two groups (p&amp;gt;0.05). The comparison of hematological analysis, serum protein changes, changes in body weight during the perioperative period and 30-day readmission rate showed no statistically significant differences (p&amp;gt;0.05). In the MD Anderson Symptom Inventory, the study group had significantly better scores in sadness, dry mouth, enjoyment of life, and general activity dimensions compared to the control group (p=0.013, p&amp;lt;0.001, p=0.045, p=0.008). Conclusion Based on the similar rehabilitation outcomes, the simplified ERAS nutritional support treatment mode without postoperative enteral nutrition by nasojejunal tube is more optimized because it is physiological sound and significantly improves quality of life on PROs.

744. LEFT THORACOABDOMINAL ESOPHAGECTOMY: ITS VALIDITY IN MODERN ESOPHAGEAL SURGERY

Abstract Background The optimal surgical approach for the treatment of esophageal and gastroesophageal junction tumors remains elusive. An open left thoracoabdominal approach may prove particularly useful in certain clinical scenarios, mainly because of its versatility and excellent exposure provided. The aim of this study is to present our experience and evaluate the early outcomes related to an open left thoracoabdominal esophagectomy (LTE). Methods A retrospective cohort study of prospectively collected data was conducted from two institutions performing esophageal surgery. Patients with distal esophageal or junctional tumors who underwent an open LTE between November 2018 and December 2023 were included. Primary outcomes were 30-day and in-hospital mortality, postoperative complications, and surrogates of oncological efficacy, including resection margin status and lymph node yield. Complications were recorded using the definitions provided by the Esophagectomy Complications Consensus Group and scored according to the Clavien-Dindo classification. Circumferential resection margin status was based on the definition used by the College of American Pathologists. Results During the study period 22 patients underwent an open LTE with a standard two-field lymphadenectomy. Eight patients (36%) suffered from postoperative complications, with pulmonary complications being the most common (7 patients; 32%). Severe complications (Clavien-Dindo ≥3) occurred in 3 patients. One patient experienced a clinical anastomotic leak. None of the patients required a reoperation or a step-up to a higher level of care. The 30-day and in-hospital mortality were zero. On histological examination, 6 patients (27%) had tumor cells at the surgical margin, most commonly the circumferential resection margin. A mean number of 27 lymph nodes were retrieved. Conclusion This small series demonstrates the applicability of an open left thoracoabdominal approach in everyday surgical practice for the treatment of distal esophageal and gastroesophageal junction tumors. Our results imply that open LTE can be implemented in select patients with acceptable morbidity and oncological efficacy.

245. ESOPHAGECTOMY AFTER NEOADJUVANT CHEMOTHERAPY WITH AN INDICATION FOR CONVERSION SURGERY FOR HIGHLY ADVANCED ESOPHAGOGASTRIC JUNCTION ADENOCARCINOMA

Abstract Background There is currently no strong evidence for preoperative chemotherapy for advanced esophagogastric junction adenocarcinoma. Furthermore, no curative treatment strategy has been established for advanced junction adenocarcinoma, including Stage IV disease, with no indication for conversion surgery. Subjects and Methods In this study, we retrospectively reviewed nine patients with highly advanced esophagogastric junctional adenocarcinoma, including Stage IV adenocarcinoma, who underwent systemic chemotherapy followed by planned resection at our hospital. Results The participants included 6 males and 3 females, with median age of 64 (range: 45–72) years. Pretreatment stages III, IVA, and IVB, categorized based on UICC TNM classification (esophageal adenocarcinoma), were observed in 1, 4, and 4 cases, respectively, with 1 case of (#104) subclavian lymph node metastases, 1 case of (#16) abdominal para-aortic lymph node metastases, and 2 cases of liver metastases, including multiple lesions. All patients received S-1 plus oxaliplatin (SOX) therapy as preoperative chemotherapy (2–40 courses). Although we observed one patient with unresectable abdomen malingnancies, the others underwent R0 resection, six underwent esophagectomy (with three total gastrectomy and one liver resection), and two open (+ continuous right thoracotomy) lower esophagectomy + total gastrectomy. Pathological stages I, II, III, and IV were observed in two, one, four, and one patients, respectively. Postoperatively, stereotactic irradiation, chemotherapy, and immune checkpoint inhibitors were administered to the patients to treat recurrent brain and liver metastases, and the 1-year survival rate was found to be 71.4% with a median observation period of 17 (range: 0–61) months. Among them, downstage and pN0 cases were relatively promising. Conclusion Even in highly advanced cases, cases with promising prognoses with multidisciplinary treatment, including surgery, were observed. We hope that large-scale clinical trials, such as JCOG2203, will help clarifying the significance of this approach, and advancements in chemotherapy regimens are expected.

787. THE CHALLENGE OF GASTRO-ESOPHAGEAL ONCOLOGICAL SURGERY AFTER BARIATRIC PROCEDURES: EXPERIENCE OF A REFERRAL HIGH-VOLUME UPPER GI SURGICAL CENTER

Abstract Background The effectiveness of bariatric surgery for weight loss in morbidly obese patients has been well established and it's becoming more common as many surgeons are trained to perform them safely, even in older patients. Obesity is associated with reflux and hormonal imbalances that increase the risk of Barrett's esophagus, esophageal adenocarcinoma and gastric cancer. Bariatric procedures alter gastric anatomy, vascularization and lymphatic drainage and render subsequent upper gastrointestinal surgery for malignancies a technical challenge, that will present more and more in the future. We present laparoscopic sleeve gastrectomy, gastric bypass and gastric banding conversion to oncological respective surgeries. Methods We retrospectively reviewed the medical records of our referral high-volume center for upper gastrointestinal surgery and identified patients who underwent upper gastrointestinal oncologic surgery from January 1998 to May 2024. We selected all patients who had previously undergone bariatric surgery (laparoscopic sleeve gastrectomy, laparoscopic gastric bypass, gastric banding, or other less common procedures). Three patients met our criteria, and we recorded: demographic characteristics, surgical technique, oncologic surgical outcome, postoperative complications, long-term complications, and oncologic follow-up. Results A hybrid IvorLewis esophagectomy was performed years after a sleeve gastrectomy for distal esophageal adenocarcinoma. The sleeve was used for gastric pull-up, adequately vascularized by the right gastroepiploic artery as demonstrated by intraoperative indocyanine green. A patient developed adenocarcinoma of the cardia after Roux-en-Y gastric bypass, infiltrating the gastric pouch, the gastric remnant and liver S2. After neoadjuvant chemotherapy, an open Ivor-Lewis esophagectomy was performed using the gastric remnant for a pull-up. In a third patient, a locally advanced adenocarcinoma of the stomach developed after gastric banding. After neoadjuvant chemotherapy, an open total gastrectomy with Roux-en-Y esophagojejunostomy was performed. Conclusion We report three cases of successful esophago-gastric oncological surgery in patients with altered anatomy and vascularization due to previous bariatric surgery, without major postoperative complications or mortality. Oncologic benchmarks for both esophageal and gastric surgery were met as a high lymph node yield and oncologic margins were maintained. Our heterogeneous series suggests that sleeve gastrectomy, gastric bypass, and gastric banding surgery can be successfully converted to resective surgeries after a metachronous neoplasia diagnosis in high-volume upper gastrointestinal centers. These and similar modified reconstructive techniques are likely to be used in the future as metabolic surgery and esophago-gastric cancer are increasing.

364. IMPROVING PERIOPERATIVE OESOPHAGECTOMY OUTCOMES WITH THE USE OF ROBOTIC SURGERY AT A HIGH VOLUME UK CENTRE

Abstract Background There is a rapid movement towards adoption of robotically assisted minimally invasive oesophagectomy (RAMIO) in the United Kingdom. Transition from an open or laparoscopic oesophagectomy to a RAMIO programme, which carries considerable financial and training cost, must ensure parity of oncological and perioperative outcomes. We sought to compare our centre’s results as we performed the three standard approaches to two-phase oesophagectomy undertaken in the UK: Open/Open (Open); laparoscopic/robotic abdomen with open chest (Hybrid); and RAMIO. Methods This prospective cohort study investigated the experience of five surgeons in a single high-volume UK institution. We analysed all consecutive patients undergoing two-phase transthoracic oesophagectomy for oncological reasons between 2018 and 2023. The study period was divided into three cohorts: Open (2018-2020, n=61), Hybrid (2020-2023, n=82) and RAMIO (2023, n=61). Patient demographics, tumour characteristics, perioperative outcomes, and oncological data were compared. Data were analysed using Kruskal-Wallis and Chi-squared statistical tests. Results No significant differences were observed in patient demographics or tumour stage between the groups. Comparison of Open vs. Hybrid vs. RAMIO demonstrated a significant reduction of major complications (Clavien-Dindo ≥III), 34.4% vs. 23.2% vs. 19.7%, respectively (p=0.033); pulmonary complications, 36.1% vs. 25.4% vs. 16.4% (p=0.007); and median length of hospital stay, 14 vs. 12 vs. 9 days (p=0.001), all favouring the RAMIO group in sub-group analysis. Comparison of Open vs. Hybrid vs. RAMIO demonstrated a non-significant reduction in anastomotic leak rate, 11.5% vs. 2.4% vs. 6.6%, respectively (p=0.112); and mortality, 4.9% vs. 1.2% vs. 0% (p=0.19), favouring the RAMIO group. Median lymph node yields were comparable across the groups, 49 vs. 43 vs. 44 (p=0.165). Conclusions This single-institution study demonstrates potential benefits of transitioning from open or hybrid to RAMIO for oesophagectomy. RAMIO was associated with significantly reduced pulmonary complications, major complications and a shorter length of hospital stay. Oncological outcomes remained on par across techniques. These findings have important patient, financial, and resource implications, and support the continued adoption of RAMIO in the UK.