Esophagectomy For Stage Research Articles

539. ASSOCIATION BETWEEN WAITING PERIOD FOR RADICAL SURGERY AND POSTOPERATIVE RELAPSE IN CLINICAL STAGE I ESOPHAGEAL CANCER

Abstract Background Esophagectomy with locolegional lymphanedectomy based on potential lymph node metastatic risk is the current standard treatment for clinical Stage I thoracic esophageal cancer. Local excision by endoscopic submucosal dissection (ESD) is the standard treatment for clinical Stage 0, however surgery is considered as an additional treatment for pathological T1b cases due to potential metastatic risk. Cases of additional resection after ESD are those pathologically demonstrated to have a high risk of metastasis based on tumor depth and vascular invasion, etc. Compared to cases of surgery for clinical Stage I, many of these cases have a high risk of metastasis, and therefore a poor prognosis is generally expected. Addionally, the prolonged waiting time between initial diagnosis and radical surgery due to ESD may be a factor in poor prognosis, but there is currently no consensus on the risk. Therefore, we conducted a study to clarify the effect of waiting period before surgery (WP) on the risk of recurrence in clinical Stage I esophageal cancer surgery. Methods We retrospectively evaluated the association between WP and 3-year postoperative recurrence-free survival (3y-RFS) in 65 patients who underwent primary esophagectomy and gastric tube reconstruction for clinical Stage I esophageal cancer and 22 patients who underwent additional resection after ESD at our hospital. Results The WP of 87 patients was 2.12 ± 1.43 months (mean± SD), and 13 patients had postoperative recurrence (3y-RFS 85.1%). A 2-arm comparison of short or long WP with a cutoff value of 2.83 months (mean+0.5 SD) showed no clear association with 3y-RFS (100% vs 81.4%, p=0.071). A strong correlation was shown between WP and ESD (r=0.647, p<0.01). WP was 1.69±1.20 months (mean± SD) in 65 patients who underwent surgery as initial treatment, and 12 patients had postoperative recurrence (3y-RFS 81.5%). A 2-arm comparison of short or long WP with a cutoff value of 2.29 months (mean+0.5 SD) suggested an association with 3y-RFS (85.7% vs 55.6%, p=0.018). Conclusion Although this is a single-center, retrospective study of a small number of cases and only a univariate study due to the small number of events, it suggests that a longer waiting period before surgery may be a risk factor for postoperative recurrence.

Association between masseter muscle sarcopenia and postoperative pneumonia in patients with esophageal cancer

Sarcopenia affects the swallowing and chewing muscles, such as the masseter muscle. However, the significance of masseter muscle loss in pneumonia remains unclear. We investigated the effects of masseter muscle sarcopenia (MMS) on postoperative pneumonia in patients with esophageal cancer. In this retrospective cohort study, we analyzed the data of 86 patients who underwent esophagectomy for stage I–III esophageal cancer at our hospital between March 2013 and October 2021. The primary endpoint was postoperative pneumonia within 3 months of surgery. MMS was defined as a (1) masseter muscle index (MMI) that was less than the sex-specific MMI cutoff values, and (2) sarcopenia diagnosed using the L3-psoas muscle index (L3-PMI). Postoperative pneumonia was noted in 27 (31.3%) patients. In multivariate analysis, FEV1.0 < 1.5 L (odds ratio, OR: 10.3; 95% confidence interval, CI 1.56–67.4; p = 0.015), RLNP (OR: 5.14; 95%CI 1.47–17.9; p = 0.010), and MMS (OR: 4.83; 95%CI 1.48–15.8; p = 0.009) were independent risk factors for postoperative pneumonia. The overall survival was significantly worse in patients with pneumonia (log-rank: p = 0.01) than in those without pneumonia. Preoperative MMS may serve as a predictor of postoperative pneumonia in patients with esophageal cancer.

596. MINIMALLY INVASIVE ESOPHAGECTOMY FOR ESOPHAGEAL AND GASTRO-ESOPHAGEAL JUNCTION TUMORS. A SINGLE CENTER EXPERIENCE

Abstract Esophagectomy carries high rates of post-operative morbidity and mortality. Minimally invasive esophagectomy was introduced more than 20 years ago offering all the advantages of minimally invasive surgery and significantly reducing post-operative pulmonary and cardiac complications associated with open esophagectomy. Clinical and oncological outcomes are vastly improved standardizing this approach as inferior in the hand of experts. Herein, we aim to present our results of minimally invasive esophagectomy for esophageal and gastro-esophageal junction cancer. This is prospective analysis of consecutive patients that underwent 2-stage minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. Operations included hybrid 2-stage esophagectomy (laparoscopic/open thoracotomic or open laparotomy/thoracoscopy) and 2-stage totally minimally invasive esophagectomy (laparoscopic/thoracoscopic). Study included adult patients with no upper age limit (&amp;gt;18 years). All esophagectomies for benign disease, as well as emergency operations were excluded from the study. Primary endpoints were 30- and 90-day mortality rate, anastomotic leak, anastomotic stricture, pulmonary complications, and length of hospital stay. Secondary endpoints were overall survival and progression-free survival rates respectively. During an 8-year-period, n=350 consecutive patients underwent 2-stage minimally invasive esophagectomy for cancer. Our team has a cumulative experience of more than 300 open-esophagectomies. Since September 1st, 2013, hybrid 2-stage esophagectomy program was initiated. On September 1st, 2016, the program offered 2-stage totally minimally invasive esophagectomy in-all comers. Most patients were males. Anastomotic leak complicated 5.1% of the patients; 10% of the patients presented anastomotic stricture post-operatively, while pulmonary and cardiac complications reached up to 25 and 12% respectively. Medial LOS was 8 days. Median follow-up was 60 months. OS survival rate was 53 months and PFS was 48 months. Advances in minimally invasive surgery can benefit all patients with esophageal and gastro-esophageal junction tumors. Hybrid and totally minimally invasive 2-stage esophagectomy are well established approaches, with safe and feasible profile in tertiary cancer centers. They can lead to significantly improved clinical and oncological outcomes comparing to open esophagectomy and its complications burden.

594. TOTALLY MINIMALLY INVASIVE 2-STAGE ESOPHAGECTOMY VERSUS HYBRID 2-STAGE ESOPHAGECTOMY. A SINGLE CENTER EXPERIENCE

Abstract Totally minimally invasive 2-stage esophagectomy (TMIE) eliminates the thoracotomy associated with hybrid 2-stage minimally invasive esophagectomy (hybrid-MIE). This has an important role in minimizing post-operative respiratory complications. There is ongoing growing evidence in published literature of improved clinical and oncological outcomes in totally MIE comparing to hybrid MIE, due to enhanced optics and extend of lymphadenectomy as well as to shorter length of hospital stay and surgical trauma associated to thoracoscopy. This is a retrospective analysis of consecutive patients that underwent 2-stage minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. TMIE combines a laparoscopic and thoracoscopic approach while hybrid-MIE includes laparoscopic open thoracotomic phase. Study included adult patients with no upper age limit (&amp;gt;18 years). All esophagectomies for benign disease, as well as emergency operations were excluded from the study. Primary endpoints were 30- and 90-day mortality rate, anastomotic leak, anastomotic stricture, pulmonary complications, and length of hospital stay. Secondary endpoints were overall survival and progression-free survival rates respectively. During an 8-year-period, 150 patients underwent hybrid-MIE, while 200 underwent TMIE. Operative-time was shorter in the hybrid-MIE group (320 vs 280 min). Anastomotic leak was significantly reduced in the TMIE group comparing to the hybrid-MIE group (2.5% vs 9.5%). Respiratory complications were reduced in the TMIE group (10 vs 25%). Median LOS was similar (7 vs 7.5 days). Median number of resected-lymph nodes was increased in the TMIE group (28 vs 35 lymph nodes). OS survival rate was 60 versus 51 months and PFS was 52 vs 43 months in the TMIE and hybrid-MIE groups respectively. In general, TMIE was associated with moderately lower morbidity compared to hybrid-MIE, but randomized controlled evidence is lacking. The higher anastomotic leakage rate, higher rate of pulmonary complications and lower lymph node count that was found after hybrid-MIE in comparative analysis, indicate that TMIE can significantly improve clinical outcomes of patients undergoing esophagectomy. The findings of this study should be considered carefully by surgeons when moving from hybrid-MIE to TMIE.

Evaluation of the perioperative period and long-term outcomes of minimally invasive LTE and minimally invasive CTLE esophagectomy for stage Ⅰ-Ⅲ cervical esophageal carcinoma based on propensity score matching analysis

Objective: To evaluate the perioperative period and long-term effects of minimally invasive gasless laparoscopic transhiatal esophagectomy (LTE) and minimally invasive combined thoracoscopic and laparoscopic esophagectomy (CTLE) for stageⅠ-Ⅲ cervical esophageal cancer. Methods: The clinical data of 158 consecutive patients with cervical esophageal cancer stageⅠto Ⅲ who underwent minimally invasive CTLE or LTE esophagectomy in the Department of Thoracic Surgery, Beijing Tongren Hospital from January 2008 to December 2019 were retrospectively analyzed. A total of 40 pairs of cases were matched (40 cases of CTLE and 40 cases of LTE surgery) after using the propensity score matching analysis which aimed to balance the influence of confounding factors between groups, including 43 males and 37 females, aged 51 to 81 (62.5±7.0) years old. The perioperative variables and long-term outcomes of the two groups were compared. Results: The operation time ((148.0±31.3) min vs (201.3±48.3) min), intraoperative blood loss ((192.6±77.9) ml vs (387.8±112.4) ml), ICU monitoring time (0 day vs 1 day), and the complication rates of postoperative pneumonia (0 vs 15%) and arrhythmia (2.5% vs 20%) were lower in the LTE group than that of in the CTLE group(all P<0.05). The number of lymph node dissections in the CTLE group was higher than that of in the LTE group (21.2±6.1 vs 12.9±4.3, P<0.001). The 3-and 5-year overall survival (OS) rate and disease-free survival (DFS) rate in the LTE group (OS: 53.53% and 34.27%, DFS: 43.62% and 24.89%, respectively) and the CTLE group (OS: 59.48% and 37.29%, DFS: 49.12% and 28.82%, respectively) had no statistical differences (all P>0.05). Conclusion: The LTE group has advantages in reducing operation time, intraoperative bleeding, ICU monitoring time, postoperative incidence of pneumonia and arrhythmia, and its long-term prognosis is comparable to that of the CTLE group.

Proposed modification of the eighth edition of the AJCC-ypTNM staging system of esophageal squamous cell cancer treated with neoadjuvant chemotherapy: Unification of the AJCC staging system and the Japanese classification

BackgroundThe eighth edition of the American Joint Committee on Cancer (AJCC) tumor node metastasis (AJCC-TNM 8th) system adopted the newly separate post-neoadjuvant pathologic stage group (ypTNM). However, it is not compatible with the Japanese pathologic classification after neoadjuvant chemotherapy (JPN-CT-pTNM). The aim of this study is to clarify the subjects of the AJCC-ypTNM 8th and propose a unification of the AJCC and Japanese systems to create novel AJCC-CT-pTNM 8th. MethodsParticipants were 304 esophageal squamous cell carcinoma (ESCC) patients who underwent neoadjuvant chemotherapy followed by 3 stage esophagectomy between 2010 and 2019. Predictive probabilities of pN, pM in AJCC-ypTNM 8th and JPN-CT-pTNM 11th systems were evaluated to propose novel system. ResultsIn training data from 234 patients, the overall survival rate was statistically better for ypStage IIIA than ypStage II (P = 0.040) resulting in staging inversion in AJCC-ypTNM 8th. Predictive probability of pathological N status in AJCC-ypTNM 8th (Akaike Information Criterion: AIC = 979.53) was superior to that in JPN-CT-pTNM 11th (AIC = 999.07). In AJCC-ypTNM 8th, 71% (15/21) of ypM1 diseases were supraclavicular lymph nodes (No. 104 L/N as regional in JPN-CT-pTNM 11th) metastases with considerably good prognosis. The predictive probability of the novel AJCC-CT-pTNM 8th [unification of ypStage II and IIIA, conversion of supraclavicular L/Ns metastases from ypM to ypN] (AIC = 1054.24) was superior to that of the existing AJCC-ypTNM 8th (AIC = 1070.74). The feasibility of novel system was validated using test data from 70 patients. ConclusionsUnification of the AJCC and Japanese systems yields a simpler and more precise predictive system after neoadjuvant chemotherapy.

Pre-operative Carboplatin/Paclitaxel Versus 5-Fluorouracil (5-FU)-based Chemoradiotherapy for Older Adults With Esophageal Cancer

This study aimed to compare the efficacy and tolerability of pre-operative platinum/5-fluorouracil (P5F) and carboplatin/paclitaxel (CP), in combination with radiation therapy in older adults with locally advanced, stage I-III esophageal cancer. We retrospectively reviewed 51 patients aged ≥70 years who underwent chemoradiotherapy followed by esophagectomy for stage I-III esophageal cancer between 2008 and 2018. Pathological complete response (pCR) and survival rates were compared across the two chemotherapy regimen arms. Treatment completion (p=0.28), pCR (p=0.89), and partial response rates were similar across both chemotherapy groups. Overall survival (OS) and disease-free survival (DFS) were similar across both groups with HR=0.80 (p=0.62) and HR=0.72 (p=0.72) respectively. The lesser toxic CP regimen may be used in older patients with locally advanced esophageal cancer, with tumor response and survival rates similar to P5F chemotherapy.

P-OGC81 The learning curve for robotic assisted abdominal phase in two stage oesophagectomy

Abstract Background Robotic assisted oesophagectomy (RAO) is increasingly being utilised in the management of oesophageal cancer. RAO implementation into practice has an inevitable learning curve. As oesophagectomy usually involves at least 2 stages, a staggered approach to training and introduction of RAO can be done. A major advantage of this is that the surgeon can concentrate on overcoming the learning curve in one phase of the procedure at a time, whilst the remaining phase can be completed by an established technique. This study looks at the learning curve of a robotic assisted abdominal phase for two-stage oesophagectomy compared to an open abdominal phase to achieve parity. Methods This study uses a prospectively maintained database to retrospectively analyse the abdominal phase of the first 17 RAO compared to the previous 20 open abdominal phase procedures. The cases are sequential, done by a single surgeon at a large UK oesophagogastric referral centre. Operating time, nodal count, and R0 rate were reviewed to determine the number of cases on the learning curve to reach parity with the open procedure. Results The open abdominal phase group had a similar age (65.6 vs 65.7), pre-op anaerobic threshold (13.9 vs 14.6 p = 0.3) but a higher BMI (mean 30.6 vs 24.6 p &amp;lt; 0.05) then the RAO group. All cases were T3 adenocarcinoma except for 2 cases in the robotic group (one HGD and one T2 adenocarcinoma). No RAO cases were converted to open. The mean time for the abdominal phase in the open group was 175.4 minutes with an average nodal count of 32.9. After 8 robotic assisted cases the mean operating time decreased from 267 minutes to 197 minutes, which was when a non-significant difference to the open group (p = 0.094) became apparent. The mean nodal count in the first 8 robotic assisted cases was 29.5 and increased to 38.4 in the subsequent cases. All patients had a R0 resection. Conclusions The multi-phase nature of oesophagectomy allows for modular implementation of a robotic programme. We have found that the learning curve for robotic assisted abdominal is around 8 cases. This allows for parity to open abdominal phase to be achieved regarding operative time, nodal count and R0 resection.

Neoadjuvant docetaxel, oxaliplatin plus S-1 for treating clinical stage III squamous cell carcinoma of the esophagus: Study protocol of an open-label phase II trial

In Japan, esophagectomy after two courses of 5-fluorouracil plus cisplatin is regarded a standard strategy for treating resectable stage II or III esophageal squamous cell carcinoma (ESCC). However, 5-fluorouracil plus cisplatin does not benefit cohorts with clinical stage III ESCC, suggesting the requirement for a more effective regimen. We are conducting a single-arm phase II study to assess the safety and efficacy of neoadjuvant docetaxel, oxaliplatin plus S-1 (DOS) for treating patients with clinical stage III ESCC. The primary endpoint is the pathological response rate, and the target number is 45 patients. Safety, response rate, R0 resection rate, and survival are secondary endpoints. This trial is registered in the Japan Registry of Clinical Trials as jRCTs041210023. We are conducting a prospective phase II trial to evaluate the safety and efficacy of three courses of neoadjuvant DOS treatment followed by radical esophagectomy for clinical stage III ESCC.

Clinical features and risk factors for early recurrence after esophagectomy following neoadjuvant chemotherapy for esophageal cancer.

The purpose of this study was to clarify the clinical features and outcomes of patients with recurrence after esophagectomy following neoadjuvant chemotherapy (NAC) related to the timing of recurrence. We reviewed 240 consecutive patients who underwent NAC followed by esophagectomy for clinical stage II/III esophageal squamous cell carcinoma between 2009 and 2014. We compared the clinical features and survival after recurrence among groups of patients stratified by the timing of recurrence diagnosis and identified the risk factors for early recurrence (ER). Recurrence was identified within 1year in 61 patients and after 1year in 23 patients. Significant differences were observed between the patients with recurrence within 1year (early recurrence; ER) and those with recurrence after 1year (late recurrence; LR). The ER patients had more advanced tumors and higher pretreatment serum squamous cell antigen (SCC-Ag) levels and less experienced downstaging than patients without recurrence (no recurrence; NR). Overall survival was significantly worse for the ER patients than for the LR patients. Multivariate analysis revealed that cN2-3, increased serum SCC-Ag levels, and clinical response to NAC were independent predictors of ER. The ER patients had distinctive clinical features from the LR and NR patients. Extensive lymph node metastasis, an elevated SCC-Ag, and inadequate response to NAC were identified as predictors of ER.

TP6.2.18 Initial experience with routine postoperative nasal high-flow oxygen as part of enhanced recovery following oesophagectomy for cancer

Abstract Introduction Pulmonary complications occur in up to 38% of patients undergoing oesophagectomy and are associated with significant risk of mortality. Nasal high-flow oxygen (NHFO) has previously been shown to reduce respiratory complications following major abdominal surgery, however, its use in oesophagectomy has not previously been assessed. We report our results using NHFO routinely as part of our enhanced recovery protocol (ERP) in consecutive patients undergoing oesophagectomy for cancer at a single tertiary referral centre. Methods We recently incorporated routine postoperative NHFO following oesophagectomy as part of our ERP at Royal Stoke University Hospital. We conducted a prospective study of patients undergoing surgery between November 2019 and September 2020. The primary outcome measure was complications related to delivery of NHFO. Secondary endpoints included rates of pulmonary complications and mortality within 30 days of surgery. Results Fifty patients underwent oesophagectomy during the study period. The median age was 66 years (range 43-78 years) and male to female ratio was 4:1.Majority (49/50) of patients underwent 2-stage oesophagectomy while one underwent 3-stage oesophagectomy. All patients received postoperative NHFO. There were no complications related to NHFO. The 30-day overall pulmonary complication rate was 30%.Of these, 28% developed pneumonia,4% pulmonary embolism,and 2% pleural effusions requiring drainage. There were no deaths within 30 days of surgery. Conclusion Routine postoperative NHFO in consecutive patients undergoing oesophagectomy is safe and feasible with lower pulmonary complication rates than previously reported, leading to better overall outcomes. The value of NHFO in oesophagectomy requires further evaluation in a randomized clinical trial.

1438 The Past, Present and Future Management of Complex Chyle Fistulae

Abstract Background Chyle leak/fistula is a rare complication of oesophageal surgery, usually consequent on an unintended breach of the thoracic duct, its tributaries, or the cisterna chyli. For high volume persistent leaks further surgery has been the traditional approach, however two cases have resulted in a new management approach at this Centre. Case Series The first patient, a 49-year-old, developed high volume drain output post three stage oesophagectomy. His jejunostomy feeding was discontinued, total parenteral nutrition and a somatostatin analogue, were commenced. Despite these measures, the drain output remained &amp;gt;1.5litres per day and an exploratory thoracotomy was performed. The second patient, an 81-year-old underwent a transhiatal-oesophagectomy. On postoperative day 10 he developed acute onset shortness of breath, CXR demonstrated a large left sided pleural effusion. CT thorax demonstrated multiloculated complex pleural effusions. US guided pig tail drain was placed in the largest targetable effusion. The fluid was chylous in appearance. In both cases, an interventional radiological approach, not previously performed at this centre, provided definitive management. Lymphangiography was performed via injection of 1mL of Lipoidol® every 5 minutes into the inguinal lymph nodes to identify the cisterna chyli. A guidewire was advanced via the cisterna chyli with coils and glue used to embolize the leaking tracts. Discussion The lessons from this experience provide an algorithm for the management of chyle leaks, that will change practice at this centre. Embolization or disruption of thoracic duct and cisterna chyli leaks will be first line therapy for complex chyle leaks, with surgery reserved for where this fails.

Preoperative transferrin level is a novel indicator of short- and long-term outcomes after esophageal cancer surgery

This study aimed to examine whether preoperative serum transferrin, a rapid-turnover protein, correlates with short- and long-term outcomes after esophagectomy. Preoperative transferrin levels, calculated by summing serum iron and unsaturated iron-binding capacity, were evaluated in 224 patients who underwent esophagectomy for stage I-III esophageal cancer without preoperative treatment. Transferrin levels are directly proportional to total iron-binding capacity (TIBC), and we defined TIBC < 250μg/dL as low transferrin. We evaluated the relationship between preoperative transferrin levels and short- and long-term outcomes after esophagectomy using univariate and multivariate Cox proportional hazards analyses. Of all patients, 25 (11.2%) had low preoperative transferrin levels. Low preoperative transferrin levels were strongly correlated with worse preoperative performance status, advanced pathological T stage, and more open esophagectomy (p = 0.0078, 0.0001, and 0.013, respectively). Patients with low preoperative transferrin levels experienced significantly more frequent postoperative pneumonia in univariate and multivariate analysis [hazard ratio (HR) 3.30, 95% confidence interval (CI) 1.032-10.033, p = 0.0443]. Additionally, these patients were significantly correlated with worse overall survival (OS) in univariate and multivariate analyses (HR 2.75, 95% CI 1.018-7.426, p = 0.0460). Furthermore, we investigated the relationship between OS and postoperative pneumonia to elucidate why low preoperative transferrin, which is an independent risk factor for postoperative pneumonia, leads to poor prognosis. Patients with postoperative pneumonia were strongly associated with a shorter OS (p = 0.0099). Preoperative serum transferrin levels may be a novel indicator of postoperative pneumonia and OS after esophagectomy.

744 THE USE OF IMMUNOFLUORESCENCE TO EVALUATE THE PERFUSION OF THE GASTRIC PLASTY DURING OESOPHAGECTOMY.

Abstract Anastomotic leakage in oesophageal cancer surgery is one of the most serious complications and occurs mainly at the cervical level between 10–30% according to series. The use of immunofluorescence could help to select a better vascularized area in which to perform the anastomosis more safely. We present the initial experience (between July and December 2020) of our group. Methods Prospective and descriptive study of patients with oesophageal neoplasia who underwent a 3 stage oesophagectomy with cervical anastomosis using immunofluorescence with indocyanine green (dose: 7,5 mg) for quick evaluation of vascularization in the theoretical anastomosis zone in gastric plasty. Intravenous injection of the indocyanine green dilution was performed intraoperatively in a peripheral line, once the plasty was positioned in place to perform the anastomosis. The route of ascent was transmediastinal in all cases. 9 patients with a mean age of 61 ± 7.6 years were included in the study. Results The mean heart rate was 83 ± 16 bpm, the mean systolic blood pressure was 111 ± 17 mmHg. The time and mean speed it took for the fluorescence to reach the marked area to perform the anastomosis was 30 ± 28 seconds and 1.83 cm/sec; and at the apex of the plasty it was 93 ± 79 seconds and 0.75 cm/sec. In all patients in whom the anastomosis was performed in the area where ICG arrived between 30 and 90 seconds, there was no leakage. In two patients, due to anatomical needs, the anastomosis was performed in areas where ICG took more than 100 seconds and in the postoperative period leaked. Conclusion Immunofluorescence is a technique that allows an immediate visual image to evaluate the vascularization of the gastric plasty during an esophagectomy. It allows characterizing the adequate vascularization of the future anastomotic area, being able to help decide the best place to carry out the anastomosis. Studies with a larger number of cases are needed to be able to define the range in which to establish the anastomosis or change the surgical strategy.

Anastomotic stricture after Ivor Lewis esophagectomy: An evaluation of incidence, risk factors, and treatment

BackgroundAnastomotic stricture is a recognized complication after esophagectomy. It can impact the patient’s quality of life and may require recurrent dilatations. Thus, the aim of this study was to evaluate the frequency of strictures, contributing factors, and long-term outcomes of management in patients undergoing esophagectomy with thoracic anastomosis using a standardized circular stapled technique. MethodsAll patients who underwent a 2-stage transthoracic esophagectomy with curative intent between January 2010 and December 2019 at NOGU, Newcastle upon Tyne, UK were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded. ResultsOverall, 705 patients were included with 192 (27.2%) developing strictures. Refractory strictures occurred in 38 patients (5.4%). One, 2, and 3 dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients, respectively. Multivariable analysis identified the occurrence of an anastomotic leak (odds ratio 1.906, 95% confidence interval 1.088–3.341, P = .024) and circular staple size <28 mm (odds ratio 1.462, 95% confidence interval 1.033–2.070, P = .032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs 4.7%, odds ratio 3.089, 95% confidence interval 1.349–7.077, P = .008). ConclusionThis study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures.

Utilization Trends and Volume-outcomes Relationship of Endoscopic Resection for Early Stage Esophageal Cancer.

We describe utilization trends and center volume-outcomes relationship of ER of early stage esophageal cancer using a large hospitalbased registry. ER is increasingly accepted as the preferred treatment for early stage esophageal cancer, however its utilization and the center volume-outcomes relationship in the United States is unknown. The National Cancer Database was used to identify patients with cT1N0M0 esophageal cancer treated with ER or esophagectomy between 2004 and 2015. Relative frequencies were plotted over time. Restricted cubic splines and maximally selected rank statistics were used to identify an inflection point of center volume and survival. A total of 1136 patients underwent ER and 2829 patients underwent esophagectomy during the study period. Overall utilization of ER, and relative use compared to esophagectomy, increased throughout the study period. Median annualized center ER volume was 1.9 cases per year (interquartile range 0.5-5.8). Multivariable Cox regression showed increasing annualized center volume by 1 case per year was associated with improved survival. Postoperative 30- or 90-day mortality, 30-day readmission, and pathologic T upstaging rates were similar irrespective of center volume. Utilization of ER compared to esophagectomy for stage I esophageal cancer has increased over the past decade, though many individual centers perform fewer than 1 case annually. increasing annualized center volume by one procedure per year was associated with improved survival. increased volume beyond this was not associated with survival benefit. Referral to higher volume centers for treatment of superficial esophageal cancer should be considered.

Real-world outcomes of esophagectomy versus chemoradiotherapy for clinical stage I esophageal squamous cell carcinoma.

178 Background: Recently, JCOG0502 trial have shown a comparable efficacy with chemoradiotherapy (CRT) and esophagectomy as standard treatment in patients with clinical stage (cStage) I esophageal squamous cell carcinoma (ESCC), showing the standard treatment option of CRT. However, there is few reports for comparison of clinical outcomes with these treatments in real-world. The aim of this study was to clarify the real-world outcomes in cStage I ESCC who performed with CRT or esophagectomy. Methods: This retrospective study included patients with clinical stage I ESCC who received thoracoscopic or open esophagectomy with three-field lymph node dissection or CRT mainly consisted of 5-fluorouracil and platinum with concurrent radiotherapy (50.4 Gy/28Fr or 60 Gy/30Fr) between 2009 and 2017 at National Cancer Center Hospital East. Survival outcomes were calculated using the Kaplan-Meier method, and the differences were evaluated using the log-rank test. Results: Among a total of 156 patients, 128 were male and median age was 68 years old. 120 and 36 patients underwent esophagectomy and CRT, respectively. ECOG performance status 0/1/2 were 138/12/6 patients. Tumor location was Ut/Mt/Lt in 16/87/53 patients. Clinical tumor depth (MM-SM1/SM2-SM3) were 33/123 patients. Patients’ characteristics were similar among treatment groups, except clinical tumor depth (SM2-3; 84.2% in esophagectomy group vs. 61.1% in CRT group, p = 0.005). All patients underwent radical surgery in esophagectomy group, while three patients (8.3%) in CRT group were received additional esophagectomy or endoscopic resection due to residual disease. With a median follow-up of 72 months, 5-year overall survival (OS) and progression-free survival rate were 81.5%/77.0% in esophagectomy group and 82.6/74.4% in CRT group (p = 0.89 and p = 0.48). In safety profile, grade 3 or higher stenosis was observed in 21.7% of esophagectomy group. There was no treatment-related death in both groups. In subgroup analysis for OS, elderly patients (75 years and older) tended to have better 5-year OS rate in CRT group (76.9% in esophagectomy group vs. 81.8% in CRT group), while younger patients ( &lt; 75 years) showed comparable 5-year OS rate in both groups (82.4% in esophagectomy group vs. 82.9% in CRT group). Conclusions: Real-world data reproduced the results of clinical trial, supporting CRT as one of the standard treatment options in patients with cStage I ESCC.

Low Preoperative Albumin-to-Globulin Ratio Is a Marker of Poor Prognosis in Patients With Esophageal Cancer.

Recent studies have reported that the albumin-to-globulin ratio (AGR) may be a useful inflammatory-nutritional biomarker to predict postoperative complications and poor prognosis in various types of patients with cancer. However, its prognostic value in patients with esophageal cancer is still unclear. We aimed to examine the utility of the AGR for predicting the short- and long-term outcomes in patients with esophageal cancer who underwent curative resection. This was a retrospective cohort analysis reviewing the medical records of consecutive patients who underwent esophagectomy for clinical stage I to III esophageal cancer at Yokohama City University. A total of 105 patients were identified between 2005 and 2018. The overall survival (OS), recurrence-free survival (RFS), and postoperative complication rates were compared between patients with high AGR (>1.48) and those with low AGR (≤1.48) group. A total of 57 and 48 patients were classified into the high and low AGR groups, respectively. There was no significant difference between the two groups in the rate of overall postoperative complications of more than Clavien-Dindo grade 3 (50.9% vs. 54.2%, p=0.85). The long-term findings showed that 5-year OS and RFS rates were significantly better for the group with a high AGR (67.2% vs. 33.8%, p<0.001 and 51.6% vs. 28.5%, p=0.003, respectively). This study suggests that a low preoperative AGR is a risk factor for poor RFS and OS in patients who are planning to undergo curative surgery for esophageal cancer. AGR may be a useful biomarker for establishing treatment strategies to improve patients' survival.

Three-Dimensional vs Two-Dimensional Completely Minimally Invasive 2-Stage Esophagectomy With Intrathoracic Hand-Sewn Anastomosis for Esophageal Cancer: Comparison of Intra-and Postoperative Outcomes.

Background. Completely minimally invasive esophagectomy (CMIE) has been associated with reduced morbidity compared to open esophagectomy in the treatment of esophageal cancer. Three-dimensional (3D) vision can enhance depth perception during minimally invasive surgery when compared to two-dimensional (2D) vision. We aimed to compare outcomes from 2-stage CMIEs when performed in 2D vs 3D. Method. All consecutive 2-stage CMIEs performed for esophageal or gastroesophageal junctional cancer at a single-centre between 2016 and 2018 were identified from a prospectively maintained database. All operations were completed in either 2D or 3D. All esophagogastric anastomoses were hand-sewn thoracoscopically. Intraoperative and postoperative clinical parameters were compared between 2D and 3D CMIE. Results. Overall, 98 patients underwent a 2-stage CMIE, of which 59 (60.2%) were in 2D and 39 (39.8%) in 3D. Median operative blood loss was less in the 3D group compared to the 2D group (283mls vs 409mls, P = .016). A higher number of lymph nodes were retrieved from 3D CMIE (30 vs 25, P = .010). The median duration of surgery was 407minutes (interquartile ranges (IQR): 358-472minutes) and 426minutes (IQR: 369-509minutes) when performed in 2D and 3D, respectively (P = .162). There were no significant intergroup differences in 30-day postoperative complications, short-term mortality, and hospital stay. Conclusion. We report reduced blood loss and higher lymph node yield when performing 3D CMIE than 2D CMIE. Other intraoperative and postoperative clinical outcomes were similar in both groups. A randomized controlled trial is needed to validate these findings of superior outcomes from CMIE performed in 3D over 2D.

Outcomes of single versus two stage oesophagectomy for squamous cell carcinoma.

Outcomes of single versus two stage oesophagectomy for squamous cell carcinoma.