Subtotal Esophagectomy Research Articles

Modified reconstruction procedure in subtotal esophagectomy with retrosternal gastric pull up to reduce anastomotic leakage: a propensity score-matched analysis.

One risk factor for anastomotic leakage (AL) after esophagectomy with retrosternal gastric reconstruction is excessive compression of the gastric tube at the thoracic inlet. In this study, we evaluated the effect of our modified procedure to reduce AL by placing the esophagogastric anastomosis below the thoracic inlet. Between January 2008 and December 2022, 174 consecutive patients underwent subtotal esophagectomy with retrosternal gastric pull up, followed by circular stapler anastomosis in our hospitals. After January 2016, the gastric tube was pulled down to place the anastomosis below the suprasternal notch. Postoperative CT then measured the level of esophagogastric anastomosis (LEA). Comparing cases before and after revision (conventional group, n = 65 vs. test group, n = 109), AL was significantly reduced from 11 (16.9%) to 3 (2.8%) cases (P = 0.002). After propensity score matching, AL was observed in 14% (8/57) and 0% (0/57) cases in the conventional and test groups, respectively (P = 0.006). Smaller circular stapler size (P < 0.001), less intraoperative blood loss (P < 0.001), and lower LEA (P < 0.001) were observed in the test group than in the conventional group. Multivariate analysis revealed that anastomotic procedure (OR [95%CI], 0.01[0.00-0.46], P = 0.008), and body mass index (OR [95%CI], 6.92[1.10-135.01], P = 0.038) were the independent risk factors for the development of AL. Our modified procedure to avoid compression of the gastric tube at the thoracic inlet is suggested to noninvasively reduce the risk of AL in the subtotal esophagectomy with retrosternal reconstruction.

OGC SO45 - Effect of anastomotic technique on leak rates in two-stage robotic-assisted subtotal oesophagectomy

Abstract Background Introduction of new surgical techniques requires constant monitoring and real time audit. In our unit the introduction of the thoracic component of our robotic oesophagectomy program resulted in an increase in the anastomotic leak rate which was recognised in real time. This prompted a decision to change from a circular to a linear stapled technique. The aim of this study was to evaluate the impact of this change in technique on the anastomotic leak rate. Method A database was used to identify all cases of patients undergoing two stage subtotal oesophagectomy where the thoracic phase was performed robotically-assisted. Demographic, operative, pathological and complications data were extracted. An anastomotic leak was defined as radiological or endoscopic disruption of the oesophagogastric anastomosis or where a clinician had documented the presence of a leak in the clinical notes. Leaks were then graded by severity according to the classification by Low et al into type 1: localised defect treated with medical therapy or observation; Type 2: localised defect requiring intervention but not surgery, and; Type 3: localised defects requiring surgery. Results Fifty-seven patients were identified. The first 25 cases were reconstructed with a circular-stapled and the subsequent 32 with a linear-stapled anastomosis. There were no differences in baseline demographics. There were no differences in thoracic operating time nor blood loss, intraoperative complications and pathological variables such as lymph node yield. Overall, 11/57 patients (19%) had an anastomotic leak, of which 7 (28%) had a circular stapled anastomosis and 4 (12%) had a linear stapled anastomosis. This difference was not statistically significant (p=0.2384). However, CUSUM analysis after the change in anastomotic technique showed an ongoing and diminished anastomotic leak rate. Conclusion In our unit changing from a circular to a linear stapled anastomotic technique resulted in a reduction in the anastomotic leak rate from 24% to 12%. While this was not statistically significant, this is a clinically appreciable result and this benefit was confirmed on CUSUM analysis.

OGC SO08 - Optimising Analgesia in Sub-total Oesophagectomy: A Dose of Success

Abstract Background Sub-total oesophagectomy (STO) is a complex and major surgery with significant associated burdens for our patients. Our centre in North-East England completes 70-80 STOs annually. In the peri-operative period, good analgesia management and delivery is key. Analgesia strategy has evolved across the UK over the past decade, influenced by multi-modal analgesia, progressing surgical approaches towards minimally invasive operations alongside the ongoing drive for enhanced recovery programmes endorsing early mobilisation. Surgical approach in our patient cohort now comprises a combination of Open-Open, combined Open-Minimally invasive and entirely minimally invasive techniques. Our analgesia strategy combines single shot intrathecal diamorphine and regional anaesthesia. Method We engaged our multi-professional (Acute Pain Specialist Nurses, Anaesthesia Consultants and Surgical Consultants) team in a PDSA cycle. A guidance analgesia package was agreed after review of retrospective cases. This package was delivered to our baseline group of 10 patients. We used subjective patient reported abdominal and thorax pain scores on a 0-10 scale, recorded by our pain team each day for post-operative days 1-5. Following analysis, we implemented a single change to Intrathecal diamorphine dosing - changing from uniform delivery of 1000micrograms intrathecal diamorphine to a dose calculated on Ideal Body Weight of 15-20micrograms/kg up to 1500micrograms maximum dose Results Our baseline group of 10 patients all received 1000micrograms of intrathecal diamorphine - mean dose 15.9mcg/kg. Our intervention group of 12 patients received doses based upon their ideal body weight - mean dose 18.9mcg/kg. Overall, there was a trend of reduced pain scores following our intervention. Thoracic reported overall pain scores were significantly lower (p=0.04) following the intervention. No significant difference was demonstrated specifically in the first 24 or 48hours in overall, abdominal or thoracic pain scores. Importantly, there were no reported adverse events related to our higher dosing regime and no recorded side effects such as pruritis or nausea. Conclusion There is little evidence with regards the use of higher dose intrathecal diamorphine in the literature. The sample sizes in our groups are small but overall reduction in patient reported pain scores appear to be associated with use of the higher dose of intrathecal diamorphine, based upon ideal body weight and importantly without any adverse effect. Continued evolution of our analgesia strategies is essential alongside that of surgical techniques. The next iterations of our guidance and PDSA cycle will consider our regional techniques to identify if further advances can be made.

A case of intraoperative detection of a central venous catheter in azygos vein arch during esophageal cancer surgery.

Central venous catheter (CVC) is often used in the perioperative management of esophageal cancer. The position of the CVC tip has been reported to shift with body positioning and, although infrequent, may traverse into the azygos vein arch. Herein, we describe a case where a migrated CVC tip in the azygous vein arch was identified during esophageal cancer surgery, preventing CVC dissection concurrent with azygous vein arch resection. A 65-year-old man was diagnosed with advanced esophageal cancer and was referred to our department for surgery after undergoing neoadjuvant chemotherapy. He underwent robot-assisted subtotal esophagectomy, followed by gastric conduit reconstruction via the posterior sternal route. Thoracic manipulation was performed with the patient in the prone position. During the surgery, a foreign body was found in the azygos vein arch, indicating that a central venous catheter had inadvertently entered the azygos vein arch. The catheter was retracted by 5cm, and after confirming that no catheter remained in the azygos arch, the azygos vein arch was separated using an autosuture device. Central venous catheter migration can occur in a various vessels. During prone esophageal cancer surgery, elevating the right upper extremity may alter the catheter tip's position from its the preoperative position. CVC amputation should be observed because the azygos vein arch is often amputated to facilitate upper mediastinal dissection during esophageal cancer surgery.

A Case of Superficial Esophageal Neuroendocrine Carcinoma with Marked Morphological Changes in a Short Period.

A de novo whitish subepithelial lesion (SEL) with irregular vascular hyperplasia was detected in the lower thoracic esophagus during endoscopic surveillance. Special types of esophageal cancer were suspected; however, endoscopic biopsy specimens were inadequate for a diagnosis. Ten days later, endoscopic ultrasound showed a 7-mm homogeneously hypoechoic round mass in the submucosa, and a biopsy confirmed a histological diagnosis of esophageal neuroendocrine carcinoma (eNEC). Based on the clinical diagnosis of cT2N0M0, subtotal esophagectomy followed by adjuvant chemotherapy was performed immediately after endoscopic reexamination revealing a 20-mm reddish SMT. We herein report the marked changes in endoscopic findings of eNEC within 1.5 months.

The first case of primary malignant melanoma of the esophagus to achieve pathologic complete response after preoperative ipilimumab + nivolumab followed by resection.

Primary malignant melanoma of the esophagus is a rare disease with a poor prognosis. Surgical resection is common, but there is no consensus on perioperative treatment. Studies have reported the efficacy of programmed cell death-1 inhibitors (e.g., nivolumab, pembrolizumab) and anti-cytotoxic T-lymphocyte-associated antigen 4 agents (e.g., ipilimumab) in treating malignant melanoma. Here, we present the first case of primary malignant melanoma of the esophagus with lymph node metastases treated with nivolumab and ipilimumab followed by resection, achieving a pathologic complete response. A 75-year-old man presented with dysphagia. Esophagogastroduodenoscopy revealed a black, elevated lesion in the mid-thoracic esophagus. Biopsy confirmed primary malignant melanoma of the esophagus, showing tumor cells with melanin deposition, positive for HBM45 and S-100 staining. Computed tomography showed enlarged lymph nodes in the subclavian and mediastinum regions, suggesting metastases. After two courses of preoperative chemotherapy with ipilimumab and nivolumab, which significantly shrank the tumor, the patient underwent robot-assisted subtotal esophagectomy and 3-field lymph node dissection. Histopathological examination revealed no tumors or lymph node metastases, confirming a pathologic complete response. Given the rarity and poor prognosis of primary malignant melanoma of the esophagus, this case provides valuable insights for treatment strategies.

Thoracoscopic and endoscopic cooperative surgery for esophageal gastrointestinal stromal tumor: a case report

BackgroundEsophageal gastrointestinal stromal tumors (GISTs) are relatively rare, accounting for 2–5% of all GISTs. Typically, the treatment is surgery in nature. However, no standard procedure established for esophageal GISTs, and in many cases, subtotal esophagectomy or local resection via thoracoscopy or mediastinoscopy is performed. Thoracoscopic and endoscopic cooperative surgery (TECS) is a surgical approach similar to laparoscopic and endoscopic cooperative surgery used for gastric GIST; however, no reports of its use for esophageal GIST have been published to date. We herein report such a case along with a review of past literature.Case presentationThe patient was a 60-year-old man. Upper gastrointestinal contrast imaging revealed a subepithelial lesion in the esophagus. An 18 × 17 mm subepithelial lesion was identified in the left wall, 35 cm from the upper incisors, during upper gastrointestinal endoscopy, and was diagnosed as a GIST through endoscopic ultrasound-guided fine needle biopsy. TECS was therefore performed. The patient was placed in a prone position with his face to the left. After confirming the lesion under endoscopy and left thoracoscopy, the periesophageal area of the lesion was dissected under thoracoscopy. Subsequently, an endoscopic full-layer resection was performed. Finally, the excision site of the lesion was sutured under thoracoscopy. The operation took a total of 3 h and 22 min, with a blood loss of 50 mL.ConclusionsThe appropriate surgical procedure for esophageal GIST should be considered according to the location and size of the lesion. TECS ensures that the resection margins are secured using an endoscopic or thoracoscopic approach. Furthermore, TECS is minimally invasive, avoiding esophagectomy and reconstruction, which makes it a potential surgical option for esophageal GISTs.

Laparoscopic repair of gastric conduit obstruction after robot-assisted minimally invasive esophagectomy: a case report

BackgroundGastric conduit obstruction (GCO) is a known complication after esophagectomy. Laparoscopic revision surgery for GCO is relatively rare, with limited reports in the literature. Here, we report a case of GCO after robot-assisted subtotal esophagectomy and posterior mediastinal gastric conduit reconstruction, which was successfully repaired laparoscopically.Case presentationA 66-year-old man presented with a passage disorder that became noticeable 14 months after surgery. Fluid passage was difficult, and the patient opted for revision surgery. The conduit had entered and deflected into the mediastinum; it also twisted due to band formation. The revision surgery was performed laparoscopically through five ports. The bands were dissected, esophageal hiatus was sutured, and conduit re-fixed. The intraoperative endoscopy was used to confirm that the obstruction had been released. The lack of adhesion of the posterior half of the gastric conduit wall, combined with postoperative weight loss leading to a decrease in omental volume, as well as inadequate fixation during the initial surgery, are believed to have contributed to the ease of the conduit deviation into the intrathoracic cavity. In addition, the twisting of the conduit due to band formation exacerbated the obstruction.ConclusionsLaparoscopic revision surgery may become an effective treatment option as the number of minimally invasive esophagectomies is expected to increase in the future. Furthermore, the fixation method during initial surgery should be carefully considered and optimized to prevent gastric conduit obstruction. Additionally, the use of intraoperative endoscopy to evaluate the lumen of the conduit during surgery proved beneficial in this case, highlighting its potential value in identifying and addressing obstruction.

Pulse Granuloma in Esophagus; A Rare finding in Achalasia Patient: Case Report and Literature Review

Abstract Introduction/Objective Pulse granuloma is a granulomatous reaction to foreign body, most commonly to food material. This is clinically silent and incidental but may be confused for a mass like lesion. This can be found any location in gastrointestinal tract but most reported in oral cavity and colon. We herein report a rare case of pulse granuloma in esophagus with literature review of the entity. Methods/Case Report A 58-year-old male with history of achalasia, surgical history of Heller myotomy, hernia reduction, hiatoplasty, gastropexy, vagotomy, presented with recurrent stricture of the esophagogastric junction. The patient received multiple esophageal balloon dilatations in the past due to high esophageal sphincter pressure and was complicated by severe reflux associated with esophagitis and large hiatal hernia. He underwent subtotal esophagectomy due to dysphagia. Gross examination of the esophagectomy specimen showed multiple previous procedure scars and was opened to reveal firm yellow food particles impacting in the mucosa. Histological examination showed gastroesophageal junctional mucosa with ulceration and fibrosis of the muscularis propria. Pink ribbon like hyalinized foci with giant cell was found which stained negative for GMS, PAS and AFB, supporting the diagnosis of pulse granuloma. Literature search for key word ‘Pulse Granuloma’ identified thirty-five case reports from year 1977 to 2024, with most reported case in the oral cavity (14 cases, 42%). Out of ten cases reported in gastrointestinal tract, 1 case was reported in small bowel and 9 cases were reported in colon and rectum and no cases were reported in esophagus. Results (if a Case Study enter NA) NA Conclusion Our patient’s history of achalasia and dysphagia along with histopathologic findings supports diagnosis of pulse granuloma in esophagus. Although clinically silent, pulse granuloma may cause mass-like lesions and result in enlargement and stenosis. In setting of esophageal achalasia recognizing this entity is important as it can mimic malignancy and other mass-forming lesions.

Risk Factors for Postoperative Pneumonia in Esophageal Cancer Patients

Purpose Patients undergoing surgery for esophageal cancer (EC) frequently experience postoperative pneumonia (POP). POP promotes poor prognosis as well as increased medical costs and longer hospital stays. Therefore, it is desirable to prevent and strictly control high-risk cases to reduce the incidence of pneumonia. The present study aimed to determine the risk factors for POP in EC. Patients and Methods The subjects of this retrospective study were 151 patients with EC who underwent subtotal esophagectomy in our department between January 2012 and December 2021. Univariate and multivariate logistic regression analyses were used to evaluate the association between the incidence of POP and clinical factors. Results Among 151 patients, 33 cases (21.8%) developed POP. Multivariate analysis identified preoperative C-reactive protein-to-albumin ratio (CAR) ≥0.03 [odds ratio (OR), 2.69; P = 0.0352], chronic obstructive lung disease (COPD) (OR, 7.32; P = 0.0001), and diabetes mellitus (DM) (OR, 3.35; P = 0.0252) as independent risk factors for POP. In accordance with the number of risk factors, the incidence rate of POP drastically increased, and its rate in patients with 3 risk factors was 80%. Conclusion High CAR, COPD, and DM are independent risk factors for the development of POP in patients undergoing subtotal esophagectomy for EC. Clinicians should be aware of the risk factors for POP and consider more intensive preventive measures and postoperative management in patients with EC.

Blood flow assessment of gastric tube with indocyanine green fluorescence angiography and postoperative endoscopy during esophagectomy: indocyanine green enhancement time indicated congestion

BackgroundDuring esophagectomy, evaluation of blood supply to the gastric tube is critically important to estimate and avoid anastomotic complications. This retrospective study investigated the relationship between indocyanine green (ICG) fluorescence angiography during esophagectomy and postoperative endoscopy findings, especially mucosal color change.MethodsThis study retrospectively collected data from 86 patients who underwent subtotal esophagectomy and reconstruction using a gastric tube for esophageal cancer at the Tokyo Medical and Dental University between 2017 and 2020. The flow speed of ICG fluorescence in the gastric tube was evaluated during the operation. Additionally, the main root of ICG enhancement and pattern of ICG distribution in the gastric tube were evaluated. On postoperative day 1 (POD1), the change in the mucosal color to white, thought to reflect ischemia, or black, thought to reflect congestion of the proximal gastric tube, was evaluated. The correlations between these factors, clinical parameters, and surgical outcomes were evaluated. Univariate and multivariate analyses used logistic regression to identify the risk factors affecting mucosal color change.ResultsMultivariate analyses revealed that the only independent significant predictor of mucosal congestion on POD1 was the ICG enhancement time of the right gastric tube tip (odds ratio, 14.49; 95% confidential interval, 2.41–87.24; P = 0.004).ConclusionsThis study indicated that the ICG enhancement time is related to venous malperfusion and congestion rather than arterial malperfusion and ischemia.

A case of refractory chylothorax due to an unenclosed esophageal hiatus after subtotal esophagectomy treated with lipiodol lymphangiography

BackgroundChylothorax, a rare but serious complication following esophagectomy, can lead to dehydration, malnutrition, and even mortality. Surgical intervention is considered when conservative treatment is ineffective; however, in some refractory cases, the cause of chylothorax remains unclear. We report a case of refractory chylothorax caused by abdominal chyle leakage into the pleural space via an unenclosed esophageal hiatus.Case presentationA 66-year-old man was diagnosed with advanced esophageal squamous cell carcinoma. The patient underwent robot-assisted thoracoscopic subtotal esophagectomy in the prone position with retrosternal gastric tube reconstruction following neoadjuvant chemotherapy. The thoracic duct was ligated and resected because of tumor invasion. Chylothorax and chylous ascites were observed 2 weeks after surgery but did not improve despite conservative management with medications and drainage. Lymphoscintigraphy through the inguinal lymph node showed tracer accumulation in the fluid in both the abdominal and pleural spaces. Lipiodol lymphangiography revealed abdominal lymphoid leakage, but no leakage was detected from the thoracic duct or mediastinum. We considered that the chylothorax was caused by chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus, and we performed surgical intervention. Laparotomy revealed abdominal chyle leakage and a fistula at the esophageal hiatus with the inflow of ascites into the thoracic cavity. Lipiodol lymphangiography was additionally performed for treating abdominal lymphorrhea after surgery, and resulted in the improvement of the chylothorax and ascites. The patient was discharged with no recurrence of chylothorax or chylous ascites.ConclusionsRefractory chylothorax can occur due to chylous ascites flowing into the pleural space via an unenclosed esophageal hiatus. When the site of chylothorax leakage is unclear, the possibility of inflowing chylous ascites via the unenclosed esophageal hiatus should be explored. Esophageal hiatus closure and lipiodol lymphangiography could be effective in treating refractory chylothorax of unknown cause after esophagectomy.

646. MCKEOWN VS IVOR-LEWIS ESOPHAGECTOMY FOR PATIENTS WITH A HISTORY OF TOTAL PHARYNGOLARYNGECTOMY: A COMPARISON STUDY

Abstract Background Oncologic esophagectomy in patients with a history of total pharyngolaryngectomy (TPL) is challenging. There are two different esophagectomy procedures: total esophagectomy with cervical anastomosis (McKeown) and subtotal esophagectomy with intrathoracic anastomosis (Ivor-Lewis). Differences in outcomes between McKeown and Ivor-Lewis esophagectomies for patients with this history remain unclear. Patients and Methods We retrospectively reviewed 36 patients with a history of TPL who underwent oncologic esophagectomy and compared the clinical outcomes between the procedures. Results Twelve (33.3%) and 24 (66.7%) patients underwent McKeown and Ivor-Lewis esophagectomies, respectively. McKeown esophagectomy was more frequently performed for the supracarinal tumors (P = 0.002). Other baseline characteristics, including the history of radiation therapy, were comparable between the groups. Postoperatively, the incidences of pneumonia and anastomotic leakage were higher in the McKeown group than in the Ivor-Lewis group (P = 0.029 and P &amp;lt; 0.001, respectively). Neither tracheal necrosis nor remnant esophageal necrosis was observed. The overall and recurrence-free survival rates were comparable between the groups (P = 0.494 and P = 0.813, respectively). Conclusion When performing esophagectomy for patients with a history of TPL, if it is oncologically acceptable and technically available, Ivor-Lewis is preferable over McKeown esophagectomy for avoiding postoperative complications.

746. ESOPHAGECTOMY, WITH CHOLECYSTECTOMY HAS A HIGH INCIDENCE OF REFLUX ESOPHAGITIS AND GASTRIC TUBE ULCER

Abstract The surgical methods for thoracic esophageal cancer was subtotal esophagectomy, with gastric pull up via retrosternal route, and cervical anastomosis. However, some cases were complicated by acute cholecystitis in the early postoperative period, and cholecystectomy was performed intraoperatively to prevent postoperative cholecystitis in some cases. The disruption of normal anti-reflux mechanisms including the lower esophageal sphincter, angle of His, and diaphragmatic muscle and the denervation of the vagus nerve are generally thought to be the main factors that interfere with gastric motor function. Furthermore, the pressure difference between thoracic (negative) and abdominal cavity (positive) is another factor that promotes reflux across the anastomosis. Due to these factors, postoperative reflux esophagitis is frequently experienced. Furthermore, after cholecystectomy, due to loss of gallbladder reservoir function after cholecystectomy and decrease in antroduodenal motility, bile is not excreted by food intermittently but continuously, resulting in duodenogastric reflux. We investigated postoperative reflux esophagitis and gastric tube ulcers in cases with and without intraoperative cholecystectomy for the past three years. We investigated cholecystectomy with esophagectomy (n=65) and non-cholecystectomy with esophagectomy (n=101) in 166 cases of radical surgery for esophageal cancer in which 2-3 regions had been dissected in the past 3 years. As shown in Fig. 1, there are no differences in location, TNM, gender, and PPI administration .reflux esophagitis of the cervical esophagus is A:0 B:2 (3%), C:5 (8%), D:3 (5%) for chole(+), A:2 (2%), B:2 (2%), C:2 (2%), and D:2 (2%) for chole(-). Gastritis was Chole(+) superficial gastritis 14 (21%), metaplasia 4 (6%), chole(-) superficial gastritis 25 (25%), metaplasia 3 (2%). However, gastric tube ulcers occurred in 5 cases (7%) of Chole(+) and 1 case of perforation, while only 1 case (1%) of gastric tube ulcers occurred in Chole(-).. (Conclusion) Esophagectomy, gastric pull up with cholecystectomy has a high incidence of reflux esophagitis in the neck and can also cause ulcers in the gastric tube. Therefore, care should be taken in postoperative follow-up.

256. PROGNOSIS AND RISK FACTORS FOR SUPRACLAVICULAR LYMPH NODE METASTASIS IN PATIENTS WITH MIDDLE AND LOWER THORACIC ESOPHAGEAL CANCER

Abstract Background Whether supraclavicular lymph node metastases (#104 LNM) in patients with thoracic esophageal cancer are classified as distant or regional metastases differs between Western countries and East Asia. Therefore, in Japan, 3FL is a standard procedure, but in Western countries, 3FL may be rarely practiced. We aimed to determine the frequency and prognosis of #104 LNM compared with other regional LN stations and to identify risk factors for #104 LNM in patients with advanced thoracic esophageal cancer to investigate value of treatment of #104 LNM. Methods The study cohort of 567 eligible patients with esophageal cancer had undergone subtotal esophagectomy radically from 2003 to 2020. LN metastasis was defined as pathologically proven metastasis or positron emission tomography positive LNs. The effectiveness of LN dissection was assessed using an efficacy index (EI) that we calculated by multiplying the rate of metastasis (%) to each LN station by the 5-year overall survival (OS) rate of each patient and then dividing by 100. In order to clarify the indication for 3FL, risk factors for #104 LNM were determined by multivariable logistic regression. Results Among of 567 patients, 66 (11.6%) had #104 LNM. #104 LNM occurred in 31.7%, 10.7%, and 5.6% of patients with upper, middle, and lower thoracic lesions respectively. All patients had squamous cell carcinoma. Neoadjuvant chemotherapy was administered to 71% of patients, and chemo-radiation to 11%. The 5-year OS was 45.8%. The EI for #104 LNs (5.3) was like that for #101 LNs. Risk factors were age &amp;lt;65 years, upper lesion, clinical stage N2–3, and #101/106rec LNM. When assessing only middle and lower lesions, the 5-year OS of patients was 38% (EI 3.1), similar to that for #101 and #8/9/11 LNs, with similar risk factors to overall population. Conclusions The EI of patients with #104 LNM was similar to that of patients with other regional LNM such as #101 and #8/9/11 LNs, Therefore, patients with #104LNM were worth treated LN dissection. However, we recommend 3FL exclusively for patients with #104 LNM or those at high risk of metastasis due to the overall metastatic rate not being high.

645. CLINICAL SIGNIFICANCE OF LOCAL TREATMENT FOR RECURRENCE WITHIN THE SURGICAL FIELD AFTER RADICAL ESOPHAGECTOMY

Abstract Background In recent years, more aggressive multidisciplinary treatment and minimally invasive approaches with meticulous lymph node dissection have become the standard in esophageal cancer surgery, but recurrence cases within the surgical field after radical resection are unfortunately frequently observed. We will compare the clinicopathological characteristics of the cases of intra-sugical field recurrence with those of extra-surgical and both intra- and extra-surgical field recurrence and discuss their significance in light of the results of local treatment for intra-surgical field recurrence. Subjects The study included 130 cases of intra-surgical field recurrence among 490 esophageal cancer patients who underwent radical subtotal esophagectomy and cervical anastomosis (Mckeown-esophagectomy) with right thoracic approach between January 2013 and April 2019. Results The 130 cases of recurrence were categorized as intra-surgical field recurrence (Group I)/extra-surgical field (Group O)/intra- and extra-surgical field (Group I+O): 19/86/25. Preoperative factors: Tumor localization tended to be more common in Ut in group I (p=0.078), but there were no other differences such as cStage or preoperative treatment. Intraoperative/postoperative factors: I+O group had significantly more blood loss (p=0.045), but there were no other differences in the range of lymph node dissected field, number of dissected lymph nodes, combined resection of the thoracic duct, postoperative complications, hospital stay, or histological therapeutic effect. 19 patients in group I had 17 patients (89.5%) who received initial local treatment (surgery/CRT/RT: 4/7/6). The response rate (R0 resection or CR+PR) was 58.8%. Compared to cervical and upper mediastinal lymph node recurrence, the response rate to initial local treatment tended to be lower in patients with middle and lower mediastinal lymph node and anastomotic recurrence (80%/43%, p=0.145). Discussion Intra-surgical field recurrence after radical resection tended to be more common in the primary site of Ut. Recurrence in the upper mediastinal lymph nodes in the cervical region shows a relatively high response rate to local treatment, and long-term recurrence-free ("cure") is achieved. On the other hand, mid and lower mediastinal lymph node and anastomotic recurrences have a low response rate to local treatment and should be complemented with more systemic treatment, such as sequential ICI to initial treatment.

553. CIRCULAR STAPLED CERVICAL ESOPHAGO-GASTROSTOMY, A VALUABLE OPTION AFTER TOTALLY MINIMALLY INVASIVE MCKEOWN ESOPHAGECTOMY?

Abstract Background The optimal choice of anastomotic technique for cervical esophagogastric anastomosis after esophagectomy remains unclear. The incidence of cervical anastomotic leak after esophagectomy can be up to 30%, which is the highest among all types of gastrointestinal anastomosis. Anastomotic stricture is another complication that can decrease the postoperative quality of life with an incidence of 9.1–46.0%. Few studies directly compared circular stapled (CS) and hand sewn (HS) cervical esophago-gastric anastomosis, with mixed results. We aim to compare the two techniques in a pre-post cohort study. Methods Medical record of all patients that underwent minimally invasive subtotal esophagectomy and cervical esophago-gastrostomy in our institution from January 2018 to January 2024 were reviewed from a prospectively collected database. We routinely performed hand sawn anastomoses until February 2022, then switched to circular stapled, with the aim of reducing the incidence of anastomotic leaks. We compared clinical data of patients who received hand sewn cervical anastomosis and circular stapled anastomosis. Primary endpoints were anastomotic leaks and strictures. Results We identified 101 patients who met the inclusion criteria. HS anastomosis was performed in 67 patients, while 34 received CS anastomosis. Anastomotic leak rate was 22.4% in the HS group and 8.8% in the CS group (OR 0.34, p=0.092). Anastomotic stricture rate was 26.9% in the HS group and 14.7% in the CS group (OR 0.47, p=0.17). Median length of stay was 18 (IQR 15-22) days in the HS group and 13.5 (IQR 12-14.5) days in the CS group (p=0.001). Severe complication rate (CD&amp;gt;2) was 16.4% in the HS group and 11.8% in the CS group (OR 0.68, p=0.53). Conclusions In our experience, the introduction of circular stapled cervical esophago-gastrostomy was feasible and safe, and resulted in a lower incidence of anastomotic leak and stricture compared to hand sewn anastomosis, though not statistically significant, possibly because of the small sample size. No difference in other major postoperative outcomes was observed. We found cervical CS anastomosis a reliable, reproducible and technically less demanding procedure, even for very high esophageal cancers. We believe that this anastomotic technique could spread even in Western countries where it has hardly ever been explored.

Genomic alterations in two patients with esophageal carcinosarcoma identified by whole genome sequencing: a case report

BackgroundEsophageal carcinosarcoma (ECS) is a relatively rare malignancy, accounting for < 1% of all esophageal cancers. Its etiopathogenesis remains unknown. This study analyzed the genomic abnormalities in sarcomatous tumors from two patients undergoing subtotal esophagectomy using whole genome sequencing to elucidate the key characteristics of ECS.Case presentationWe identified TP53 driver mutations, copy number gains in 11q13 (including CCND1), and Apolipoprotein B mRNA editing enzyme catalytic polypeptide (APOBEC) signature enrichment in both ECS patients. Along with common genetic abnormalities, we identified CDKN2A driver mutations in case 1 and RAC1, NOTCH1, and TTC28 as novel fusion gene partners of MECOM in case 2. Notably, we detected germline pathogenic variant in Fanconi anemia (FA) complementation group I (FANCI) and group G (FANCG), which are involved in repairing DNA double-strand breaks by homologous recombination, for the first time, in ECS blood samples. These germline variants were truncating-type, Lys1221fs of FANCI (rs1567179036) for case 1 and Gln365Ter of FANCG (rs121434426) for case 2. We also identified somatic changes in cancer-associated pathways, such as PI3K/Akt/mTOR, cell cycle, and NOTCH signaling pathways, and structural chromosomal defects such as chromosome doubling.ConclusionsOur findings indicate that therapeutic drugs targeting the activation signal or FA pathway might be effective in treating ECS, however, their therapeutic significance should be elucidated in future studies.

Swallowing Safety after Remote sub-total Esophagectomy: How Important is Tongue Pressure?

The factors related to oropharyngeal dysphagia after remote esophagectomy (greater than five months) remain unclear. This study aimed to assess patient perception of dysphagia, maximum anterior isometric pressure (MAIP), maximum posterior isometric pressure (MPIP), lingual swallowing pressure (LSP) and radiographic physiological components of the oral and pharyngeal phases of swallowing in patients who are post remote sub-total esophagectomy (SE). Patient perception of dysphagia was assessed using the Eating Assessment Tool (EAT-10). MAIP, MPIP, and LSP were measured using the Iowa Oral Performance Instrument. Videofluoroscopy was used to assess the physiologic components of swallowing with the Modified Barium Swallow Impairment Profile (MBSImP) and the Penetration-Aspiration Scale (PAS). Ten patients were included in the study (53.2% male; mean age 54.5 ± 18.0). The mean postoperative time was 30 months (range, 5.0-72 months). Seven patients had elevated EAT-10 scores (> 3). All patients demonstrated impaired oropharyngeal swallowing on at least three MBSImP components (range 3-12) and two patients aspirated (PAS 8). There was a significant difference in MAIP values when comparing patients with normal versus impaired laryngeal elevation and epiglottic movement (p < 0.001). MPIP values were significantly different in patients with normal versus impaired epiglottic movement as well as normal versus elevated PAS scores (p < 0.001). Decreased lingual pressure and physiological changes in swallowing coexist after SE. Our results indicate that the decrease in tongue strength may be one of the factors related to unsafe swallow. The assessment of lingual pressure provides diagnostic value and should be incorporated as part of a comprehensive assessment in this population.

Subtotal esophagectomy and concurrent reconstruction with free jejunal flap for primary esophageal cancer after pancreatoduodenectomy.

Pancreatoduodenectomy and subtotal esophagectomy are widely considered the most invasive and difficult surgical procedures in gastrointestinal surgery. Subtotal esophagectomy after pancreatoduodenectomy is expected to be extremely difficult due to complicated anatomical changes, and selecting an appropriate intestinal reconstruction method will also be a difficult task. Therefore, perhaps because the method is considered impossible, there have been few reports of subtotal esophagectomy after pancreatoduodenectomy. A 73-year-old man with a history of pancreatoduodenectomy was diagnosed with superficial thoracic esophageal squamous cell carcinoma. Definitive chemoradiation therapy was recommended at another hospital; however, he visited our department to undergo surgery. We performed the robot-assisted thoracoscopic subtotal esophagectomy. There were some difficulties with the reconstruction: the gastric tube could not be used, the reconstruction was long, and the organs reconstructed in the previous surgery had to be preserved. However, the concurrent reconstruction was achieved with the help of a free jejunal flap and vascular reconstruction. All reconstructions from the previous surgery, including the remnant stomach, were preserved via regional abdominal lymph node dissection. After reconstruction, intravenous indocyanine green showed that circulation in the reconstructed intestines was preserved. On postoperative day 1, no recurrent nerve paralysis was observed during laryngoscopy. The patient could start oral intake smoothly 2weeks after surgery and did not exhibit any postoperative complications related to the reconstruction. The patient was transferred to another hospital on postoperative day 21. Owing to the free jejunal flap interposition method, we safely performed one stage subtotal esophagectomy and concurrent reconstruction, preservation of the remnant stomach, and pancreaticobiliary reconstruction in patients with a history of pancreatoduodenectomy. We believe that this method is acceptable and useful for patients undergoing complicated reconstruction.