Subtotal Esophagectomy Research Articles

Current status of gastrectomy and reconstruction types for patients with proximal gastric cancer in Japan

BackgroundSurgical procedures for proximal gastric cancer remain a highly debated topic. Total gastrectomy (TG) is widely accepted as a standard radical surgery. However, subtotal esophagectomy, proximal gastrectomy (PG) or even subtotal gastrectomy, when a small upper portion of the stomach can technically be preserved, are alternatives in current clinical practice. MethodsUsing a cohort of the PGSAS NEXT trial, consisting of 1909 patients responding to a questionnaire sent to 70 institutions between July 2018 and December 2019, gastrectomy type, reconstruction method, and furthermore the remnant stomach size and the anti-reflux procedures for PG were evaluated. ResultsTG was the procedure most commonly performed (63.0%), followed by PG (33.4%). Roux-en-Y was preferentially employed following TG irrespective of esophageal tumor invasion, while jejunal pouch was adopted in 8.5% of cases with an abdominal esophageal stump. Esophagogastrostomy was most commonly selected after PG, followed by the double-tract method. The former was preferentially employed for larger remnant stomachs (≧3/4), while being used slightly less often for tumors with as compared to those without esophageal invasion in cases with a remnant stomach 2/3 the size of the original stomach. Application of the double-tract method gradually increased as the remnant stomach size decreased. Anti-reflux procedures following esophagogastrostomy varied markedly. ConclusionsTG is the mainstream and PG remains an alternative in current Japanese clinical practice for proximal gastric cancer. Remnant stomach size and esophageal stump location appear to influence the choice of reconstruction method following PG.

Akiyama Procedure as a Surgical Option for Esophageal Cancer

Background The purpose of this study is to introduce our experience with the Akiyama procedure as a surgical option for treatment of esophageal cancer in the Mother Theresa Hospital Center of Tirana, Albania. Selection of the suitable site for anastomosis after esophagectomy, whether cervical or thoracic is the key for optimal oncological results. The goal is to minimize recurrence in oncological patients and to avoid complications related to surgery. Controversy still exists among surgeons as the optimal site for anastomosis as well as whether the anastomosis is done manually or with a stapler. Material and methods From October 2018 to June 2021, 27 surgical interventions of esophageal cancer were performed in our surgical unit. In 15 patients, subtotal esophagectomy Ivor-Lewis with a mediastinal esophago-gastric anastomosis was performed. In 8 patients, distal esophagectomy and proximal gastrectomy with an abdominal esophago-gastric anastomosis was performed. In 4 patients, subtotal esophagectomy with a cervical esophago-gastric anastomosis, Akiyama procedure was performed. In this study we are evaluating the Akiyama procedure with description of the technique, patient criteria of inclusion, oncological protocol and postoperative care. Discussion In our practice we used chemotherapy and radiotherapy as part of a multimodality treatment plan. All of our patients with carcinoma had radiation and chemotherapy prior to surgery. The use of stapler devices in cervical anastomoses in some studies is linked with higher rate of leakage but we consider it a preferential choice of the surgeon. We opted for a one-layer esophagogastric anastomosis in the neck as shown in some studies instead of the two-layer technique because of lower rates of stricture formation. The level of exposure in the cervical route is advantageous in making an accurate anastomosis. In our patients we used the retrosternal space for esophageal replacement to avoid local tumor recurrence in the posterior mediastinum. Conclusion As in other cancers there is a mandatory evaluation in congruence to the guidelines in order to each patient have a surgical or adjuvant therapy according to its stage. As per guidelines patients in a T1-2, N0 stage are treated with surgery alone and a close follow up for recurrence and patients in a T3 or N1/M1 stage should be considered for adjuvant therapy prior to surgery. In patients that have extensive disease and are not surgical candidates are considered for chemotherapy and radiation alone. It is advised that the type of surgery performed is the one in which the surgeon is more experienced and has the best outcome in terms of surgical strategy in terms of morbidity and mortality. Keywords: General surgery, Esophageal cancer, Akiyama procedure, Cervical esophago-gastric anastomosis. DOI: 10.7176/ALST/96-02 Publication date: December 31 st 2022

Mapping of lymph node dissection determined by the epicenter location and tumor extension for esophagogastric junction carcinoma.

Previous studies identified the extent of lymph node dissection for esophagogastric junction (EGJ) carcinoma based on the metastatic incidence. The study aimed to determine the optimal extent and priority of lymphadenectomy based on the therapeutic efficacy from each station. The studies on the lymph node metastasis (LNM) and therapeutic efficacy index (EI) for EGJ carcinomas were identified until April 2022. The obligatory stations with the LNM rates over 5% and therapeutic EI exceeding 2% should be routinely resected for D2 dissection, whereas the optional stations with EI between 0.5% and 2% should be resected for D3 dissection in selective cases. The survey yielded 16 eligible articles including 6,350 patients with EGJ carcinoma. The metastatic rates exceeded 5% at no. 1, 2, 3, 7, 9, 11p, and 110 stations and were less than 5% in abdominal no. 4sa~6, 8a, 10, 11d, 12a, and 16a2/b1 and mediastinal no. 105~112 stations. Consequently, obligatory stations with EI over 2% were largely determined by the epicenter location and located at the upper perigastric, lower mediastinal, and suprapancreatic zones, corresponding to those with rates of LNM over 5%. Consistent with the LNM rates less than 5%, the optional stations with EI between 0.5% and 2% were largely dependent on the degree of tumor extension toward the lower perigastric, splenic hilar (grecurvature), para-aortic (less curvature of the cardia), and middle or upper mediastinal zones. The obligatory stations can be resected as an "envelope-like" wrap by transhiatal proximal gastrectomy with lower esophagectomy, whereas the optional stations for dissection are indicated by the tumor extension. The extended gastrectomy is required for the lower perigastric in the stomach-predominant tumor with gastric involvement exceeding 5.0cm, para-aortic dissection in the less curvature-predominant tumor and splenic hilar dissection in the grecurvature-predominant tumor whereas transthoracic subtotal esophagectomy is required for complete mediastinal dissection and adequate negative margin in the esophagus-predominant tumor with esophageal invasion exceeding 3.0cm.

A case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for recurrent malignant melanoma of the esophagus

BackgroundThe treatment strategy for metastatic lesions of primary malignant melanoma of the esophagus (PMME) is currently determined on a case-by-case basis, based on the National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma. The NCCN guidelines state that resection should be considered in patients with resectable metastatic recurrence. Herein, we report a case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for the metastatic recurrence of PMME.Case presentationA 65-year-old female patient with PMME underwent thoracoscopic subtotal esophagectomy, gastric tube reconstruction via the posterior mediastinal route, and cervical esophagogastric anastomosis. Histopathological examination of the resected specimen revealed that the tumor was PMME with tumor invasion into the muscularis propria and no lymph node metastasis. At the age of 68 years, she developed intestinal invagination due to jejunal metastasis of malignant melanoma and underwent resection of the jejunum. Histopathological examination of the resected specimen revealed two metastases of malignant melanoma in the jejunum and one metastasis to the mesenteric lymph node. At the age of 75 years, a recurrence of malignant melanoma was found in the cervical esophagus. She underwent thoracoscopic mobilization of the gastric tube and esophagus followed by cervical esophagectomy and reconstruction with a free jejunum flap. She received 24 courses of nivolumab therapy for 1 year as a postoperative adjuvant therapy. Subsequently, at the age of 78 years, an enlarged left cervical lymph node and a mass in the right lower lobe of the lung were found. She underwent left cervical lymph node dissection and thoracoscopic wedge resection of the right lung. Histopathological examination of the resected specimens revealed that both tumors were metastases of malignant melanoma. At age 79 years, she received eight courses of nivolumab therapy as a second postoperative adjuvant therapy, with no sign of recurrence in a 9-month follow-up period after the third metastasectomy.ConclusionIn cases of metastatic recurrence of PMME, aggressive resection of oligometastasis with postoperative adjuvant nivolumab therapy may result in long-term survival.

A nationwide validation of the prognostic impact of pathological response and the distribution of recurrence patterns in responders after neoadjuvant chemotherapy for esophageal squamous cell carcinoma.

We previously reported that postoperative recurrence in responders occurred in the regional field mostly as a solitary lesion without distant failure. However, further validation is necessary due to the low percentage of pathological responders, especially those with pCR. This study aimed to validate the prognostic impact of pathological response and the distribution of residual tumors in pathological responders using a nationwide database from 85 Japanese esophageal centers. We retrospectively reviewed patients with esophageal squamous cell carcinoma (ESCC) who underwent subtotal esophagectomy at 85 authorized institutes for esophageal cancer between 2010 and 2015. The recurrence free survival (RFS), overall survival (OS), and recurrent tumor patterns were compared among the pathological responses. Of 4781 patients initially enrolled, 3840 were selected for subsequent analysis, including 237 patients with pathological complete response (pCR, 6%). The RFS and OS were significantly correlated with pathological response. When the recurrence pattern was classified into regional or distant recurrence, the incidence of distant failure was significantly lower in patients with pCR in cT1/2. Three percent of all patients with pCR in cT1/2 encountered postoperative recurrence in distant organs. The prognostic impact of pathological response was reproduced in the nationwide data. pCR in ESCC patients with cT1/2 provides a favorable prognosis with less incidence of distant failure. This finding may contribute to selecting appropriate candidates for an organ preservation approach based on the response to induction therapy.

Nationwide Validation Study of the Prognostic Significance of Stratification Using Pathological Stage and Response to Neoadjuvant Chemotherapy for Esophageal Squamous Cell Carcinoma.

This study aimed to validate the prognostic significance of stratification using pathological stage and response to neoadjuvant chemotherapy with a nationwide database from an authorized institute by the Japan Esophageal Society. We proposed the combined criteria using pStage and pathological response. Conducting a validation study using an expanded cohort in the clinical setting would be valuable since it was developed using retrospective data collection. Patients with esophageal squamous cell carcinoma who underwent subtotal esophagectomy at 85 authorized institutes were retrospectively reviewed for esophageal cancer between 2010 and 2015. The prognostic value of the pathological response was evaluated within the same pStage. Moreover, risk stratification was developed to predict cancer-specific survival (CSS). The pathological response showed significant stratification of CSS in 3761 patients included in this analysis. We classified the patients into 7 groups as survival was significantly different between responders and nonresponders under the stratification with pStage, excluding pStage I comprising pStage 0-I/II responder/II nonresponder/III responder/III nonresponder/IV responder/IV nonresponder with the 5-year CSS of 83.7%/75.8%/68.9%/59.8%/44.4%/40.7%/23.1%, respectively. Furthermore, the area under the curve was significantly higher under the new classification than in the pStage alone ( P <0.001). The prognostic value of classification using pStage and the pathological response was successfully validated using real-world data in Japan. This result would guide appropriate treatment for patients with esophageal squamous cell carcinoma who received neoadjuvant chemotherapy followed by esophagectomy.

Management of End-Stage Achalasia

Background: End-stage Achalasia correspond to the final stage in the evolution of this disease, characterized by the presence of severe dysphagia and weight loss despite aggressive treatment, associated to massive esophageal dilatation and tortuosity of the esophagus, with loss of its axis and adopting a sigmoid-shape or L-shape distal esophagus. It is also called advanced sigmoid esophagus. The diagnosis is based on radiological evaluations, but different authors use different criteria to define end-stage. This fact makes difficult to compare the results, due to a great heterogeneity of the patients. Methods: Total of 65 reports contently treatment of patients with end stage achalasia were carefully review. Results: Until the year 2000 subtotal esophagectomy with gastric or long-colon interposition was employed as primary treatment or after several medical and endoscopic failed treatments. The mean mortality rate range 3% to 5%, with a high morbidity rate and 10 to 12 days of hospital stay. From 2000 to 2015 Laparoscopic Heller Myotomy (LHM) was employed as the primary treatment, with a mortality rate of 0%, low postoperative morbidity (6%-8%) and 2 days of Hospital stay. The long-term follow up was satisfactory in near 2/3 of the patients with end-stage esophagus. In the last years POEM (Peroral endoscopic Myotomy) has been employed mainly by Asian authors, reporting 0% mortality, high rate of postoperative morbidity (over 20%), a hospital stay of 5 to 7 days and a very short follow up, usually less than 2 years. Although the control of dysphagia is high, the main problem with this technique is the marked increase in pathologic acid reflux to the esophagus, with values near to 50% of the patients. It is not known the late effect 10 to 15 years after this procedure of this severe reflux in an aperistaltic esophagus, with retention of food and acid inside the esophageal lumen. Conclusion: Up to now Laparoscopic Heller Myotomy seems the best option for these patients with severe end-stage esophagus. If there is a failure after this procedure, thoracoscopic esophagectomy would be the best option.

Primary tracheobronchial necrosis after esophagectomy: A nationwide multicenter retrospective study in Japan.

The clinical features of postoperative primary tracheobronchial necrosis (P-TBN; the necrosis without anastomotic leakage or other cervical and mediastinal abscess) remains unclear. This nationwide multicenter retrospective study first investigated the clinical features of P-TBN after esophagectomy for upper aerodigestive tract cancer with a large cohort. As a study of the Japan Broncho-Esophagological Society, a nationwide questionnaire survey was conducted in 67 institutions. The clinical data of 6370 patients who underwent esophagectomy for laryngeal, pharyngeal, and esophageal cancer between 2010 and 2019 were collected. Grades of P-TBN were defined as follows: Grade 1, mucosal necrosis; Grade 2, transmural bronchial wall necrosis without fistula or perforation; Grade 3, transmural bronchial wall necrosis with fistula or perforation. P-TBN was observed in 48 (0.75%) of 6370 patients. The incidences of P-TBN for pharyngo-laryngo-cervical esophagectomy (PLCE; n=1650), total pharyngo-laryngo-esophagectomy (TPLE; n=205), and subtotal esophagectomy (SE; n=4515) were 2.0%, 5.4%, and 0.1%, respectively. The upper mediastinal LN dissection (P=0.016) and the higher level of the tracheal resection (P=0.039) were significantly associated with a higher grade of necrosis in PLCE and TPLE. Overall survival rates were significantly lower in patients with Grade 2 (P=0.009) and Grade 3 (P=0.004) than in those with Grade 1. The incidence of TBN restricted to P-TBN was lower than previously reported. Maintaining the tracheal blood flow is essential to prevent worsening P-TBN, especially in PLCE and TPLE. Our new P-TBN severity grade may predict the outcome of patients with P-TBN.

Controlling Nutritional Status Score Serves as a Prognosticator in Esophageal Squamous Cell Carcinoma: Optimal Timing of Evaluation of Patients Undergoing Neoadjuvant Treatment.

Usefulness of various nutritional indices for management of patients with esophageal squamous cell carcinoma (ESCC) has been reported. Although Controlling Nutritional Status (CONUT) score is among promising indices to predict outcome, the optimal timing for its measurement during the perioperative period remains unknown. Here the prognostic value of the CONUT score was assessed among patients with ESCC. We analyzed 464 patients who underwent subtotal esophagectomy of ESCC, of which 276 patients were treated with neoadjuvant treatment (NAT). The significance of the associations between candidate parameters including the CONUT score and postoperative prognosis were evaluated. Among the 25 candidate predictors, the preoperative CONUT score had the highest correlation with overall survival (OS) after surgery. Patients were categorized as follows: normal, mild, and moderate or severe, on the basis of the preoperative CONUT score. OS was significantly shortened as the CONUT score worsened. Multivariable analysis revealed that the CONUT scores of the subgroups mild (Hazard ratio [HR] 1.69) and moderate or severe (HR 2.18) were independent predictors of poor prognosis for OS. Furthermore, in an analysis limited to patients who underwent NAT, OS was significantly shortened as the preoperative CONUT score worsened. On the contrary, there was no significant difference in RFS among patient groups stratified by the CONUT score determined before NAT. Our study indicates that the preoperative CONUT score serves as a prognosticator in resectable ESCC. The preoperative CONUT value was more useful than that before NAT in patients administered NAT.

Adenocarcinoma of the Esophagogastric Junction:Classification and Surgical Treatment Strategy

Despite substantial declines in gastric cancer incidence, the incidence of adenocarcinoma of the esophagogastricjunction (AEG) has been rising remarkably worldwide and is drawing considerable attention as well as concern.However, the optimal extent of esophagogastric resection for this tumor entity, especially Siewert type II tumorslocated at the true cardia, remains highly controversial. Given the uncertainty about the optimal extent of prophylactic lymph node dissection, both subtotal esophagectomy and extended total gastrectomy have been advocatedfor this tumor entity. A recent Japanese questionnaire-based national retrospective study showed that completenodal clearance along the distal portion of the stomach offered marginal survival benefits for patients with AEGless than 4 cm in diameter. A prospective nationwide multicenter study accurately identified the distribution oflymph node metastases from advanced AEG, suggesting that it is not recommended to completely dissect lymphnode stations along the distal portion of the stomach. Total gastrectomy might be employed less frequently andconsequently replaced by subtotal esophagectomy or extended proximal gastrectomy in clinical practice.

S2398 Under Pressure: An Uncommon Case of Extraluminal Esophageal Air

Introduction: The presence of air adjacent to the esophagus on imaging can be an emergent finding warranting surgical or endoscopic evaluation, and the etiology can be esophageal, pulmonary, or vascular in nature. We report a case of an aortoesophageal fistula (AEF) in a critically ill patient after a recent thoracoabdominal endovascular aortic aneurysm repair (TEVAR). Case Description/Methods: A 70-year-old woman with hypertension and atrial fibrillation was in intensive care after a recent complicated TEVAR performed for aortic rupture. She was noted to have tachycardia and hypotension; she denied any nausea, melena, or hematochezia. Vital signs revealed a heart rate of 123 beats per minute and a blood pressure of 85/51 mm Hg. Physical exam showed a critically-ill appearing woman in no distress, a clear oropharynx, a non-tender abdomen, and a rectal exam without blood. Labs noted a leukocytosis of 19.0 x109/L, a Hgb of 6.8 g/dL, and a lactate of 2.1 mmol/L. Labs drawn 12 hours prior noted a Hgb of 8.2 g/dL and a lactate of 0.9 mmol/L. CT imaging of the chest (Figure A-B) showed interval air in the excluded thoracic aneurysmal sac adjacent to the esophagus (arrow 1), which was intubated by an enteric tube (arrow 2). EGD (Figure C-D) revealed 2 large non-bleeding perforations in the middle esophagus with possible fistulation to the mediastinum. The clinical presentation suggested post-TEVAR AEF, likely due to compressive ischemia and necrosis of the esophagus from the aneurysmal sac compounded by prolonged shock. Given high operative risk, an esophageal stent and gastrostomy tube were placed by cardiothoracic surgery. Discussion: Post-TEVAR AEF formation is a rare but serious complication occurring in 1.7–1.9% of patients after TEVAR, and can be due to graft infection, aortic pressure necrosis, or esophageal erosion related to aortic expansion. Chiari’s triad, the hallmark symptoms of AEF, include mid-thoracic pain and sentinel hematemesis followed by massive hematemesis. However, massive hemorrhage may be observed soon after a sentinel episode of hematemesis or can be delayed by years. Imaging findings include air within the aortic thrombus or esophageal wall, expanding fluid collection around the graft, or extraluminal aortic contrast extravasation. Endoscopic findings include esophageal submucosal protrusions, ulcerative lesions, or fistula formation. In stabilized patients, management options include subtotal esophagectomy and aortic debridement and reconstruction.Figure 1.: Endoscopic and Imaging Investigations for Aortoesophageal Fistula. Panels A-B. Coronal and axial, respectively, CT images of the chest with contrast. The development of air was noted in the excluded aortic aneurysmal sac adjacent to the esophagus after TEVAR (arrow 1); the esophagus is intubated by an enteric tube (arrow 2). Panels C-D. EGD revealed 2 large non-bleeding perforations in the middle esophagus with surrounding ulceration and possible fistulation to the mediastinum.

614. SIGNIFICANCE OF LAPAROSCOPIC SURGERY IN OPEN THORACOTOMY ESOPHAGECTOMY

Abstract The usefulness of laparoscopic surgery in esophageal cancer surgery has been reported in the MIRO trial, but there are few reports of laparoscopic surgery in esophageal subtotal resection, which is the standard surgical procedure in Japan. Furthermore, chest procedures are often performed by thoracoscopic surgery, making it difficult to evaluate laparoscopic operations. This time, we retrospectively examined the usefulness of laparoscopic procedure in right thoracotomy surgery. From 2007 to 2019, 135 patients with esophageal cancer who underwent thoracotomy and subtotal esophagectomy and were reconstructed by gastric tube (post-sternal route, cervical anastomosis) were included. In the laparoscopic group (Lap group), gastric mobilization and perigastric lymph node dissection were performed under 5-port. The stomach was pulled out of the abdominal cavity with a small laparotomy of 4-5 cm to prepare a gastric tube. In the case of open surgery (Open group), epigastric midline incision (15-20 cm) was performed up to the navel. There were 67 cases in the Lap group and 68 cases in the Open group. There was no difference in thoracotomy time between the two groups. In the Lap group, the amount of bleeding was significantly less than in the Open group (289g vs 376g), and the operation time was longer. Lung complications of Clavien-Dindo classification Grade 2 or higher were significantly less in the Lap group (10% vs 24%). There was no difference between the two groups in anastomotic insufficiency and recurrent laryngeal nerve palsy. The number of dissected lymph nodes was significantly higher in the Lap group. Laparoscopic abdominal manipulation in open esophageal cancer surgery was useful in reducing pulmonary complications.

623. A NEW PROGNOSTIC EVALUATION OF POSTOPERATIVE ESOPHAGEAL CANCER: LONG-TERM FLAIL INVESTIGATION

Abstract Recurrence-free survival and 5-year survival rates are still commonly used as prognostic indicators for gastrointestinal cancer. We believe that there is a need to find an appropriate index to evaluate changes in health status over time in postoperative patients. We evaluated changes in "frailty" after esophageal cancer surgery using the Kihon Checklist (KCL) developed by the Japanese Ministry of Health, Labour and Welfare, and examined risk factors for worsening health status after surgery. Twenty-four patients (21 thoracoscopic sub-total esophagectomy, 1 mediastinoscopic sub-total esophagectomy, and 2 total laryngopharyngoesophagectomy) who underwent esophageal cancer surgery in our department from December 2019 to April 2021 were included. Patients were asked to write down their KCL before surgery and one year after surgery at an outpatient clinic, and changes over time were checked. We compared the background factors in the "maintain" group (M group) and the "worsened" group (W group), and investigated the risk factors for pre-frail and frail states one year after the surgery. 8 patients worsened from robust to pre-frail to frail and pre-frail to frail, and 16 patients maintained their condition, with 33% of them worsening. Age (M/W: 70/72, p=0.296), male (M/W: 0.88/1.0, p=0.536), BMI (M/W: 22.4/19.6, p=0.142), pStage≥3 (M/W: 0.38/0.38, p=1.0), preoperative chemotherapy (M/W: 0.69/0.63, p=1.0), operative time (M/W: 566/610 minutes, p=0.327), blood loss (M/W: 103/151 ml, p=0.342), postoperative pneumonia (M/W: 0.25/0.25, p=1.0), and cancer recurrence (M/W: 0.19/0.50, p=0.167). The preoperative blood samples were Alb (M/W: 4.3/3.8 g/dl, p=0.046), Hb (M/W: 14.2/12.8 g/dl, p=0.015) and Cre (M/W: 0.85/0.79 mg/dl, p=0.713). At 1 year after esophageal cancer surgery, health worsened and 33% of patients were in a pre-frail or frail state. Risk factors for worsening health were low Alb and low Hb, which were not related to stage or actual age. Further study is needed to clarify risk factors for frailty.

388. PREOPERATIVE TREATMENT AND THORACOSCOPIC ESOPHAGECTOMY FOR BORDERLINE RESECTABLE ESOPHAGEAL CANCER

Abstract Preoperative DCF therapy is recommended for cStage II/III esophageal cancer based on the results of JCOG1109. However, there is no established treatment strategy for Borderline Resectable (BR) esophageal cancer that is suspected of invading vital organs. And the pros and cons of thoracoscopic surgery have not been clarified. We have been performing preoperative chemoradiotherapy (NACRT) followed by thoracoscopic subtotal esophagectomy for BR esophageal cancer. Details and short-term results are presented. After 2 courses of FP therapy and 40 Gy total dose (2 Gy x 20 times) of fractionated conventional irradiation, patients underwent thoracoscopic subtotal esophagectomy with D2 dissection if T4 factor was considered to have been removed by CT evaluation. From April 2017 to present, NACRT was performed in 25 BR esophageal cancer patients. Two of them were unresectable, and thoracoscopic subtotal esophagectomy was performed in 23 cases. All patients had squamous cell carcinoma. 4 patients had complications of Clavien-Dindo Grade III or higher. The median postoperative hospital stay was 23 days. Of the 23 cases that were resectable, R0 resection could be performed in 21 cases (91.3%). The pathological response of the primary tumor was Grade3 in 11 patients (47.8%), Grade2 in 5 (21.7%), and Grade1 in 7 (30.4%). Pathological-CR including regional lymph nodes was 7 cases (30.4%). NACRT is effective for BR esophageal cancer, and thoracoscopic subtotal esophagectomy can be performed safely. We would like to continue to study the long-term results of NACRT with more cases in the future.

268. COMPARISON OF OUTCOME OF GASTRIC TUBE RECONSTRUCTION FOR ESOPHAGEAL CANCER BETWEEN RECONSTRUCTIVE ROUTES

Abstract The route of gastric tube reconstruction after esophageal cancer resection is generally adopted as either posterior sternal or posterior mediastinal. There have been no large-scale comparative studies, and each institution has chosen a route based on its own experience. Therefore, we conducted an observational study at our institution to compare the postoperative outcomes of posterior sternal and posterior mediastinal reconstruction in gastric tube reconstruction for esophageal cancer. The study included 159 patients with thoracic esophageal cancer who underwent subtotal esophagectomy and gastric tube reconstruction (73 patients in the posterior sternal reconstruction (RS) group and 86 patients in the posterior mediastinal reconstruction (PM) group) from 2016 to 2018 and compared perioperative and postoperative complications and postoperative nutritional status. There were no differences in age, location, or pStage between the reconstructive routes, but BMI was significantly higher in RS (22.0 ± 2.9) and PM (20.8 ± 3.1). Anastomotic leakage (RS:PM = 8%:3%) and respiratory complications (RS:PM = 6%:15%) were not significantly different. PM was also significantly more common with ileus (13%). Anastomotic stenosis requiring dilation was significantly less common in PM than RS (31%:17%, p = 0.04). Weight loss was significantly higher in the RS group at 1 year postoperatively (RS/PM:13.9%/10.2%, p = 0.02). We have changed to PM with gastrostomy and the modified Collard anastomosis. These procedures have decreased the occurrence of ileus due to jejunostomy. Anastomotic stenosis was reduced to 5%. In gastric tube reconstruction after subtotal esophageal resection for esophageal cancer, the reconstructive route (posterior sternal or posterior mediastinal route) showed no significant difference in the incidence of postoperative pneumonia or anastomotic leakage. By changing the anastomotic procedure, a decrease in anastomotic stenosis was observed even with posterior sternal reconstruction. We plan to accumulate more cases and investigate the effects on quality of life and nutritional status in the future.

293. STRATEGY FOR RECONSTRUCTION AFTER ESOPHAGECTOMY—AIMING FOR ESOPHAGO-GASTRIC ANASTOMOSIS WITHOUT LEAKAGE, NECROSIS, STENOSIS

Abstract The important points in esophagogastric anastomosis after esophagectomy are ensuring blood flow at the tip of the gastric tube and releasing tension at the anastomotic site. The biggest drawback of the retrosternal route is the narrow space behind the sternoclavicular joint at the thoracic inlet, which increases the risk of anastomotic leakage and stenosis. We note the following three points during anastomosis. (1) Confirm the blood flow of the gastric tube using ICG fluorescence method, (2) Insert circular stapler from the side wall of the gastric tube and be careful not to put tension on the wall of the gastric tube. (3) Adjust the length of the residual esophagus so that the anastomotic site is not located behind the sternoclavicular joint that can cause anastomotic leakage and stenosis. Of the 132 cases of subtotal esophagectomy for esophageal cancer performed in our department from January 2017 to March 2022, 94 cases underwent retrosternal reconstruction. There are 66 and 28 cases, respectively, before and after the procedure revision in November 2020. Improvement was observed in the incidence of anastomotic leakage which decreased from 43.9% to 10.7%, and the incidence of anastomotic stenosis which decreased from 34.8% to 17.9%. It is suggested that securing blood flow at the tip of the gastric tube, releasing the tension at the anastomotic site, and adjusting the anastomotic site not to be located behind the sternoclavicular joint may reduce anastomotic leakage and stenosis in the retrosternal esophagogastric anastomosis after esophagectomy.

544. NON-EPSTEIN-BARR VIRUS ASSOCIATED LYMPHOEPITHELIOMA-LIKE CARCINOMA OF THE ESOPHAGUS WITH SURGICAL TREATMENT: A REPORT OF TWO CASES

Abstract Lymphoepithelioma-like carcinoma (LELC) can occur in many organs such as lung, stomach, skin, breast, bile ducts, esophagus, and other many organs. Esopahageal lymphoepithelioma-like carcinoma is an extremely rare disease. LELC has been reported to be associated with Epstein-Barr virus (EBV) in some organs, although there are many controversies. Here, we report a surgically treated two cases of non-Epstein-Barr virus associated LELC of the esophagus. Case 1was a 46-year-old woman who was presented epigastralgia while eating. Upper gastrointestinal endoscopy showed a submucosal tumor in the lower esophagus. Biopsies were taken, and they identified atypical cells proliferating follicular manner and heavy infiltration of lymphocytes. Case 2 was a 71-year-old man who was pointed out to have a tumor in the esophagus by barium examination and was referred to our hospital. Upper gastrointestinal endoscopy showed submucosal tumor was found 23-26 cm from the cut tooth. Endoscopic Ultrasound-guided Fine Needle Aspiration (EUS-FNA) was performed and diagnosed with LELC. These patients underwent subtotal esophagectomy with lymphadenectomy and reconstruction with gastric tube. Case1 was pathologically diagnosed with LELC, SM3, INFa, ly0, V0, pIM0, pPM0 (100mm), pDM0 (120mm), pRM0, pN0, cM0, pStageI, and case2 was diagnosed with LELC, ly1, V1, pIM0, pPM0, pDM0, pRM0, pN0, cM0, pStageI, according to the 10th edition of Japanese classification of Esophageal cancer. Immunohistochemical staining of the specimen from case 1 was positive for AE1/AE3, P40, p63, and negative for CD56 and chromogranin A. Immunohistochemical staining of the specimen from case 2 was positive for CK, EMA, P40, and negative forαSMA and desmin. EBV was not detected by EBER in situ hybridization in the specimen from both patients. LELC is relatively common in salivary glands, thymus, lungs, stomach, skin, and cervix, and EBV that directly infects epithelial cells or infects lymphocytes infects epithelial cells and infects them. EBV infects epithelial cells and is thought to be associated with carcinogenesis of these organs. However, esophageal LELC is rare and it has been argued that EBV may not be involved. In these two cases, EBV was not detected in situ hybridization.

647. A CASE OF ACUTE GASTRIC TUBE ULCER BLEEDING SAVED BY EMERGENCY SURGERY

Abstract Gastric tube ulcer is recognized as one of the complications after esophageal cancer surgery. When a ulcer bleeds, or penetrates to the pericardial space, or perforates, it often follows a fatal course due to its anatomical position and the complexity of surgical treatment. We report a case of persistent bleeding from a gastric tube ulcer after esophageal cancer operation, which was unable to treat endoscopically. The case was a 67-year-old man. Thoracoscopic subtotal esophagectomy and posterior mediastinal route subtotal gastric reconstruction were performed for middle thoracic esophageal cancer. His fifth-year regular endoscopy revealed a gastric tube ulcer. As a cause of myalgia, the patient was prescribed NSAIDs every day by a nearby doctor. Initially, no bleeding was observed, and discontinuance of NSAIDs and conservative treatment with PPI was continued. However, five months later, sudden hematemesis was observed at night, and he was transferred to a nearby doctor. Emergency endoscopy revealed gastric tube ulcer bleeding. And he was transferred to our hospital in an emergency. However, two days later, hematemesis and persistent ulcer hemorrhage were observed. Due to the difficulty of cauterizing to heartbeat, emergency surgery was performed. The first attempt was made to approach by a posterior mediastinal route, but it was difficult to confirm the ulcer and it was difficult to control bleeding without compression. Adding the thoracotomy, the ulcer was confirmed under direct vision. An ulcer defect was about 5 cm, bleeding was from the ulcer margin. Barbed suture closure and the omental patch were performed. The postoperative course was uneventful and discharged from the hospital 21 days after the operation. We experienced a rare case of acute hemorrhagic gastric tube ulcer that was difficult to treat conservatively and was saved by emergency surgery. After reconstruction of esophageal cancer, there are complicated situations such as the route of the elevated gastric tube, the position of the ulcer, and the risk of perforation to the pericardial space. Prompt and accurate medical care is required.

546. THE IMPACT OF PREOPERATIVE DENTITION ON POSTOPERATIVE SPUTUM SURVEILLANCE CULTURE AND POSTOPERATIVE PNEUMONIA IN PATIENTS WITH ESOPHAGEAL CANCER

Abstract Preoperative dental cleaning and treatment are increasingly performed as part of perioperative management, and postoperative pneumonia has been reported to be reduced by these dental interventions in patients with esophageal cancer. However, few studies have surveyed the impact of dentition on postoperative sputum culture and pneumonia. Fifty-five consecutive patients who underwent subtotal esophagectomy at Center Hospital of the National Center for Global Health and Medicine between November 2015 and August 2020 were included. Salvage cases, two-stage procedures, and cases with inadequate dental findings were excluded. The number of lost teeth was investigated, and the relationship between sputum surveillance cultures collected on the first to fourth day after surgery and the development of postoperative pneumonia was analyzed. Postoperative sputum surveillance culture revealed pathogenic organisms in 31 (56%) patients. Candida species/P. aeruginosa/Klebsiella species/E. cloacae/S. maltophilia/S. pneumoniae/S. aureus were detected in 27/13/9/7/5/4/4/4%, respectively. Pathogenic organisms were detected significantly more frequently in cases with more than ten lost teeth (p&amp;lt;0.01, odds ratio 6.42, 95% CI 1.58-26.1). Twelve patients (22%) had postoperative pneumonia with Clavien-Dindo grade 2 or higher. Postoperative pneumonia occurred significantly more frequently in patients with more than ten lost teeth (p=0.03, odds ratio 4.62, 95% CI 1.20-17.8). Postoperative pneumonia occurred significantly more frequently in patients in whom pathogens were detected (p=0.046, odds ratio 5.75, 95% CI 1.12-29.4). Patients with many lost teeth tended to have pathogens detected in early postoperative surveillance cultures before the onset of pneumonia and have more risk of developing postoperative pneumonia.

Case report: Surgical repair of a large tracheo-esophageal fistula in a patient with post-transplant esophageal lymphoproliferative disorder

Introduction and importanceThe management of large malignant tracheo-esophageal fistulas (TEF) is not standardized. Herein, we report a case with a malignant TEF associated with esophageal post-transplant lymphoproliferative disorder (PTLD) for whom we successfully performed a surgical repair. This contributes to the knowledge on how to treat large acquired malignant TEFs.Case presentationA 69-year old male presented with a one-week history of fever, productive cough and bilateral coarse crackles. In addition, he described a weight loss of 10 kg during the past three months. The patient's history included a kidney transplantation twenty years ago. Esophagogastroduodenoscopy with a biopsy of the esophagus was performed nine days before. Histopathology showed a PTLD of diffuse large B-cell lymphoma subtype. Subsequent diagnostics revealed a progressive TEF (approx. 2.0 × 1.5 cm) 3.0 cm above the carina. PET-CT scan showed an esophagus with slight tracer uptake in the middle third (approx. 11.5 cm length, SUV max 7.4). After decision against stenting, transthoracic subtotal esophagectomy with closure of the tracheal mouth of the fistula by a pedicled flap was performed. PTLD was treated with prednisone and rituximab. Tumor progression (brain metastasis) led to death 95 days after surgery.Clinical discussionThe treatment of a malignant TEF is complex and personalized while both the consequences of the esophago-tracheal connection and those of the underlying responsible diagnosis have to be considered concurrently. In this case, we considered surgery as the best treatment option due to a relatively good prognosis of the underlying diagnosis (PTLD) and a large fistula. Esophageal or dual stenting, the treatment of choice for small malignant TEF, would have been associated with a high risk of failure due to the wide trachea, extensively dilated esophagus, proximal location and large diameter of the fistula.ConclusionSurgery can be considered for patients with a large acquired malignant TEF and positive long-term prognosis of the underlying diagnosis. Due to the complexity of TEF management, immediate pre-operative multidisciplinary discussion is advised.