Transthoracic Resection Research Articles

Technical considerations in robotic aberrant right subclavian artery resection for dysphagia lusoria

Dysphagia lusoria occurs due to compression of the esophagus as an aberrant right subclavian artery (ARSA) crosses the mediastinum. Surgical management includes open, hybrid, and endovascular techniques, with no consensus gold standard. There are few reports of robotic-assisted ARSA resection. We describe the innovative technique and outcomes for two patients who successfully underwent robotic-assisted transthoracic resection of an ARSA after right carotid–subclavian bypass for dysphagia lusoria. Both patients experienced improvement or resolution of their dysphagia and no major complications. In select patients with a noncalcified origin of the ARSA without aneurysmal degeneration, the robotic-assisted approach represents a viable option.

176. NON-REGIONAL LYMPHADENOPATHY IN PATIENTS WITH ESOPHAGEAL CANCER TREATED WITH CURATIVE INTENT: A PROPENSITY MATCHED ANALYSIS OF PATHOLOGICAL AND SURVIVAL OUTCOMES

Abstract Background The management of patients with esophageal cancer and concurrent retroperitoneal or supraclavicular lymphadenopathy is controversial. Whilst these patients could be considered non-resectable, the survival benefit of neoadjuvant treatment followed by en bloc resection is not well described. The aim of this study was to explore the perioperative, pathological and survival outcomes of patients with esophageal cancer who presented with oligometastatic non-regional lymphadenopathy treated with neoadjuvant therapy and subsequent en bloc transthoracic esophagogastrectomy. Methods Between 01/2010 and 12/2022, a single center retrospective review of a prospectively maintained comprehensive esophageal cancer surgical database was performed. All patients with esophageal and junctional cancer with clinical non-regional (supraclavicular and retroperitoneal) lymphadenopathy were identified (Tany, Nany, M+). Only patients treated with neoadjuvant chemotherapy/chemoradiotherapy (nCT/nCRT) and extended en bloc transthoracic esophagogastrectomy including resection of the non-regional lymph node basin were included. Patients with gastric cancer and solid organ metastases were excluded. Propensity score matching was used to create a control group of clinically M- patients from same database to compare survival outcomes. Results Of the 46/1235 patients with non-regional lymphadenopathy, 39 met the inclusion criteria. Most had adenocarcinoma (35/39,89.7%) with retroperitoneal and supraclavicular lymphadenopathy in 26/39 (66.7%) and 16/39 (41.0%). nCRT and nCT was used in 5 and 34 patients respectively. Twenty-four received taxane based regimens and 24/39 (61.5%) adjuvant therapy. A trend towards improved overall survival was noted when comparing the study and control groups (27.0 vs 17.0 months, p = 0.065). However, cM+(retroperitoneal) had similar survival to the control group with both being higher than cM+(supraclavicular) (27.0 vs 21.0 vs 13.0 months, p = 0.039). Non-regional nodal basin sterilization occurred in 20/36 (55.6%) and was not associated with improved survival. Conclusion Whilst non-regional lymph node disease in the setting of esophageal cancer can be treated with neoadjuvant therapy and curative en bloc extended transthoracic resection, it seems that in terms of survival patients with retroperitoneal disease benefit the most. In this group of patients, equivalent survival to those with non-metastatic disease is achievable. Further understanding into those who would benefit from such a regimen is urgently needed.

Transthoracic resection of hyperplastic parathyroid gland via a uniportal video-assisted thoracic surgery technique

Uniportal video-assisted thoracic surgery has grown in popularity in recent years, becoming the treatment of choice for minimally invasive resections of mediastinal lesions. The many advantages of video-assisted thoracic surgery, including decreasing postoperative pain, morbidity and length of hospitalization, have increased its utilization for optimal patient care. In our case, this approach was used on a 55-year-old female patient who presented with a retrotracheal mass protruding through the thoracic inlet. The resection was performed through the chest via a uniportal video-assisted thoracic surgery technique with an unremarkable operative and postoperative course.

Extensive clinical target volume in postoperative chemoradiotherapy for esophageal squamous cell carcinoma: a phase II clinical trial (ESO-Shanghai 9)

BackgroundTo compare the efficacy and safety of postoperative extensive target volume irradiation with elevated radiation dose and concurrent chemotherapy with radiotherapy only for the postoperative treatment of esophageal squamous cell carcinoma.MethodsThis trial was a single-arm phase II trial. Patients who underwent a radical transthoracic resection with negative margins within 3 months and histologically confirmed esophageal squamous cell carcinoma (pT3-4N0M0 or pTxN + M0, AJCC 7th) were eligible for this study. Postoperative radiotherapy was performed at a total dose of 45 Gy in 25 fractions with clinical target volumes of the tumor bed, anastomosis, bilateral supraclavicular, mediastinal, left gastric and celiac trunk lymph node areas. Five cycles of weekly TC (paclitaxel 50 mg/m2, d1, carboplatin AUC = 2, d1) were given as concurrent chemotherapy. The primary endpoint was the 2-year local control rate, and the secondary endpoints were overall survival, disease free survival, local-regional recurrence free survival, distant metastasis free survival and adverse events. All endpoints were compared with those in ESO-Shanghai 8 study with postoperative radiotherapy alone (40 Gy/20Fx).ResultsA total of 70 patients were enrolled from 2016 to 2018. The 2-year local control rate was 87.9% (95% CI: 83.3–92.3) in this study, which achieved the hypothesized 2-year local control rate of at least 83%. Overall survival, disease free survival, local-regional recurrence free survival and distant metastasis free survival in this study were also longer than those in previous ESO-Shanghai 8 study while most toxicities were increased and two patients in this study died of radiation pneumonitis.ConclusionsPostoperative extensive target volume irradiation with elevated radiation dose and concurrent chemotherapy was effective. Treatment related toxicity was increased due to higher treatment intensity.Trial registration clinicaltrials.gov: NCT02916511.

Minimally invasive transthoracic resection of a segment eight liver tumor

Despite advances in technology and technique of minimally invasive liver surgery, resection of lesions in the posterosuperior segments such as segment 8 (S8) remains challenging. Compared to open surgery, there are specific differences that make minimally invasive access to S8 challenging. These include the caudal view along the axis of the hepatoduodenal ligament, increased distance between trocars and the operative field, and the liver fulcrum created by the anterolateral segments limiting the view. However, several advancements have helped to overcome these challenges, such as the use of intercostal trocars (combined lateral-abdominal approach) and a flexible tip camera. Consequently, a total thoracoscopic (transthoracic) approach was developed to resect subdiaphragmatic tumors, which may particularly benefit patients with a hostile abdomen. This article summarizes the anatomic, technical, and technological considerations for safe resection of lesions in S8.

Postoperative Concurrent Chemoradiotherapy for Locally Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Phase II Clinical Trial.

BackgroundThis study aims to investigate the efficacy and safety of postoperative intensity-modulated radiotherapy (IMRT) covering partial regional lymph node areas combined with chemotherapy for locally advanced thoracic esophageal squamous cell carcinoma patients.MethodsThis was a single-center, single-arm phase II clinical trial that began in 2014. Patients who underwent radical transthoracic resection within 3 months and were histologically confirmed esophageal squamous cell carcinoma (pT3-4 or N+, M0 determined according to AJCC Guidelines, Edition 7) were recruited. Postoperative radiotherapy was performed with a total dose of 50.4Gy in 28 fractions using IMRT. Clinical target volumes (CTVs) included tumor bed, anastomosis, bilateral supraclavicular region, and superior mediastinal lymph nodes. Synchronous chemotherapy for 2 cycles (paclitaxel 150mg/m2, day1; Cisplatin 25mg/m2, day1-3; every 4 weeks), followed by 2 cycles of consolidation chemotherapy with the same regimen. The primary endpoint was the 2-year local control rate, and the secondary endpoints were overall survival (OS) and adverse events (AEs).ResultsA total of 75 eligible patients were included from 2014 to 2017. The 2-year LRFS rate, as the primary endpoint, was 73.3%. The 1-year and 3-year OS rates were 88.0% and 68.0%, respectively. Local recurrence occurred in 13/75 (17.4%) patients, of which 2.7% (2/75) were extra-target lymph nodes. Grade 4 adverse events reported in this study included 10 cases (13.3%) of neutropenia, 1 case (1.3%) of anemia, and 2 cases (2.7%) of thrombocytopenia, without toxic-related deaths. Almost all (96%) patients completed the entire postoperative radiotherapy course, and 62 (82.7%) patients completed at least 2 cycles of chemotherapy.ConclusionPostoperative IMRT (clinical target volume including tumor bed, anastomosis, bilateral supraclavicular region, and superior mediastinal lymph nodes) combined with synchronous chemotherapy in patients with locally advanced thoracic esophageal squamous cell carcinoma was well tolerated, with a high local control rate and a low probability of recurrence outside the irradiation field.Clinical Trial Registration https://clinicaltrials.gov/ChiCTR1900022689.

Transhiatal versus transthoracic esophagectomy for esophageal SCC: outcomes and complications

BackgroundTranshiatal esophagectomy (THE) and transthoracic esophagectomy (TTE) are both accepted procedures for esophageal cancer but still the most effective surgical approach continues to be controversial. This study aimed to determine post-operative complications and outcomes of TTE compared with THE.MethodsA retrospective analysis was performed on data of 243 adult patients with resectable esophageal cancer who underwent THE or TTE between December 2016 and October 2018. Demographic data, consisting of preoperative co-morbidities, disease stage, and perioperative morbidity and mortality were collected.ResultsAmong the patients, 99 individuals (40.7%) had a transhiatal resection and 144 (59.3%) had a transthoracic resection. Most patients (83.1%) were above 50 years old with no significant difference between groups (p = 0.297). The frequency distribution of comorbidities was similar in both groups. The most common site of the tumor in TTE group was middle esophagus and in THE group was lower esophagus. The most common complication was recurrence of dysphagia which was more common in THE group without significant difference. The other complications including pulmonary and cardiac events, tracheal and recurrent laryngeal nerve injury, chylothorax and anastomosis stricture did not differ between the groups. The operative mortality within 30 days after the operation was 2.8% with significant difference favored the THE group (THE 0%, TTE 5.2%, p = 0.033).ConclusionBecause of the controversies, the decision on the type of surgical technique in esophageal cancer treatment hinges on patient’s co-morbidities, cancer stage, tumor location and surgeon’s experience.

New Approaches to Neoadjuvant Treatment for Locally Advanced Esophageal Cancer

The treatment paradigm of esophageal carcinoma is evolving as is the appreciation that histology drives treatment decisions. For adenocarcinoma, neoadjuvant chemotherapy followed by en bloc transthoracic resection is the gold standard of care. In this setting, the addition of radiotherapy does not seem to be associated with a survival benefit. For squamous cell carcinoma, neoadjuvant chemoradiotherapy is currently the best therapeutic option. However, modern neoadjuvant chemotherapy regimens may engender better survival outcomes for these patients too. Moreover, the role of immunomodulating therapies and selective surgical approaches are yet to be fully appreciated and may influence future recommendations.

The Prognosis and Feasibility of Extensive Clinical Target Volume in Postoperative Radiotherapy for Esophageal Squamous Cell Carcinoma: A Phase II Clinical Trial

BackgroundThis trial aims to explore the feasibility and safety of postoperative radiotherapy covering all regional lymph node areas for locally advanced thoracic esophageal squamous cell carcinoma patients treated with intensity-modulated radiation therapy (IMRT).MethodsThis was a single-center single-arm, phase II clinical trial initiated in 2014. Patients who were treated with radical transthoracic resection and had negative margins within 3 months and histologically confirmed esophageal squamous cell carcinoma (pT3-4 or N+, M0 determined by the 7th edition of the AJCC guidelines) were recruited in this trial. Postoperative radiotherapy was performed with a total dose of 40 Gy in 20 fractions using IMRT. Clinical target volumes (CTVs) included the tumor bed, anastomosis, bilateral supraclavicular region, mediastinal lymph nodes, left gastric lymph nodes and celiac trunk lymph nodes. The primary endpoint was the 2-year local control rate, and the secondary endpoints were overall survival (OS) and adverse events (AEs).ResultsA total of 70 eligible patients were recruited from 2014 to 2016. The 2-year local control rate, as the primary endpoint, was 67.3%. In addition, the median OS was 57.0 months, with 1-year and 3-year OS rates of 92.8% and 60.9%, respectively. Among the patients, 28/40 (40%) developed locoregional recurrence, with 25.7% involving hematogenous recurrences. All reported AEs occurred during the course of IMRT or within 6 months thereafter. None of them suffered grade 4 hematological or nonhematological AEs. Nearly all patients completed the entire course of postoperative radiotherapy, with a completion rate of 97.1%.ConclusionFor an extensive target volume, 40 Gy is feasible and shows acceptable toxicity in patients with locally advanced thoracic esophageal squamous cell carcinoma, although the local recurrence rate is relatively high. Our findings provide a basis for further exploration of high-dose radiation with extensive CTV combined with chemotherapy.Clinical Trial Registration[http://www.clinicaltrials.gov/ct2/results?cond=&term=NCT02384811&cntry=&state=&city=&dist=], identifier [NCT02384811].

Feasibility, effectiveness, and safety of endoscopic vacuum therapy for intrathoracic anastomotic leakage following transthoracic esophageal resection

BackgroundAnastomotic leakage (AL) in the upper gastrointestinal (GI) tract is associated with high morbidity and mortality rates. Especially intrathoracic anastomotic leakage leads to life-threatening complications. Endoscopic vacuum therapy (EVT) for anastomotic leakage after transthoracic esophageal resection represents a novel concept. However, sound clinical data are still scarce. This retrospective, single-center study aimed to evaluate the feasibility, effectiveness, and safety of EVT for intrathoracic anastomotic leakage following abdomino-thoracic esophageal resection.MethodsFrom March 2014 to September 2019 259 consecutive patients underwent elective transthoracic esophageal resection. 72 patients (27.8%) suffered from AL. The overall collective in-hospital mortality rate was 3.9% (n = 10). Data from those who underwent treatment with EVT were included.ResultsFifty-five patients were treated with EVT. Successful closure was achieved in 89.1% (n = 49) by EVT only. The EVT-associated complication rate was 5.4% (n = 3): bleeding occurred in one patient, while minor sedation-related complications were observed in two patients. The median number of EVT procedures per patient was 3. The procedures were performed at intervals of 3–5 days, with a 14-day median duration of therapy. The mortality rate of patients with AL was 7.2% (n = 4). Despite successfully terminated EVT, three patients died because of multiple organ failure, acute respiratory distress syndrome, and urosepsis (5.4%). One patient (1.8%) died during EVT due to cardiac arrest.ConclusionsEVT is a safe and effective approach for intrathoracic anastomotic leakages following abdomino-thoracic esophageal resections. It offers a high leakage-closure rate and the potential to lower leakage-related mortalities.Trial registration: This trial was registered and approved by the Institutional Ethics Committee of the University of Heidelberg on 16.04.2014 (Registration Number: S-635/2013).

Prognostic value of inflammatory markers for detecting anastomotic leakage after esophageal resection

BackgroundEarly diagnosis of anastomotic leakage (AL) after esophageal resection is crucial for the successful management of this complication. Inflammatory serological markers are indicators of complications during the postoperative course. The aim of the present study was to evaluate the prognostic value of routine inflammatory markers to predict anastomotic leakage after transthoracic esophageal resection.MethodsData from all consecutive patients undergoing transthoracic esophageal resection between January 2010 and December 2016 were analyzed from a prospective database. Besides clinicodemographic parameters, C-reactive protein, white blood cell count and albumin were analyzed and the Noble/Underwood (NUn) score was calculated to evaluate their predictive value for postoperative anastomotic leakage. Diagnostic accuracy was measured by sensitivity, specificity, and negative and positive predictive values using area under the receiver operator characteristics curve.ResultsOverall, 233 patients with transthoracic esophageal resection were analyzed, 30-day mortality in this group was 3.4%. 57 patients (24.5%) suffered from AL, 176 patients were in the AL negative group. We found significant differences in WBCC, CRP and NUn scores between patients with and without AL, but the analyzed markers did not show an independent relevant prognostic value. For CRP levels below 155 mg/dl from POD3 to POD 7 the negative predictive value for absence of AI was > 80%. Highest diagnostic accuracy was detected for CRP levels on 4th POD with a cut-off value of 145 mg/l reaching negative predictive value of 87%.ConclusionsIn contrast to their prognostic value in other surgical procedures, CRP, WBCC and NUn score cannot be recommended as independent markers for the prediction of anastomotic leakage after transthoracic esophageal resection. CRP is an accurate negative predictive marker and discrimination of AL and no-AL may be helpful for postoperative clinical management.Trial registration The study was approved by the local ethical committee (S635-2013).

Trans-thoracic versus trans-hiatal resection for oesophageal carcinoma: a retrospective comparative study of a single-centre case series

BackgroundOesophageal carcinoma (EC) is the eighth most common cancer. Surgery is the cornerstone of management for resectable EC. Trans-thoracic oesophagectomy (TTE) and trans-hiatal oesophagectomy (THE) are the two most widely practised procedures. Most of the related controversies are centred on both early and late post-operative complications and mortality (in terms of overall survival and cancer-free survival).This was a single-centre, retrospective, comparative study analysing the outcomes of two EC resection methods. All 87 patients underwent surgery by the same surgical team over 13 years. Consequently, 87 oesophagectomies with curative intent were performed and divided into the TTE group (group A = 47) and the THE group (group B = 40).ResultsThe mean patient age was 65.60 ± 6.30 years in the TTE group and 63.48 ± 9.34 years in the THE group. No significant difference was found in operative time, blood loss or duration of stay in the intensive care unit. The duration of hospital stay was significantly different between the THE and TTE groups (17.25 ± 5.92 vs. 12.93 ± 3.44, respectively; P ≤ 0.001). In-hospital mortality was higher in the TTE group (9/47, 19.14%) than in the THE group (5/40, 12.5%) (P = 0.400). The mean survival rate from our series showed the superiority of group A (TTE) (65.56 months) over group B (THE) (45.01 months), with P = 0.146.ConclusionNo high level of evidence suggests the superiority of one surgical procedure over another. The THE procedure is less time-consuming concerning care and follow-up, and most patients were more satisfied and experienced less pain than with the TTE procedure. Both THE and TTE have comparable post-operative anastomotic complications, and they have no significant long-term survival differences.

Two-Year Quality of Life Outcomes After Robotic-Assisted Minimally Invasive and Open Esophagectomy

Robotic-assisted minimally invasive esophagectomy (RAMIE) is a safe alternative to open esophagectomy (OE). However, differences in quality of life (QOL) after these procedures remain unclear. We previously reported short-term QOL outcomes after RAMIE and OE and describe here our results from 2 years of follow-up. We conducted a prospective, nonrandomized trial of patients with esophageal cancer undergoing transthoracic resection by RAMIE or OE at a single institution. The primary outcomes were patient-reported QOL, measured by the Functional Assessment of Cancer Therapy-Esophageal (FACT-E), and pain, measured by the Brief Pain Inventory (BPI). Generalized linear models were used to assess the relationship between QOL outcomes and surgery cohort. P values were adjusted (P-adj) within each model using the false discovery rate correction. Esophagectomy was performed in 170 patients (106 OE and 64 RAMIE). The groups did not differ significantly by any measured clinicopathologic variables. After covariates were controlled for, FACT-E scores were higher in the RAMIE cohort than in the OE cohort (parameter estimate [PE], 6.13; P-adj= .051). RAMIE was associated with higher esophageal cancer subscale (PE, 2.72; P-adj= .022) and emotional well-being (PE, 1.25; P-adj= .016) scores. BPI pain severity scores were lower in the RAMIE cohort than in the OE cohort (PE,-0.56; P-adj= .005), but pain interference scores did not differ significantly between groups (P-adj= .11). During 2 years of follow-up, RAMIE was associated with improved patient-reported QOL, including esophageal symptoms, emotional well-being, and decreased pain, compared with OE.

Efficacy and Safety of Large-field Postoperative Radiotherapy Using Three-dimensional Radiation Technique for Local Advanced Thoracic Esophageal Squamous Cell Carcinoma: A Phase II Clinical Trial

This trial aimed to explore the feasibility and safety of large-field postoperative radiotherapy for locally advanced (T3-4 or N+, M0) esophageal cancer using three-dimensional radiation technique. This trial is a single-center single-arm, phase II clinical trial initiated in 2014. Patients who underwent a radical transthoracic resection with negative margins within 3 months and histologically confirmed as esophageal squamous cell carcinoma (pT3-4 or N+, M0 according to AJCC 7th) were eligible for this study. Radiotherapy was delivered with total dose of 40Gy in 20 fractions using three-dimensional conformal radiation technique including conformal and intensity modulated radiotherapy. TV included tumor bed, anastomosis site, bilateral supraclavicular region, all mediastinal lymph node site, left gastric and celiac trunk lymph node site. The primary endpoint was 2-year local control rate. The secondary endpoint was overall survival (OS) and adverse events. 70 patients were enrolled in this phase II study from 2014 to 2016. The majority of patients were Ilia (40%), IIIA (27.1%) and IIIB (27.1%). 17 patients died. The 2 year-local control rate is 67.29%. Median OS was 57months. The 1, 2, 3 and 4-year OS rate were 92.75%, 69.57%, 60.87%, 53.47%. Locoregional recurrence was found in 28 patients (40%), most of which in mediastinal lymph node region (16 patients) and supraclavicular lymph node region (10 patients), followed by anastomosis (5 patients), celiac lymph node region (3 patients). 18 patients (25.7%) was found hematogenous recurrence. Nearly all patients complete the whole course postoperative radiotherapy with the completion rate of 97.1%, except for two patients. Although the tumor volume is relatively high with the median PTV volume of 1273.22cm3, despite the average dose of the heart is slightly higher, the dose volume histogram parameters of the other normal tissue and organ dose-volume are relatively ideal. Incidences of acute grade 3 hematological toxicity including 4(5.7%) leukopenia and 1(1.4%) neutropenia. In term of acute grade 3 nonhematological toxicity, nausea and vomiting (7.1%) were the most frequent AE followed by fatigue (2.8%) and radiation induced pneumonitis (1.4%). Nobody suffered grade 4 hematological or nonhematological AE. A No late AE occurred. This study is the first phase II study of postoperative radiotherapy in three-dimensional era, which proves that the dose distribution of large-field radiation is feasible and the toxicity is acceptable. It provides a basis for further exploration of higher dose large-field radiation and combined chemotherapy.

Risk Factors and Prognostic Impact of Mediastinal Lymph Node Metastases in Patients with Esophagogastric Junction Cancer.

We retrospectively investigated the risk factors for mediastinal lymph node (MLN) metastasis in esophagogastric junction (EGJ) cancer with an epicenter within 2cm above and below the anatomical cardia, including both adenocarcinoma (AC) and squamous cell carcinoma (SCC). Fifty patients who underwent initial surgery for EGJ cancer from January 2002 to December 2013 were included in this study. We defined metastatic lymph nodes as pathological metastases in resected specimens and recurrence within 2years postoperatively. Thirty-four patients had AC and 16 had SCC; 24 patients underwent transhiatal resection and 26 underwent transthoracic resection. MLN metastasis was observed in 13 patients (26%) regardless of the histological type, 9 of whom had metastasis in the upper and middle mediastinum. Metastasis occurred when the esophageal invasion length (EIL) exceeded 20mm. In addition, 10/13 patients had stage pN2-3 cancer. Multivariable analysis identified EIL ≥ 20mm and stage pN2-3 as significant risk factors for MLN metastasis. The 5-year overall survival was 38% and 65% in the MLN-positive and -negative groups, respectively (p = 0.12). Multivariable Cox regression analysis showed that only stage pN2-3, and not the presence of MLN metastasis, was a significantly poor prognostic factor. MLN metastasis in EGJ cancer may have a close association with the EIL of the tumor, but the presence of MLN metastasis itself was not a poor prognostic factor. The significance and indications for MLN dissection should be clarified in prospective clinical trials.

P104 SELECTIVE LYMPHATIC EMBOLIZATION TO MANAGE SEVERE POSTOPERATIVE LYMPHATIC LEAK

Abstract Aim To describe methods and clinical outcomes in a cohort of patients at Uppsala University Hospital who underwent selective lymphatic embolization due to severe lymphatic leak. Background & Methods Surgery for malignant disease with extensive lymph node dissection in the abdomen or thorax can be complicated by postoperative lymphatic leak. This is a relatively rare condition, associated with great morbidity and can be difficult to treat. Selective embolization of leaking lymphatic vessels is a recently introduced method for management of thoracic and abdominal lymphatic leaks. Patients that had undergone treatment with selective embolization for severe lymphatic leaks were studied retrospectively. Lymphatic leaks were diagnosed with dynamic contrast enhanced magnetic resonance imaging (MRI)-lymphangiography and/or nodal lymphangiography utilizing Lipiodol. Selective embolization of leaking lymphatic vessels was performed in local anesthesia through transabdominal access, selective catheterization of lymphatic vessels with microcatheters, followed by occlusion of the vessel with coils and glue. Alternatively the leaking lymphatic vessel was occluded by injection of Lipiodol or Fibrovein via an adjacent lymph node. Data was analyzed with descriptive statistics. Results The study comprised 14 patients with severe postoperative lymphatic leak (six following transthoracic esophageal resection and eight following abdominal resections). Prior to intervention the average daily lymph output was 2092 ml and average serum albumin was 19 g/l (range 7-27). Median time from primary surgery to selective embolization was 73 days indicating that conservative treatment had previously been tried and failed. Selective embolization was successful in 93% (n=13) and in nine patients the lymphatic leak ceased instantly. A few patients needed more than one embolization procedure. Median time in hospital care after embolization was two days. No procedure-related complications occurred and only one patient later needed open surgery due to persisting lymphatic leakage. Conclusion Selective lymphatic embolization appears to be a safe and effective method with potential to preclude open surgery in patients with persistent severe postoperative lymphatic leak. The procedure can be performed under local anesthesia but demands a highly skilled and dedicated interventional radiologist. The most detailed imaging to facilitate the procedure was achieved through dynamic contrast enhanced MRI-lymphangiography.

WS05.06 Relevance of Lymphadenectomy in Carcinoma of the Esophagus and of the Esophagogastric Junction

WS05.06 Relevance of Lymphadenectomy in Carcinoma of the Esophagus and of the Esophagogastric Junction

Low-Fat Tube Feeding After Esophagectomy Is Associated With a Lower Incidence of Chylothorax

Chylothorax is a treacherous complication after esophagectomy associated with significant morbidity. Early enteral nutrition after esophagectomy is important for recovery but increases the pressure in the lymphatic system owing to the absorption of triglycerides. To lower the incidence of chylothorax after esophagectomy, the use of low fat-containing tube feeding was evaluated as a standard of care after esophagectomy. All consecutive patients who underwent an esophagectomy with gastric tube reconstruction and placement of jejunostomy at the University Medical Center Utrecht between January 1, 2012, and December 31, 2017, were included. Tube feeding was started as standard of care on postoperative day 1 with a normal fat-containing formula in the period between 2012 and 2014 and with a low fat-containing formula between 2014 and2017. Between 2012 and 2017, 198 patients were included. The tube feeding formula contained normal fat in 86 (43.4%) and low fat in 112 (53.6%). Chylothorax, associated with triglyceride levels exceeding 1.24 mmol/L in 27 patients (61.4%) with a clinical diagnosis of chylothorax, was significantly less observed in the low fat-formula group (15 [13.4%] vs 29 [33%], p= 0.001). No difference was seen in drain output, triglyceride levels in the pleura fluid, treatment strategy, and hospital mortality. At multivariable analysis, the normal-fat formula was associated with a 5.1 odds (95% confidence interval, 2.1 to 12.1) for postoperative chylothorax. Other factors independently associated with chylothorax were transthoracic resection, anastomotic leakage, number of resected lymph nodes, and lower body mass index. Administration of low fat-containing tube feed after esophagectomy was associated with a lower incidence of chylothorax.

PS02.165: THE INCIDENCE OF CHYLOTHORAX AFTER ESOPHAGECTOMY CAN BE REDUCED BY LOW FAT TUBE FEEDING

Abstract Background Chylothorax is a treacherous complication after esophagectomy associated with significant morbidity. Early enteral nutrition after surgery is important for recovery, but increases the pressure in the lymphatic system due to the absorption of triglycerids. To lower the incidence of chylothorax after esophagectomy, the use of low fat-containing tube feeding was evaluated as a standard of care following esophagectomy. Methods All consecutive patients who underwent an esophagectomy with gastric tube reconstruction and placement of jejunostomy at the UMC Utrecht between the 1st of January 2012 and the 31st of December 2017 were included. Tube feeding was started as standard of care on postoperative day 1 with a normal fat-containing formula in the period between 2012 and 2014 and with a low fat-containing formula between 2014 and 2017. The clinical diagnosis of chylothorax was confirmed by triglyceride levels > 1.24mmol/L in 27 patients (61.4%). Results Between 2012–2017 200 patients were included; 88(44.0%) received normal fat-containing tube feeding, 112(56.0%) low fat-containing tube feeding. Chylothorax was significantly less observed in the low fat formula group (n = 15, 13.4% versus n = 29, 33%, P = 0.001) No difference was seen in drain output, triglyceride levels in the pleura fluid, treatment strategy and hospital mortality. At multivariable analysis normal fat formula was associated with a 5.1 [2.1–12.1] odds for postoperative chylothorax. Other factors independently associated with chylothorax were transthoracic resection, anastomotic leakage, number of resected lymph nodes, and lower body mass index. Conclusion Administration of low fat-containing tube feed after esophagectomy lowers the incidence of chylothorax. Disclosure All authors have declared no conflicts of interest.

FA01.06: ON THE RELATIONSHIP BETWEEN HISTOLOGY, ESOPHAGEAL-GASTRIC INTESTINAL METAPLASIA, GREATER CURVATURE LYMPHATIC METASTASES AND SURVIVAL IN SIEWERT II ADENOCARCINOMA

Abstract Background In Siewert type II adenocarcinoma we investigated the relationship between adenocarcinoma subtypes and survival, histologic/biologic patterns related to the presence/absence of gastric greater curvature metastases. Methods 154 patients who underwent primary transthoracic esophageal resection, total gastrectomy, thoracic-abdominal lymphadenectomy according to a research prospective protocol were considered. Cases were categorized in intestinal and diffuse subtypes, in Barrett's-like, cardiopyloric-like, and gastric-like adenocarcinoma according to the presence/absence of intestinal metaplasia in esophagus and stomach. Cancer specific survival and gastric greater curvature metastases were studied in those categories. Results Pathological stage (7th TNM ed) was IA-IIA in 11%; IIB in 15.6%; IIIA-IV in 73.4%. Cases were: 59% intestinal-type, 41% diffuse-type; Barrett's-type 1.3%, cardiopyloric-type 65%, gastric-type 33.7%. Greater gastric curvature lymph node metastases were detected in 22%, in stage IIIa-IV only, intestinal type 47%; diffuse type 53%. The number of metastatic lymph nodes at station 4 was higher in cardiopyloric-like than in gastric-like type (P < .0001).Five years cancer-specific survival of 154 cases was 40.5%, 59.4.% for intestinal type, 0% for diffuse type; 5-year cancer-specific survival in the absence/presence of greater gastric curvature metastases was respectively 48.7% and 14.9%, for intestinal type it was 67.4% and 27.9%. Histological subtype was an independent prognostic factor. Conclusion The radical difference of 5 year survival between intestinal and diffuse types of Siewert type II adenocarcinoma after primary surgery, the relevant frequency and biologic patterns of station 4 nodal metastases do require further investigation in light of current indications for neoadjuvant therapy and total gastrectomy. Disclosure All authors have declared no conflicts of interest.