Underwent Ivor-Lewis Esophagectomy Research Articles

Effect of pyloroplasty on clinical outcomes following esophagectomy.

The role of concurrent pyloroplasty with esophagectomy is unclear. Available literature on the impact of pyloroplasty during esophagectomy on complications and weight loss is varied. Data on the need for further pyloric intervention are scarce. Our study compares the clinical outcomes after esophagectomy with or without pyloroplasty and investigates the role of post-operative pyloric dilatation. Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, mortality rate, anastomotic leak, respiratory complications (Clavien-Dindo grade ≥ 3), anastomotic stricture rate, and percentage weight loss at 1 and 2 year post-operatively were evaluated. For weight analysis at 1 and 2 year post-operatively, patients were excluded if they had been diagnosed with recurrence or died prior to the 1 or 2 year timepoints. Ninety-two patients did not have a pyloroplasty, and 115 patients had a pyloroplasty. There were no complications resulting from pyloroplasty. There was no significant demographic difference between the groups except for age. Mortality rate, anastomotic leak, respiratory complications, anastomotic stricture rate, and percentage weight loss at 1 and 2 years were statistically similar between the two groups. However, 14.1% of patients without pyloroplasty required post-operative endoscopic pyloric balloon dilatation to treat respiratory complications or gastroparesis. Subgroup analysis of patients without pyloroplasty indicated that patients requiring dilatation had greater weight loss at 1 year (15.8% vs 9.4%, p = 0.02) and higher respiratory complications rate (27.3% vs 4.7%, p = 0.038). Overall results from our study that pyloroplasty during Ivor Lewis esophagectomy is safe and useful to prevent the need for post-operative pyloric dilatation.

TRANSCRIPTOME PROFILING AND EXAMINATION OF INDIVIDUALS DIAGNOSED WITH ESOPHAGEAL SQUAMOUS CELL CARCINOMA ORIGINATING FROM KAZAKHSTAN

Esophageal cancer stands as the eighth most prevalent cancer globally and the sixth most prevalent in Kazakhstan, with esophageal squamous cell carcinoma (ESCC) as its primary histological subtype, often diagnosed in advanced stages. This project aimed to unveil the genetic underpinnings of ESCC by examining differentially expressed genes (DEGs) via whole-transcriptome sequencing of Kazakhstani patients. Tissue samples from 22 individuals undergoing Ivor-Lewis esophagectomy at the Oncology Center in Astana were collected. Utilizing STAR software and DESeq2 package, DEGs were mapped and defined, followed by functional analysis using various R packages. The study encompassed 13 males and 9 females, averaging 65.72 ± 8.26 years old, with 86% diagnosed at advanced stages T3-T4. Analysis of tumor and normal esophageal tissues unveiled 6689 DEGs, including 2056 upregulated and 4633 downregulated genes (adjusted p-value <0.05). Additionally, 42 up-regulated and 2 down-regulated KEGG pathways were identified (p-value <0.05). The top 300 DEGs were mapped to a protein-protein interaction (PPI) network, and functional enrichment analysis revealed three modules comprising closely connected genes. Within our patient cohort, ESCC with moderate dysplasia emerged as the most prevalent histologic subtype, associated with poor prognosis. High-throughput sequencing techniques facilitate the identification of molecular pathways implicated in esophageal carcinogenesis, potentially revolutionizing diagnosis and treatment strategies. This research has been funded by the Science Committee of the Ministry of Science and Higher Education of the Republic of Kazakhstan (Program targeted funding BR18574184 and grant AP09058660), and Nazarbayev University funding CRP grant 021220CRP2222.

Semaphorin 3F (SEMA3F) influences patient survival in esophageal adenocarcinoma

In esophageal adenocarcinoma, the presence of lymph node metastases predicts patients' survival even after curative resection. Currently, there is no highly accurate marker for detecting the presence of lymph node metastasis. The SEMA3F/NRP2 axis was initially characterized in axon guidance and recent evidence has revealed its significant involvement in lymphangiogenesis, angiogenesis, and carcinogenesis. Hence, the objective of this study was to elucidate the roles of SEMA3F and its receptor NRP2 in esophageal adenocarcinoma. We conducted an immunohistochemical evaluation of SEMA3F and NRP2 protein expression in 776 patients with esophageal adenocarcinoma who underwent Ivor-Lewis esophagectomy at the University Hospital of Cologne. Total and positive cancer cell counts were digitally analyzed using QuPath and verified by experienced pathologists to ensure accuracy. Positive expression was determined as a cell percentage exceeding the 50th percentile threshold. In our cohort, patients exhibiting SEMA3F positive expression experience significantly lower pT- and pN-stages. In contrast, positive NRP2 expression is associated with the presence of lymph node metastases. Survival analyses showed that the expression status of NRP2 had no impact on patient survival. However, SEMA3F positivity was associated with a favorable patient survival outcome (median OS: 38.9 vs. 26.5 months). Furthermore, SEMA3F could be confirmed as an independent factor for better patient survival in patients with early tumor stage (pT1N0-3: HR = 0.505, p = 0.014, pT1-4N0: HR = 0.664, p = 0.024, pT1N0: HR = 0.483, p = 0.040). In summary, SEMA3F emerges as an independent predictor for a favorable prognosis in patients with early-stage esophageal adenocarcinoma. Additionally, NRP2 expression is linked to a higher risk of lymph node metastases occurrence. We hypothesize that low SEMA3F expression could identify patients with early-stage tumors who might benefit from more aggressive treatment options or intensified follow-up. Furthermore, SEMA3F and its associated pathways should be explored as potential tumor-suppressing agents.

528. IMPACT OF SARCOPENIA AND MYOSTEATOSIS ON THE SURGICAL OUTCOME OF PATIENTS WITH ESOPHAGEAL CANCER

Abstract Background Alterations in muscle mass, sarcopenia and myosteatosis might negatively affect the surgical outcome of patients with cancer. Body composition correlation with biochemical markers and impact on surgical outcome in esophageal cancers is yet to be fully determined. Study design Patients with esophageal and esophageal-gastric junction cancer undergoing resection with curative intent were enrolled in a prospective clinical trial from to 2019 to 2023. Patients were assessed at presentation for anthropometric measures, past medical history and biohumoral markers. Contrast-enhanced CT-scans were used to analyze body composition and to detect low lumbar skeletal muscle index (SMI) and low mean muscle attenuation. We investigated the association between the presence of sarcopenia and/or myosteatosis and malnutrition or systemic inflammatory state. Results We enrolled 130 esophagogastric cancer patients who underwent Ivor-Lewis esophagectomy. Postoperative morbidity was not significantly higher in the sarcopenic group compared to non-sarcopenic patients (p=0.35). Myosteatosis and albumin level weren’t associated with post-operative morbidity (p=0.11). No differences in overall survival were found in patients with myosteatosis or sarcopenia compared to subjects with normal body composition (p=0.12 and p=0.16). Conclusion Our preliminary data shows no significant correlations between sarcopenia and myosteatosis and postoperative outcome and survival following esophagectomy for esophageal cancer. These findings from an high volume center suggest that factors other than these body composition parameters may play a more significant role in determining postoperative outcomes in patients undergoing esophagectomy. Further research is warranted to elucidate additional prognostic indicators and optimize patients care in this population.

403. ROBOTIC-ASSISTED IVOR LEWIS ESOPHAGECTOMY COMPARED TO CONVENTIONAL MINIMALLY INVASIVE ESOPHAGECTOMY: RESULTS FROM SEVEN HIGH VOLUME ITALIAN CENTERS

Abstract Background Over the past decade, minimally invasive esophagectomy has gained increasing attention, supported by numerous trials and retrospective series highlighting its advantages over the traditional open approach. In addition to the conventional minimally invasive surgery (CMIE), robotic assisted minimally invasive esophagectomy (RAMIE) has gained global popularity, due to its advantages in terms of 3D visualization and instrument stability. Methods This is a collaborative study involving seven high-volume Italian centers affiliated with the Italian Society for the Study of Esophageal Diseases (SISME). Patients who underwent Ivor Lewis esophagectomy for esophageal cancer between January 2015 and July 2022 were identified from seven institutional databases and divided in two groups according to the thoracic approach: CMIE versus RAMIE. Results We identified 316 patients in CMIE and 123 in RAMIE group. Operative time was significantly longer for RAMIE procedures (p<0.001). A borderline significant reduction in overall complication rate was observed (48% vs 59% in CMIE group, p=0.045), however there were no differences in severe (p=0.3) and pulmonary (p=0.13) complications rate. 90-day mortality (CMIE 3.2% vs RAMIE 0.8%, p=0.15) and readmission rate (CMIE 9.5% vs RAMIE 7.3%, p=0.47) were comparable. R0 rate was 94.9% in CMIE vs 92.7% in RAMIE (p=0.4). The most performed anastomosis was circular stapled anastomosis. Anastomotic leak rate was 13.9% for CMIE and 12.2% for RAMIE (p=0.6). Conclusion Minimally invasive Ivor Lewis esophagectomy has reached adequate surgical and oncological results with both conventional and robotic technique. Nowadays there is no clear superiority of one anastomotic technique.

Risk factors for and treatment of anastomotic strictures after Ivor Lewis esophagectomy.

Anastomotic strictures following esophagectomy occur frequently and impact on nutrition and quality of life. Although strictures are often attributed to ischemia and anastomotic leaks, the role of anastomosis size and pyloroplasty is not well evaluated. Our study aims to assess the rate of and risk factors for anastomotic stricture following esophagectomy, and the impact of treatment with regular endoscopic balloon dilatations. Consecutive patients (n = 207) undergoing Ivor Lewis esophagectomy performed by two surgeons at our institution were included. Data on patient demographics, surgical outcomes and anastomotic strictures were recorded. Relationship of anastomotic strictures with circular stapler size, pyloroplasty and anastomotic leak was analyzed. Treatment of strictures with endoscopic balloon dilatation was reviewed and percentage weight loss at 1 year was evaluated. Anastomotic strictures occurred in 17.4% of patients. Patient demographics between those with and without stricture were similar. Stricture rate was similar in patients with or without pyloroplasty (13.9% vs 21.7%, respectively, p = 0.14) and in those with or without an anastomotic leak (25.0% vs 16.6%, respectively, p = 0.345). Stricture risk increased with smaller sized stapler (25mm = 33.3%, 28mm = 15.3%, 31mm = 4.8%; p = 0.027). The median number of dilatations required to fully treat strictures was 2 (IQR: 1-3). The median length of time from surgery to first dilatation was 2.9 months (IQR: 2.0-4.7) and to last dilatation was 6.1 months (IQR: 4.8-10.0). Median maximum dilatation diameter was 20mm (IQR: 18.0-20.0). There were no complications from dilatations. Percentage weight loss at 1 year in patients with strictures was similar to those without strictures (8.7% vs 11.1%, respectively, p = 0.090). Post-esophagectomy anastomotic strictures are common and not necessarily related to anastomotic leaks or absence of pyloroplasty. Smaller anastomosis size was strongly linked with stricture formation. A driven approach with regular endoscopic balloon dilation is safe and effective in treating these strictures with no excess weight loss at 1 year once treated.

Surgical and multimodal treatment of metastatic oesophageal cancer: retrospective cohort study.

In contrast to the well-established multimodal therapy for localized oesophageal cancer, the metastatic stage is commonly treated only with systemic therapy as current international guidelines recommend. However, evidence suggesting that multimodal therapy including surgery could benefit selected patients with metastasized oesophageal cancer is increasing. The aim of this study was to investigate the survival of patients diagnosed with metastatic oesophageal cancer after different treatment regimens. This was a retrospective single-centre study of patients with adenocarcinoma or squamous cell carcinoma of the oesophagus with synchronous or metachronous metastases who underwent Ivor Lewis oesophagectomy between 2010 and 2021. Each patient received an individual treatment for their metastatic burden based on an interdisciplinary tumour board conference. Survival differences between different treatments were assessed using the Kaplan-Meier method, as well as univariable and multivariable Cox regression models. Out of 1791 patients undergoing Ivor Lewis oesophagectomy, 235 patients diagnosed with metastases were included. Of all of the included patients, 42 (17.9%) only underwent surgical resection of their metastatic disease, 37 (15.7%) underwent multimodal therapy including surgery, 78 (33.2%) received chemotherapy alone, 49 (20.9%) received other therapies, and 29 (12.3%) received best supportive care. Patients who underwent resection or multimodal therapy including surgery of their metastatic burden showed superior overall survival compared with chemotherapy alone (median overall survival of 19.0, 18.0, and 11.0 months respectively) (P < 0.001). This was confirmed in subcohorts of patients with metachronous solid-organ metastases and with a single metastasis. In multivariable analyses, resection with or without multimodal therapy was an independent factor for favourable survival. Surgical resection could be a feasible treatment option for metastasized oesophageal cancer, improving survival in selected patients. Further prospective randomized studies are needed to confirm these findings and define reliable selection criteria.

Multicenter study on the incidence and treatment of mediastinal leaks after esophagectomy (MuMeLe 2)

BackgroundManagement of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. This study aimed to describe the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in 3 Italian high-volume centers that routinely use EVAC for MAL. MethodsPatients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included. ResultsA total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had MAL. The MAL rates for open, minimally invasive, and robotic esophagectomies were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as the primary treatment was chosen for 62 patients. EVAC was the most common NOM (62.9%), and the most common operative management (OM) was anastomotic redo (53.8%). Diversion was the OM for 7 patients, of whom 3 patients died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment, including EVAC, was successful in 79.0% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatments for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients. ConclusionThe incidence of MALs after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.

Robotic-Assisted Ivor Lewis Esophagectomy Is Safe and Cost Equivalent Compared to Minimally Invasive Esophagectomy in a Tertiary Referral Center.

In recent decades, robotic-assisted minimally invasive esophagectomy (RAMIE) has been increasingly adopted for patients with esophageal cancer (EC) or cancer of the gastroesophageal junction (GEJ). However, concerns regarding its costs compared to conventional minimally invasive esophagectomy (MIE) have emerged. This study examined outcomes and costs of RAMIE versus total MIE in 128 patients who underwent Ivor Lewis esophagectomy for EC/GEJ at our department between 2017 and 2021. Surgical costs were higher for RAMIE (EUR 12,370 vs. EUR 10,059, p < 0.001). Yet, median daily (EUR 2023 vs. EUR 1818, p = 0.246) and total costs (EUR 30,510 vs. EUR 29,180, p = 0.460) were comparable. RAMIE showed a lower incidence of postoperative pneumonia (8% vs. 25%, p = 0.029) and a trend towards shorter hospital stays (15 vs. 17 days, p = 0.205), which may have equalized total costs. Factors independently associated with higher costs included readmission to the intensive care unit (hazard ratio [HR] = 7.0), length of stay (HR = 13.5), anastomotic leak (HR = 17.0), and postoperative pneumonia (HR = 5.4). In conclusion, RAMIE does not impose an additional financial burden. This suggests that RAMIE may be considered as a valid alternative approach for esophagectomy. Attention to typical cost factors can enhance postoperative care across surgical methods.

Copy-number-gain of telomerase reverse transcriptase (hTERT) is associated with an unfavorable prognosis in esophageal adenocarcinoma

Esophageal adenocarcinoma exhibits one of the highest mortality rates among all cancer entities. Multimodal therapy strategies have improved patients’ survival significantly. However, patients in early stages are currently limited to receiving only local therapies, even though some patients within this group showcase short survival periods. Until now, there has been no widely established clinically used biomarker to detect these high-risk patients. Telomerase reverse transcriptase (TERT), a gene encoding a crucial subunit of the telomerase enzyme, plays a significant role in establishing cancer cell immortality and is under suspicion for its potential contribution to tumor progression. Therefore, we aimed to evaluate the clinical relevance of the TERT amplification status. We included 643 patients with esophageal adenocarcinoma, who underwent Ivor-Lewis esophagectomy at the University Hospital of Cologne. The TERT amplification status was characterized using fluorescence in situ hybridization. Clinicopathological values and patients’ overall survival were compared between patients with and without TERT amplification. Further sub-cohort analyses were conducted for patients with pT1N0-3 tumor stage. Eighty-One patients (12.6%) exhibited TERT amplification. Patients with amplified TERT showed significantly worse overall survival (median OS: 22.6 vs. 36.8 months, p = 0.009). Interestingly, TERT amplification could be characterized as an independent risk factor for worse overall survival in multivariate analysis in patients with pT1N0-3 tumor stage (HR = 2.440, 95% CI 1.095–5.440, p = 0.029). In this study, we describe the TERT amplification status as an independent risk factor for worse survival in patients diagnosed with esophageal adenocarcinoma at pT1N0-3 tumor stage, encompassing cases involving tumor infiltration of the lamina propria, muscularis mucosae, and/or submucosa. Based on our findings, we put forth the proposition that evaluating the TERT amplification status may serve as a valuable tool in identifying a specific subgroup of patients, namely those with TERT amplification and pT1N0-3 tumor-stage esophageal adenocarcinoma. The patients of this subgroup could potentially benefit from enhanced follow-up protocols, more aggressive treatment approaches, or possible targeted TERT inhibition therapies, all aimed at improving their overall clinical outcomes.

Postoperative Hiatal Hernia after Ivor Lewis Esophagectomy-A Growing Problem in the Age of Minimally Invasive Surgery.

Even though minimally invasive esophagectomy is a safe and oncologically effective procedure, several authors have reported an increased risk of postoperative hiatal hernia (PHH). This study evaluates the incidence and risk factors of PHH after hybrid minimally invasive (HMIE) versus open esophagectomy (OE). A retrospective single-center analysis was performed on patients who underwent Ivor Lewis esophagectomy between January 2009 and April 2018. Computed tomography scans and patient files were reviewed to identify the PHH. 306 patients were included (152 HMIE; 154 OE). Of these, 23 patients (8%) developed PHH. Most patients (13/23, 57%) were asymptomatic at the time of diagnosis and only 4 patients (17%) presented in an emergency setting with incarceration. The rate of PHH was significantly higher after HMIE compared to OE (13.8% vs. 1.3%, p < 0.001). No other risk factors for the development of PHH were identified in uni- or multi-variate analysis. Surgical repair of PHH was performed in 19/23 patients (83%). The recurrence rate of PHH after surgical repair was 32% (6/19 patients). The development of PHH is a relevant complication after hybrid minimally invasive esophagectomy. Although most patients are asymptomatic, surgical repair is recommended to avoid incarceration with potentially fatal outcomes. Innovative techniques for the prevention and repair of PHH are urgently needed.

Prediction of postoperative complications after oesophagectomy using machine-learning methods.

Oesophagectomy is an operation with a high risk of postoperative complications. The aim of this single-centre retrospective study was to apply machine-learning methods to predict complications (Clavien-Dindo grade IIIa or higher) and specific adverse events. Patients with resectable adenocarcinoma or squamous cell carcinoma of the oesophagus and gastro-oesophageal junction who underwent Ivor Lewis oesophagectomy between 2016 and 2021 were included. The tested algorithms were logistic regression after recursive feature elimination, random forest, k-nearest neighbour, support vector machine, and neural network. The algorithms were also compared with a current risk score (the Cologne risk score). 457 patients had Clavien-Dindo grade IIIa or higher complications (52.9 per cent) versus 407 patients with Clavien-Dindo grade 0, I, or II complications (47.1 per cent). After 3-fold imputation and 3-fold cross-validation, the overall accuracies were: logistic regression after recursive feature elimination, 0.528; random forest, 0.535; k-nearest neighbour, 0.491; support vector machine, 0.511; neural network, 0.688; and Cologne risk score, 0.510. For medical complications, the results were: logistic regression after recursive feature elimination, 0.688; random forest, 0.664; k-nearest neighbour, 0.673; support vector machine, 0.681; neural network, 0.692; and Cologne risk score, 0.650. For surgical complications, the results were: logistic regression after recursive feature elimination, 0.621; random forest, 0.617; k-nearest neighbour, 0.620; support vector machine, 0.634; neural network, 0.667; and Cologne risk score, 0.624. The calculated area under the curve of the neural network was 0.672 for Clavien-Dindo grade IIIa or higher, 0.695 for medical complications, and 0.653 for surgical complications. The neural network scored the highest accuracies compared with all of the other models for the prediction of postoperative complications after oesophagectomy.

Anatomic patterns of anastomotic leaks after Ivor Lewis esophagectomy for cancer: Impact on management and outcomes

BackgroundAnastomotic leakage presentation after Ivor Lewis esophagectomy may vary on imaging. Such variations may influence anastomotic leakage management and outcomes. MethodsAll consecutive patients who underwent Ivor Lewis esophagectomy for cancer between 2012 and 2019 in 2 referral centers were included. Anatomical patterns of anastomotic leakage were defined on imaging as follows: eso-mediastinal anastomotic leakage was a leak contained in the posterior mediastinum, eso-pleural anastomotic leakage was a leak involving the pleural cavity, and eso-bronchial anastomotic leakage was a leak communicating with the tracheobronchial tract. According to the Esophageal Complications Consensus Group definition, management and 90-day mortality were evaluated according to these patterns. ResultsAmong 731 patients, 111 (15%) developed anastomotic leakage consisting of eso-mediastinal anastomotic leakage (n = 87, 79%), eso-pleural anastomotic leakage (n = 16, 14%) and eso-bronchial anastomotic leakage (n = 8, 7%). There was no difference among these groups regarding preoperative characteristics or time to anastomotic leakage diagnosis. There was a significant difference in initial management according to anastomotic leakage anatomic patterns (P = .001). More than half of patients who experienced eso-mediastinal anastomotic leakage (n = 46, 53%) were initially treated conservatively without requiring intervention (Esophageal Complications Consensus Group type I), whereas most patients with eso-pleural anastomotic leakage (n = 14, 87.5%) and all with eso-bronchial anastomotic leakage (n = 8, 100%) initially required interventional or surgical treatment (Esophageal Complications Consensus Group type II–III). Anastomotic leakage anatomic patterns had a statistically significant impact on 90-day mortality, intensive care unit stay, and total hospital stay (P < .001). ConclusionAnastomotic leakage anatomic patterns after Ivor Lewis esophagectomy influence outcomes. Further studies are warranted to validate it in a prospective setting. Anastomotic leakage anatomic patterns may help in guiding anastomotic leakage management.

Hybrid Minimally Invasive Esophagectomy vs. Open Esophagectomy: A Retrospective Propensity Score Matched Comparison.

Background and Objectives: Though widely used, only limited data is available that shows the superiority of hybrid minimally-invasive esophagectomy (HMIE) compared to open esophagectomy (OE). The present study aimed to analyze postoperative morbidity, mortality, and compare lengths of hospital stay. Materials and Methods: A total of 174 patients underwent Ivor Lewis esophagectomy in our surgical department, of which we retrospectively created a matched population of one hundred (HMIE n = 50, OE n = 50). Morbidity and mortality data was categorized, analyzed, and risk factor analyzed for complications. Results: The oncological results were found to be comparable in both groups. A median of 23.5 lymphnodes were harvested during OE, and 21.0 during HMIE. Negative tumor margins were achieved in 98% of OE and 100% of HMIE. In-hospital mortality rate showed no significant difference between techniques (OE 14.0%, HMIE 4.0%, p = 0.160). Hospital (OE Median 23.00 days, HMIE 16.50 days, p = 0.004) and ICU stay (OE 5.50 days, HMIE 3.00 days, p = 0.003) was significantly shorter after HMIE. The overall complication rate was 50%, but complications in general (OE 70.00%, HMIE 30%, p < 0.001) as well as severe complications (Clavien Dindo ≥ III: HMIE 16.0%, OE 48.0%, p < 0.001) were significantly more common after OE. In multivariate stepwise regressions the influence of OE proved to be independent for said outcomes. We observed more pulmonary complications in the OE group (46%) compared to HMIE patients (26%). This difference was statistically significant after adjustment for sex, age, BMI, ASA classification, histology, neoadjuvant treatment or not, smoking status, cardiac comorbidities, diabetes mellitus, and alcohol abuse (p = 0.019). Conclusions: HMIE is a feasible technique that significantly decreases morbidity, while ensuring equivalently good oncological resection compared to OE. HMIE should be performed whenever applicable for patients and surgeons.

Sarcopenia and Patient’s Body Composition: New Morphometric Tools to Predict Clinical Outcome After Ivor Lewis Esophagectomy: a Multicenter Study

BackgroundThe impact of preoperative body composition as independent predictor of prognosis for esophageal cancer patients after esophagectomy is still unclear. The aim of the study was to explore such a relationship. MethodsThis is a multicenter retrospective study from a prospectively maintained database. We enrolled consecutive patients who underwent Ivor-Lewis esophagectomy in four Italian high-volume centers from May 2014. Body composition parameters including total abdominal muscle area (TAMA), visceral fat area (VFA), and subcutaneous fat area (SFA) were determined based on CT images. Perioperative variables were systematically collected. ResultsAfter exclusions, 223 patients were enrolled and 24.2% had anastomotic leak (AL). Sixty-eight percent of patients were sarcopenic and were found to be more vulnerable in terms of postoperative 90-day mortality (p = 0.028). VFA/TAMA and VFA/SFA ratios demonstrated a linear correlation with the Clavien-Dindo classification (R = 0.311 and 0.239, respectively); patients with anastomotic leak (AL) had significantly higher VFA/TAMA (3.56±1.86 vs. 2.75 ± 1.83, p = 0.003) and VFA/SFA (1.18±0.68 vs. 0.87 ± 0.54, p = 0.002) ratios. No significant correlation was found between preoperative BMI and subsequent AL development (p = 0.159). Charlson comorbidity index correlated significantly with AL (p = 0.008): these patients had a significantly higher index (≥ 5). ConclusionAnalytical morphometric assessment represents a useful non-invasive tool for preoperative risk stratification. The concurrent association of sarcopenia and visceral obesity seems to be the best predictor of AL, far better than simple BMI evaluation, and potentially modifiable if targeted with prehabilitation programs.

Endoscopic vacuum therapy for anastomotic leakage after esophagectomy: a retrospective analysis at a tertiary university center

IntroductionAnastomotic leakage after esophagectomy with gastric-pullup is the most feared postoperative complication associated with high morbidity and mortality rates. Management of anastomotic leakage underwent an evolution in the last decade from surgical and conservative to an endoscopic management. However, to date there is no clear consensus on management and if endoluminal vacuum therapy (EVT) is the most superior therapy. Material and methodsBetween 2012 and 2022 all patients that underwent Ivor-Lewis esophagectomy for an underlying malignancy were included in this study. Patients that developed an anastomotic leakage and received endoscopic vacuum therapy were further analysed. ResultsA total of 17 patients were treated with EVT following AL after esophagectomy. The median duration of EVT was 23 days with a median number of 5,5 vacuum sponge changes per patient. EVT-systems were placed 12 times intraluminal and 5 times extraluminal. Successful closure of the defect was achieved in 14 patients. ConclusionEndoscopic vacuum therapy can be successfully applied in the treatment of anastomotic leakage after esophagectomy even in septic patients with an extraluminal cavity. Event-related complications are present but rare.

Risk Factors and Effect of Intrathoracic Anastomotic Leakage after Esophagectomy for Underlying Malignancy-A Ten-Year Analysis at a Tertiary University Centre.

Aim: Surgical resection remains the treatment of choice for curable esophageal cancer patients. Anastomotic leakage after esophagectomy with an intrathoracic anastomosis is the most feared complication, and is the main cause of postoperative morbidity and mortality. The aim of this study was to identify risk factors associated with anastomotic leakage and its effect on the postoperative outcome. Methods: Between 2012 and 2022, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. We performed a retrospective analysis of 174 patients. The dataset was analyzed to identify risk factors for the occurrence of anastomotic leakage. Results: A total of 174 patients were evaluated. The overall anastomotic leakage rate was 18.96%. The 30-day mortality rate was 8.62%. Multivariate logistic regression analysis identified diabetes (p = 0.0020) and obesity (p = 0.027) as independent risk factors associated with anastomotic leakage. AL had a drastic effect on the combined ICU/IMC and overall hospital stay (p < 0.001. Conclusion: Anastomotic leakage after esophagectomy with intrathoracic anastomosis is the most feared complication and major cause of morbidity and mortality. Identifying risk factors preoperatively can contribute to better patient management.

223. INTRAOPERATIVE PYLOROPLASTY DURING OESOPHAGECTOMY: A 12 YEAR TERTIARY CENTRE EXPERIENCE

Abstract Delayed gastric emptying (DGE) is a known complication following oesophagectomy with gastric conduit reconstruction. Pyloroplasty is often performed to mitigate the consequences of DGE. It remains contentious whether performing a pyloroplasty has a significant role in reducing DGE. We discuss our twelve-year experience at a single centre routinely performing Heineke-Mikulicz pyloroplasty for all oesophagectomies. This retrospective study employed an electronic database containing information on all patients who underwent elective Ivor Lewis oesophagectomies from April 2009 to December 2021 in a tertiary upper gastrointestinal cancer centre. Across six surgeons in the centre, a standardised pyloroplasty technique was performed. DGE was defined as patients who had high nasogastric output (&amp;gt; 1.5 litres per day) after ten post-operative days or required endoscopic pyloric balloon dilatation within one year following oesophagectomy. 578 patients underwent Ivor Lewis oesophagectomy during the study period. The mean age was sixty years and the male to female ratio was 1.8:1. The median length of stay was 13 days (3–148). DGE was seen in 9.9% (n = 57) patients. Of these patients, 39.7% (n = 29) cases required oesophageal dilatation within 12 months after their oesophagectomy. 50.8% (n = 21) required in-patient endoscopic dilatation, 14.0% (n = 8) required out-patient endoscopic dilatation. From those who developed DGE, the 30- and 90-day mortality was nil. There were 1.2% (n = 7) leaks specifically from the pyloroplasty which were all managed conservatively. The rate of delayed gastric emptying is reported to be approximately 15% (Zhang &amp; Zhang, 2018). Our study demonstrates that performing a pyloroplasty reduces this risk to 9.9% and is worthwhile as the complication rate from pyloroplasty is low. Although there are various methods employed in overcoming pyloric sphincter denervation following oesophagectomy (pyloroplasty, pyloromyotomy, digital or instrumental pyloric stretching or intra-operative balloon dilatation), the most effective method of reducing DGE warrants a randomised control trial.

421. THE STAPLED ANASTOMOSIS IN ESOPHAGECTOMY: NO DIFFERENCES IN LEAKAGE AND STRICTURE-RATES BETWEEN THE 25 MM AND 28 MM CIRCULAR STAPLER

Abstract For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and post- operative anastomotic strictures. Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed. In 222 patients (64%), the 25 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412). There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

390. ACUTE NUTRITIONAL AND FUNCTIONAL STATUS CHANGES IN PATIENTS UNDERGOING ESOPHAGECTOMY FOR CANCER

Abstract Nutritional status of esophageal cancer patients who undergo esophagectomy is significantly exacerbated postoperatively. The aim of this study is to investigate changes in nutritional status and muscle function between preoperative period and the time of hospital discharge in cancer patients undergoing esophagectomy. The study sample consisted of 70 patients with esophageal (n = 13) and gastroesophageal junction cancer (n = 57) who were admitted for surgery in our Department between September 2015 and February 2020. Out of them, 52 patients underwent Ivor-Lewis esophagectomy, while 18 patients underwent McKewon esophagectomy. The preoperative evaluation of nutritional status was based on Patient Generated Subjective Global Assessment (PG-SGA), while the preoperative assessment of muscle function was based on Handgrip Strength (HG). Weight loss and anthropometric measurements were also recorded. Patients’ follow-up was done at the time of hospital discharge. Patients’ mean length of stay was 17.7 ± 12.5 days. Mean postoperative involuntary weight loss was 6% ± 3%. HG dominant hand was significantly lower at the time of discharge (−3.02 ± 3.80 kg, p &amp;lt; 0.001) compared to preoperative levels. Moreover, a significant change was observed for PG-SGA score (+2.61 ± 1.73) indicating greater rates of impaired nutritional status. There was a significant reduction in BMI (−3.7 ± 2.47 kg/m2, p &amp;lt; 0.001) and in arm circumference values (−0.8 ± 0.03 cm, p &amp;lt; 0.05), whereas no statistically significant alterations were observed in triceps skinfold measurements postoperatively (−0.007 ± 0.49, p = 0.368). Esophageal cancer patients who undergo esophagectomy exhibit overt deterioration of nutritional and functional status during the postoperative course. Timely nutritional interventions are of great significance in order to avoid patients underfeeding and improve patients’ postoperative outcome.