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Interdisciplinary Reporting of Outcomes: A Meta-Analysis of Definitive Chemoradiation vs. Surgery for Esophageal Cancer
0.576 and p=0.232 respectively). Cumulative survival was significantly associated with operative morbidity severity score (p=0.028) but not with CPET variables. Conclusion: CPET is a significant predictor of morbidity after esophageal cancer surgery with peak VO2 rather than AT proving to be the most important factor.
Lower esophageal sphincter (LES) and Crural diaphragm (CD) with swallow-induced esophageal body contraction. Number of episodes of EBS of ≥1 cm was counted for 10 swallows. Patients were divided into 2 groups: 1. EBS positive group (EBS present in ≥3 swallows), 2. EBS negative group (EBS present in ≤2 swallows). Maximum length of EBS was also measured. RESULTS: A total of 90 patients underwent HRM and pH study during the study period. 41 patients had Chicago EGJ-Type I. Mean age was 47.2 years with 35 females and a BMI of 33.9. Median number of EBS ≥1 cm was 1. Sixteen patients were categorized as EBS positive group (≥3 EBS of ≥1 cm). EBS positive group had higher rate of abnormal DeMeester score than negative group (56% vs 28%), however, this did not reach statistical significance (p=0.070). There were 17 patients who had maximal EBS ≥2 cm and were more likely to have pathological reflux than patients with maximal EBS <2 cm group (59% vs 25%, p=0.029). CONCLUSIONS: Esophageal body shortening of ≥2 cm in patients with Chicago EGJ-Type I have a higher prevalence of pathological reflux disease. The degree of swallow-induced hiatal hernia could be an early indicator of lower esophageal sphincter dysfunction. Further studies are needed to confirm these findings. Table
Tu1288 PROGNOSTIC SIGNIFICANCE OF 18-FDG PET/CT ENHANCED STAGING IN PATIENTS UNDERGOING SURGERY FOR ESOPHAGEAL CANCER Neil Patel, Jeniffer Wheat, Paul Blake, Chris Brown, Arfon G. Powell, David Chan, Kieran G. Foley, Guy Blackshaw, Stuart A. Roberts, Wyn G. Lewis Background: CT-PET has become an integral part of the staging pathway for potentially curable esophageal cancer (OC) in order to identify occult distant metastases unseen by conventional radiological modalities. The aim of this study was to analyse the effect of CTPET inception on overall survival and assess patterns of recurrence after esophagectomy. Methods: Consecutive 424 patients undergoing esophagectomy performed for cancer [median age 62 (24-80) yr, 337 male, 360 ACA, 64 SCC, 254 neoadjuvant therapy] were studied. One hundred and sixty-nine patients underwent CT-PET enhanced staging protocols and the primary outcome measure was survival based on intention to treat. Results: Overall 5-year survival pre CT-PET was 37%, compared with 49% post CT-PET (Chi2 4.991, df 1, p<0.025). On multivariable analysis, pT stage (HR 1.497 [95% CI 1.344-1.667], p< 0.001) and CT-PET (HR 0.509 [95% CI 0.352-0.735], p<0.001) were independently associated with duration of survival. Recurrent cancer was observed in 119 patients pre CT-PET (46.7%); 24.4% local, 58.8% distant, 16.8% both, compared with 33 (19.5%) recurrences post CT-PET (19.5%, Chi2 32.554, df 1, p<0.0001); 27.3% local; 57.6% distant; 15.1% both. Conclusion: CT-PET enhanced staging independently improves survival in patients undergoing esophagectomy for esophageal cancer.
Tu1289
SSAT Abstracts
IS PERORAL ENDOSCOPIC MYOTOMY (POEM) FEASIBLE IN PEDIATRIC PATIENTS WITH ACHALASIA? A META-ANALYSIS AND SYSTEMATIC REVIEW Harsha V. Moole, Ayesha Waqar, Anthony Baldoni, Sowmya Dharmapuri, Vu Nguyen, Vishnu Moole, Anwesh Poosala, Raghuveer R. Boddireddy, Achuta Uppu, Abhiram Duvvuri, Vamsi Emani, Sowjanya Kapaganti, Srinivas R. Puli
M:F = male:female; EGJOO = EGJ outflow obstruction; IEM = Ineffective esophageal motility. Values are reported as median (IQR).
Tu1292
Background: Achalasia is a primary esophageal motility disorder characterized by failure of lower esophageal sphincter to relax in response to swallowing, along with loss of peristalsis of esophagus. Although surgical myotomy has been the mainstay treatment modality, peroral endoscopic myotomy (POEM) has emerged as an endoscopic alternative, and there is limited experience in pediatric population. Aims: This is a meta-analysis to pool the evidence for the success of POEM in treating achalasia in pediatric population. Primary outcomes are to evaluate the technical success rate and clinical success rate of POEM in treating pediatric patients with achalasia. Methods: Study selection criterion: Studies that evaluated POEM in achalasia patients were included in this analysis. Only pediatric patient (age <18years) studies were included in this analysis. Studies must have mentioned regarding either technical success rate and / or clinical success rate of POEM in this patient population. Technical success was defined as adequate and successful completion of the peroral endoscopic myotomy. Clinical success was defined as an improvement in Eckardt score to <3. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement. Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using I2 statistic. Results: Initial search identified 168 reference articles, of which 31 articles were selected and reviewed. Data was extracted from 9 studies (N=587) which met the inclusion criteria. Median age of the patients was 15 years, with 52% males. Median follow up period was 12 months. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. In the pooled patient population that underwent POEM, technical success was achieved in 94.69% (95% CI= 92.36 to 96.62). Clinical success was achieved in 93.89% (95%CI = 91.82 to 95.67) of the pooled POEM patients. I2 heterogeneity calculated for the technical and clinical success was 77.8% and 57.2% respectively. Bias indicator for technical success variable, Begg-Mazumdar: Kendall's tau b = 0.04; P >0.99. Bias indicator for clinical success variable, Begg-Mazumdar: Kendall's tau b = -0.17; P = 0.48. Conclusions: In pediatric patients with achalasia, POEM procedure seems to have excellent technical and clinical success rates. It is a viable alternative to surgical management when appropriate technical and operator expertise are available.
INTERDISCIPLINARY REPORTING OF OUTCOMES: A META-ANALYSIS OF DEFINITIVE CHEMORADIATION VS. SURGERY FOR ESOPHAGEAL CANCER Andrea Wirsching, Sheraz R. Markar, Mustapha El Lakis, Donald Low Background: Definitive chemoradiotherapy has been suggested as an alternative to surgery for the treatment of esophageal cancer. A decrease in mortality and morbidity with similar long-term survival has been proposed in favor of definitive chemoradiotherapy. With this meta-analysis we aimed to summarize current evidence comparing short-term outcomes and long-term outcomes associated with surgery and definitive chemoradiotherapy. Methods: Embase, Medline, Web of Science and Cochrane library databases were searched for randomized controlled trials (RCT) or cohort studies comparing definitive chemoradiotherapy with surgery for esophageal cancer. Studies published after 2000 and including more than 10 patients per study arm were included. Results: Fourteen studies were identified, which met all inclusion criteria. There were 2 RCT and 12 cohort studies. 30-day mortality and 90day mortality were reported in 7 and 5 studies for the surgery group and in 5 and 3 studies for the dCRT group. Median 30-day mortality was 0% associated with dCRT and 5% (range 0-8%) associated with surgery (p=0.035). Overall morbidity was reported in 4 and 9 studies for the dCRT and surgery groups, respectively. Adverse events were systematically graded in 9 and 1 study for the dCRT and surgery groups, respectively. There was no difference in one- and two-year overall survival, disease-free survival and overall recurrence. Surgery was associated with a reduction in locoregional recurrence compared to definitive chemoradiotherapy (p=0.027). Conclusion: Comparison of short-term outcomes after definitive chemoradiotherapy vs. surgery remains poor, since mortality and morbidity are reported heterogeneously and inconsistently. There is a need for a common language in order to compare different treatment modalities for esophageal cancer treatment. Long-term outcomes were reported more consistently and did not show superiority of one treatment modality.
Tu1293 PREOPERATIVE HIGH RESOLUTION MANOMETRY CRITERIA DOES NOT PREDICT DYSPHAGIA AFTER NISSEN FUNDOPLICATION Steve Siegal, Christy M. Dunst, Steven R. DeMeester, Ben Robinson, Lee L. Swanstrom Background: Esophageal manometry, using water perfused systems that indicate failed peristalsis and weak contractile amplitudes are associated with a risk for post-fundoplication dysphagia, is widely used in the preoperative evaluation of patients undergoing antireflux surgery. Recently, high-resolution manometry (HRM) has become standard of care in esophageal physiologic testing. However, metrics derived from HRM have not been well correlated with the outcome of antireflux surgery. The aim of this study was to determine if distal contractile integral or other HRM variables reliably predict postoperative dysphagia after Nissen fundoplication. Methods: The records of patients who underwent a laparoscopic Nissen fundoplication (LNF) from 2013-2015 were retrospectively reviewed. All patients had a preoperative HRM and patients without raw data from the manometry study were excluded. Per protocol at our center, a LNF was only offered to patients with confirmed GERD, a percent peristalsis (PP) >50% and distal esophageal contraction amplitude (DECA) > 25mmHg. HRM metrics such as distal contractile integral (DCI), contractile front velocity (CFV), and integrated relaxation pressure (IRP) were not included in preoperative patient selection. Dysphagia was graded using a standard system (0=never, 1=1-2 times a month, 2=1-2 times per week, 3=daily). A score of >2 defined dysphagia. Four groups were identified:
Tu1290 SWALLOW-INDUCED TRANSIENT SPATIAL SEPARATION OF CRURAL DIAPHRAGM AND LOWER ESOPHAGEAL SPHINCTER IS ASSOCIATED WITH GASTROESOPHAGEAL REFLUX Takahiro Masuda, Saurabh Singhal, Shunsuke Akimoto, Sumeet Mittal INTRODUCTION: A subset of patients with manometrically normal lower esophageal sphincter has pathological distal esophageal acid exposure. The aim of this study is to assess the association of gastro-esophageal reflux with swallow-induced transient hiatal hernia secondary to esophageal body shortening (EBS) in these patients. METHODS AND PROCEDURES: After IRB approval, we queried prospectively maintained database to identify patients who underwent pH study and high-resolution manometry (HRM) between Jan. to Dec. 2015. Patients with Type I EGJ morphology (no hiatal hernia) based on Chicago Classification v 3.0 were included in this study. EBS was measured as distance between
SSAT Abstracts
S-1284
Lower esophageal sphincter (LES) and Crural diaphragm (CD) with swallow-induced esophageal body contraction. Number of episodes of EBS of ≥1 cm was counted for 10 swallows. Patients were divided into 2 groups: 1. EBS positive group (EBS present in ≥3 swallows), 2. EBS negative group (EBS present in ≤2 swallows). Maximum length of EBS was also measured. RESULTS: A total of 90 patients underwent HRM and pH study during the study period. 41 patients had Chicago EGJ-Type I. Mean age was 47.2 years with 35 females and a BMI of 33.9. Median number of EBS ≥1 cm was 1. Sixteen patients were categorized as EBS positive group (≥3 EBS of ≥1 cm). EBS positive group had higher rate of abnormal DeMeester score than negative group (56% vs 28%), however, this did not reach statistical significance (p=0.070). There were 17 patients who had maximal EBS ≥2 cm and were more likely to have pathological reflux than patients with maximal EBS <2 cm group (59% vs 25%, p=0.029). CONCLUSIONS: Esophageal body shortening of ≥2 cm in patients with Chicago EGJ-Type I have a higher prevalence of pathological reflux disease. The degree of swallow-induced hiatal hernia could be an early indicator of lower esophageal sphincter dysfunction. Further studies are needed to confirm these findings. Table
Tu1288 PROGNOSTIC SIGNIFICANCE OF 18-FDG PET/CT ENHANCED STAGING IN PATIENTS UNDERGOING SURGERY FOR ESOPHAGEAL CANCER Neil Patel, Jeniffer Wheat, Paul Blake, Chris Brown, Arfon G. Powell, David Chan, Kieran G. Foley, Guy Blackshaw, Stuart A. Roberts, Wyn G. Lewis Background: CT-PET has become an integral part of the staging pathway for potentially curable esophageal cancer (OC) in order to identify occult distant metastases unseen by conventional radiological modalities. The aim of this study was to analyse the effect of CTPET inception on overall survival and assess patterns of recurrence after esophagectomy. Methods: Consecutive 424 patients undergoing esophagectomy performed for cancer [median age 62 (24-80) yr, 337 male, 360 ACA, 64 SCC, 254 neoadjuvant therapy] were studied. One hundred and sixty-nine patients underwent CT-PET enhanced staging protocols and the primary outcome measure was survival based on intention to treat. Results: Overall 5-year survival pre CT-PET was 37%, compared with 49% post CT-PET (Chi2 4.991, df 1, p<0.025). On multivariable analysis, pT stage (HR 1.497 [95% CI 1.344-1.667], p< 0.001) and CT-PET (HR 0.509 [95% CI 0.352-0.735], p<0.001) were independently associated with duration of survival. Recurrent cancer was observed in 119 patients pre CT-PET (46.7%); 24.4% local, 58.8% distant, 16.8% both, compared with 33 (19.5%) recurrences post CT-PET (19.5%, Chi2 32.554, df 1, p<0.0001); 27.3% local; 57.6% distant; 15.1% both. Conclusion: CT-PET enhanced staging independently improves survival in patients undergoing esophagectomy for esophageal cancer.
Tu1289
SSAT Abstracts
IS PERORAL ENDOSCOPIC MYOTOMY (POEM) FEASIBLE IN PEDIATRIC PATIENTS WITH ACHALASIA? A META-ANALYSIS AND SYSTEMATIC REVIEW Harsha V. Moole, Ayesha Waqar, Anthony Baldoni, Sowmya Dharmapuri, Vu Nguyen, Vishnu Moole, Anwesh Poosala, Raghuveer R. Boddireddy, Achuta Uppu, Abhiram Duvvuri, Vamsi Emani, Sowjanya Kapaganti, Srinivas R. Puli
M:F = male:female; EGJOO = EGJ outflow obstruction; IEM = Ineffective esophageal motility. Values are reported as median (IQR).
Tu1292
Background: Achalasia is a primary esophageal motility disorder characterized by failure of lower esophageal sphincter to relax in response to swallowing, along with loss of peristalsis of esophagus. Although surgical myotomy has been the mainstay treatment modality, peroral endoscopic myotomy (POEM) has emerged as an endoscopic alternative, and there is limited experience in pediatric population. Aims: This is a meta-analysis to pool the evidence for the success of POEM in treating achalasia in pediatric population. Primary outcomes are to evaluate the technical success rate and clinical success rate of POEM in treating pediatric patients with achalasia. Methods: Study selection criterion: Studies that evaluated POEM in achalasia patients were included in this analysis. Only pediatric patient (age <18years) studies were included in this analysis. Studies must have mentioned regarding either technical success rate and / or clinical success rate of POEM in this patient population. Technical success was defined as adequate and successful completion of the peroral endoscopic myotomy. Clinical success was defined as an improvement in Eckardt score to <3. Data collection & extraction: Articles were searched in Medline, Pubmed, Ovid journals, CINAH, International pharmaceutical abstracts, old Medline, Medline nonindexed citations, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Two reviewers independently searched and extracted data. Any differences were resolved by mutual agreement. Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model). The heterogeneity among studies was tested using I2 statistic. Results: Initial search identified 168 reference articles, of which 31 articles were selected and reviewed. Data was extracted from 9 studies (N=587) which met the inclusion criteria. Median age of the patients was 15 years, with 52% males. Median follow up period was 12 months. The p for chi-squared heterogeneity for all the pooled accuracy estimates was > 0.10. In the pooled patient population that underwent POEM, technical success was achieved in 94.69% (95% CI= 92.36 to 96.62). Clinical success was achieved in 93.89% (95%CI = 91.82 to 95.67) of the pooled POEM patients. I2 heterogeneity calculated for the technical and clinical success was 77.8% and 57.2% respectively. Bias indicator for technical success variable, Begg-Mazumdar: Kendall's tau b = 0.04; P >0.99. Bias indicator for clinical success variable, Begg-Mazumdar: Kendall's tau b = -0.17; P = 0.48. Conclusions: In pediatric patients with achalasia, POEM procedure seems to have excellent technical and clinical success rates. It is a viable alternative to surgical management when appropriate technical and operator expertise are available.
INTERDISCIPLINARY REPORTING OF OUTCOMES: A META-ANALYSIS OF DEFINITIVE CHEMORADIATION VS. SURGERY FOR ESOPHAGEAL CANCER Andrea Wirsching, Sheraz R. Markar, Mustapha El Lakis, Donald Low Background: Definitive chemoradiotherapy has been suggested as an alternative to surgery for the treatment of esophageal cancer. A decrease in mortality and morbidity with similar long-term survival has been proposed in favor of definitive chemoradiotherapy. With this meta-analysis we aimed to summarize current evidence comparing short-term outcomes and long-term outcomes associated with surgery and definitive chemoradiotherapy. Methods: Embase, Medline, Web of Science and Cochrane library databases were searched for randomized controlled trials (RCT) or cohort studies comparing definitive chemoradiotherapy with surgery for esophageal cancer. Studies published after 2000 and including more than 10 patients per study arm were included. Results: Fourteen studies were identified, which met all inclusion criteria. There were 2 RCT and 12 cohort studies. 30-day mortality and 90day mortality were reported in 7 and 5 studies for the surgery group and in 5 and 3 studies for the dCRT group. Median 30-day mortality was 0% associated with dCRT and 5% (range 0-8%) associated with surgery (p=0.035). Overall morbidity was reported in 4 and 9 studies for the dCRT and surgery groups, respectively. Adverse events were systematically graded in 9 and 1 study for the dCRT and surgery groups, respectively. There was no difference in one- and two-year overall survival, disease-free survival and overall recurrence. Surgery was associated with a reduction in locoregional recurrence compared to definitive chemoradiotherapy (p=0.027). Conclusion: Comparison of short-term outcomes after definitive chemoradiotherapy vs. surgery remains poor, since mortality and morbidity are reported heterogeneously and inconsistently. There is a need for a common language in order to compare different treatment modalities for esophageal cancer treatment. Long-term outcomes were reported more consistently and did not show superiority of one treatment modality.
Tu1293 PREOPERATIVE HIGH RESOLUTION MANOMETRY CRITERIA DOES NOT PREDICT DYSPHAGIA AFTER NISSEN FUNDOPLICATION Steve Siegal, Christy M. Dunst, Steven R. DeMeester, Ben Robinson, Lee L. Swanstrom Background: Esophageal manometry, using water perfused systems that indicate failed peristalsis and weak contractile amplitudes are associated with a risk for post-fundoplication dysphagia, is widely used in the preoperative evaluation of patients undergoing antireflux surgery. Recently, high-resolution manometry (HRM) has become standard of care in esophageal physiologic testing. However, metrics derived from HRM have not been well correlated with the outcome of antireflux surgery. The aim of this study was to determine if distal contractile integral or other HRM variables reliably predict postoperative dysphagia after Nissen fundoplication. Methods: The records of patients who underwent a laparoscopic Nissen fundoplication (LNF) from 2013-2015 were retrospectively reviewed. All patients had a preoperative HRM and patients without raw data from the manometry study were excluded. Per protocol at our center, a LNF was only offered to patients with confirmed GERD, a percent peristalsis (PP) >50% and distal esophageal contraction amplitude (DECA) > 25mmHg. HRM metrics such as distal contractile integral (DCI), contractile front velocity (CFV), and integrated relaxation pressure (IRP) were not included in preoperative patient selection. Dysphagia was graded using a standard system (0=never, 1=1-2 times a month, 2=1-2 times per week, 3=daily). A score of >2 defined dysphagia. Four groups were identified:
Tu1290 SWALLOW-INDUCED TRANSIENT SPATIAL SEPARATION OF CRURAL DIAPHRAGM AND LOWER ESOPHAGEAL SPHINCTER IS ASSOCIATED WITH GASTROESOPHAGEAL REFLUX Takahiro Masuda, Saurabh Singhal, Shunsuke Akimoto, Sumeet Mittal INTRODUCTION: A subset of patients with manometrically normal lower esophageal sphincter has pathological distal esophageal acid exposure. The aim of this study is to assess the association of gastro-esophageal reflux with swallow-induced transient hiatal hernia secondary to esophageal body shortening (EBS) in these patients. METHODS AND PROCEDURES: After IRB approval, we queried prospectively maintained database to identify patients who underwent pH study and high-resolution manometry (HRM) between Jan. to Dec. 2015. Patients with Type I EGJ morphology (no hiatal hernia) based on Chicago Classification v 3.0 were included in this study. EBS was measured as distance between
SSAT Abstracts
S-1284