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Minimally Invasive Esophagectomy: A Single Center Comparative Study of Outcomes with 638 Esophagectomy for Squamous Cell Cancer of the Esophagus
and repair is possible in these cases. They have good prognosis. Cases that come later than 24 hours have the worst prognosis. They require lavage and drainage in addition. Repair is not possible in majority of these late cases due to severe inflammation and sepsis. All case who underwent surgery had a feeding jejunostomy and those who underwent only endoscopic management required naso jejunal feeding to avoid Total Parenteral Nutrition and feeds could be resumed early with adequate nutritional support. Good success was achieved with all forma of management in 88.9% cases. Two deaths were due to severe ongoing sepsis and associated comorbidities of the patient. Conclusions: Esophageal perforations pose serious management problems. Not one treatment is enough for all. Surgery and endoscopy with highly skilled intensive care are required for better outcomes and salvaging the patients. Early diagnosis and initiation of management are the key factors for better outcomes. Late diagnosis and referrals with ongoing sepsis are bad prognostic factors. Findings
Mo1044
SSAT Abstracts
MINIMALLY INVASIVE ESOPHAGECTOMY: A SINGLE CENTER COMPARATIVE STUDY OF OUTCOMES WITH 638 ESOPHAGECTOMY FOR SQUAMOUS CELL CANCER OF THE ESOPHAGUS Ian Yu Hong Wong, Daniel King Hung Tong, Siu Y. Chan, Kwan Kit Chan, Claudia Wong, Tsz Ting Law, Simon Law Introduction: The optimal surgical approach for esophagectomy remains controversial. The advent of minimally invasive technique has generated more controversies with regards to its true value. The present study aimed to evaluate our results of minimally invasive esophagectomy compared with open surgery. Methods: From 1994 to 2013, 638 patients who underwent esophagectomy for squamous cell cancers of the esophagus were studied. They were divided into three groups: 85 had VATS esophagectomy (VATS group), 104 had VATS and laparoscopic gastric mobilization and cervical anastomosis (total MIE group), and 449 had open esophagectomy (Open group). Their clinical-pathological features, morbidity and mortality rates were compared. Long-term prognosis was studied with multivariate analysis to look at independent prognostic factors. Results: More patients in the total MIE group had neoadjuvant chemoradiation (64.4% vs. 44.7% for the VATS group and 42.8% in the Open group). This was because total MIE was started later in the series. Open esophagectomy resulted in more blood loss but a shorter operation duration. Wound infection rate was higher in the Open group. Total MIE had higher incidence of ischemic stomach compared with Open surgery (8.7% vs. 1.8%), and also a higher recurrent laryngeal nerve palsy rate (19.2% vs. 10.5%). These were believed to be related to a change in gastric tubularization method and more aggressive policy of RLN nodal dissection rather than the VATS or laparoscopic method per se. There was no significant difference in postoperative pneumonia. VATS group had higher mortality compared to the Open group (5.9% vs. 1.3%) while total MIE had intermediate result (4.8%). On pathological variables, total MIE group had most lymph node sampled, significantly more than the other groups.On multivariate analysis, gender, pT stage, number of lymph nodes sampled, number of involved nodes, and R-category were independent prognostic factors. Conclusions: Both minimally invasive surgery and Open surgery have relative merits. Selection biases and change in treatment strategy over time could explain many differences in outcome. Extended lymphadenectomy could improve outcome by increasing the number of lymph nodes harvested.
Mo1046 ECKARDT SCORES WITH PERORAL ENDOSCOPIC MYOTOMY (POEM) IN SPASTIC ESOPHAGEAL DISORDERS (EXCLUDING ACHALASIA) WITH FAILED MEDICAL THERAPY: A META-ANALYSIS AND SYSTEMATIC REVIEW Harsha V. Moole, Anwesh Poosala, Sowjanya Kapaganti, Vu Nguyen, Achuta Uppu, Raghuveer R. Boddireddy, Vishnu Moole, Abhiram Duvvuri, Anthony Baldoni, Ayesha Waqar, Vamsi Emani, Sowmya Dharmapuri, Srinivas R. Puli Background: Peroral endoscopic myotomy (POEM) is primarily being studied in achalasia patients. There is limited experience with POEM in other spastic esophageal disorders nutcracker esophagus, jack hammer esophagus and diffuse esophageal spasms. Based on the current guidelines, the primary treatment options for these spastic esophageal disorders are medications like calcium channel blockers, nitrites, botulinum toxin; esophageal dilation, surgical myotomy. Eckardt score is a clinical scoring system for spastic esophageal disorders (maximum score, 12), based on symptoms scores for dysphagia, regurgitation, chest pain and weight loss. Aims: This is a meta-analysis to evaluate the effect of POEM on Eckardt scores of patients with spastic esophageal disorders. Primary outcomes are the Eckardt scores of patients that underwent POEM - preoperative, post-operative (<30days since procedure) and at follow up period (median 12 months). Methods: Study selection criterion: Studies that evaluated POEM in either nutcracker esophagus, jack hammer esophagus or diffuse esophageal spasms, with failed medical therapy were included in this analysis. Studies evaluating only achalasia patients were excluded from this analysis. Studies must have mentioned regarding Eckardt scores in this patient population. Data collection & extraction: Articles were searched in Medline, Pubmed, and Ovid journals. 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) and DerSimonian Laird method (random effects). The heterogeneity among studies was tested using I2 statistic. Results: Initial search identified 127 reference articles, of which 42 articles were selected and reviewed. Data was extracted from 8 studies (N=567) which met the inclusion criteria. Median age of the patients was 52 years, with 54% 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, effect size of preoperative Eckardt scores in patients that underwent POEM was 6.47 (95% CI = 6.18 to 6.77). Postoperative Eckardt scores and Eckardt scores at median follow up period were 1.13 (95% CI = 0.99 to 1.26) and 1.20 (95% CI = 0.96 to 1.43) respectively. I2 heterogeneity calculated for the POEM group Eckardt scores preoperative, post-operative and at follow up are 87.4%, 0%, 73.7% respectively. Conclusions: In patients with nutcracker esophagus, jack hammer esophagus or diffuse esophageal spasms, that failed medical therapy, POEM procedure resulted in exceptionally improved Eckardt scores. POEM seems to be a viable endoscopic alternative to surgical myotomy if appropriate technical and operator expertise are available.
Mo1045 A RETROSPECTIVE ANALYSIS OF 18 CONSECUTIVE CASES OF ESOPHAGEAL PERFORATIONS MANAGED AT OUR INSTITUTE FROM DECEMBER 2013 TO NOVEMBER 2016 Pankaj N. Desai, Dhaval Mangukiya Aim: To understand for the best modality of management of management of esophageal perforations. Methods: All the cases which presented with esophageal perforations were given immediate resuscitative management with airway support, intravenous fluids, third generation cephalosporin or carbapenem antibiotics. A Contrast enhanced CT scan was done and they were then subjected to either surgical or endoscopic management. Cases who came between 6 to 24 hours after perforation and all case that came after 24 hours, were subjected to surgical management. It included thoracoscopic lavage, attempt at repair of the perforation and drainage. Feeding jejunostomy was performed in all cases who underwent surgery. All cases were then post operatively stented using a fully covered esophageal wide flange SEMS. Those cases which presented with six hours and without mediastinal sepsis, were subjected to esophageal stenting. Cases where the perforation was around 2 cms in diameter were closed with a Padlock clip and then stented. A naso jejunal feeding tube was then placed for feeding in these cases. Observations: Commonest cause of esophageal perforation in our series is Boerhaave's Syndrome followed by Iatrogenic ( post dilatation elsewhere ) and chronic foreign body impaction ( dentures in both cases ). Cases that come within 6 hours have excellent prognosis and surgery can be avoided. Only placement of FCSEMS or application of Padlock clip with FCSEMS suffices. Cases that come within 24 hours require surgery without fail due to mediastinal contamination and FCSEMS but only surgical lavage
SSAT Abstracts
S-1262
Mo1044
SSAT Abstracts
MINIMALLY INVASIVE ESOPHAGECTOMY: A SINGLE CENTER COMPARATIVE STUDY OF OUTCOMES WITH 638 ESOPHAGECTOMY FOR SQUAMOUS CELL CANCER OF THE ESOPHAGUS Ian Yu Hong Wong, Daniel King Hung Tong, Siu Y. Chan, Kwan Kit Chan, Claudia Wong, Tsz Ting Law, Simon Law Introduction: The optimal surgical approach for esophagectomy remains controversial. The advent of minimally invasive technique has generated more controversies with regards to its true value. The present study aimed to evaluate our results of minimally invasive esophagectomy compared with open surgery. Methods: From 1994 to 2013, 638 patients who underwent esophagectomy for squamous cell cancers of the esophagus were studied. They were divided into three groups: 85 had VATS esophagectomy (VATS group), 104 had VATS and laparoscopic gastric mobilization and cervical anastomosis (total MIE group), and 449 had open esophagectomy (Open group). Their clinical-pathological features, morbidity and mortality rates were compared. Long-term prognosis was studied with multivariate analysis to look at independent prognostic factors. Results: More patients in the total MIE group had neoadjuvant chemoradiation (64.4% vs. 44.7% for the VATS group and 42.8% in the Open group). This was because total MIE was started later in the series. Open esophagectomy resulted in more blood loss but a shorter operation duration. Wound infection rate was higher in the Open group. Total MIE had higher incidence of ischemic stomach compared with Open surgery (8.7% vs. 1.8%), and also a higher recurrent laryngeal nerve palsy rate (19.2% vs. 10.5%). These were believed to be related to a change in gastric tubularization method and more aggressive policy of RLN nodal dissection rather than the VATS or laparoscopic method per se. There was no significant difference in postoperative pneumonia. VATS group had higher mortality compared to the Open group (5.9% vs. 1.3%) while total MIE had intermediate result (4.8%). On pathological variables, total MIE group had most lymph node sampled, significantly more than the other groups.On multivariate analysis, gender, pT stage, number of lymph nodes sampled, number of involved nodes, and R-category were independent prognostic factors. Conclusions: Both minimally invasive surgery and Open surgery have relative merits. Selection biases and change in treatment strategy over time could explain many differences in outcome. Extended lymphadenectomy could improve outcome by increasing the number of lymph nodes harvested.
Mo1046 ECKARDT SCORES WITH PERORAL ENDOSCOPIC MYOTOMY (POEM) IN SPASTIC ESOPHAGEAL DISORDERS (EXCLUDING ACHALASIA) WITH FAILED MEDICAL THERAPY: A META-ANALYSIS AND SYSTEMATIC REVIEW Harsha V. Moole, Anwesh Poosala, Sowjanya Kapaganti, Vu Nguyen, Achuta Uppu, Raghuveer R. Boddireddy, Vishnu Moole, Abhiram Duvvuri, Anthony Baldoni, Ayesha Waqar, Vamsi Emani, Sowmya Dharmapuri, Srinivas R. Puli Background: Peroral endoscopic myotomy (POEM) is primarily being studied in achalasia patients. There is limited experience with POEM in other spastic esophageal disorders nutcracker esophagus, jack hammer esophagus and diffuse esophageal spasms. Based on the current guidelines, the primary treatment options for these spastic esophageal disorders are medications like calcium channel blockers, nitrites, botulinum toxin; esophageal dilation, surgical myotomy. Eckardt score is a clinical scoring system for spastic esophageal disorders (maximum score, 12), based on symptoms scores for dysphagia, regurgitation, chest pain and weight loss. Aims: This is a meta-analysis to evaluate the effect of POEM on Eckardt scores of patients with spastic esophageal disorders. Primary outcomes are the Eckardt scores of patients that underwent POEM - preoperative, post-operative (<30days since procedure) and at follow up period (median 12 months). Methods: Study selection criterion: Studies that evaluated POEM in either nutcracker esophagus, jack hammer esophagus or diffuse esophageal spasms, with failed medical therapy were included in this analysis. Studies evaluating only achalasia patients were excluded from this analysis. Studies must have mentioned regarding Eckardt scores in this patient population. Data collection & extraction: Articles were searched in Medline, Pubmed, and Ovid journals. 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) and DerSimonian Laird method (random effects). The heterogeneity among studies was tested using I2 statistic. Results: Initial search identified 127 reference articles, of which 42 articles were selected and reviewed. Data was extracted from 8 studies (N=567) which met the inclusion criteria. Median age of the patients was 52 years, with 54% 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, effect size of preoperative Eckardt scores in patients that underwent POEM was 6.47 (95% CI = 6.18 to 6.77). Postoperative Eckardt scores and Eckardt scores at median follow up period were 1.13 (95% CI = 0.99 to 1.26) and 1.20 (95% CI = 0.96 to 1.43) respectively. I2 heterogeneity calculated for the POEM group Eckardt scores preoperative, post-operative and at follow up are 87.4%, 0%, 73.7% respectively. Conclusions: In patients with nutcracker esophagus, jack hammer esophagus or diffuse esophageal spasms, that failed medical therapy, POEM procedure resulted in exceptionally improved Eckardt scores. POEM seems to be a viable endoscopic alternative to surgical myotomy if appropriate technical and operator expertise are available.
Mo1045 A RETROSPECTIVE ANALYSIS OF 18 CONSECUTIVE CASES OF ESOPHAGEAL PERFORATIONS MANAGED AT OUR INSTITUTE FROM DECEMBER 2013 TO NOVEMBER 2016 Pankaj N. Desai, Dhaval Mangukiya Aim: To understand for the best modality of management of management of esophageal perforations. Methods: All the cases which presented with esophageal perforations were given immediate resuscitative management with airway support, intravenous fluids, third generation cephalosporin or carbapenem antibiotics. A Contrast enhanced CT scan was done and they were then subjected to either surgical or endoscopic management. Cases who came between 6 to 24 hours after perforation and all case that came after 24 hours, were subjected to surgical management. It included thoracoscopic lavage, attempt at repair of the perforation and drainage. Feeding jejunostomy was performed in all cases who underwent surgery. All cases were then post operatively stented using a fully covered esophageal wide flange SEMS. Those cases which presented with six hours and without mediastinal sepsis, were subjected to esophageal stenting. Cases where the perforation was around 2 cms in diameter were closed with a Padlock clip and then stented. A naso jejunal feeding tube was then placed for feeding in these cases. Observations: Commonest cause of esophageal perforation in our series is Boerhaave's Syndrome followed by Iatrogenic ( post dilatation elsewhere ) and chronic foreign body impaction ( dentures in both cases ). Cases that come within 6 hours have excellent prognosis and surgery can be avoided. Only placement of FCSEMS or application of Padlock clip with FCSEMS suffices. Cases that come within 24 hours require surgery without fail due to mediastinal contamination and FCSEMS but only surgical lavage
SSAT Abstracts
S-1262