- Email: [email protected]
Mo1636 The Requirement of Lymphadenectomy for Esophageal Carcinoma: Harvesting Least Lymph Node Stations Is More Applicable
position. The lymph nodes around the trachea and bronchus, above the diaphragm and along the bilateral recurrent laryngeal nerves are dissected. Working space at the left upper mediastinal area for lymph nodes dissection around recurrent laryngeal nerve is limited in prone position. To obtain the space the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose. (2) Safe Anastomotic technique in the narrow neck field At first the circular stapler (CDH25) is introduced into the gastric conduit and joined to an anvil, and close a little because anastomosis is performed in the narrow neck field. And then an anvil is placed into the proximal esophagus and secured by means of a pursestring suture. The gastric conduit opening is closed using an additional firing of a 60 mm linear stapler and the anastomosis is completed. Results 1. Mean estimated blood loss was 34 ml of chest procedure in prone position and mean chest operative time 322 minutes. 2. The rate of permanent recurrent laryngeal nerve paralysis was 2.8%, and anastomotic leak and postoperative pneumonia was 5.6% and 8.3%, respectively. Conclusion 1. Lymphadenectomy along the left recurrent laryngeal nerve after esophageal stripping is available in prone position of VATS-E. 2. Our anastomotic technique is safe in the narrow neck field
>4 positive LNs and LNR>0.2 were predictors of recurrence. Conclusion: Higher number of positive lymph nodes and higher LNR were associated with lower overall and disease free survival in patients undergoing en bloc esophagectomy with D2 lymphadenectomy for esophageal adenocarcinoma. Irrespective of extent of LN involvement, the majority of recurrences were distant, implying efforts to improve outcomes should be directed towards enhancing systemic, rather than local, control.
Mo1638 Mo1636
Dysphagia After Nissen Fundoplication - Is Preoperative Esophageal Motility a Factor? Anna Aronova, Kayvon Sharif, Brendan M. Finnerty, Rasa Zarnegar, Cheguevara Afaneh, Thomas J. Fahey, Thomas Ciecierega, Carl V. Crawford
The Requirement of Lymphadenectomy for Esophageal Carcinoma: Harvesting Least Lymph Node Stations Is More Applicable Long-Qi Chen, Jun Peng, Yu-Shang Yang
Background - There is controversy over the incidence of dysphagia after Nissen fundoplication, especially in patients with abnormal preoperative esophageal motility. As such, some clinicians recommend partial wraps in this subgroup. We aimed to assess the relationship between preoperative esophageal dysmotility and the degree and duration of dysphagia after laparoscopic and robot-assisted Nissen fundoplication. Methods - A retrospective review was performed on all consecutive patients who underwent laparoscopic and robot-assisted Nissen fundoplication at a single center between 2009 and 2014. We excluded patients undergoing re-operative fundoplication, as well as those with a primary motility disorder. Preoperative factors examined included: demographics, symptoms, DeMeester scores, and duration of acid suppression therapy. Analyzed outcomes included postoperative symptom resolution and duration of dysphagia, as self-reported by patients at their two-week and three-month visits. Patients were classified as having normal or abnormal preoperative motility based on the results of high-resolution esophageal manometry. Postoperative dysphagia was graded in accordance with the Chicago classification criteria. Results - Eighty-two patients met inclusion criteria. No significant preoperative differences were found between normal (n= 48) and abnormal (n=34) motility groups including age, DeMeester scores, and duration of acid suppression therapy. All patients experienced dysphagia at 2 weeks, but the mean Chicago classification dysphagia scores between patients with normal and abnormal preoperative motility did not differ [1.89±0.56 vs. 2±0.65, respectively, p=0.62]. At 3 months, 8.7% and 24% of patients with normal and abnormal preoperative motility, respectively, experienced dysphagia (p=0.11). Per patient, the Chicago Classification scores improved significantly more for the normal preoperative motility group (0.11±0.38) compared to the abnormal motility group (0.24±0.44), p<0.01. However, all patients with abnormal preoperative motility who experienced dysphagia at 3 months postoperatively reported full resolution of dysphagia within 18 months. Lastly, rates of dysphagia did not differ between laparoscopic (n=26) or robotic (n=56) approaches at 2 weeks (p=0.81) or 3 months (p= 0.67). Conclusions -Some degree of dysphagia is to be expected postoperatively regardless of preoperative esophageal motility status; however patients with normal preoperative esophageal motility have a more pronounced improvement in dysphagia at three months. As such, clinicians should counsel patients accordingly prior to Nissen fundoplication surgery.
SSAT Abstracts
Objective: The new AJCC TNM system for esophageal cancer recommends at least 12 regional lymph nodes (LN) should be harvested in order to have an accurate N-staging and radical dissection. However, the counting of LN might be difficult or inaccurate due to the calcification, inflammation or fusion of LN themselves. The aim of this study was to investigate if using least LN stations to optimize the lymphadenectomy requirement. Methods: The clinicopathological data on patients with esophageal cancer admitted between 2007 through 2013 was reviewed. Patients with radical-intent esophagectomy with at least 12 regional lymph nodes resected were included for the analysis. The heterogeneity in numbers for lymph nodes sampling, as well as the optimal station number for lymphadenectomy were investigated. Results: Totally 1328 patients were included, with a follow-up rate of 94%, and overall 5-year survival rate of 39%. The number of LN resection ranged between 12 and 62, with a median of 19. The LN number varied mostly in the following stations: Gruop 1 (1-26), Group 2 (1-22), Group 4 (1-18), Group 7 (1-29), Group 8 (1-18) and Group 17 (1-24). Log-rank analysis demonstrated that the cut-point for LN stations number between <7 and >=7 revealing a most significant survival difference (36.2% vs. 47.4%;X2=8.823,P= 0.003)(Table 1). Conclusion: The requirement of removal at least 7 LN stations is better than least 12 lymph nodes themselves for a radical lymphadenectomy and an accurate N staging for esophageal carcinoma. Survival with lymph node stations harvested
Mo1639 Quantitative Assessment of Esophageal Emptying in Achalasia Patients Using Esophageal Transit Scintigraphy Joshua A. Boys, Daniel S. Oh, Jack Seto, Robert W. Henderson, Steven R. DeMeester, Jeffrey A. Hagen
Mo1637 Extent of Lymph Node Involvement After Esophagectomy With Extended Lymphadenectomy for Esophageal Adenocarcinoma Predicts Recurrence: A Large North American Cohort Study Sara Najmeh, Henry Jiang, Mara L. Leimanis, Pedram Mossallanejad, Jonathan CoolsLartigue
Introduction: Timed barium studies using x-ray images 1 and 5 minutes following ingestion of liquid barium is currently the most common method to assess esophageal emptying before and after treatment in achalasia patients. However, interpretation of this study is relatively subjective and variable. An alternative technique of esophageal transit scintigraphy (ETS) was developed to assess esophageal clearance in a quantitative manner. We report the technical protocol that we have developed and its initial utilization in a cohort of achalasia patients before and after surgical myotomy. Methods: Patients were prepared for the study by being NPO overnight. The entirety of the study was performed with the patient standing or sitting upright. The camera was centered to include the esophagus, stomach, and as much small bowel as possible. The patient was instructed to swallow 1.5mCi of technetium 99m sulfur colloid mixed in 30 cc of water followed immediately by an additional 120 cc of water for a total of 150 cc ingested. With the patient upright, 15 second static images were obtained at 0, 1, 5 and 10 minutes. Post scintigraphy analysis included outlining 2 regions of interest (ROI): ROI 1 over the esophagus and ROI 2 over the esophagus, stomach and as much small bowel as present in field of view. The percent of liquid remaining in the esophagus was calculated by dividing ROI1 by ROI2 with reporting of the percent remaining in the esophagus at time 0, 1, 5 and 10 minutes. Results: There were 3 patients studied with the present protocol: 2 males and 1 female. All patients were diagnosed with achalasia and had a laparoscopic Heller myotomy with Dor fundoplication. The median percent emptying pre myotomy at 0, 1, 5, and 10 min was: 0% (0-4%), 4% (0-5%), 5% (0-10%), and 5% (0-10%). The median percent emptying post myotomy at 0, 1, 5, and 10 min was: 61% (29-76%), 77% (71-95), 85% (78-95%), and 83% (78-95%). Examples of ETS images with ROI outlines and percent emptying are shown in the figure. Conclusion: We report a standardized technique of esophageal transit scintigraphy that allows quantitative assessment of esophageal clearance in patients with achalasia. By taking into account the amount of radioisotope that can immediately enter the stomach and small bowel with swallowing, it avoids the subjective nature of timed barium studies, particularly in the post-treatment
Background: Esophagectomy remains the cornerstone of curative treatment for esophageal adenocarcinoma, however recurrence remains high. Although previous studies have examined the rate of recurrence related to lymph node involvement, there is little data on these patterns after extended D2 lymphadenectomy for esophageal adenocarcinoma. We sought to identify patient, tumor and surgery-related factors associated with disease recurrence after en-bloc esophagectomy and extended lymphadenectomy for esophageal adenocarcinoma. Methods: Patients undergoing complete resection of esophageal or EGJ adenocarcinoma from 2005-2014 in a university-affiliated North American hospital were identified from a prospectively collected database. Patient demographics, neoadjuvant treatment, OR and tumor characteristics, pathology outcomes, and follow up data were reviewed. Survival data was compared based on extent of lymph node involvement (absolute number and ratio). Chi-square test was used to test independence and colinearity within predictors of recurrence and survival. DFS and OS were analyzed using the Kaplan-Meier method, and the association of variables with time to recurrence and death was modeled using the Cox Proportional Hazards model. Student's t-test and Fisher's exact test were used to compare continuous and categorical variables, p <0.05 = *. Results: A total of 216 patients who underwent curative resection for esophageal and EGJ cancers were identified. 123 patients (58%) received neoadjuvant chemotherapy and 168 patients (79.2%) underwent a D2 lymphadenectomy. The median total number of lymph nodes resected was 31[5-84] and median number of positive lymph nodes was 2[0-34]. 80 patients (37%) recurred at a median follow up of 13.6 months [1.5-72.7]; with 65 patients (81.25%) having distant recurrences vs 15 patients (18.75%) having locoregional recurrences. Having a positive lymph node number (+LN) >4 and a positive:total lymph node ratio (LNR)> 0.2 were associated with decreased overall and disease free survival. T stage>2, poor grade, lymphovascular invasion, perineural invasion,
SSAT Abstracts
S-1158
>4 positive LNs and LNR>0.2 were predictors of recurrence. Conclusion: Higher number of positive lymph nodes and higher LNR were associated with lower overall and disease free survival in patients undergoing en bloc esophagectomy with D2 lymphadenectomy for esophageal adenocarcinoma. Irrespective of extent of LN involvement, the majority of recurrences were distant, implying efforts to improve outcomes should be directed towards enhancing systemic, rather than local, control.
Mo1638 Mo1636
Dysphagia After Nissen Fundoplication - Is Preoperative Esophageal Motility a Factor? Anna Aronova, Kayvon Sharif, Brendan M. Finnerty, Rasa Zarnegar, Cheguevara Afaneh, Thomas J. Fahey, Thomas Ciecierega, Carl V. Crawford
The Requirement of Lymphadenectomy for Esophageal Carcinoma: Harvesting Least Lymph Node Stations Is More Applicable Long-Qi Chen, Jun Peng, Yu-Shang Yang
Background - There is controversy over the incidence of dysphagia after Nissen fundoplication, especially in patients with abnormal preoperative esophageal motility. As such, some clinicians recommend partial wraps in this subgroup. We aimed to assess the relationship between preoperative esophageal dysmotility and the degree and duration of dysphagia after laparoscopic and robot-assisted Nissen fundoplication. Methods - A retrospective review was performed on all consecutive patients who underwent laparoscopic and robot-assisted Nissen fundoplication at a single center between 2009 and 2014. We excluded patients undergoing re-operative fundoplication, as well as those with a primary motility disorder. Preoperative factors examined included: demographics, symptoms, DeMeester scores, and duration of acid suppression therapy. Analyzed outcomes included postoperative symptom resolution and duration of dysphagia, as self-reported by patients at their two-week and three-month visits. Patients were classified as having normal or abnormal preoperative motility based on the results of high-resolution esophageal manometry. Postoperative dysphagia was graded in accordance with the Chicago classification criteria. Results - Eighty-two patients met inclusion criteria. No significant preoperative differences were found between normal (n= 48) and abnormal (n=34) motility groups including age, DeMeester scores, and duration of acid suppression therapy. All patients experienced dysphagia at 2 weeks, but the mean Chicago classification dysphagia scores between patients with normal and abnormal preoperative motility did not differ [1.89±0.56 vs. 2±0.65, respectively, p=0.62]. At 3 months, 8.7% and 24% of patients with normal and abnormal preoperative motility, respectively, experienced dysphagia (p=0.11). Per patient, the Chicago Classification scores improved significantly more for the normal preoperative motility group (0.11±0.38) compared to the abnormal motility group (0.24±0.44), p<0.01. However, all patients with abnormal preoperative motility who experienced dysphagia at 3 months postoperatively reported full resolution of dysphagia within 18 months. Lastly, rates of dysphagia did not differ between laparoscopic (n=26) or robotic (n=56) approaches at 2 weeks (p=0.81) or 3 months (p= 0.67). Conclusions -Some degree of dysphagia is to be expected postoperatively regardless of preoperative esophageal motility status; however patients with normal preoperative esophageal motility have a more pronounced improvement in dysphagia at three months. As such, clinicians should counsel patients accordingly prior to Nissen fundoplication surgery.
SSAT Abstracts
Objective: The new AJCC TNM system for esophageal cancer recommends at least 12 regional lymph nodes (LN) should be harvested in order to have an accurate N-staging and radical dissection. However, the counting of LN might be difficult or inaccurate due to the calcification, inflammation or fusion of LN themselves. The aim of this study was to investigate if using least LN stations to optimize the lymphadenectomy requirement. Methods: The clinicopathological data on patients with esophageal cancer admitted between 2007 through 2013 was reviewed. Patients with radical-intent esophagectomy with at least 12 regional lymph nodes resected were included for the analysis. The heterogeneity in numbers for lymph nodes sampling, as well as the optimal station number for lymphadenectomy were investigated. Results: Totally 1328 patients were included, with a follow-up rate of 94%, and overall 5-year survival rate of 39%. The number of LN resection ranged between 12 and 62, with a median of 19. The LN number varied mostly in the following stations: Gruop 1 (1-26), Group 2 (1-22), Group 4 (1-18), Group 7 (1-29), Group 8 (1-18) and Group 17 (1-24). Log-rank analysis demonstrated that the cut-point for LN stations number between <7 and >=7 revealing a most significant survival difference (36.2% vs. 47.4%;X2=8.823,P= 0.003)(Table 1). Conclusion: The requirement of removal at least 7 LN stations is better than least 12 lymph nodes themselves for a radical lymphadenectomy and an accurate N staging for esophageal carcinoma. Survival with lymph node stations harvested
Mo1639 Quantitative Assessment of Esophageal Emptying in Achalasia Patients Using Esophageal Transit Scintigraphy Joshua A. Boys, Daniel S. Oh, Jack Seto, Robert W. Henderson, Steven R. DeMeester, Jeffrey A. Hagen
Mo1637 Extent of Lymph Node Involvement After Esophagectomy With Extended Lymphadenectomy for Esophageal Adenocarcinoma Predicts Recurrence: A Large North American Cohort Study Sara Najmeh, Henry Jiang, Mara L. Leimanis, Pedram Mossallanejad, Jonathan CoolsLartigue
Introduction: Timed barium studies using x-ray images 1 and 5 minutes following ingestion of liquid barium is currently the most common method to assess esophageal emptying before and after treatment in achalasia patients. However, interpretation of this study is relatively subjective and variable. An alternative technique of esophageal transit scintigraphy (ETS) was developed to assess esophageal clearance in a quantitative manner. We report the technical protocol that we have developed and its initial utilization in a cohort of achalasia patients before and after surgical myotomy. Methods: Patients were prepared for the study by being NPO overnight. The entirety of the study was performed with the patient standing or sitting upright. The camera was centered to include the esophagus, stomach, and as much small bowel as possible. The patient was instructed to swallow 1.5mCi of technetium 99m sulfur colloid mixed in 30 cc of water followed immediately by an additional 120 cc of water for a total of 150 cc ingested. With the patient upright, 15 second static images were obtained at 0, 1, 5 and 10 minutes. Post scintigraphy analysis included outlining 2 regions of interest (ROI): ROI 1 over the esophagus and ROI 2 over the esophagus, stomach and as much small bowel as present in field of view. The percent of liquid remaining in the esophagus was calculated by dividing ROI1 by ROI2 with reporting of the percent remaining in the esophagus at time 0, 1, 5 and 10 minutes. Results: There were 3 patients studied with the present protocol: 2 males and 1 female. All patients were diagnosed with achalasia and had a laparoscopic Heller myotomy with Dor fundoplication. The median percent emptying pre myotomy at 0, 1, 5, and 10 min was: 0% (0-4%), 4% (0-5%), 5% (0-10%), and 5% (0-10%). The median percent emptying post myotomy at 0, 1, 5, and 10 min was: 61% (29-76%), 77% (71-95), 85% (78-95%), and 83% (78-95%). Examples of ETS images with ROI outlines and percent emptying are shown in the figure. Conclusion: We report a standardized technique of esophageal transit scintigraphy that allows quantitative assessment of esophageal clearance in patients with achalasia. By taking into account the amount of radioisotope that can immediately enter the stomach and small bowel with swallowing, it avoids the subjective nature of timed barium studies, particularly in the post-treatment
Background: Esophagectomy remains the cornerstone of curative treatment for esophageal adenocarcinoma, however recurrence remains high. Although previous studies have examined the rate of recurrence related to lymph node involvement, there is little data on these patterns after extended D2 lymphadenectomy for esophageal adenocarcinoma. We sought to identify patient, tumor and surgery-related factors associated with disease recurrence after en-bloc esophagectomy and extended lymphadenectomy for esophageal adenocarcinoma. Methods: Patients undergoing complete resection of esophageal or EGJ adenocarcinoma from 2005-2014 in a university-affiliated North American hospital were identified from a prospectively collected database. Patient demographics, neoadjuvant treatment, OR and tumor characteristics, pathology outcomes, and follow up data were reviewed. Survival data was compared based on extent of lymph node involvement (absolute number and ratio). Chi-square test was used to test independence and colinearity within predictors of recurrence and survival. DFS and OS were analyzed using the Kaplan-Meier method, and the association of variables with time to recurrence and death was modeled using the Cox Proportional Hazards model. Student's t-test and Fisher's exact test were used to compare continuous and categorical variables, p <0.05 = *. Results: A total of 216 patients who underwent curative resection for esophageal and EGJ cancers were identified. 123 patients (58%) received neoadjuvant chemotherapy and 168 patients (79.2%) underwent a D2 lymphadenectomy. The median total number of lymph nodes resected was 31[5-84] and median number of positive lymph nodes was 2[0-34]. 80 patients (37%) recurred at a median follow up of 13.6 months [1.5-72.7]; with 65 patients (81.25%) having distant recurrences vs 15 patients (18.75%) having locoregional recurrences. Having a positive lymph node number (+LN) >4 and a positive:total lymph node ratio (LNR)> 0.2 were associated with decreased overall and disease free survival. T stage>2, poor grade, lymphovascular invasion, perineural invasion,
SSAT Abstracts
S-1158