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Prognostic Factors for Adenocarcinoma of Esophagogastric Junction
collar anastomosis, have shown similar oncologic effectiveness, it remains undecided whether subsequent quality of life is different. The present analysis compares these reconstruction methods, focusing on dysphagia as the main postoperative symptom. Methods: Between 2003 and 2007, 71 patients (mean age 61.5 years; 72% male, 28% female) with complete resection of esophageal carcinomas (37 adenocarcinomas, 34 squamous cell cancers) and with long-term survival of at least 18 months were contacted and completed a modified quality of life (QoL) questionnaire (median 24.1 months after surgery). Our analysis compared the reconstruction groups using a gastric tube with either collar (group A; n=36) or high intrathoracic anastomosis (group B; n=35). In order to quantify the given answers from the patients and the extent of the dysphagia, we have devised a scoring system. For each question we have assigned a point allocation, depending on the impact of the symptoms or grade of dysphagia. Results: Postoperatively, the rate of surgical complications of our study population was 27.8 % (anastomotic leakage 22.2%) in group A vs. 11.4 % in group B (p=0.075). The long-term follow-up showed symptoms of dysphagia in 29 patients (group A, n=20; group B, n=9; p=0.007). Significantly more patients within group A had to undergo endoscopic bougienage (13 vs. 1, p<0.0001). The scoring system showed significantly severe symptoms in patients with collar anastomosis (median 17) compared to intrathoracic anastomosis (median 8). Conclusion: High intrathoracic anastomosis appears to carry a lower risk for dysphagic symptoms compared with collar anastomosis, and should therefore be the preferred method for reconstruction after surgical resection of esophageal carcinoma.
Su1619 Revisional Surgery After Failed Esophagogastric Myotomy for Achalasia: Successful Esophageal Preservation Ross F. Goldberg, Steven P. Bowers, Michael Parker, John Stauffer, Ronald A. Hinder, Horacio J. Asbun, C. Daniel Smith Introduction: Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10% of patients, most of whom will seek reoperation. There exist only limited reports of reoperation with esophageal preservation in such patients. Methods and Procedures: We retrospectively reviewed the records of patients presenting for symptomatic treatment failure after Heller myotomy. From March 1998 to November 2010, 47 patients were evaluated. Seven patients had undergone more than one prior myotomy. Three patients became symptom-free after endoscopic dilation and/or Botox injection therapy, and seven patients opted not to undergo reoperation. Thirty-five of 37 patients underwent reoperation with the goal of esophageal preservation. Two patients with sigmoid megaesophagus underwent minimally invasive esophagectomy as our initial reoperation. Our approach was to proceed with a takedown of their previous fundoplication, dissection of the periesophageal fibrosis, and assessment of need for an extension of the myotomy. Results: Thirty-five patients underwent laparoscopic reoperation for either presumed incomplete myotomy or anatomic distortion due to the fundoplication. Intraoperative findings were incomplete myotomy in 28 patients and fundoplication failure in 7 patients. Intraoperative esophagogastric perforation occurred in six patients. Fundoplication was not reconstructed in 15 patients. Of the 31 patients undergoing a first-time reoperation, 24 achieved relief of symptoms without reintervention (77%). Less than half of patients undergoing two or more reoperations had successful relief of symptoms. However, esophageal preservation was possible in 32 of the 35 patients in whom it was attempted (91%). Three patients failed a strategy of esophageal preservation and eventually required esophagectomy. Conclusions: Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. Not surprising, there is a decrement in the rate of success with each successive reoperation.
Su1617
SSAT Abstracts
The Myotomy Length on the Gastric Side Doesn't Influence the Final Outcome of Laparoscopic Heller Dor for Esophageal Achalasia Valentina Caruso, Renato Salvador, Mario Costantini, Lisa Zanatta, Nicola Passuello, Loredana Nicoletti, Francesco Cavallin, Ermanno Ancona, Giovanni Zaninotto Background: The controversy about the myotomy length on the gastric side for esophageal achalasia is still an unexplored field. The aim of this study was to investigate the final outcome after classic myotomy (CM) vs long myotomy on the gastric side (LM) in two cohort of achalasia patients. Patients and Methods: We evaluated 44 achalasia patients who underwent laparoscopic Heller Dor. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy and esophageal manometry were performed, before and 6 months after surgical treatment. 24 hours pH-monitoring were performed 6 months after the Heller Dor. CM was defined as gastric myotomy length between 1.5-2.5 cm and LM as 2.5-3 cm gastric myotomy length. The surgical treatment (CM or LM) were performed in two consecutive cohorts. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 7). Results: 44 patients (M:F=24:20) represented the study population: 20 patients underwent CM and 24 patients had LM. Demographic and clinical parameters (age, sex, symptom score, duration of symptoms, esophageal diameter and manometric pattern) were similar among the two groups. Median follow-up was 18 months (IRQ 8-33). Mucosal tears were nil in both groups. One patient per each group was considered a failure. In the CM group the median symptom score decreased from 19.5 (IQR 13.5-20.5) to 0 (IQR 0-4) (p<0.0001). The median LES resting pressure dropped from 23.5 mmHg(18-30) to 10 mmHg (7-15) (p=0.006) and the median LES residual pressure from 11 mmHg (8-17) to 1.5 mmHg (0.4-3) (p=0.002). In the LM the preoperative symptom score median was 16.5 (11-21.5) vs 3 (0-5) (p<0.0001) of the postoperative evaluation. The median LES resting pressure decreased from 28 mmHg (25.666.8) to 10.3 mmHg (7-18) (p<0.0002) and the median LES residual pressure from 15 mmHg (7-39.5) to 3.7 mmHg (1.3-7) (p=0.0005). Post-operative symptom score, resting and residual LES pressure, total and abdominal LES length were not statistically different in the two groups. Positive post-operative 24 hours pH-monitoring were similar in the two groups. Seven patients changed the manometric pattern after surgery (2 CM and 5 LM). Conclusion: Extending the myotomy length into the gastric side over 2.5 cm doesn't change the final outcome of laparoscopic Heller Dor.
Su1620 Endoscopic Stapling System for Trans Oral Treatment of GERD -Three Years Follow up Aviel Roy-Shapira, Amol Bapaye Objectives: Long Term Efficacy of an endoscopic staling system for trans oral treatment of GERD Introduction: Between May and October 2007, an IRB approved, pilot study of a new endoscopic stapling device for the treatment of GERD was conducted on 13 subjects in Pune, India. Subjects with history of PPI use > 2y for GERD and no co-morbidity were included. The device is a modified gastroscope, which includes a surgical stapler, that fires a staggered quintuplet of standard titanium B shaped 4.8mm staples, and an ultrasonic range finder. All procedures were done under general anesthesia by a single operator. Either 2 or 3 staple quintuplets were used to staple the fundus to the esophagus,creating a 90180 degree anterior fundoplication over the distal 2-3cm of the esophagus. This is a report of the results of a three year follow up on this group of subjects Methods: The original Informed consent specified that the subjects may be contacted annually for 5 years following the study. Accordingly subjects were contacted for a telephone interview during the first week of October 2010. The following data were collected: Velanovich GERD-HRQL scores, PPI use, symptoms, satisfaction with the procedure, and wllingness to repeat the procedure again. Results: 11 of the 13 subjects could be reached by phone. GERD-HRQL scores were less than 9 or less in 10 subjects and 15 in one subject, The latter subject improved his score from 29 to 15, in all others score improved by more than 50%. All subjects would have agreed to do the procedure again. Mean satisfaction score was 7.7 (6-10) on a scale of 1-10. There was no dysphagia. Three subjects resumed PPI intake, (compared to 2 at the 2y follow up) 3 subjects require PPI at a reduced dose 1 subjects takes PPI only after a large meal and 4 subjects remained completely off PPI Conclusion: At 3 years, the procedure remained effective in improving the quality of life in moderate to severe GERD without causing dysphagia. PPI use was eliminated or reduced in 73% of subjects. All subjects remain satisfied with the procedure and would do it all over again. Further studies are necessary to validate these data and determine optimal staple placement.
Su1618 Prognostic Factors for Adenocarcinoma of Esophagogastric Junction Fion S. Chan, Daniel K. Tong, Kam H. Wong, Simon Law Introduction: The incidence of Barrett's esophagus is low in Chinese population. Most of our patients who have adenocarcinomas of the esophagogastric junction (AEG) are Siewert type II or III. This study aims to evaluate the outcome after surgical resection in this group of patients, comparing clinicopathological differences between type II and III cancers, and identify prognostic factors. Material and Methods: Patients who underwent resection for AEG tumors between 1995 and 2008 were included. Those with Siewert type I cancers were excluded. Data were retrieved from a prospectively collected database. Patient characteristics and clinicopathological data and outcome were evaluated. Results: There were 126 patients (99 men, 27 women). The median age was 70 yrs (range: 23-87). Type II tumors were found in 65 patients and type III in 61. Thoracotomy was required for tumor extirpation in 50 (76.9%) and 34 (55.7%) patients, respectively (p=0.014). The operative blood loss was higher for type III tumors (median 300 ml vs. 400ml, p=0.005). There was no hospital mortality. Type III AEG was associated with significantly higher incidence of poorly differentiated cancer (44.6% vs. 73.8%, p=0.003), higher number of nodal metastasis (median 3 vs. 7, p=0.031), and advanced TNM stage (stage IIIA-IV disease in 64.6% vs. 86.9%, p=0.004). Overall median survival for the whole group was 17 months. Patients with type II AEG had longer survival (37.6 vs. 10.4 months), (p<0.01). Independent variables identified by Cox regression model for better survival were Siewert type II (p=0.021), earlier N-stage (p<0.01) and R0 resection (p<0.01). Conclusion: Type III AEG tumors were more likely to be poorly differentiated, more advanced and had worse survival compared to type II AEG cancers. Other independent prognostic factors were N-stage and R-category of resection.
SSAT Abstracts
Su1621 Neoadjuvant Chemo-Radiotherapy Modifies the Histologic Grade of Esophageal Cancer Renato Salvador, Gianpietro Zanchettin, Mantoan Silvia, Luca Faccio, Angela Pecchielan, Antonio Rella, Francesco Cavallin, Michele Valmasoni, Carlo Castoro, Matteo Cagol, Rita Alfieri, Ermanno Ancona, Alberto Ruol Background The introduction of the number of nodal metastasis, grading and tumor location in the 2010 TNM staging could redefine the management of esophageal cancer. In early stages (T1a/T1b and T2a/T2b) histologic grade modulates stage grouping and prognosis. The aim of the study was to investigate the hypothesis that neoadjuvant Chemo or ChemoRadioTherapy (nCRT) may modify the grading of esophageal cancer. Patients and methods We evaluated 463 patients who underwent surgical resection for esophageal cancer or esophago-gastric junction: 252 had surgery (SURG) as first treatment and 211 had nCRT before surgery. Pathological findings were evaluated from the pre-treatment endoscopic biopsies and the surgical specimen. Patients who had R1-R2 resection or a pathological stage M1 were excluded. The change of histologic grade (i.e. shift from well-differentiated to less well-differentiated and vice versa) were retrospectively investigated analyzing prospectively collected data. Results The histological type was adenocarcinoma (AK) in 170 pts (123 SURG / 47 nCRT) and squamous cell carcinoma (SCC) in 293 pts (129 SURG / 164 nCRT). Median age was statistically different between SURG 60.4 years (IQR 53.9-66.3) and nCRT 65.6 years (IQR 58-71.2)(p<0.0001), while the sex distribution was similar in the SURG and nCRT. Histologic grade was unchanged in 172/252 (68.3%) in SURG group and 63/
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Su1619 Revisional Surgery After Failed Esophagogastric Myotomy for Achalasia: Successful Esophageal Preservation Ross F. Goldberg, Steven P. Bowers, Michael Parker, John Stauffer, Ronald A. Hinder, Horacio J. Asbun, C. Daniel Smith Introduction: Treatment failure with recurrent dysphagia after Heller myotomy occurs in fewer than 10% of patients, most of whom will seek reoperation. There exist only limited reports of reoperation with esophageal preservation in such patients. Methods and Procedures: We retrospectively reviewed the records of patients presenting for symptomatic treatment failure after Heller myotomy. From March 1998 to November 2010, 47 patients were evaluated. Seven patients had undergone more than one prior myotomy. Three patients became symptom-free after endoscopic dilation and/or Botox injection therapy, and seven patients opted not to undergo reoperation. Thirty-five of 37 patients underwent reoperation with the goal of esophageal preservation. Two patients with sigmoid megaesophagus underwent minimally invasive esophagectomy as our initial reoperation. Our approach was to proceed with a takedown of their previous fundoplication, dissection of the periesophageal fibrosis, and assessment of need for an extension of the myotomy. Results: Thirty-five patients underwent laparoscopic reoperation for either presumed incomplete myotomy or anatomic distortion due to the fundoplication. Intraoperative findings were incomplete myotomy in 28 patients and fundoplication failure in 7 patients. Intraoperative esophagogastric perforation occurred in six patients. Fundoplication was not reconstructed in 15 patients. Of the 31 patients undergoing a first-time reoperation, 24 achieved relief of symptoms without reintervention (77%). Less than half of patients undergoing two or more reoperations had successful relief of symptoms. However, esophageal preservation was possible in 32 of the 35 patients in whom it was attempted (91%). Three patients failed a strategy of esophageal preservation and eventually required esophagectomy. Conclusions: Laparoscopic reoperation with esophageal preservation is successful in the majority of patients with recurrent dysphagia after Heller myotomy. Not surprising, there is a decrement in the rate of success with each successive reoperation.
Su1617
SSAT Abstracts
The Myotomy Length on the Gastric Side Doesn't Influence the Final Outcome of Laparoscopic Heller Dor for Esophageal Achalasia Valentina Caruso, Renato Salvador, Mario Costantini, Lisa Zanatta, Nicola Passuello, Loredana Nicoletti, Francesco Cavallin, Ermanno Ancona, Giovanni Zaninotto Background: The controversy about the myotomy length on the gastric side for esophageal achalasia is still an unexplored field. The aim of this study was to investigate the final outcome after classic myotomy (CM) vs long myotomy on the gastric side (LM) in two cohort of achalasia patients. Patients and Methods: We evaluated 44 achalasia patients who underwent laparoscopic Heller Dor. Patients with sigmoid-shaped esophagus were excluded. Symptoms were scored using a detailed questionnaire for dysphagia, regurgitation, and chest pain; barium swallow, endoscopy and esophageal manometry were performed, before and 6 months after surgical treatment. 24 hours pH-monitoring were performed 6 months after the Heller Dor. CM was defined as gastric myotomy length between 1.5-2.5 cm and LM as 2.5-3 cm gastric myotomy length. The surgical treatment (CM or LM) were performed in two consecutive cohorts. Treatment failure was defined as a postoperative symptom score >10th percentile of the preoperative score (i.e. > 7). Results: 44 patients (M:F=24:20) represented the study population: 20 patients underwent CM and 24 patients had LM. Demographic and clinical parameters (age, sex, symptom score, duration of symptoms, esophageal diameter and manometric pattern) were similar among the two groups. Median follow-up was 18 months (IRQ 8-33). Mucosal tears were nil in both groups. One patient per each group was considered a failure. In the CM group the median symptom score decreased from 19.5 (IQR 13.5-20.5) to 0 (IQR 0-4) (p<0.0001). The median LES resting pressure dropped from 23.5 mmHg(18-30) to 10 mmHg (7-15) (p=0.006) and the median LES residual pressure from 11 mmHg (8-17) to 1.5 mmHg (0.4-3) (p=0.002). In the LM the preoperative symptom score median was 16.5 (11-21.5) vs 3 (0-5) (p<0.0001) of the postoperative evaluation. The median LES resting pressure decreased from 28 mmHg (25.666.8) to 10.3 mmHg (7-18) (p<0.0002) and the median LES residual pressure from 15 mmHg (7-39.5) to 3.7 mmHg (1.3-7) (p=0.0005). Post-operative symptom score, resting and residual LES pressure, total and abdominal LES length were not statistically different in the two groups. Positive post-operative 24 hours pH-monitoring were similar in the two groups. Seven patients changed the manometric pattern after surgery (2 CM and 5 LM). Conclusion: Extending the myotomy length into the gastric side over 2.5 cm doesn't change the final outcome of laparoscopic Heller Dor.
Su1620 Endoscopic Stapling System for Trans Oral Treatment of GERD -Three Years Follow up Aviel Roy-Shapira, Amol Bapaye Objectives: Long Term Efficacy of an endoscopic staling system for trans oral treatment of GERD Introduction: Between May and October 2007, an IRB approved, pilot study of a new endoscopic stapling device for the treatment of GERD was conducted on 13 subjects in Pune, India. Subjects with history of PPI use > 2y for GERD and no co-morbidity were included. The device is a modified gastroscope, which includes a surgical stapler, that fires a staggered quintuplet of standard titanium B shaped 4.8mm staples, and an ultrasonic range finder. All procedures were done under general anesthesia by a single operator. Either 2 or 3 staple quintuplets were used to staple the fundus to the esophagus,creating a 90180 degree anterior fundoplication over the distal 2-3cm of the esophagus. This is a report of the results of a three year follow up on this group of subjects Methods: The original Informed consent specified that the subjects may be contacted annually for 5 years following the study. Accordingly subjects were contacted for a telephone interview during the first week of October 2010. The following data were collected: Velanovich GERD-HRQL scores, PPI use, symptoms, satisfaction with the procedure, and wllingness to repeat the procedure again. Results: 11 of the 13 subjects could be reached by phone. GERD-HRQL scores were less than 9 or less in 10 subjects and 15 in one subject, The latter subject improved his score from 29 to 15, in all others score improved by more than 50%. All subjects would have agreed to do the procedure again. Mean satisfaction score was 7.7 (6-10) on a scale of 1-10. There was no dysphagia. Three subjects resumed PPI intake, (compared to 2 at the 2y follow up) 3 subjects require PPI at a reduced dose 1 subjects takes PPI only after a large meal and 4 subjects remained completely off PPI Conclusion: At 3 years, the procedure remained effective in improving the quality of life in moderate to severe GERD without causing dysphagia. PPI use was eliminated or reduced in 73% of subjects. All subjects remain satisfied with the procedure and would do it all over again. Further studies are necessary to validate these data and determine optimal staple placement.
Su1618 Prognostic Factors for Adenocarcinoma of Esophagogastric Junction Fion S. Chan, Daniel K. Tong, Kam H. Wong, Simon Law Introduction: The incidence of Barrett's esophagus is low in Chinese population. Most of our patients who have adenocarcinomas of the esophagogastric junction (AEG) are Siewert type II or III. This study aims to evaluate the outcome after surgical resection in this group of patients, comparing clinicopathological differences between type II and III cancers, and identify prognostic factors. Material and Methods: Patients who underwent resection for AEG tumors between 1995 and 2008 were included. Those with Siewert type I cancers were excluded. Data were retrieved from a prospectively collected database. Patient characteristics and clinicopathological data and outcome were evaluated. Results: There were 126 patients (99 men, 27 women). The median age was 70 yrs (range: 23-87). Type II tumors were found in 65 patients and type III in 61. Thoracotomy was required for tumor extirpation in 50 (76.9%) and 34 (55.7%) patients, respectively (p=0.014). The operative blood loss was higher for type III tumors (median 300 ml vs. 400ml, p=0.005). There was no hospital mortality. Type III AEG was associated with significantly higher incidence of poorly differentiated cancer (44.6% vs. 73.8%, p=0.003), higher number of nodal metastasis (median 3 vs. 7, p=0.031), and advanced TNM stage (stage IIIA-IV disease in 64.6% vs. 86.9%, p=0.004). Overall median survival for the whole group was 17 months. Patients with type II AEG had longer survival (37.6 vs. 10.4 months), (p<0.01). Independent variables identified by Cox regression model for better survival were Siewert type II (p=0.021), earlier N-stage (p<0.01) and R0 resection (p<0.01). Conclusion: Type III AEG tumors were more likely to be poorly differentiated, more advanced and had worse survival compared to type II AEG cancers. Other independent prognostic factors were N-stage and R-category of resection.
SSAT Abstracts
Su1621 Neoadjuvant Chemo-Radiotherapy Modifies the Histologic Grade of Esophageal Cancer Renato Salvador, Gianpietro Zanchettin, Mantoan Silvia, Luca Faccio, Angela Pecchielan, Antonio Rella, Francesco Cavallin, Michele Valmasoni, Carlo Castoro, Matteo Cagol, Rita Alfieri, Ermanno Ancona, Alberto Ruol Background The introduction of the number of nodal metastasis, grading and tumor location in the 2010 TNM staging could redefine the management of esophageal cancer. In early stages (T1a/T1b and T2a/T2b) histologic grade modulates stage grouping and prognosis. The aim of the study was to investigate the hypothesis that neoadjuvant Chemo or ChemoRadioTherapy (nCRT) may modify the grading of esophageal cancer. Patients and methods We evaluated 463 patients who underwent surgical resection for esophageal cancer or esophago-gastric junction: 252 had surgery (SURG) as first treatment and 211 had nCRT before surgery. Pathological findings were evaluated from the pre-treatment endoscopic biopsies and the surgical specimen. Patients who had R1-R2 resection or a pathological stage M1 were excluded. The change of histologic grade (i.e. shift from well-differentiated to less well-differentiated and vice versa) were retrospectively investigated analyzing prospectively collected data. Results The histological type was adenocarcinoma (AK) in 170 pts (123 SURG / 47 nCRT) and squamous cell carcinoma (SCC) in 293 pts (129 SURG / 164 nCRT). Median age was statistically different between SURG 60.4 years (IQR 53.9-66.3) and nCRT 65.6 years (IQR 58-71.2)(p<0.0001), while the sex distribution was similar in the SURG and nCRT. Histologic grade was unchanged in 172/252 (68.3%) in SURG group and 63/
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