Bruno Sgromo

Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines.

Objective:This article aims to provide the first systematic review of enhanced recovery after surgery (ERAS) programs for esophagectomy and generate guidelines. Background:ERAS programs use multimodal approaches to reduce complications and accelerate recovery. Although ERAS is well established in colorectal surgery, experience after esophagectomy has been minimal. However, esophagectomy remains an extremely high-risk operation, commonly performed in patients with significant comorbidities. Consequently, ERAS may have a significant role to play in improving outcomes. No guidelines or reviews have been published in esophagectomy. Methods:We undertook a systematic review of the PubMed, EMBASE, and the Cochrane databases in July 2012. The literature was searched for descriptions of ERAS in esophagectomy. Components of successful ERAS programs were determined, and when not directly available for esophagectomy, extrapolation from related evidence was made. Graded recommendations for each component were then generated. Results:Six retrospective studies have assessed ERAS for esophagectomy, demonstrating favorable morbidity, mortality, and length of stay. Methodological quality is, however, low. Overall, there is little direct evidence for components of ERAS, with much derived from nonesophageal thoracoabdominal surgery. Conclusions:ERAS in principle seems logical and safe for esophagectomy. However, the underlying evidence is poor and lacking. Despite this, a number of recommendations for practice and research can be made.

Non-radical, stepwise complete endoscopic resection of Barrett’s epithelium in short segment Barrett’s esophagus has a low stricture rate

Background and aims: Radical endoscopic excision of Barrett’s epithelium performing 4 – 6 endoscopic resections during the same endoscopic session results in complete Barrett’s eradication but has a high stricture rate (40 – 80 %). Therefore radiofrequency ablation is preferred after endoscopic mucosal resection (EMR) of visible nodules. We investigated the clinical outcome of non-radical, stepwise endoscopic mucosal resection with a maximum of two endoscopic resections per endoscopic session. Methods: We analysed our prospectively maintained database of patients undergoing esophageal EMR for early neoplasia in Barrett’s esophagus from 2009 to 2014. EMR was performed using a maximum of two band ligation mucosectomies per endoscopic session; thereafter, follow-up was 3-monthly and EMR was repeated as required for Barrett’s eradication. Results: In total, 118 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumor stages or were managed conservatively. The remaining 91 patients with high grade dysplasia (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months. Remission of dysplasia/neoplasia was achieved in 95.6 % after 12 months treatment. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s eradication in 36/91 patients (39.6 %) in a mean of four sessions; 40/91 patients (44.0 %) had a short circumferential Barrett’s segment (< 3 cm). In this group, repeated EMR achieved complete Barrett’s excision in 85.0 %. One patient developed a stricture (1.1 %), one a delayed bleeding, and there were no perforations. Conclusion: In patients with a short Barrett’s segment, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow-up allows complete Barrett’s eradication with very low stricture rate.

Technical tips associated with reduction in leak rate after laparoscopic sleeve gastrectomy: lessons to learn from a nested case-control study

Background Laparoscopic sleeve gastrectomy (LSG) is one of the common bariatric procedures for the treatment of morbid obesity. One of the most drastic complications of this procedure is leak. Objective The aim of the study was to discuss the possible technical factors that might contribute to the occurrence of postoperative leak and how to avoid it through analyzing our series. Materials and methods Analysis of the influence of technical adaptations on the outcome of LSG was performed in a nested case-control group of patients. The main modification adapted was performing invaginating sutures over the staple line. The primary outcome was the occurrence of leak. The secondary outcomes were bleeding, operative time, prolonged hospital stay, back pain, and mortality. Results The group who had invaginating sutures (group 2) had a significantly lower frequency of leak (0%) than those without invaginating sutures (7.3%; group 1) (PF = 0.016). There was no significant difference in the occurrence of postoperative bleeding or mortality between the groups (PF = 0.162 and 0.250, respectively). The frequencies of a hospital stay longer than 48 h and back pain were significantly higher in group 1 (PF = 0.004, PF There were no significant differences between groups in the preoperative BMI (Students t = 0−0.763, P = 0.45) or the age (Students t = −0.5, P = 0.61). The operative time was longer in group 1 (Students t = 3.56, P Conclusion From our experience, leak after LSG could be minimized by invaginating sutures of the staple line and by adapting the ergonomic trocar positioning described herein.

PTH-007 Non-Radical, Stepwise Complete Endoscopic Resection of Barrett’s Epithelium in Short Segment Barrett’s Oesophagus is Effective with Low Stricture Rate

Introduction Radical endoscopic ablation of Barrett’s epithelium performing 4–6 endoscopic resections during the same endoscopic session has been shown to result in complete Barrett’s ablation but has a high stricture rate (40–80%). Therefore radiofrequency ablation is preferred for the ablation of Barrett’s epithelium after endoscopic mucosal resection (EMR) of visible nodules. We investigated whether non-radical, stepwise endoscopic mucosal resection with maximal 2 endoscopic resections per endoscopic session can result in complete remission of intestinal metaplasia and dysplasia in short segment Barrett’s oesophagus. Methods We analysed our database of patients undergoing oesophageal EMR for early neoplasia in Barrett’s oesophagus from 2009 to 2014. Patients showing poorly differentiated cancer or advanced cancer (>T1sm2) after staging EMR were excluded. In patients suitable for further endoscopic therapy, EMR was performed using maximal two band ligation mucosectomies per endoscopic session; thereafter followup was 3 monthly and EMR was repeated as required for Barrett’s ablation. If no dysplasia was detected after a year, the follow up interval was increased to 6 months. Results 118 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumour stages or were managed conservatively depending on patient’s fitness, comorbidities and choice. 91 patients with HGD (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months (8–36 months IQR). Remission of dysplasia/neoplasia was achieved in 94.5% after 12 months treatment. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s ablation in 36 patients (39.6%) in a mean of 4 sessions. 40 patients (43.9%) had a short circumferential Barrett’s segment (C < 3 cm). In this group, repeated EMR achieved complete Barrett’s ablation in 85.0%. One patient developed a stricture (1.1%), one a delayed bleeding, there were no perforations. Conclusion In patients with short Barrett’s segment, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow up allows complete Barrett’s ablation with very low stricture rate. Disclosure of Interest None Declared

PTU-029 Finding the dysplastic lesion: outcome of endoscopic mucosal resection after detecting dysplasia on biopsies in barrett’s oesophagus

Introduction High grade dysplasia (HGD) is often reported after Seattle protocol biopsies have been taken or the exact position of a targeted lesion within a Barrett’s segment has not been precisely documented. We investigated how often the histology of subsequent endoscopic resection agreed with the initial biopsy of HGD. Method We searched our prospectively maintained database for patients referred for endoscopic therapy of high grade dysplasia or early cancer in Barrett’s oesophagus. All biopsies from referring hospitals had been reviewed and confirmed by our expert pathologists. Endoscopy was routinely performed using acetic acid spraying and narrow band imaging to identify and delineate lesions for endoscopic resection. Endoscopic resection was performed using band ligation mucosectomy. Results 100 patients with HGD (71) or early cancer (29) were included. In 34 (47.9%) of the patients with HGD on biopsy, no lesion or abnormality had been reported on the initial endoscopy report. In all of the cancer patients and in 70 (98.6%) of the HGD patients a suspicious lesion could be identified using advanced imaging. One patient with focal HGD but without detectable mucosal lesion was directly treated using RFA. EMR confirmed HGD in 35 of 70 (50%) patients with HGD on initial biopsy but upgraded to intramucosal in 30 patients (42.8%) and to submucosal cancer in 5 patients (7.1%). Conclusion High grade dysplasia in Barrett’s oesophagus is almost always detectable using acetic acid spraying and/or narrow band imaging. Endoscopic resection of all detected lesions before RFA is recommended due to the high risk of intramucosal and even submucosal cancer. Disclosure of interest None Declared.

PTU-024 Non-radical, Stepwise Endoscopic Ablation Of Barrett’s Epithelium In Short Segment Barrett’s Oesophagus Has Low Stricture Rate

Introduction Radical endoscopic ablation of Barrett’s epithelium performing 4–6 endoscopic resections during the same endoscopic session has been shown to result in complete Barrett’s ablation but has a high stricture rate (48–88%).1–3 Therefore radiofrequency ablation is preferred for the ablation of Barrett’s epithelium after endoscopic mucosal resection (EMR) of visible nodules. We investigated whether non-radical, stepwise endoscopic mucosal resection with maximal 2 endoscopic resections per endoscopic session also resulted in complete remission of Barrett’s epithelium. Methods We analysed our database of patients undergoing oesophageal EMR for early neoplasia in Barrett’s oesophagus from 2008 to 2013. Patients undergoing surgery or palliative therapy after staging EMR showing poorly differentiated cancer or advanced cancer (>T1sm) were excluded. In patients suitable for further endoscopic therapy, EMR was performed using maximal two band ligation mucosectomies per endoscopic session. Patients were endoscopically followed up 3 monthly and EMR was repeated as required for Barrett’s ablation. If no dysplasia was detected after a year, the follow up interval was increased to 6 months. Only patients with circumferential Barrett’s length of more than 5 cm underwent radiofrequency ablation. Results 83 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 25 patients underwent surgery/chemotherapy due to submucosal or more advanced tumour stages or were managed conservatively depending on patient’s fitness, comorbidities and choice. 58 patients with HGD (21), intramucosal (22) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months (8–36 months IQR). Remission of dysplasia/neoplasia was achieved in 96.5%. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s ablation in 28 patients (48.3%) in a median of 4 sessions (IQR 2–5). 31 patients (53.4%) had a short Barrett’s segment (<3 cm). In this group, repeated EMR achieved complete Barrett’s ablation in 87%. Only two patients developed a stricture (3.4%), there were no perforations. Conclusion Stepwise, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow up allows complete Barrett’s ablation with very low stricture rate in patients with short Barrett’s segment. References van Vilsteren FG, Pouw RE, Seewald S et al. Gut 2011;60:765–73 Alvarez Herrero L, Pouw RE, van Vilsteren FG et al. Endoscopy 2011;43:177–83 Pouw RE, Seewald S, Gondrie JJ et al. Gut 2010;59:1169–77 Disclosure of Interest None Declared.

PWE-214 Endoscopic mucosal resection for early neoplasia in Barrett's epithelium in patients on anticoagulation using warfarin: is it safe?

Introduction Endoscopic mucosal resection (EMR) has become an established treatment modality in the managment of patients with high grade dysplastic lesions and intramucosal cancer in Barrett oesophagus. The mucosal defect caused by the endoscopic resection usually takes several weeks to heal. There is no data whether this procedure is also safe for patients requiring anticoagulation. The aim of the study was to investigate the risk of acute and delayed bleeding in patients on anticoagulation undergoing EMR for treatment of early neoplasia in Barrett oesophagus. We compared the complication rate of EMR in patients taking warfarin as anticoagulants with that of a control group. Methods Warfarin was stopped 5 days before the planned EMR and restarted on the evening of the procedure day. Patients with high risk conditions such as recent pulmonary thromboemboli received bridging with low molecular weight heparin. All EMRs were performed when the INR was <1.5. Results 34 EMRs were performed in nine patients requiring anticoagulation. 8 were on warfarin due to atrial fibrillation, one took warfarin after pulmonary embolism. One patient on warfarin was readmitted 10 days after EMR with haematemesis, melaena and an drop in haemoglobin >5 g/dl caused by bleeding from an EMR resection ulcer; the bleeding had settled spontaneously at the time of endoscopy. Out of 138 EMRs in 35 controls, five acute bleeding events occurred during EMR which required treatment by clipping, coagulation grasper or heater probe. No delayed bleeding event occurred in the control group. The maximal diameter of the resected specimen did not differ between anticoagulated patients and controls (median 17 mm; 25%>75% percentile: 15–18 mm vs 17 mm; 25%>75% percentile: 15–20 mm; p=0.68). No perforations were observed in either groups. The number of bleeding events did not differ between groups (p=0.85), neither for acute (p=0.60) or delayed bleeding (p=0.46). Conclusion EMR of early oesophageal neoplasia can be safely performed in patients requiring anticoagulation when warfarin is discontinued 5 days before the endoscopic intervention and reinstituted on the evening of the procedure day. Competing interests None declared.