Shajahan Wahed

Spectrum of oesophageal perforations and their influence on management

Oesophageal perforations are associated with high mortality and morbidity rates. A spectrum of aetiologies and clinical presentations has resulted in a variety of operative and non‐operative management strategies. This analysis focused on the impact of these strategies in a single specialist centre.

Management and outcomes of anastomotic leaks after oesophagectomy

Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high‐volume institution that did not use stenting as a primary treatment modality.

Management and outcomes of leaks after oesophagectomy

Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high‐volume institution that did not use stenting as a primary treatment modality.

PTH-141 Pattern of single lymph node metastasis in carcinoma of the oesophagus

Introduction The presence of lymphatic dissemination in oesophageal cancer affects prognosis. The relevance of location of an involved solitary lymph node is unclear. The concept of sentinel node guided lymphadenectomy to reduce surgical stress of a transthoracic operation has some advocates. However, the site of solitary lymph node metastasis, is unpredictable. Similarly, metastases to anatomically distant lymph nodes, known as skip lesions, could develop in the early phase of lymphatic invasion. The aim of this study was to examine the pattern of a single named lymph node metastasis in patients with oesophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) who underwent resection with curative intent. No study to date has investigated this concept. Method Results of consecutive patients from a prospectively maintained database were analysed. All patients with potentially curable AC or SCC who underwent a radical two-field, two-stage, transthoracic oesophagectomy were included. Ex-vivo surgical dissection of the specimen was carried out post-operatively by the surgeon, with harvested lymph node stations labelled. This permitted accurate ‘lymph node mapping’. All harvested lymph nodes were examined by a consultant histopathologist. Results Between 1995 and 2014 a total of 120 patients with one positive lymph node who had undergone a radical two-field, two-stage oesophagectomy were identified. A median age of 65 (45–80) was observed. Seventy three ACs and 47 SCCs were noted. Twenty three middle oesophageal (19.2%), 54 lower oesophageal (45%) and 43 (35.8%) junctional tumours were resected. There was no difference between patterns of solitary lymphatic metastases between AC and SCC. The pattern and number of solitary lymph node metastasis is as follows: paracardial 34 (28.3%); paraoesophageal 31 (25.8%); left gastric 28 (23.3%); subcarinal/bronchial 10 (8.3%) and truncal/coeliac/splenic 9 (7.5%). Tumour location and corresponding single node metastasis are summarised in Table 1.Abstract PTH-141 Table 1 Location of tumour Single positive node location Frequency (n) Percent (%) Middle oesophageal N = 23 Abdomen 8 34.8 Chest 15 65.2 Lower oesophageal N = 54 Abdomen 36 66.7 Chest 18 33.3 Junctional N = 43 Abdomen 27 62.8 Chest 16 37.2 Median survival for patients with AD and SCC were similar at 45 months and 52 months respectively (p = 0.84). Conclusion This study provides further support to the concept that metastasis to anatomically distant lymph nodes (skip metastasis), could develop even in the early phase of lymphatic invasion in oesophageal carcinoma. This unpredictability necessitates a radical resection. This can only be achieved with an extended transthoracic operation to allow a complete two-field lymphadenectomy in order to provide locoregional clearance and a potentially curative resection. Disclosure of interest None Declared.

Pattern of single lymph node metastasis in carcinoma of the oesophagus

Introduction The presence of lymphatic dissemination in oesophageal cancer affects prognosis. The relevance of location of an involved solitary lymph node is unclear. The concept of sentinel node guided lymphadenectomy to reduce surgical stress of a transthoracic operation has some advocates. However, the site of solitary lymph node metastasis, is unpredictable. Similarly, metastases to anatomically distant lymph nodes, known as skip lesions, could develop in the early phase of lymphatic invasion. The aim of this study was to examine the pattern of a single named lymph node metastasis in patients with oesophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) who underwent resection with curative intent. No study to date has investigated this concept. Method Results of consecutive patients from a prospectively maintained database were analysed. All patients with potentially curable AC or SCC who underwent a radical two-field, two-stage, transthoracic oesophagectomy were included. Ex-vivo surgical dissection of the specimen was carried out post-operatively by the surgeon, with harvested lymph node stations labelled. This permitted accurate ‘lymph node mapping’. All harvested lymph nodes were examined by a consultant histopathologist. Results Between 1995 and 2014 a total of 120 patients with one positive lymph node who had undergone a radical two-field, two-stage oesophagectomy were identified. A median age of 65 (45–80) was observed. Seventy three ACs and 47 SCCs were noted. Twenty three middle oesophageal (19.2%), 54 lower oesophageal (45%) and 43 (35.8%) junctional tumours were resected. There was no difference between patterns of solitary lymphatic metastases between AC and SCC. The pattern and number of solitary lymph node metastasis is as follows: paracardial 34 (28.3%); paraoesophageal 31 (25.8%); left gastric 28 (23.3%); subcarinal/bronchial 10 (8.3%) and truncal/coeliac/splenic 9 (7.5%). Tumour location and corresponding single node metastasis are summarised in Table 1.Abstract PTH-141 Table 1 Location of tumour Single positive node location Frequency (n) Percent (%) Middle oesophageal N = 23 Abdomen 8 34.8 Chest 15 65.2 Lower oesophageal N = 54 Abdomen 36 66.7 Chest 18 33.3 Junctional N = 43 Abdomen 27 62.8 Chest 16 37.2 Median survival for patients with AD and SCC were similar at 45 months and 52 months respectively (p = 0.84). Conclusion This study provides further support to the concept that metastasis to anatomically distant lymph nodes (skip metastasis), could develop even in the early phase of lymphatic invasion in oesophageal carcinoma. This unpredictability necessitates a radical resection. This can only be achieved with an extended transthoracic operation to allow a complete two-field lymphadenectomy in order to provide locoregional clearance and a potentially curative resection. Disclosure of interest None Declared.

PTH-141 Pattern of single lymph node metastasis in carcinoma of the oesophagus: Abstract PTH-141 Table 1

Introduction The presence of lymphatic dissemination in oesophageal cancer affects prognosis. The relevance of location of an involved solitary lymph node is unclear. The concept of sentinel node guided lymphadenectomy to reduce surgical stress of a transthoracic operation has some advocates. However, the site of solitary lymph node metastasis, is unpredictable. Similarly, metastases to anatomically distant lymph nodes, known as skip lesions, could develop in the early phase of lymphatic invasion. The aim of this study was to examine the pattern of a single named lymph node metastasis in patients with oesophageal adenocarcinoma (AC) or squamous cell carcinoma (SCC) who underwent resection with curative intent. No study to date has investigated this concept. Method Results of consecutive patients from a prospectively maintained database were analysed. All patients with potentially curable AC or SCC who underwent a radical two-field, two-stage, transthoracic oesophagectomy were included. Ex-vivo surgical dissection of the specimen was carried out post-operatively by the surgeon, with harvested lymph node stations labelled. This permitted accurate ‘lymph node mapping’. All harvested lymph nodes were examined by a consultant histopathologist. Results Between 1995 and 2014 a total of 120 patients with one positive lymph node who had undergone a radical two-field, two-stage oesophagectomy were identified. A median age of 65 (45–80) was observed. Seventy three ACs and 47 SCCs were noted. Twenty three middle oesophageal (19.2%), 54 lower oesophageal (45%) and 43 (35.8%) junctional tumours were resected. There was no difference between patterns of solitary lymphatic metastases between AC and SCC. The pattern and number of solitary lymph node metastasis is as follows: paracardial 34 (28.3%); paraoesophageal 31 (25.8%); left gastric 28 (23.3%); subcarinal/bronchial 10 (8.3%) and truncal/coeliac/splenic 9 (7.5%). Tumour location and corresponding single node metastasis are summarised in Table 1.Abstract PTH-141 Table 1 Location of tumour Single positive node location Frequency (n) Percent (%) Middle oesophageal N = 23 Abdomen 8 34.8 Chest 15 65.2 Lower oesophageal N = 54 Abdomen 36 66.7 Chest 18 33.3 Junctional N = 43 Abdomen 27 62.8 Chest 16 37.2 Median survival for patients with AD and SCC were similar at 45 months and 52 months respectively (p = 0.84). Conclusion This study provides further support to the concept that metastasis to anatomically distant lymph nodes (skip metastasis), could develop even in the early phase of lymphatic invasion in oesophageal carcinoma. This unpredictability necessitates a radical resection. This can only be achieved with an extended transthoracic operation to allow a complete two-field lymphadenectomy in order to provide locoregional clearance and a potentially curative resection. Disclosure of interest None Declared.

Poorer Survival for Stage IIa Patients After Minimally Invasive Esophagectomy.

To the Editor: W e read with great interest the article from a leading center for totally minimally invasive esophagectomy (MIE) and would like to congratulate Luketich and colleagues1 on their excellent short-term outcomes. No other center can compete in terms of experience and case volume with MIE. Other units practicing MIE must use these results as a benchmark, although without such case volume, similar results will be difficult to reproduce in other centers. The authors have refined their techniques over time with acceptable morbidity and low mortality. The in-hospital mortality was 2.8%, with an even lower value of 1.7% for the most recent 500 cases. As indicated in the “Discussion” section following the article, this in-hospital figure is a more accurate reflection of mortality than 30-day mortality. We wish to pose 2 specific questions. First, the Kaplan-Meier plot for overall survival excludes any patients who received neoadjuvant therapy. Does it combine both patients with adenocarcinoma and squamous cell carcinoma? It is now recognized that these 2 cancers have different etiology, behavior, and response to treatment and consequently offer differing prognosis.2,3 It would therefore be important to present results for each appearing as separate plots. Second, how do the authors explain the apparent poor prognosis of patients with stage IIa (TNM 6th edition) disease? The plot illustrates that survival for this group of patients, who were node-negative on histology, was worse than patients with stage IIb disease. Furthermore, the median overall survival for stage IIa disease was lower than one would expect. Although the groups were not matched, Northern Oesophago-Gastric Cancer Unit’s results for an open, 2-phase subtotal esophagectomy with 2-field lymph node dissection from 1992 to 2011 had a median overall survival of 109 months for stage IIa disease treated with surgery alone (95% confidence interval, 49– 169) (unpublished data). The recent publication from The Netherlands similarly demonstrated survival advantages for stage IIa over

Limited Versus Extended Lymphadenectomy

The main aims of surgery for oesophageal cancer resection are to prolong survival, achieve long-term cure and minimise the chances of locoregional disease recurrence. The primary tumour and surrounding tissues including the relevant lymphatic drainage fields are therefore removed during oesophagectomy with extended lymphadenectomy. Limited lymphadenectomy is defined as the removal of peritumoural lymph nodes immediately adjacent to the resected part of the oesophagus or stomach. This chapter discusses the effects of the extent of lymphadenectomy on staging, locoregional disease recurrence and long-term survival. It gives additional consideration to lymphadenectomy in the context of mucosal disease. The chapter also highlights some of the problems with definitions in published literature and the non-standardised processing of specimens.

OC-128 The effect of obesity on the radicality of subtotal oesophagectomy for oesophageal adenocarcinoma

Introduction Obesity is on the increase in the UK and is a known risk factor for adenocarcinoma of the oesophagus. It is recognised that oesophagectomy in obese patients is more difficult with concerns that radicality of resection is reduced. The aims of this study were to evaluate body mass index (BMI) in patients with oesophageal adenocarcinoma who underwent subtotal oesophagectomy with radical lymphadenectomy and to evaluate the effect of obesity on lymph node (LN) dissection and survival. Methods All patients who underwent subtotal oesophagectomy for adenocarcinoma between January 2000 and December 2010 were identified from a prospectively maintained database. All other histological types were excluded. Patients were categorised according to BMI using the WHO criteria: underweight (2), normal (18.5–24.99 kg/m2), overweight (25-29.99 kg/m2) and obese (≥30 kg/m2). Demographics, presence of Barretts oesophagus or reflux disease, operative time, R0 resections, complications, LN resection and positivity were analysed. Long-term and disease free survival were calculated using the Kaplan–Meier method. Results 413 patients were identified. 23 had no BMI recorded and were excluded leaving 390 patients: eight underweight; 117 normal BMI; 172 overweight; 93 obese. BMI significantly increased over time (mean BMI 26.0 in 2000–2001, 27.8 in 2010, p=0.041). Obese patients were younger compared to normal BMI patients (mean age 60.1 and 64.4 respectively, p=0.003). The incidence of Barretts oesophagus and reflux disease were not significantly different between groups. Operating time was significantly longer for obese patients (p=0.018). R0 resections were similar between groups (normal patients 96.4% and obese 95.5%). The mean number of LNs resected (33 for both normal BMI and obese groups) and the LN ratio did not differ significantly between groups. Obese patients had significantly lower disease stages (32.3% stage 1 obese patients vs 16.2% stage 1 normal BMI patients, p=0.006). Overall survival was longer for obese patients compared with those of normal BMI (81 months vs 55 months, p=0.004). When matched for stage, this difference did not reach significance (p=0.236). Disease free survival did not differ between groups. The overall complication rate was similar between groups (70.1% for normal BMI, 66.3% for obese). Conclusion This is the first study to evaluate BMI in a homogenous group of patients with adenocarcinoma undergoing subtotal oesophagectomy with a standardised radical lymphadenectomy. BMI and obesity among these patients increased with time. The radicality of surgery, in terms of LN yields and R0 resections, did not reduce in the obesity group and this is further supported by equivalent stage-matched long-term survival. Competing interests None declared.