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The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized Ivor-Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749-1.1090) or time to recurrence (HR 0.973 95%CI 0.768-1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731-1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P < 0.0001). In conclusion, this is the largest series of left thoracoabdominal esophagectomies to be submitted for publication and the only one to compare two different transthoracic esophagectomy strategies. It demonstrates oncological equivalence between operative approaches but possible short- term advantages to the left thoracoabdominal esophagectomy. [ABSTRACT FROM AUTHOR]

Achalasia is a neurodegenerative motility disorder of the esophagus; dysphagia, weight loss, chest pain, and regurgitation are its main symptoms. Surgical myotomy (HM) is considered the gold standard treatment. However, peroral endoscopic myotomy (POEM) seems to be a safe and effective alternative option. The aim of this study is to compare the safety and efficacy of these techniques. From March 2012 to June 2015, 74 patients with symptomatic primary achalasia underwent myotomy. The two groups were compared in terms of intraoperative and postoperative outcomes and Eckardt score at last follow-up. A morphofunctional comparison was also performed. Thirty-two myotomies were performed endoscopically (POEM group) and 42 were performed laparoscopically with a 180◦ anterior fundoplication (surgical myotomy [SM] group). Operative time was significantly shorter for the POEM group (63 [range: 32-114] vs. 76 minutes [54-152]; P = 0.0005). Myotomy was significantly longer for the POEM group (12 [range: 10-15] vs. 9 cm [range: 7-10]; P = 0.0001). Postoperative morbidity occurred in two patients (4.7%) in the SM group; no complications (P = not significant) were recorded for the POEM group. The median Eckardt score at last follow-up decreased for each group from 6 to 1 (P < 0.001). Morphological evaluation was performed for 20 patients and functional evaluation was performed in 18 patients of each group. Lower esophageal sphincter resting and relaxation pressures were significantly reduced in both groups (P < 0.001). Eight patients in the POEM group (40%) had esophagitis at endoscopy: 4 (20%) with Los Angeles (LA) grade A, 3 (15%) with LA grade B, and 1 patient with LA grade D (5%). Five patients in POEM group (28%) had a pathologic DeMeester score. In the SM group, one patient (5%) had esophagitis (P = 0.04; 95% CI) and 4 patients (22%) presented a pathological DeMeester score. Perioperative results for POEM and SM are similar. The absence of an antireflux wrap leads to an increased risk of reflux with consequent esophagitis. SM with an antireflux wrap could be a preferred choice when a long standing gastroesophageal reflux could potentially lead to a damage as, for example, in young patients. [ABSTRACT FROM AUTHOR]

Background and aim Despite adequate preoperative staging, 25% of patients with oesophageal cancer treated with primary surgery have microscopically positive resection margins (R1), and the 5-year survival rate rarely exceeds 40%. The CROSS trial demonstrated that neoadjuvant chemoradiotherapy (nCRT) double the median overall survival, with 29% of patients achieving a pathological complete response. Many authors suggest that this subgroup of patients do not benefit from additional surgery also having regard to the fact that oesophageal resections are associated with substantial morbidity and postoperative mortality rates of 3–5%. On the other hand 18% of patients who underwent nCRT were found to be non-responders, only suffering from nCRT side effects. Thus, rationale exists for identifying novel biomarkers allowing early, non-invasive prediction of pathological tumour response. Methods Starting from January 2020, all consecutive patients with biopsy proven potentially resectable oesophageal cancer scheduled to receive nCRT (CROSS regimen) were prospectively enrolled. In addition to standard of care imaging, a fully integrated hybrid PET/MR was performed at three time points (prior to, during and six weeks after treatment completion). For each patient, an early regression index (ERI) was computed according to the formula: ERI = ln [1—(tumour volume mid/tumour volume pre) tumour volume pre]. Tumour volumes were contoured on axial high resolution T2 weighted images by an experienced radiologist. Finally, after surgery, these data were systematically correlated with the pathological outcome in terms of Tumour Regression Grade(TRG). TRG = 1 refers to pathological complete response status. Results At present, of ten patients enrolled, seven underwent surgery after completion of nCRT; of these, three patients had TRG = 1. Interestingly, patients with a pathological complete response demonstrated significantly lower ERI values when compared with those patients with TRG ≥ 2 (4.09 vs. 27.94, P  < 0.001). Of note, no PET parameter was significantly associated with subsequent pathological complete response status. Conclusion Preliminary results point out the existence of a novel imaging, MR based biomarker (ERI), able to early predict pathological tumour response during nCRT, thus providing an actual aid for patients' management. The research leading to these results has received funding from AIRC (Italian Association for Cancer Research) under Investigator Grant—IG 2019—ID. 23015 project; NCT04359732. [ABSTRACT FROM AUTHOR]

Background and aim Anastomotic leakage represents one of the most dreadful complications following esophagectomy. Although preoperative body composition has been identified as an independent predictor of prognosis for esophageal cancer patients after esophagectomy, its actual contribution to subsequent anastomotic leakage development is still unclear. The aim of the study was to further explore such a relationship. Methods We conducted a multicenter retrospective study from a prospectively acquired database on consecutive patients who underwent Ivor Lewis esophagectomy in four italian high volume centers from May 2014. All patients who were evaluated with at least one preoperative CT scan were enrolled. Body composition parameters including total abdominal muscle area (TAMA), visceral fat area (VFA) and subcutaneous fat area (SFA) were determined based on two consecutive axial CT images extending upwards from the level of the third lumbar vertebra; sarcopenia was defined using predetermined sex specific values: 52.4 cm2/m2 for men, 38.5 cm2/m2 for women. Perioperative variables (ASA, neoadjuvant treatment, tumour site, anastomosis type were systematically collected. Results 237 patients were enrolled. Preoperative BMI: 25.16 kg/m2; 23.6% of patients suffered from anastomotic leakage. According to CT morphometric assessment, 64.1% were classified as sarcopenic; these patients were more vulnerable in terms of postoperative death (within 90 days, P  = 0.028). The mean VFA/TAMA and VFA/SFA ratios were 2.93 ± 1.87 and 0.93 ± 0.59, respectively. Both these ratios demonstrated a linear correlation with the Clavien Dindo classification of postoperative complications (R = 0.311 and 0.239, respectively); specifically, patients with anastomotic leakage had significantly higher VFA/TAMA (3.56 ± 1.86 vs. 2.75 ± 1.83, P  = 0.006) and VFA/SFA (1.18 ± 0.68 vs. 0.87 ± 0.54, P  = 0.003) ratios. In patients suffering from anastomotic leakage, the highest VFA/TAMA ratio values were found in those experiencing type III (P  = 0.044). No significant correlation was found between preoperative BMI and subsequent anastomotic leakage development (P  = 0.154). Conclusion Analytical morphometric assessment represents a useful non invasive tool for preoperative risk stratification. The concurrent association of sarcopenia and visceral obesity seems to be the best predictor of anastomotic leakage, far better than simple BMI evaluation, and potentially modifiable if targeted with prehabilitation programs. [ABSTRACT FROM AUTHOR]