Search

OBJECTIVE: To describe the pooled learning curves of Ivor Lewis totally minimally invasive esophagectomy (TMIE) in hospitals stratified by predefined hospital- and surgeon-related factors.BACKGROUND: Ivor Lewis (TMIE is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.METHODS: A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity, and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and 2-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, TMIE experience, clinic visits, courses and fellowships followed, and proctor supervision.RESULTS: This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume >50 compared to centers with an annual volume CONCLUSIONS: More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

Objectives: Frail patients with malnourishment due to an esophageal condition and dysphagia are often unamenable to safe surgery. Thus, in high-risk patients, less invasive techniques such as percutaneous endoscopic gastrostomy (PEG) are regarded as a safer choice. Nevertheless, as described here, PEG insertion can have rare serious complications.Materials and methods: We report the case of a frail patient with dysphagia due to a large Zenker's diverticulum and concomitant giant hiatal hernia. To improve her nutrinitional status before surgery she received a PEG after endoscopic repositioning of the hernia.Results: Within 48 hours after hernia repositioning and PEG insertion, a severe adverse event ensued: dislodgement of the PEG due to stomach reherniation.Conclusions: This case challenges the use of PEG as an only means for gastric fixation for hiatal hernia.

Background: Patients with pulmonary aspergillomas occasionally undergo surgery but it is somewhat unclear who of these patients benefit from surgical treatment. Methods: We retrospectively evaluated all 22 patients that underwent surgery in Helsinki University Central Hospital between 2004 and 2017. We assessed their clinical backgrounds, anti-fungal medication, indication for surgery, complications, recurrent infections and survival. Results: Of the 22 patients, 14 male and 8 female, mean age 56, an underlying pulmonary disease was present in 20. On immunosuppressive medication were 8 (36%). Most received anti-fungal medication preoperatively (n=12) and/or postoperatively (n=17), 3 patients did not receive anti-fungal medication. Length of the medication periods were diverse. Main indication for surgery was haemoptysis. One in-hospital-death occurred, and other complications included prolonged air-leak, postoperative pneumonia, pneumothorax and pneumomediastinum. No Aspergillus empyema or pleurites occurred. Five-year survival was 54%. One in-hospital-death and one other death were the result of Aspergillus disease, other deaths were unrelated to Aspergillus . Recurrent disease occurred in four cases. Three of these patients were asthma patients with allergic bronchopulmonary aspergillosis (ABPA). Conclusions: Overall results of surgery in this cohort were good and number of complications was low. Therapy with antifungals was diverse. Surgical treatment of aspergilloma can be life-saving for patients suffering of haemoptysis, and patients with restricted disease and well-preserved pulmonary capacity may benefit from surgery. Careful patient selection is crucial.

BACKGROUND Overexpression of heat shock proteins (HSPs) is associated with several malignancies and contributes to the development, progression, and metastasis of cancer, in addition to the inhibition of cellular death. In recent years, there has been active research into using HSP inhibitors in several malignancies. Due to the poor prognosis of esophageal adenocarcinoma (EAC), it would be valuable to find new biomarkers for the development of cancer treatments. AIM To evaluate the expressions of HSP27 and HSP70 and their effect on survival in EAC. METHODS Immunohislochemical analyses and evaluations of HSP27 and HSP70 expression were performed on all available samples from 93 patients diagnosed with EAC between 1990 and 2007 at two university hospitals. Fifteen cases with Barrett's metaplasia and 5 control cases from the same patient population were included in the analysis. HSP expression was quantitatively assessed and classified as high or low. Kaplan-Meier analyses and Cox regression models adjusting for age and sex as well as tumor site, stage, and grade were used to evaluate the effect on survival. RESULTS Tumor stage and surgical treatment were the main prognostic factors. High HSP27 expression in cancer cases was a strong negative predictive factor, with a mean survival of 23 mo compared to the 49 mo in cases with a low expression (P = 0.018). The results were similar for HSP70, with a poorer survival of 17 mo in cases with high HSP70 expression, in contrast to 40 mo (P = 0.006) in cases with a low expression. A Cox regression survival analysis was performed, adjusting for possible confounding factors, and higher HSP27 and HSP70 expressions remained an independent negative prognostic factor. The HSPs' correlation with survival was not affected by cancer treatments. When the analysis was adjusted for all factors, the odds ratios for HSP27 and HSP70 were 3.3 (CI: 1.6-6.6, P = 0.001) and 2.2 (CI: 1.2-3.9, P = 0.02), respectively. CONCLUSION HSP27 and HSP70 overexpression is associated with poor survival in EAC, which is, to the best of our knowledge, reported for the first time.

Objectives: In Siewert type I/II oesophageal adenocarcinoma, the sensitivity and specificity of computed tomography (CT), positron emission tomography (PET)-CT and endoscopic ultrasound (EUS) for assessment of the N descriptor in defined groups of lymph nodes were investigated. Methods: CT, PET/CT, EUS images and the pathological data of 101 oesophageal adenocarcinomas submitted to primary resection were compared. The lymph nodes were identified as (a) right paratracheal/subcarinal/pulmonary ligament; (b) paraoesophageal; (c) paracardial; (d) left gastric artery, lesser curvature; (e) coeliac trunk, hepatic/splenic artery. Results: Of the 2451 lymph nodes identified, 273 (11.1%) were histologically positive. Overall sensitivity, specificity and negative and positive predictive value for detection of lymph nodes metastatic were respectively: CT sensitivity 39%, specificity 86%, negative 58% and positive 74% predictive value; PET/CT sensitivity 30%, specificity 98%, negative 58% and positive 93% predictive value; EUS sensitivity 50%, specificity 81%, negative 72% and positive 62% predictive value. The sensitivity of CT, PET/CT and EUS in the thoracic nodal groups (a) and (b) was, respectively, 58.3%, 7.1% and 87.5% and 33.3%, 20% and 80%. Sensitivity was below 47% for all tests in the abdominal nodal groups. In contrast, specificity (88.6-100%) was super imposable in all nodal groups. The strength of agreement among the 3 imaging techniques was poor (kappa < 0.30) for the thoracic anatomical groups of interest: (a) lower paratracheal/subcarinal/pulmonary ligament and (b) paraoesophageal; it was moderate/good (kappa >0.30) for the abdominal N groups of interest: c, d and e. Conclusions: The diagnostic performance of CT, PET and EUS for assessing the N descriptor in the paracardial and abdominal stations close to the primary tumour is not satisfactory. EUS can efficiently assess the presence/absence of nodal metastases in the thoracic stations.

Item does not contain fulltext BACKGROUND: Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity. OBJECTIVE: Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival. METHODS: Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival. RESULTS: A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found. CONCLUSION: The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.

Background We aim to shed light on long-term subjective outcomes after re-operations for failed fundoplication. Methods 1809 patients were operated on for hiatal hernia and/or gastroesophageal reflux disease (GERD) at the Helsinki University Hospital between 2000 and 2017. 111 (6%) of these had undergone a re-operation for a failed antireflux operation. Overall, HRQoL was assessed in 89 patients at the latest follow-up using the generic 15D© instrument. The results were compared to a sample of the general population, weighted to reflect the age and gender distribution of patients. Disease-specific HRQoL was assessed using the GERD-HRQoL questionnaire. We studied variation in the overall HRQoL with respect to disease-specific HRQoL and known patients' parameters using univariate and multivariable linear regression models. Results The median postoperative follow-up period was 9.3 years. All patients were operated on laparoscopically (6% conversion rate), and 87% were satisfied with the re-operation. Postoperative complications were minimal (5%). Twelve patients (11%) underwent a second re-operation. The median GERD-HRQoL score was nine. In multivariable analysis, four variables were independently associated with the 15D score, suggesting a decrease in the 15D score with increasing GERD-HRQoL score, increasing Charlson Comorbidity Index (CCI) and the presence of chronic pain syndrome (CPS) and depression. Conclusion Re-do LF is a safe procedure in experienced hands and may offer acceptable long-term alleviation in patients with recurring symptoms after antireflux surgery. Decreased HRQoL in the long run is related to recurring GERD and co-morbidities.

Background Computed tomography (CT) is widely used in the diagnosis of giant paraesophageal hernias (GPEH) but has not been utilised systematically for follow-up. We performed a cross-sectional observational study to assess mid-term outcomes of elective laparoscopic GPEH repair. The primary objective of the study was to evaluate the radiological hernia recurrence rate by CT and to determine its association with current symptoms and quality of life. Methods All non-emergent laparoscopic GPEH repairs between 2010 to 2015 were identified from hospital medical records. Each patient was offered non-contrast CT and sent questionnaires for disease-specific symptoms and health-related quality of life. Results The inclusion criteria were met by 165 patients (74% female, mean age 67 years). Total recurrence rate was 29.3%. Major recurrent hernia (> 5 cm) was revealed by CT in 4 patients (4.3%). Radiological findings did not correlate with symptom-related quality of life. Perioperative mortality occurred in 1 patient (0.6%). Complications were reported in 27 patients (16.4%). Conclusions Successful laparoscopic repair of GPEH requires both expertise and experience. It appears to lead to effective symptom relief with high patient satisfaction. However, small radiological recurrences are common but do not affect postoperative symptom-related patient wellbeing.

Background In esophageal cancer, nutritional challenges are extremely common. Malignant obstruction resulting from esophageal cancer (EC) is often treated by the insertion of expandable stents, but little is known as to the role and evolution of sarcopenia in this patient population. The aim of this article was to determine the effects of body mass parameters on survival of advanced EC patients who received a stent for palliation of malignant obstruction. Methods This was a retrospective observational study of 238 EC patients who had a stent inserted for palliation of malignant obstruction between 2005 and 2013. Skeletal muscle mass was calculated from abdominal computed tomography scans, and the patients were divided into sarcopenic and non-sarcopenic groups. A follow-up computed tomography scan was available in 118 patients. The primary outcome was survival, and complication rates and the need for an alternative enteral feeding route were secondary outcomes. Results Sarcopenia occurred in 199 (85%) patients. Median survival was 146 (range: 76-226) days in the sarcopenia group and 152 (range: 71-249) days in the non-sarcopenic group (P = 0.61). Complication rates between the groups were not significantly different (P = 0.85). In Cox regression analysis, the skeletal muscle index was inversely correlated with overall survival (hazard ratio 0.98, 95% confidence interval 0.97-0.99; P = 0.033). Conclusions Sarcopenia, defined by consensus thresholds, at the time of stent insertion cannot effectively predict poor survival in this patient cohort, but a lower skeletal muscle index correlates with poor prognosis as a continuous variable.

OBJECTIVES We investigated long-term symptom control of myasthenia gravis following robotic-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) thymectomy in a retrospective single-centre cohort. METHODS From 1999 to 2015, a total of 147 patients underwent thymectomy for myasthenia gravis. Demographic data, medications, operative details, hospital length of stay (LOS), procedure complications and follow-up data were collected by chart review. The Myasthenia Gravis Foundation of America classification was used to evaluate preoperative and postoperative myasthenia gravis status. The primary outcome was complete stable remission (CSR) status. RESULTS Of the 147 patients, 86 (59%) patients underwent VATS thymectomy and 61 (42%) patients underwent RATS thymectomy. There was no operative mortality. The median follow-up was 12 years in the VATS group [interquartile range (IQR) 9–14 years] and 5 years in the RATS group (IQR 3–6 years) (P = 0.001). Two patients in the VATS (2%) and 2 patients (3%) in the RATS group had Clavien–Dindo grade 3 complications. The median LOS was 3 days in the VATS group (IQR 2–4 days) and 2 days in the RATS group (IQR 2–3 days) (P = 0.013). The rate of CSR was 18% (14/65) in the VATS group compared to 26% (16/44) in the RATS group (P = 0.06). Younger age, RATS approach and preoperative medical remission were independently predictive of CSR by Cox regression analysis. CONCLUSIONS Patients who underwent RATS thymectomy and were younger or medically remitted before surgery were more likely to achieve CSR. Both methods yield excellent perioperative outcome.

Background: Adjuvant chemotherapy after resection of colorectal cancer (CRC) lung metastases may reduce recurrences and improve survival. The choice of best candidates for adjuvant chemotherapy in this setting is controversial, especially when a single lung metastases (SLM) is resected. The aim of this study is to evaluate the risk of recurrence after radical resection for single lung metastasis from CRC.Patients and methods: Demographic, clinical, and pathological data were retrospectively collected for patients radically operated on for single pulmonary metastasis from CRC in 4 centers. Survival was computed by Kaplan-Meyer methods. Chi-square, log-rank test, and for multivariate analysis, Cox-regression and binary logistic regression were used when indicated.Results: The sample consisted of 344 patients, mean age 65 yrs. Overall 5 yrs survival was 61.9%. Recurrence occurred in 113 pts (32.8%). At univariate analysis, age > 70 (p = 0.046) and tumor size > 2 cm (p = 0.038) were predictive of the worst survival chance, while synchronous lung metastasis (p = 0.039), previous resection of extrathoracic metastasis (p = 0.017), uptake at FDG-PET scan (p = 0.006) and short (4 ng/mL) was associated with worst survival (HR: 4.3, p = 0.014), while prior abdominal surgery (HR: 3, p = 0.033), PET positivity (HR: 2.7, p = 0.041), and DFI > 12 months (HR: 0.14, p < 0.001) confirmed to predict recurrence of disease.Conclusions: Surgical resection of solitary lung metastases from CRC is associated with prolonged survival. High value of CEA, PET positivity, previous extrathoracic resected metastasis, and short (

Volumetric parameters based on 3-dimensional reconstruction have recently been introduced for cancer staging. We aimed to improve the ability to diagnose hilar lymph node metastasis in patients with non-small cell lung cancer.We evaluated 142 patients with non-small cell lung cancer who underwent right upper lobectomy and radical lymph node dissection. Metastatic involvement of right upper lobar lymph nodes was assessed using high-resolution computed tomography (HRCT) and 18F-2-floro-2-deoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT).On receiver operating characteristic (ROC) curve analysis, the area under the curves (AUC) for short axis, maximum of standardized uptake value (SUVModified TLG is a good parameter to diagnose metastatic right upper lobar lymph nodes. Micrometastasis in the lymph node is difficult to predict using the current diagnostic method. However, more careful evaluation is required in patients with symmetric FDG accumulation at hilar region because hilar lymph nodes respond to various causes such as benign pulmonary diseases.

Nuss bars are increasingly used for minimally invasive correction of pectus excavatum and are usually removed within 3 years of insertion. Previously, several complications related to pectus bar removal have been reported with only 1 case report of aortic haemorrhage. Herein, we report a case with life-threatening aortic haemorrhage during late removal of displaced double Nuss bars.

OBJECTIVES: Oxidative stress (OS) is an essential element in the pathogenesis of Barrett's esophagus (BE) and its transformation to adenocarcinoma (EAC). The state of OS in the proximal stomach of patients with BE and EAC is unknown. Isoprostanes are a specific marker of OS not previously used to determine OS from BE/EAC tissue samples. PATIENTS AND METHODS: OS was measured in 42 patients with BE (n = 9), EAC (n = 9), or both (n = 24) and 15 control patients. A STAT-8-Isoprostane EIA Kit served to identify 8-Isoprostanes (8-IP), and a Glutathione Assay Kit was used to measure glutathione reduced form(GSH) and glutathione oxidized form. An OxiSelect Oxidative DNA Damage ELISA Kit (8-OHdG) served to measure 8-OH-deoxyguanosine. RESULTS: The 8-IP (P = .039) and 8-OHdG (P = .008) levels were higher, and the GSH level lower (P = .031), in the proximal stomach of the study group than in that of the controls. Helicobacter pylori infection was present in 8% of the study patients. CONCLUSIONS: In the proximal stomach of BE and EAC patients, OS was elevated and antioxidative capacity was reduced. This finding suggests that the gastroesophageal reflux causing BE also induces oxidative stress in the proximal stomach and may contribute to the development of cancer in the proximal stomach and gastric cardia.

Background Esophagectomy has a high incidence of postoperative morbidity. Complications lead to a decreased short-term survival, however the influence of those complications on long-term survival is still unclear. Most of the performed studies are small, single center cohort series with inconclusive or conflicting results. Minimally invasive esophagectomy (MIE) has been shown to be associated with a reduced postoperative morbidity. In this study, the influence of complications on long-term survival for patients with esophageal cancer undergoing a MIE were investigated. Methods Data was collected from the EsoBenchmark database, a collaboration of 13 high-volume centers routinely performing MIE. Patients were included in this database from June 1, 2011 until May 31, 2016. Complications were scored according to the Clavien-Dindo (CD) classification for surgical complications. Major complications were defined as a CD grade ≥ 3. The data were corrected for 90-day mortality to correct for the short-term effect of postoperative complications on mortality. Overall survival was analyzed using the Kaplan Meier, log rank- and (uni- and multivariable) Cox-regression analyses. Results A total of 926 patients were eligible for analysis. Mean follow-up time was 30.8 months (SD 17.9). Complications occurred in 543 patients (59.2%) of which 39.3% had a major complication. Anastomotic leakage (AL) occurred in 135 patients (14.5%) of which 9.2% needed an intervention (CD grade ≥ 3). A significant worse long-term survival was observed in patients with any AL (HR 1.73, 95% CI 1.29–2.32, P Conclusion The occurrence and severity of anastomotic leakage and cardiac complications after MIE negatively affect long-term survival of esophageal cancer patients. Disclosure All authors have declared no conflicts of interest.

Background Nutritional deficits, cachexia, and sarcopenia are extremely common in esophageal cancer. The aim of this article was to assess the effect of loss of skeletal muscle mass during neoadjuvant treatment on the prognosis of esophageal cancer patients. Methods Esophageal cancer patients (N = 115) undergoing neoadjuvant therapy and surgery between 2010 and 2014 were identified from our surgery database and retrospectively analyzed. Computed tomography imaging of the total cross-sectional muscle tissue measured at the third lumbar level defined the skeletal muscle index, which defined sarcopenia (SMI

Diagnosis of a Bochdalek hernia in an adult is rare and even more so in the right diaphragm. We review a case of a 55-year-old woman with a right-sided giant Bochdalek hernia who was experiencing progressive shortness of breath and performance decline. The diagnosis of Bochdalek hernia was made by computed tomography and the right side of liver, right kidney, omentum and flexura hepatica of the colon were herniated to the right hemithorax. The operation was carried out via right thoraco-laparotomy and she made an uneventful recovery. We conclude that maximal exposure was necessary for safe operation and good outcome.

Objective: To define "best possible" outcomes in total minimally invasive transthoracic esophagectomy (ttMIE). Background: TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy. Patients and Methods: From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score = grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were = 23 for lymph node yield. Benchmarks at 30 and 90 days were

OBJECTIVES Previous studies have shown a link between oesophageal stenting before oesophagectomy and worse oncological outcomes. Our objective was to determine the effect of preoperative self-expanding covered metallic stent (SEMS) on survival, progression-free survival (PFS), operative time and complication rates in oesophageal cancer (EC). METHODS This study included EC patients undergoing surgery between January 2006 and January 2014 with a cT2 tumour or higher ( n = 174; 135 adenocarcinomas and 39 squamous cell carcinomas). We propensity matched 1:1 a preoperative SEMS group ( n = 30) to a control group. Despite the propensity matching, statistically non-significant residual covariate imbalances persisted. Median follow-up time was 33 months (range: 0-118 months). We performed Kaplan-Meier survival analysis for OS and PFS, the Student's t -test for operative time and the chi-squared test for complication rates. RESULTS Median survival in the SEMS group was 28.5 months (range: 0-116 months) vs 34 months (4-118 months) in the control group and median PFS was 22 months (0-111 months) vs 27 (4-113 months) ( P = 0.748 and P = 0.764, respectively). Mean operative times between groups were 436 min vs 375 min ( P = 0.017). No differences emerged in intraoperative (23.3% vs 10%, P = 0.299), early (50.0% vs 46.7%, P = 1) or late complication rates (53.3% vs 43.3%, P = 0.606). CONCLUSIONS SEMS application has no significant effect on survival, PFS or complications. Mean operative time was significantly higher in the SEMS insertion group. We therefore conclude that preoperative SEMS insertion makes the operation more challenging by increasing operative time, but is otherwise a feasible and safe strategy in experienced centres as a bridge to surgery.

Background In esophageal adenocarcinoma clinical staging (cStaging), interest for N-descriptor according to single lymph nodal station has emerged, but no specific data are available. CT, PET, EUS sensitivity/specificity for N-descriptor in single stations were investigated. Methods In 101 esophageal adenocarcinoma cases (60/41 Siewert I/II) preoperative staging and primary radical surgical resection (prospective protocols) were performed. Resected lymphatic nodes (LNY) and lymphatic metastases (LNM) were reported for the following stations: A) right paratracheal/sub carinal/pulmonary ligament; B) paraesophageal thoracic; C) pericardial; D) left gastric artery, lesser curvature; E) celiac trunk, hepatic/splenic artery. Pathological N data were compared with clinical N-descriptors. Results LN stations: A) LNY 137 LNM 6, Sensitivity CT 58.3%, PET 7.1%, EUS 87.5%—Specificity CT 94.3%, PET 98.8%, EUS 88.6%; B) LNY 79 LNM 18, Sensitivity CT 33.3%, PET 20%, EUS 80%—Specificity CT 92.1%, PET 96.6%, EUS 87.2%; C) LNY189 LNM 36, Sensitivity CT 46.6%, PET 23.5%, EUS 28.5%—Specificity CT 95.3%, PET 97.5%, EUS 97.7%; D) LNY 383 LNM 66, Sensitivity CT 24.1%, PET 21.4%, EUS 33.3%—Specificity CT 97.2%, PET 97.2%, EUS 100%; E) LNY 148 LNM 17, Sensitivity CT 13.3%, PET 5.5%, EUS 33.3%—Specificity CT 93%, PET 98.7%, EUS 95.2%. Figure Staging in adenocarcinoma of the esophageal-gastric junction; CT (A), PET (B) and fused PET/CT sessions (C) at the level of the primary tumor (red arrows) and para-esophageal lymph nodes including one PET-positive (red arrowheads), and one PET-negative detectable on CT only (yellow arrowheads). Panel D the box-plot for median SUVmax according to pathologic lymph node status. In the true positive lymph nodes, SUVmax was significantly higher than in true negative (median, 13.6 vs 5.0, P = 0.001) and false negative lymph nodes (median, 13.6 vs 6.9; P = 0.026). Abbreviations: FN = false negative; TP = true positive; TN = true negative. Conclusion For esophageal adenocarcinoma cStaging, CT, PET, EUS N-descriptor is not reliable, particularly PET data for N stations close to primary T. To tailor therapy, new biological descriptors are necessary. Disclosure All authors have declared no conflicts of interest.

The incidence of gastroesophageal junction adenocarcinoma (GEJAC) in Western countries has increased over the last few decades (1). Some increase in the incidence of GEJAC has been seen in Asia as well (2,3).

Background: Esophageal stents are a widely used treatment method for various esophageal pathologies such as malign and benign obstruction and contained perforations of the esophagus. The aim of this study was to identify the risk factors affecting esophageal stent failure rates. Methods: A total of 469 patients receiving esophageal stents were included in this retrospective observational study. The stents were inserted between January 2005 and December 2013 in a single tertiary center. Primary outcome was stent failure, classified as any major complication related to the stent or the need to replace or urgently remove the esophageal stent. Results: Esophageal cancer was found in 331 (70.6%) patients, whereas non-esophageal cancer in 79 (16.8%) and benign esophageal disease in 59 (12.6%) patients. Dysphagia was the most common symptom indicating the stent insertion with 371 (79.1%) patients, perforation being the second most common (N=33, 7.0%). Stent failure rate was 34.3% (N=161), with median time to stent failure of 75 days (24–161 days). Multivariate Cox proportional hazards analysis showed stent location in the middle third of the esophagus to carry a higher risk for stent failure compared to distal esophagus [hazard ratio (HR) =1.818, 95% confidence interval (CI): 1.26–2.63, P=0.002]. Stent length of 12–15 cm was associated with higher risk of stent failure than stent lengths of Conclusions: Stent failure is more prevalent when stenting the mid-esophagus, using longer stents or after performing esophageal dilatation prior to stenting.

The purpose of this study was to evaluate long-term prognosis and cause of death in patients with superficial esophageal adenocarcinoma (SEAC) after surgery. A total of 85 patients without adjuvant or neoadjuvant treatment underwent surgery for SEAC (pT1N0–1, M0) 1984–2011. Medical records and causes of death were reviewed, and 79 specimens (93 %) were reanalyzed for cancer penetration. Survival was calculated according to Kaplan–Meier and comparisons of survival with log-rank test. Multivariate survival was analyzed with Cox proportional hazards model. Of 85 patients, 36 had transhiatal, 33 transthoracic en bloc, 6 minimally invasive en bloc, 5 vagal sparing esophageal resection and 5 endoscopic mucosal resections; 7 patients (8 %) had lymph node metastasis (LNM). Cancer penetration: 35 pT1a and 44 pT1b. Overall survival was 67 % at 5 years and 50 % at 10 years. Disease-specific survival was 82 % at 5 years and 78 % at 10 years. Recurrence-free survival was 80 % at 5 years. In a Cox multivariate model, poor overall survival was predicted only by LNM. Cumulative mortality during median follow-up of 5 years (0–25 years): 37 of 85 (44 %). Cause of death of these 37: SEAC recurrence for 15 (41 %), postoperative complications for 4 (11 %), another primary malignancy for 5 (14 %), non-cancer-related for 11 (30 %) and for 2 (5 %) cause unknown. Mortality after 5-year follow-up: 11 (30 %); 82 % of these deaths were unrelated to SEAC recurrence. With SEAC recurrence as the single most common cause of death, disease-specific 5-year survival was good. Overall and late (> 5-year) survival is affected by diseases related to aging.

([18F])fluorodeoxyglycose-Positron Emission Tomography/Computer Tomography (([18F])FDG-PET/CT) is commonly used in staging of locally advanced esophageal cancer. Its predictive value for response to neoadjuvant therapy and survival after multimodality therapy is controversial.Sixty-six consecutive patients with locally advanced adenocarcinoma of the esophagus or esophagogastric junction underwent surgery after neoadjuvant chemotherapy. Staging was done prospectively with ([18F])FDG-PET/CT, before and after completion of neoadjuvant therapy. Pre- and post-therapy maximal standardized uptake values for the primary tumor (SUV1 and SUV2) were determined, and their relative change (SUV∆%) calculated. Percentage change in SUV1 was compared with histopathologic response (HPR, complete or subtotal histologic remission), disease-free- (DFS) and overall survival (OS).Resection with negative margins was achieved in 60 patients. HPR rate was 14 of 66 (21.2%). Median follow-up was 16 months (range 4-72). For all patients, OS probability at three years was 59% and DFS 50%. In receiver operating characteristics (ROC) analysis, HPR was optimally predicted by a67% change in baseline maximal SUV (sensitivity 79% and specificity 75%). In univariate survival analysis (Cox regression proportional hazards), HPR associated with improved DFS (HR 0.208, p = 0.033) but not OS (HR 0.030, p = 0.101), SUV %67% associated with improved OS (HR 0.249, p = 0.027) and DFS (HR 0.383, p = 0.040). In a multivariate model (adjusted by age, sex, and ASA score), neither HPR nor SUV∆%67% was predictive of improved OS and DFS. However, SUV∆% as a continuous variable was an independent predictor of OS (HR 0.966, p0.0001) or DFS (HR 0.973, p0.0001).Our results support previous results showing that ([18F])FDG-PET/CT can distinguish a group of patients with worse prognosis after neoadjuvant chemotherapy in adenocarcinoma of the esophagus or esophagogastric junction. This information could offer a new independent preoperative marker of prognosis.

Background Heat shock protein (HSP) 27 and 70 overexpression is associated with several malignancies but reports of their incidence and association with survival among patients with esophageal carcinoma (EC) are scarce. COX-2 expression is induced by inflammation, and it has been linked to a Barrett's esophagus and a wide variety of cancers. High COX-2 expression has been linked to poor survival in EC but results regarding association to clinicopathological factors are conflicting. Methods Immunohistochemical analysis for HSP27, HSP70 and COX-2 was performed on 97 cancer cases, 19 Barrett cases and 5 controls treated between 1990 - 2007. Data was gathered from patient records and survival data was acquired in December 2015. Results Higher tumor stage was significantly associated with poorer survival (P Conclusion Moderate or high HSP27 and HSP70 staining intensities were associated with poor survival among patients with esophageal adenocarcinoma, which is now reported for the first time. According to previous studies opposite conclusions for esophageal squamous cell carcinoma was found. COX-2 did not impact survival in our study even though it's been found to be a negative prognostic factor in several previous studies. Disclosure All authors have declared no conflicts of interest.

Background miRNAs play a key role in cancer development. In esophageal adenocarcinoma (EAC), we analyzed the relationship between miR-221 and 483–3p expression, cancer specific survival, recurrence, their distribution in EAC sub types characterized by the presence/absence of intestinal metaplasia in esophagus (BIM) and stomach (GIM) [BIM + GIM- (Barret's like) and BIM-GIM- (cardio-pyloric like) types]. Methods RNAs was extracted from 39 formalin-embedded surgical specimens (EAC and normal gastric). miRNA221 and miR-483–3p validation with TaqMan MicroRNA Assay was performed and data were normalized using RNU44. Kruskall-Wallis and Mann-Whitney tests were used to study correlations. Results A statistically significant relationship between miRNAs (miR-483–3p P = 0.017; miR-221 P = 0.037) and cancer specific survival and between miR-221 and recurrence (P = 0.043) was detected. miR-221 and miR-483–3p showed a significant decreased expression in the Barret's like group vs Cardio-pyloric-like group (miR-483–3p Kruskall-Wallis test P = 0.009; miR221 Kruskall-Wallis test P = 0.066; miR-483–3p Mann-Whitney test P = 0.002; miR-221 Mann-Whitney test P = 0.047) Conclusion In EAC increase of miR-221 and miR-483 is linked with poor survival and recurrence. Their different distribution patterns, support a biological differentiation of Barret's like versus cardio-pyloric like subtypes. Disclosure All authors have declared no conflicts of interest.

Background Our objective was to analyze the results of laparoscopic giant paraesophageal hernia (GPEH) repair in tertiary hospital setting. The main endpoints were recurrence of the hernia, postoperative quality of life, symptoms and satisfaction with the operation. To assess radiographical recurrence we used computerized tomography imaging, which has not been used in previous studies. Methods We identified all non-emergent giant (more than 30% of stomach in the chest) esophageal hernia repairs in our hospital from medical records. The patients were sent standardized 15D health-related quality of life and Gastroesophageal reflux disease (GERD-HRQL) questionnaires. Patients who gave their consent were assigned to a non-contrast computerized tomography (CT)-study to assess radiographical recurrence. Results Altogether 165 patients were reviewed. 74% of the patients were female, with a mean age of 67. 1 patient (0.6%) had died perioperatively. Complications were reported in 28 patients (17%). 10 patients (6.1%) had to undergo reoperation within 30 days. 7 patients (5.9%) were dissatisfied with the operation. 66% had an excellent result on GERD-HRQL. 4 patients had a major recurrent hernia in CT, but the radiographic findings did not correlate with symptoms. The mean D15 score was 0853 for our patients and 0896 for the age-adjusted control population (P Conclusion The complication rate was comparable to previous studies. Perioperative mortality was low, significant radiographical recurrences were rare and only few patients were dissatisfied with the result. However the overall quality of life of the study group was slightly below age-adjusted population average. Disclosure All authors have declared no conflicts of interest.

The incidence of thoracic empyema is increasing. Early treatment of empyema should focus on optimal drainage and antibiotics. If conventional therapy fails, surgical intervention has to be considered and approximately 30% of all patients require surgery. In a three-year period (2011-2013), 182 patients were operated at Helsinki University Hospital due to pleural empyema. Thoracoscopic decortication was performed on 44% of the patients and 56% underwent open surgery. After thoracoscopy, the patients had a shorter hospital stay and fewer reoperations. Thoracoscopic decortication should therefore be the first-line procedure in the surgical treatment of pleural empyema.

We compared oncologic and surgical outcome between minimally invasive esophagectomy (MIE) and the Ivor Lewis-type open approach (OE) in the treatment of locally advanced esophageal adenocarcinoma (EAC).Of 284 patients undergoing surgery for EAC between 2003 and 2013, the 153 selected with locally advanced EAC were 74 MIEs and 79 OEs [median age, 66 for MIE, 63 for OE (p = 0.009)]. Neoadjuvant therapy was given to 82% of MIEs and 78% of OEs. In the OE group, 86% was male, and in the MIE group, 78%. Data assessed were oncologic, intraoperative, and postoperative.Mortality at 30 days was 3% for MIE and 1% for OE; and 90-day mortality was 4% for MIE and 5% for OE. The complication rate for MIE was 50%, and 60% for OE (p = 0.181). The pneumonia rate was 18% for MIE and 19% for OE; leak rate was 7% for MIE and 6% for OE; conduit necrosis was 0 for MIE and 3% for OE; and rate of airway-conduit fistula was 3% for MIE and 1 % for OE. Median blood loss (MIE 300 vs. OE 800, p0.0001), overall stay (MIE 13 vs. OE 14, p = 0.040), and harvested lymph nodes (MIE 20 vs. OE 22, p = 0.021) all were in favor of MIE. Median ICU stay and operative time did not differ. Neither did overall (OS) nor recurrence-free (RFS) 3-year survival differs significantly (MIE 64% vs. OS OE 49%, MIE 57% vs. RFS OE 53%).In our institution, MIE appears to produce oncologic and survival results similar to those of OE. Shorter length of stay and less operative blood loss may reduce costs for MIE.

In chylothorax, chyle has accumulated into the pleural clarity. Chylothorax is a fairly rare finding, most commonly arising after procedures within the thoracic cavity. Suspicion of chylothorax is based on anamnesis and clinical picture, with chest radiograph and pleural fluid puncture as the basic tests. Treatment should be started immediately after a confirmed diagnosis. In the early stages it is vital that the production of chyle is minimized and the fluid is drained. If the conservative treatment fails, surgery is recommended