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Background: The preferred surgical approach for esophageal cancer is a minimally invasive transthoracic esophagectomy with a two-field lymph node dissection. The thoracoscopic phase may be performed either in prone- or in left lateral decubitus (LLD) position. Prone positioning has been associated with better pulmonary outcomes compared to LLD positioning; however, conversion to a classic thoracotomy is more difficult. The semiprone position has been proposed as an alternative approach. Methods: A retrospective review of a prospectively maintained database (2008–2014) was performed to compare postoperative complications, surgical radicality, and lymph node yield between patients who underwent three-stage minimally invasive transthoracic esophagectomy in either the prone or semiprone position. Comparative analyses were conducted before and after propensity score matching. Results: One hundred and twenty-one patients were included. In total, 82 patients underwent minimally invasive esophagectomy (MIE) in semiprone position and 39 patients in prone position. After propensity score matching, both groups consisted of 39 patients. The operative time in the semiprone group was longer (368 vs. 225 min, P < 0.001) and in this group the lymph node yield was significantly higher (16 (range 6–80) vs. 13 (range 3–33), P = 0.019). There were no statistically significant differences regarding radical resections, postoperative complications, and hospital stay. Conclusion: The use of semiprone positioning in MIE is safe, feasible, and at least comparable to MIE in prone position in terms of oncological clearance and postoperative complications.

Objective Per-Oral Endoscopic Myotomy (POEM) has seen increasing application and comparisons to laparoscopic Heller myotomy (LHM). The aim of the present study was to compare perioperative and short-term outcomes, and costs between the two procedures at a single institution. Methods Fifty-one consecutive patients documented in a prospective IRB approved database from January 2014 to December 2017 were included. Perioperative data, pre-operative and 3-month postoperative Eckardt Scores, and cost data were compared. Results Median hospital stay was comparable between POEM and LHM (1 day each). Complications were minor (Clavien-Dindo 1, 2) and rare in both groups. Median Eckardt scores improved significantly after POEM (5 to 0) and LHM (5 to 0). Normalized median costs were comparable: 14 201 USD (POEM) vs. 13 328 USD (LHM) p = 0.45. Conclusions POEM demonstrates comparable clinical outcomes and costs to LHM. Long-term issues related to GERD require ongoing assessment in POEM patients. Summary In patients with achalasia, extended myotomy of the lower esophageal sphincter offers excellent palliation of symptoms. In the last decades, laparoscopic Heller myotomy (LHM) has been the gold standard. Over the past decade, per-oral endoscopic myotomy (POEM) has seen wide application in specialized centers worldwide. In our patient cohort, we demonstrate, that POEM can be introduced with similar outcomes and costs compared to LHM.

Introduction A subset of oesophageal cancer patients has residual nodal disease despite complete pathologic response of the primary tumour after neoadjuvant chemoradiation and resection. The aim of this study was to determine the exact location of metastatic nodes with regard to the neoadjuvant radiation field and to assess progression-free (PFS) and overall survival (OS) in this group of patients. Materials and methods From January 2010 to January 2017, complete tumour responders (ypT0) after neoadjuvant chemoradiotherapy and oesophagectomy were identified from a prospective database and grouped according to residual nodal disease (ypT0N + or ypT0N0). Radiation fields were analysed for location of the metastatic nodes and PFS and OS were determined. Results In a total of 192 patients, 53 complete responders (ypT0) were identified. Of those, 11 patients (20.8%) were ypT0N+ with a total of 12 metastatic nodes: 8 (66.7%) located within the neoadjuvant radiation field and 4 (33.3%) located outside this field. Although not statistically significant, 1- and 2-year PFS were worse in ypT0N + patients (ypT0N+ 64.3% vs. ypT0N0 84.4%; ypT0N+ 48.2% vs. ypT0N0 80.7%, respectively; p = 0.051), just as 1- and 2-year OS rates, however, to a lesser extent (ypT0N+ 75.0% vs. ypT0N0 76.3%; ypT0N+ 75.0% vs. ypT0N0 72.9%, respectively; p = 0.956). Conclusion Most ypT0N + lymph nodes are located within the neoadjuvant radiation field. Although a small heterogeneous population was included, this might be due to an inadequate response to neoadjuvant chemoradiotherapy leading to a trend towards worse PFS and OS in ypT0N + patients. Larger studies need to validate our findings.

Background: This study aims to evaluate the feasibility and safety of resection of sarcoma liver metastases, and to identify possible prognostic factors for long-term survival. Methods: All patients who underwent resection of liver metastases of sarcoma in the Netherlands from 1998 to 2014 were included. Study data was retrospectively collected from patient files. Survival rates were calculated using Kaplan-Meier survival analysis. Results: Some 38 patients treated in 16 hospitals were included (15 male, 23 female). The median age was 57 years (37–80 years). The most common histological subtype was leiomyosarcoma (63%). The predominant site of primary tumour was the abdomen (59%). R0 resection was achieved in 16 patients. Mortality was 3 and 16% of included patients had 1 or more complications. The median follow-up period was 18 months (range 1–161). After liver resection, 1-, 3-, and 5-year survival were 88, 54, and 42% respectively. Median overall survival was 46 months (1–161 months). One- and three-year progression-free survival (PFS) after liver resection were 54 and 19% respectively. Median PFS was 16 months (1–61 months). Conclusions: Liver surgery for sarcoma metastases is safe and leads to a relatively good survival. The choice for surgical treatment should always be discussed in a multidisciplinary sarcoma and liver team.

Introduction: The aim of this study is to provide insight in accuracy of diagnosing, current treatment and survival in patients with resectable esophageal and gastric neuroendocrine- and mixed adenoneuroendocrine carcinomas (NEC, MANEC).Methods: All patients with esophageal or gastric (MA)NEC, who underwent surgical resection between 2006 and 2016, were identified from the Dutch national registry for histo-and cytopathology (PALGA). Patients with a neuroendocrine tumor lower than grade 3 were excluded. Data on patients, treatment and outcomes were retrieved from the patient records. Diagnosis by endoscopic biopsy was compared with diagnosis by resection specimen. Kaplan Meier survival analysis was performed.Results: A total of 49 patients were identified in 25 hospitals, including 21 patients with esophageal (MA)NEC and 26 patients with gastric (MA)NEC on resection specimen. Biopsy diagnosis of (MA)NEC was correct in 23/27 patients. However, 20/47 patients with definitive diagnosis of (MA)NEC, were misdiagnosed on biopsy. Neoadjuvant therapy was administered in 13 (62%) esophageal (MA)NEC5 and 12 (46%) gastric (MA)NECs. Survival curves were similar with and without neoadjuvant therapy. One (4.8%) esophageal (MA)NEC and 4 (15%) gastric (MA)NEC5 died within 90 days postoperatively. For esophageal (MA)NEC the median overall survival (OS) after surgery was 37 months and 1-, 3- and 5-year OS were 71%, 50% and 35%, respectively. For gastric (MA)NEC, the median OS was 23 months and 1-, 3- and 5-year OS were 62%, 50% and 39%, respectively.Conclusion: Localized esophageal and gastric (MA)NEC are often misdiagnosed on endoscopic biopsies. After resection, long-term survival was achieved in respectively 35% and 39% of patients. (C) 2018 Published by Elsevier Ltd.

BACKGROUND: Pneumonia is an important complication following esophagectomy; however, a wide range of pneumonia incidence is reported. The lack of one generally accepted definition prevents valid inter-study comparisons. We aimed to simplify and validate an existing scoring model to define pneumonia following esophagectomy. PATIENTS AND METHODS: The Utrecht Pneumonia Score, comprising of pulmonary radiography findings, leucocyte count, and temperature, was simplified and internally validated using bootstrapping in the dataset (n = 185) in which it was developed. Subsequently, the intercept and (shrunk) coefficients of the developed multivariable logistic regression model were applied to an external dataset (n = 201) RESULTS: In the revised Uniform Pneumonia Score, points are assigned based on the temperature, the leucocyte, and the findings of pulmonary radiography. The model discrimination was excellent in the internal validation set and in the external validation set (C-statistics 0.93 and 0.91, respectively); furthermore, the model calibrated well in both cohorts. CONCLUSION: The revised Uniform Pneumonia Score (rUPS) can serve as a means to define post-esophagectomy pneumonia. Utilization of a uniform definition for pneumonia will improve inter-study comparability and improve the evaluations of new therapeutic strategies to reduce the pneumonia incidence.

New-onset atrial fibrillation (AF) is frequently observed following esophagectomy and may predict other complications. The aim of the current study was to determine the association between, and the possible predictive value of, new-onset AF and infectious complications following esophagectomy. Consecutive patients who underwent elective esophagectomy with curative intent for esophageal cancer between 2004 and 2016 in the University Medical Center Utrecht were included from a prospective database. The date of diagnosis of the complications included in the current analysis was retrospectively collected from the computerized medical record. The association between new-onset AF and infectious complications was studied in univariable and multivariable logistic regression analyses. A total of 455 patients were included. In 93 (20.4%) patients new-onset AF was encountered after esophagectomy. There were no significant differences in patient and treatment-related characteristics between the patients with and without AF. In 9 (9.7%) patients, AF was the only adverse event following surgery. In multivariable analyses, AF was significantly associated with infectious complications in general (OR 3.00, 95% CI: 1.73-5.21). More specifically, AF was associated with pulmonary complications (OR 2.06, 95% CI: 1.29-3.30), pneumonia (OR 2.41, 95% CI: 1.48-3.91) and anastomotic leakage (OR 3.00, 95% CI: 1.80-4.99). In patients who underwent esophagectomy, new-onset AF was highly associated with infectious complications. AF may serve as an early clinical warning sign for anastomotic leakage. Therefore, further evaluation of patients who develop new-onset AF after esophagectomy is warranted.

Objective: The aim of this study was to compare open esophagectomy (OE) with minimally invasive esophagectomy (MIE) in a population-based setting. Background: Randomized controlled trials and cohort studies have shown that MIE is associated with reduced pulmonary complications and shorter hospital stay as compared to OE. Methods: Patients who underwent transthoracic esophagectomy for cancer between 2011 and 2015 were selected from the national Dutch Upper Gastrointestinal Cancer Audit. Hybrid, transhiatal, and emergency procedures were excluded. Patients who underwent OE were compared with those treated by MIE. Propensity score matching was used to correct for differences in baseline characteristics. The primary endpoint was postoperative pulmonary complications; secondary endpoints were morbidity, mortality, convalescence, and pathology. Results: Some 1727 patients were included. After propensity score matching the percentage of patients with 1 or more complications was 62.6% after OE (N = 433) and 60.2% after MIE (N = 433) (P = 0.468). Pulmonary complication rate did not differ between groups: 34.2% (OE) versus 35.6% (MIE) (P = 0.669). Anastomotic leak (15.5% vs 21.2%, P = 0.028) and reintervention rates (21.1% vs 28.2%, P = 0.017) were higher after MIE. Mortality was 3.0% in the OE group and 4.7% in the MIE group (P = 0.209). Median hospital stay was shorter after MIE (14 vs 13 days, P = 0.001). Percentages of R0 resections (93%) did not differ between groups. The median (range) lymph node count was 18 (2-53) (OE) versus 20 (2-52) (MIE) (P < 0.001). Conclusions: This population-based study showed that mortality and pulmonary complications were similar for OE and MIE. Anastomotic leaks and reinterventions were more frequently observed after MIE. MIE was associated with a shorter hospital stay.

Surgery is a central component of multimodality therapy for esophageal and gastroesophageal junction cancer. Pneumonia is a common sequela of esophagectomy, leading to an increase in intensive care unit stay, hospital stay, readmission rates, and postoperative mortality. Developing strategies to reduce pneumonia after esophagectomy is hampered by the absence of a standardized methodology for defining pneumonia. This study aims to validate the Uniform Pneumonia Score (UPS) in a high volume center in the USA. The UPS was developed to define pneumonia after esophagectomy for cancer and is based on the assessment of temperature (°C), leukocyte count (×109/L), and pulmonary radiography. The UPS has been validated utilizing a prospective, Institutional Review Board approved database of esophageal cancer patients treated in a high volume esophagectomy center in the USA between 2010 and 2015. One hundred ninety-three consecutive patients were included and 21 (10.9%) were treated for pneumonia. The UPS was able to predict treatment for suspected pneumonia with a good sensitivity (85.7%, confidence interval (CI): 63.7%-96.7%), specificity (97.1%, CI: 93.4%-99.1%), positive predictive value (78.3%, CI: 59.9%-89.7%), and negative predictive value (98.2%, CI: 95.1%-99.4%). The diagnostic accuracy was 95.9%, CI: 92.0%-98.2%. The UPS demonstrated to be a reliable scoring system to define pneumonia after esophagectomy for cancer. Global application of this model will standardize the definition of pneumonia after esophagectomy. This will improve outcome reporting and comparisons of complications between individual institutions, clinical trials, and national audits.

Purpose Uncertainty exists regarding the optimal imaging modality for timely detection of disease progression (DP) after ablation therapy for colorectal liver metastases. We evaluated the diagnostic accuracy of 18 F-FDG PET(/CT), CT and MRI for detection of DP following ablation therapy. Methods A systematic search was performed on May 18, 2016. The analysis included studies that reported on the diagnostic accuracy of 18 F-FDG PET(/CT), CT and/or MRI for post-ablative evaluation of patients with liver metastases. Primary outcome was the diagnostic accuracy of the imaging modalities for detection of DP. Methodological quality was assessed using the QUADAS-2 tool. Pooled sensitivities and specificities were estimated using bivariate random-effects models. Results Ten studies were included in the meta-analysis, including seven comparative studies. Nine reported data on diagnostic accuracy of 18 F-FDG PET(/CT), seven on CT imaging. Only two studies reported the diagnostic accuracy of MRI, hence not included in the meta-analysis. Quality assessment raised concerns about the risk of bias regarding the use of the reference standard, blinding of the index tests and the follow-up time. Pooled sensitivity was respectively 84.6% (75.0–90.6) and 53.4% (29.0–76.4) for 18 F-FDG PET(/CT) and CT ( P = 0.005). Pooled specificity was respectively 92.4% (86.5–95.9) and 95.7% (87.5–98.6) ( P = 0.392). Conclusion 18 F-FDG PET/(CT) yields a higher sensitivity for detecting DP after ablation therapy compared with CT and has a comparably high specificity. These findings indicate that the use of 18 F-FDG PET(/CT) in this setting particularly allows for minimization of the false-negative rate compared with CT without compromising the low false-positive rate.

Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment. Video online The online version of this article (doi:10.1007/s00104-016-0200-7) contains a video, which is available to authorized users.

Esophagectomy with en-bloc lymphadenectomy after neoadjuvant chemo(radio)therapy is the standard of care for resectable locally advanced esophageal cancer. Postoperative complications may have a significant impact on the duration of hospital stay and quality of life. Early recognition and treatment of complications may reduce failure to rescue rates and improve postoperative outcomes. New-onset atrial fibrillation (AF) after esophagectomy for cancer is frequently observed, and may be related to other postoperative complications. AF could function as an early warning sign for other complications in the postoperative course after esophagectomy and may thus be of clinical value. This review discusses the pathophysiology and possible risk factors of AF, the association between AF and other postoperative complications, and the influence of AF on postoperative outcomes after esophagectomy for cancer. Furthermore, clinical recommendations for the management of new-onset AF after esophagectomy for cancer are provided.

The cornerstone of curative care for esophageal cancer is neoadjuvant chemoradiotherapy followed by esophagectomy with a radical lymphadenectomy. An esophagectomy is a major and complex surgical procedure and is often followed by postoperative morbidity, especially pulmonary complications. These complications may lead to an increase in hospital stay, intensive care unit admission rate and mortality. Therefore, perioperative strategies to reduce these complications have been investigated and implemented in clinical practice. In this review we highlight the influence of minimally invasive surgery, postoperative pain management, early identification of complications and the usage of uniform definitions on (pulmonary) complications after esophagectomy. Finally, we will discuss some future perspectives.

BACKGROUND: Minimally invasive gastrectomy has been introduced in Western populations during the last decade. As minimally invasive distal gastrectomy (MIDG) versus total gastrectomy (MITG) are procedures with a different complexity, outcomes may differ. The aim of this population-based cohort study was to evaluate the safety of MIDG and MITG. MATERIALS AND METHODS: All patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit (2011-2016). Propensity score matching was applied to create comparable groups of patients receiving open distal gastrectomy (ODG) versus MIDG and open total gastrectomy (OTG) versus MITG, using patient and tumor characteristics. Postoperative outcomes and short-term oncological outcomes were appraised. RESULTS: Of the 1970 eligible patients, 1138 underwent distal gastrectomy and 832 underwent total gastrectomy. For distal gastrectomy, 390 ODG were matched to 288 MIDG patients. Although overall postoperative morbidity and mortality were similar, patients who underwent MIDG encountered less intra-abdominal abscesses (4% vs. 1%, p = 0.039) and wound complications (6% vs. 2%, p = 0.021). The median hospital stay was shorter after MIDGs (9 vs. 7 days, p < 0.001). For total gastrectomy, 323 OTG patients were matched to 258 MITG patients. Overall postoperative morbidity, mortality and hospital stay were similar, whereas the anastomotic leakage rate was higher after MITGs (11% vs. 17%, p = 0.030). Short-term oncological outcomes between both groups were equal for distal and total gastrectomy. CONCLUSION: Benefits of MIG during the early introduction were demonstrated for distal gastrectomy but not for total gastrectomy. An increased anastomotic leakage rate was encountered for MITG.

Uncertainty exists regarding the optimal imaging modality for timely detection of disease progression (DP) after ablation therapy for colorectal liver metastases. We evaluated the diagnostic accuracy ofA systematic search was performed on May 18, 2016. The analysis included studies that reported on the diagnostic accuracy ofTen studies were included in the meta-analysis, including seven comparative studies. Nine reported data on diagnostic accuracy of

Esophagolymphadenectomy is the cornerstone of multimodality treatment for resectable esophageal cancer. The preferred surgical approach is transthoracic, with a two-field lymph node dissection and gastric conduit reconstruction. A minimally invasive approach has been shown to reduce postoperative complications and increase quality of life. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed to facilitate this complex thoracoscopic procedure. RAMIE has been shown to be safe with good oncologic results and reduced morbidity. The use of RAMIE opens new indications for curative surgery in patients with T4b tumors, high mediastinal tumors, and lymph node metastases after neoadjuvant treatment.

Die Ösophagolymphadenektomie ist der Eckpfeiler der multimodalen Behandlung des resektablen Ösophaguskarzinoms. Der chirurgische Zugang erfolgt bevorzugt transthorakal, mit 2‑Feld-Lymphadenektomie und Rekonstruktion durch Magenhochzug. Für einen minimal-invasiven Ansatz wurde gezeigt, dass er die postoperativen Komplikationen reduziert und die Lebensqualität erhöht. Die roboterassistierte minimal-invasive Ösophagektomie (RAMIE) wurde mit dem Ziel entwickelt, dieses komplexe thorakoskopische Verfahren zu erleichtern. Die Sicherheit der RAMIE ist belegt, die onkologischen Ergebnisse sind gut, die Morbidität wird verringert. Die Anwendung eröffnet neue Indikationen für die kurative chirurgische Behandlung von Patienten mit T4b-Tumoren, Tumoren im oberen Mediastinum und Lymphknotenmetastasen nach neoadjuvanter Therapie.

The aim of this study was to evaluate the worldwide trends in surgical techniques for esophageal cancer surgery by comparing it to our survey from 2007. In addition, new questions were added for gastroesophageal junction (GEJ) cancer. An international survey on surgery of esophageal and GEJ cancer was performed among surgical members of the International Society for Diseases of the Esophagus, the World Organization for Specialized Studies on Disease of the Esophagus, the International Gastric Cancer Association. Also, surgeons from personal networks were contacted. The participants filled out a web based questionnaire about surgical strategies for esophageal and gastroesophageal cancer. The overall response rate was 478/1147 (42%). The respondents represented 49 different countries and 6 different continents. The annual cumulative number of esophageal and gastric resections per surgeon was low (≤11) in 11%, medium (11-21) in 17%, and high (≥21) in 72% of respondents. In a subgroup analysis of esophageal surgeons the number of high volume surgeons increased from 45 to 54% over the past 7 years. The preferred lymph node dissection was two-field in 86%. A gastric conduit was the preferred method of reconstruction in 95%. In 2014, the preferred approach to esophagectomy was minimally invasive transthoracic in 43%, compared with 14% in 2007. In minimally invasive transthoracic esophagectomy the cervical anastomosis was favored in 54% of respondents in 2014 compared with 87% in 2007. The preferred technique of construction of the cervical anastomosis was hand-sewn in 64% and stapled in 36%, whereas the thoracic anastomosis was stapled in 77% and hand-sewn in 23%. The preferred surgical approach for Siewert type 1 tumors (5-1 cm proximal of the GEJ) was esophagectomy in 93% of respondents, whereas 6% favored gastrectomy and 3% combined a distal esophagectomy with a proximal gastrectomy. For Siewert type 2 tumors (1-2 cm from the GEJ) an extended gastrectomy was favored by 66% of respondents, followed by esophagectomy in 27% and total gastrectomy in 7%. Siewert type 3 tumors (2-5 cm distal of the GEJ) were preferably treated with gastrectomy in 90% of respondents, esophagectomy in 6%, and extended gastrectomy in 4%. The preferred curative surgical treatment of esophageal cancer is minimally invasive transthoracic esophagectomy with a two-field lymph node dissection and gastric conduit reconstruction. A strong worldwide trend toward minimally invasive surgery is observed. The preferred surgical treatment of GEJ tumors is esophagectomy for Siewert type 1 tumors and gastrectomy for Siewert type 3 tumors. The majority of surgeons favor an extended gastrectomy for Siewert type 2 tumors.

The aim of this study was to evaluate the worldwide trends in surgical techniques for esophageal cancer surgery by comparing it to our survey from 2007. In addition, new questions were added for gastroesophageal junction (GEJ) cancer. An international survey on surgery of esophageal and GEJ cancer was performed among surgical members of the International Society for Diseases of the Esophagus, the World Organization for Specialized Studies on Disease of the Esophagus, the International Gastric Cancer Association. Also, surgeons from personal networks were contacted. The participants filled out a web based questionnaire about surgical strategies for esophageal and gastroesophageal cancer. The overall response rate was 478/1147 (42%). The respondents represented 49 different countries and 6 different continents. The annual cumulative number of esophageal and gastric resections per surgeon was low (≤11) in 11%, medium (11-21) in 17%, and high (≥21) in 72% of respondents. In a subgroup analysis of esophageal surgeons the number of high volume surgeons increased from 45 to 54% over the past 7 years. The preferred lymph node dissection was two-field in 86%. A gastric conduit was the preferred method of reconstruction in 95%. In 2014, the preferred approach to esophagectomy was minimally invasive transthoracic in 43%, compared with 14% in 2007. In minimally invasive transthoracic esophagectomy the cervical anastomosis was favored in 54% of respondents in 2014 compared with 87% in 2007. The preferred technique of construction of the cervical anastomosis was hand-sewn in 64% and stapled in 36%, whereas the thoracic anastomosis was stapled in 77% and hand-sewn in 23%. The preferred surgical approach for Siewert type 1 tumors (5-1 cm proximal of the GEJ) was esophagectomy in 93% of respondents, whereas 6% favored gastrectomy and 3% combined a distal esophagectomy with a proximal gastrectomy. For Siewert type 2 tumors (1-2 cm from the GEJ) an extended gastrectomy was favored by 66% of respondents, followed by esophagectomy in 27% and total gastrectomy in 7%. Siewert type 3 tumors (2-5 cm distal of the GEJ) were preferably treated with gastrectomy in 90% of respondents, esophagectomy in 6%, and extended gastrectomy in 4%. The preferred curative surgical treatment of esophageal cancer is minimally invasive transthoracic esophagectomy with a two-field lymph node dissection and gastric conduit reconstruction. A strong worldwide trend toward minimally invasive surgery is observed. The preferred surgical treatment of GEJ tumors is esophagectomy for Siewert type 1 tumors and gastrectomy for Siewert type 3 tumors. The majority of surgeons favor an extended gastrectomy for Siewert type 2 tumors.

Background Cancer of the esophagus has one of the highest known associations with cancer–related malnutrition. The aim of the current study was to investigate variation in the body composition of esophageal cancer patients receiving supplementary jejunostomy feeding during neoadjuvant chemoradiotherapy (nCRT) and to assess its correlation with outcomes. Methods Retrospective review of esophageal cancer patient's receiving jejunal feeding during nCRT. Patients selected for jejunal feeding tube placement were considered at high nutritional risk according to ASPEN criteria. Assessment of body composition was performed using L3-axial CT images acquired at diagnosis and after nCRT. Results Eighty-one patients were eligible for inclusion (67 M, 65.9 ± 9.7 yrs). Average weight loss and BMI at diagnosis was 11.4 ± 6.5 Kg and 26.1 ± 4.6 Kg/m2 respectively. Failure to complete nCRT as prescribed occurred in one patient. Following nCRT the prevalence of sarcopenia increased significantly in males despite jejunal feeding (69% vs. 87%; P = 0.013) but fell in females (57% vs. 50%; P = 0.705). Patients could be categorized into three distinct groups according to the degree of skeletal muscle loss (ΔSMM) during nCRT: minor-loss/no-change (n = 28; Δ > −6 cm2); moderate loss (n = 27; Δ−17 to −6 cm2), and; severe loss (n = 26; Δ 0.05). Conclusion This is the first study to report variation in body composition in esophageal cancer patients receiving a defined nutritional intervention during nCRT. In selected patients jejunal feeding appeared to stabilize parameters of body composition whilst other patients experienced significant losses. Observed changes in body composition predominantly reflect sex differences and may offer an opportunity to improve nutritional monitoring and future patient care. Disclosure All authors have declared no conflicts of interest.

Background: Recurrent laryngeal nerve (RLN) injury caused by esophagectomy may lead to postoperative morbidity, however data on long-term recovery are scarce. The aim of this study was to evaluate the consequences of RLN palsy (RLNP) in terms of pulmonary morbidity and long-term functional recovery. Methods: Patients who underwent a 3-stage transthoracic (McKeown) or a transhiatal esophagectomy for esophageal carcinoma in the University Medical Center Utrecht (UMCU) between January 2004 and March 2016 were included from a prospective database. Multivariable analyses were conducted to assess the association between RLNP and pulmonary complications and hospital stay. Data regarding long-term recovery were summarized using descriptive statistics. Results: Out of the 451 included patients, 47 (10%) were diagnosed with RLNP. Of the patients with RLNP, 34 (7%) had a unilateral lesion, 8 (2%) had a bilateral lesion, and in 5 (1%) the location of the lesion was unknown. The incidence of RLNP was 3/127 (2%) in the transhiatal group, and 44/324 (14%) in the McKeown group. RLNP after McKeown esophagectomy was associated with a higher incidence of pulmonary complications (OR 2.391; 95% CI 1.222–4.679; P=0.011), as well as a longer hospital stay (+4 days) (P=0.001). Of the RLNP patients with more than 6 months follow up almost half recovered fully {median follow-up of 17.5 [7–135] months}. Of the remainder, six required a surgical intervention and the others had residual symptoms. Conclusions: RLNP after McKeown esophagectomy is associated with an increased pulmonary complication rate, longer hospital stay, and a moderate long-term recovery. Further studies are necessary that examine technologies, which may reduce RLNP incidence and contribute to the early detection and treatment of RLNP.