Peroral endoscopic myotomy for management of cricopharyngeal bars (CP-POEM): a retrospective evaluation

Background Cricopharyngeal bars (CPBs) are a unique etiology of oropharyngeal dysphagia. Symptomatic patients are managed with endoscopic dilation or surgical myotomy. Cricopharyngeal peroral endoscopic myotomy (CP-POEM) is an emerging technique for the management of dysphagia due to CPBs. This study evaluated technical success, clinical success, adverse events, and long-term recurrence following CP-POEM. Methods Consecutive patients who underwent POEM for management of CPBs between May 2015 and December 2020 at four tertiary care centers were included. Primary outcome was clinical success (defined as improvement of dysphagia score to ≤ 1). Secondary outcomes were technical success, rate and severity of adverse events, procedure duration, and symptom recurrence. Results 27 patients (mean age 69 years; 10 female) underwent CP-POEM during the study period. The most common presenting symptoms at the time of index procedure were dysphagia (26; 96.3 %) and regurgitation (20; 74.1 %). Clinical and technical success were achieved in all patients. Mild/moderate adverse events occurred in two patients (7.4 %). CP-POEM significantly reduced the median dysphagia score. Conclusions CP-POEM was a safe and effective treatment for symptomatic CPBs. Although symptom recurrence was low, long-term outcome data are needed. CP-POEM should be considered as a management option for symptomatic CPBs at centers with POEM expertise.

TP6.2.17 How good is Edinburgh Dysphagia Score in identifying patients with oesophageal cancer?

Aims Due to limited resources and increase in the referral for endoscopy, various scoring systems have been developed in an attempt to identify high risk patients of having oesophageal cancer. The aim of this study was to analyze the utility of Edinburgh Dysphagia Score (EDS) in patients who have presented with oesophageal cancer. Methods A retrospective cohort study of all newly diagnosed oesophageal cancers with dysphagia in a single regional MDT was performed between October 2019 and September 2020. Electronic records were interrogated and EDS calculated. EDS contained six parameters: age, sex, weight loss, duration of symptoms, localization of dysphagia and acid reflux. Patients divided into lower-risk group (EDS <3.5) and higher-risk group (EDS ≥ 3.5). Results Of the 349 patients, 182 (52.1%) had dysphagia at presentation. 149 (81.9%) were referred from the primary care. There were 127 (69.8%) male and the mean age was 69.1 ± 11.0 years. 135 (74.2%) patients had adenocarcinoma, 51 (28.0%) were T4 disease and 58 (31.9%) were metastatic. The median EDS was 7 (IQR 6-8). 178 (97.8%) patients had higher-risk EDS and 4 (2.2%) patients lower-risk EDS. Conclusions This study suggests that EDS can positively identify patients who are high risk of having oesophageal cancer in majority of patients. This simple scoring system can be used to vet the referrals in order to reduce the pressure in the secondary care setting to effectively use the available resources.

645 THE OUTCOMES OF PALLIATIVE SELF-EXPANDING METALLIC SEM) STENTS IN THE MANAGEMENT OF INOPERABLE ESOPHAGEAL CARCINOMA.

The incidence of esophageal carcinoma (EC) in Singapore is declining since 1970s. However, the age-incidence curve in 2010s shows a steep rise after age 40-50s. The majority of EC patients presented late with locally advanced or metastatic disease. The outcomes of inoperable esophageal carcinoma treated with palliative self-expanding metallic (SEM) stents were reviewed. Methods Consecutive cases of EC including Siewert Type I adenocarcinoma of esophago-gastric junction (AEG) were identified from electronic medical records from August 2015 to February 2021. There were 78 cases of EC and of which 14 were stented. The outcomes of inoperable or metastatic EC cases treated with palliative SEM stents were analyzed. Other palliative treatment included best supportive care and palliative chemotherapy with or without radiotherapy. Results The demographics showed the mean age of 73 ± 11 years with ECOG score 0-1 in 86% and mean BMI 19.1 ± 3.8. All were males with the risks from smoking in 85% and alcohol in 50%. The mean length of EC was 6.2 ± 2.6 cm. There were 10 Wallflex and 4 Ultraflex partially covered stents deployed successfully. The pre-stent dysphagia score was 3 in 72% and 4 in 29% whilst all had post-stent score of 1. The mean duration of survival was 4.4 ± 4.1 months. Post-stent complications included stent migration without obstruction and food bolus obstruction. Conclusion About 18% of patients diagnosed with advanced symptomatic EC were treated with palliative SEM stent insertion in a safe and effective manner. Those at risk were elderly males with smoking history. All stented cases had immediate improvement of dysphagia score and were able to tolerate soft diet. The overall duration of survival was variable up to 1 year likely due to different tumour biology and concurrent palliative systemic therapy.

646 PREDICTING RESPONSE TO NEOADJUVANT CHEMOTHERAPY IN PATIENTS WITH OESOPHAGEAL ADENOCARCINOMA

Neoadjuvant chemotherapy is often used prior to surgical resection for oesophageal adenocarcinoma but remains ineffective in a high proportion of patients. The histological Mandard tumour regression grade is used to determine chemoresponse but is not available at the time of treatment decision-making. The aim of this study was to identify factors that predict chemotherapy response prior to surgery. Methods A prospectively collected database of patients undergoing surgical resection for oesophageal adenocarcinoma from a high-volume UK institution was used. Patients were subcategorised using pathological tumour response into ‘responders’ (Mandard grade 1–3) and ‘non-responders’ (Mandard grade 4&5). Multivariable logistic regression analysis was performed to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for responder status adjusting for a variety of parameters. Receiver-operator curves (ROC) were calculated. Results Among 315 patients included, 102 (32%) were responders and 213 (68%) non-responders. A decrease in radiological tumour volume (OR 1.92 95%CI 1.02–3.62; p = 0.05), a ‘partial response’ RECIST score (OR 7.16 95%CI 1.49–34.36; p = 0.01), a clinically improved dysphagia score (OR 2.79 95%CI 1.05–7.04; p = 0.04) and lymphovascular invasion (OR 0.06 95%CI 0.02–0.13; p = 0.000) influenced responder status. ROC curve analysis for responder status utilising all available parameters had an area under the curve (AUC) of 0.86. Conclusion This study has highlighted the potential for using pre-defined factors to identify those patients who have responded to neoadjuvant chemotherapy, prior to surgical resection, potentially facilitating a more individualised therapeutic approach.

Development and Validation of a Nutritional Risk Screening Scale for Stroke Patients

IntroductionStroke is a global health problem, and around 62% of stroke patients suffer from malnutrition due to dysphagia, eating speed, or stress response. This study aimed to develop a Nutritional Risk Screening Scale for Stroke Patients (NRSS-SP).Material and methodsIn the current study we construct a theoretical framework by combining stroke characteristics, the risk factors of malnutrition in stroke patients, and clinical experience. Then, using the Delphi method, we formed a pool for entries and combined the opinions and suggestions discussed by experts in a research team. Next, we collected all of the data and information, categorized, merged, and split the pool of entry items' contents. Finally, we formed a pretest scale comprising 11 items after scoring their importance.ResultsThe pretest NRSS-SP comprised 10 items in three fields: physical, psychological, and independence. The score was assigned to each factor according to the evaluation results. (e.g., Disease severity, serum albumin and dysphagia: Score 3, age ≥70 years: Score 1). The cumulative effect of four factors (depression, anxiety, serum level of albumin, and body mass index (BMI)) was 65.512%. The item-level Content Validity Index (CVI) of the NRSS-SP ranged from 0.081 to 1.000, and the scale-level CVI was 0.912. The coefficient of Cronbach’s α ranged from 0.822 to 0.911.ConclusionsAn NRSS-SP (including National Institutes of Health Stroke Scale score, BMI, serum level of albumin, recent weight loss, recent food intake, dysphagia, age, depression, anxiety, and Barthel Index) score ≥6.5 was classified as a malnourishment risk; an NRSS-SP score <6.5 denoted normal nutrition.

Clinical Outcomes between Stand-Alone Zero-Profile Spacers and Cervical Plate with Cage Fixation for Anterior Cervical Discectomy and Fusion: A Retrospective Analysis of 166 Patients

Stand-alone (SA) zero-profile implants are an alternative to cervical plating (CP) in anterior cervical discectomy and fusion (ACDF). In this study, we investigate differences in surgical outcomes between SA and CP in ACDF. We conducted a retrospective analysis of 166 patients with myelopathy and/or radiculopathy who had ACDF with SA or CP from Jan 2013–Dec 2016. We measured surgical outcomes including Bazaz dysphagia score at 3 months, Nurick grade at last follow-up, and length of hospital stay. 166 patients (92F/74M) were reviewed. 92 presented with radiculopathy (55%), 37 with myelopathy (22%), and 37 with myeloradiculopathy (22%). The average operative time with CP was longer than SA (194 ± 69 vs. 126 ± 46 min) (p < 0.001), as was the average length of hospital stay (2.1 ± 2 vs. 1.5 ± 1 days) (p = 0.006). At 3 months, 82 patients (49.4%) had a follow-up for dysphagia, with 3 patients reporting mild dysphagia and none reporting moderate or severe dysphagia. Nurick grade at last follow-up for the myelopathy and myeloradiculopathy cohorts improved in 63 patients (85%). Prolonged length of stay was associated with reduced odds of having an optimal outcome by 0.50 (CI = 0.35–0.85, p = 0.003). Overall, we demonstrate that there is no significant difference in neurological outcome or rates of dysphagia between SA and CP, and that both lead to overall improvement of symptoms based on Nurick grading. However, we also show that the SA group has shorter length of hospital stay and operative time compared to CP.

Dysphagia progression-free survival in oesophageal cancer patients treated with palliative radiation therapy

Background: In patients with advanced oesophageal carcinoma, palliation of dysphagia is important to maintain a reasonable quality of life.Aim: To determine the dysphagia progression-free survival (DPFS) in patients with advanced oesophageal carcinoma treated with palliative radiotherapy (RT).Setting: Groote Schuur Hospital, Cape Town, between January 2015 and December 2016.Methods: The medical records of all patients with oesophageal carcinoma were reviewed, and patients who were not candidates for curative treatment and received palliative RT were selected. For these patients, the dysphagia score (DS) was recorded prior to RT, six weeks after RT and at each follow-up visit. The DPFS was calculated as the time from completion of RT to worsening of DS by ≥ 1 point or until death. Other outcomes measured were objective change in DS and survival post RT.Results: The study population comprised 84 patients. Squamous cell cancer was the primary histological subtype (93%). The median duration of DPFS after RT was 73 days, with approximately two-thirds of remaining patients able to swallow at least liquids and soft diet until death. The difference in median duration of DPFS was not statistically significant in stented versus non-stented patients (54 days vs 83 days, p = 0.224). The mean change in DS was 0.45 ± 0.89 points following RT and the post-RT survival was significantly shorter in patients with stent insertion (81 days vs 123 days, p = 0.042).Conclusion: Palliative RT can successfully be used to prolong DPFS in patients with locally advanced and metastatic squamous cell cancer of the oesophagus.