V-OG01 Minimally invasive oesophagectomy: Technique of linear stapled anastomosis

Background Several anastomotic techniques have been described when performing an oesophagectomy. Each technique has its own merits and drawbacks. The stapled side to side technique creates a widely patent anastomosis with low stricture rate. Methods This video highlights the technique adopted and developed over the last 5 years. There are several key steps that need to be adhered to, to create a reliable, robust and reproducible anastomosis. These include the orientation of the oesophagus during transection, the use of mucosal retaining sutures, the use of a 34 bougie for the oesophagotomy and the correct retraction of the conduit when performing the anastomosis. Results The anastomosis was successfully performed without complications. Check endoscopy revealed a widely patent secure join. The anastomosis typically now takes 15–18 minutes. At the end of the procedure, the conduit cap was buried under the pleura and the anastomosis wrapped in omental fat. The patient was discharged on day 10 on a low residue diet. Conclusions This technique has been adopted and developed over the last 5 years. It has proved reliable and reproducible with a low stricture rate and a very low leak rate. It is easier to perform than a total hand sewn anastomosis and permits visualisation of the luminal oesophagus prior to anastomosis.

P-BN46 Risk Factors for Anastomotic Stricture after Hepaticojejunostomy for Bile Duct Injury – A Systematic Review and Meta-Analysis

Background After major bile duct injury (BDI), hepaticojejunostomy (HJ) is usually required. This can lead to good long-term patency but anastomotic stricture unfortunately remains common cause of long-term morbidity after major BDI. Although risk factors for adverse outcomes of BDI repair are reasonably well understood, there is a need to assimilate high level evidence to establish risk factors specifically for development of anastomotic stricture after HJ for BDI. Methods This was a systematic review of studies reporting rate of anastomotic stricture after HJ for BDI was performed according to PRISMA guidelines. Where possible, meta-analyses were then performed to establish risk factors for anastomotic stricture after HJ for BDI. Results The meta-analyses performed included five factors with a total of 2,155 patients from 17 studies. An increased rate of anastomotic stricture after HJ for BDI was shown amongst patients with concomitant vascular injury (OR 4.96; 95%CI 1.92-12.86; p = 0.001), post-repair bile leak (OR: 8.03; 95%CI 2.04-31.71; p = 0.003) and repair by non-specialist surgeon (OR 11.29; 95%CI 5.21-24.47; p < 0.0001). Level of injury according to Strasberg Grade did not significantly affect the rate of anastomotic stricture (OR: 0.97; 95%CI 0.45-2.10; p = 0.93). Due to heterogeneity of reporting it was not possible to perform meta-analysis for impact of timing of repair on anastomotic stricture rate. Conclusions Repair by a non-specialist surgeon was the only modifiable risk factor revealed by this meta-analysis and systematic review, which demonstrates the importance of broad awareness of these data. That said, knowledge of these risk factors permits evidence-based risk stratification of follow-up as well as better informed consent and understanding of prognosis for patients who have experienced major BDI and require HJ.

P-OGC47 Anastomotic stricture after Ivor Lewis Oesophagectomy - An evaluation of incidence, risk factors and treatment

Background Anastomotic stricture is a recognised complication after oesophagectomy. It can impact the patient’s quality of life and may require recurrent dilatations. The aim of this study was to evaluate the frequency of benign strictures, contributing factors, and the long-term outcomes of management in patients undergoing oesophagectomy with thoracic anastomosis using a standardised circular stapler technique. Methods All patients who underwent a two-stage transthoracic oesophagectomy with curative intent between January 2010 and December 2019 at this single, high volume centre were included. All patients who underwent a stapled (circular) intrathoracic anastomosis using gastric conduits were included. Those with variations to anastomotic technique or those not having a transthoracic anastomosis were excluded to reduce heterogeneity. Patients who developed malignant anastomotic strictures and patients who died in hospital were excluded from the analysis. Benign stricture incidence, number of dilatations to resolve strictures, and refractory stricture rate were recorded and analysed. Results Overall, 705 patients were included with 192 (27.2%) developing benign strictures. Refractory strictures occurred in 38 patients (5.4%). One, two, and three dilatations were needed for resolution of symptoms in 46 (37.4%), 23 (18.7%), and 20 (16.3%) patients respectively. Multivariable analysis identified the occurrence of an anastomotic leak (OR 1.906, 95% CI 1.088-3.341, p = 0.024) and circular stapler size <28mm (OR 1.462, 95% CI 1.033-2.070, p = 0.032) as independent predictors of stricture occurrence. Patients with anastomotic leaks were more likely to develop refractory strictures (13.1% vs. 4.7%, OR 3.089, 95% CI 1.349-7.077, p = 0.008). Conclusions This study highlights that nearly 30% of patients having a circular stapled anastomosis will require dilatation after surgery for a benign anastomotic stricture. Although the majority will completely resolve after 2 dilatations, 5% will have longer-term problems with refractory strictures. Smaller circular stapler size and anastomotic leak have been identified as independent risk factors for developing a benign anastomotic stricture following oesophagectomy, and these patients should be monitored closely for symptomatology following surgery.

EP.TH.43Biliary cooling during radiofrequency ablation of liver tumours close to central biliary tree: A systematic review and pooled analysis

Aims Biliary cooling during radiofrequency ablation (RFA) of liver tumours has been proposed as a protective measure for RFA-related biliary complications in cases whereby the RFA-site is close to central biliary tree. This systematic review aims to assess the effect of biliary cooling on i) the development of biliary complications and ii) tumour recurrence rates at ablation site. Methods A systematic literature search was performed using the PubMed/EMBASE databases using PRISMA methodology (2000-2019). The initial search yielded 75 reports which were potentially suitable for inclusion. Studies reporting at least one outcome of interest were considered to be suitable for inclusion. Conference abstracts, case reports and animal studies were excluded. Data was retrieved on patient demographics, tumour characteristics, method of cooling, biliary complications, local tumour recurrence and duration of follow-up. Results The final number of studies which met the inclusion criteria was 7, involving 100 patients. There were no randomized controlled trials identified after the literature search. The mean age of the patients included was 65 years. Biliary cooling was performed with the use of a nasobiliary tube in 4 out of 7 studies, via a choledochal incision in 2 out of 7 studies and through the cystic duct in a single study. The overall biliary stricture rate was 2% and the overall tumour recurrence rate at RFA treated site was 14.5%. Conclusion Biliary complications appear to be low after biliary cooling during RFA close to central biliary tree. More evidence is required to assess the tumour recurrence rates.

Technique selection of ureteroileal anastomosis in hautmann ileal neobladder with chimney modification: Reliability of patient-based selection strategy and its impact on ureteroentric stricture rate

Objective: We aimed to establish the reliability of technique selection strategy for ureteroileal anastomosis (Bricker vs. Wallace) by comparing perioperative outcomes, complications, and anastomotic stricture rate in a contemporary series of patients who underwent open radical cystectomy followed by reconstruction of modified Hautmann neobladder. Materials and methods: A total of 60 patients underwent radical cystectomy and modified Hautmann neobladder, of whom 30 patients (group I) with Bricker anastomotic technique were compared to 30 matched paired patients with end-to-end ureteroileal anastomosis (group II). Long-term results, including ureteroileal stricture (UIS) and postoperative complication rate at two year follow up were available. The choice of anastomosis type was successively based on chimney size, ureteral length after retro-sigmoidal tunneling and diameter of distal ureter. Postoperative complications were graded according to the Clavien-Dindo system. Results: Ureteroileal stricture rate was 6.6% in group I vs. 0% in group II, after three months (p < 0.05), while anastomotic leakage rate was 6.6% vs. 3.3% (group I vs group II) between the two groups for the same follow up period (p > 0.05). High-grade complications (Clavien III-V) were more in Bricker group as compared to Wallace group and the difference was significant (20% vs 10.3%, p = 0.03). Conclusion: Our preliminary outcomes demonstrate that this selection strategy seems to be clinically reliable, with lower incidence of postoperative complications in Wallace group.

Modification of the Indiana Pouch Ileo-Caecal Cutaneous Continent Urinary Diversion: Tubular Ileal Afferent Limb for Ureteral Anastomosis Has Low Stricture Rate and Allows Ileal Ureter Replacement

<b><i>Objective:</i></b> The aim of the study was to introduce our new modification of the Indiana pouch with a refluxing ureteral anastomosis in a tubular afferent ileal segment of the ileo-caecal urinary reservoir. <b><i>Patients and Methods:</i></b> Between February 2008 and December 2020, we performed a total of 37 modified continent ileo-caecal pouches for urinary diversion when orthotopic bladder substitution was not possible. Hereby, we modified the Indiana pouch procedure with a new refluxing end-to-end ureteral anastomosis into an 8-cm afferent tubular ileal segment. <b><i>Results:</i></b> We performed the modified Indiana pouch in 27 women (73%) and 10 men (27%). The median age of the patients at time of operation was 64 years (43–80 years). To date, the average follow-up is 69 months (3–156 months). In 32/37 cases, we performed the new pouch procedure after radical cystectomy for muscle-invasive bladder cancer and in 1/37 cases after radical cystectomy for locally advanced prostate cancer. In 4 cases, the procedure was performed after total exenteration of the pelvis due to locally advanced bladder, colorectal, or gynaecological cancers. Ureteral anastomotic strictures were seen in 2/37 patients (5.4%) or 2/72 (2.8%) of renal units. <b><i>Conclusions:</i></b> Our modification of the Indiana pouch cutaneous continent urinary diversion with the ureteral anastomosis to a tubular segment of the pouch is easy to perform and effective in reducing the rate of ureteral anastomotic strictures. By lengthening, the afferent tubular ileal segment, it additionally allows easy ureteral replacement.

Feasibility and Short-Term Outcomes of Three-Dimensional Hand-Sewn Esophago-Jejunal Anastomosis in Completely Laparoscopic Total Gastrectomy for Cancer

Laparoscopic total gastrectomy is on the rise. One of the most technically demanding steps of the approach is the construction of esophago-jejunal anastomosis. Several laparoscopic anastomotic techniques have been described, like linear stapler side-to-side or circular stapler end-to-side anastomosis; limited data exist regarding hand-sewn esophago-jejunal anastomosis. The study took place between January 2018 and June 2021. Patients enrolled in this study were adults with proximal gastric or esophago-gastric junction Siewert type III tumors that underwent 3D-assisted laparoscopic total gastrectomy. A hand-sewn esophago-jejunal anastomosis was performed in all cases laparoscopically. Forty consecutive cases were performed during the study period. Median anastomotic suturing time was 55 min, with intra-operative methylene blue leak test being negative in all cases. Median operating time was 240 min, and there were no conversions to open. The anastomotic leak rate and postoperative stricture rate were zero. The 30- and 90-day mortality rates were zero. Laparoscopic manual esophago-jejunal anastomosis utilizing a 3D platform in total gastrectomy for cancer can be performed with excellent outcomes regarding anastomotic leak and stricture rate. This anastomotic approach, although technically challenging, is safe and reproducible, with prominent results that can be disseminated in the surgical community.

756 LONG-TERM OUTCOME AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION FOR ENTIRE CIRCUMFERENTIAL CT1AN0M0 ESOPHAGEAL SQUAMOUS CELL CARCINOMA

Endoscopic submucosal dissection (ESD) is the standard treatment for cT1a esophageal squamous cell carcinoma (ESCC), however its indication for the entire circumferential lesions is still controversial because of the risk of severe stricture after ESD. Therefore, several treatment options are performed based on physicians’ choice, however, each clinical course is unclear. This study aimed to clarify the long-term outcome after ESD for patients with entire circumferential cT1aN0M0 ESCC, comparing with esophagectomy or chemoradiotherapy. Methods Patients with entire circumferential cT1aN0M0 SESCC treated with ESD, chemoradiotherapy, or esophagectomy as the initial treatment between January 2010 and December 2016 in our institution were included. Patients who had a history of any malignancy at cStage II-IV within 5 years were excluded. The 5-year overall survival (OS), 5-year disease-free survival (DFS), stricture rate, refractory stricture rate (defined as requiring &gt;6 dilations), curative resection (defined as pT1a without lymphovascular invasion and negative for vertical margin in the pathological evaluation) rate of ESD, and complete response rate of chemoradiotherapy were evaluated for each treatment. Results Of the 48 eligible patients, 25/13/10 patients were performed ESD/chemoradiotherapy/esophagectomy as an initial treatment. Curative resections rate of ESD was 72%, and additional esophagectomy and chemoradiotherapy were performed in three and one patients with non-curative resection. Complete response rate of chemoradiotherapy was 100%, however, 4 patients had recurrence thereafter. No recurrences occurred after esophagectomy in all patients treated with esophagectomy. During median follow-up of 83 months, stricture and refractory stricture rate was 80/44% after ESD, 0/0% after chemoradiotherapy, and 20/10% after esophagectomy. The 5-year OS/DFS was 91/87% after ESD, 92/59% after chemoradiotherapy, and 90/90% after esophagectomy. Conclusion While some patients required additional treatments due to non-curative resection, the long-term survival after ESD for circumferential cT1aN0M0 ESCC was similar as those after chemoradiotherapy or esophagectomy. In contrast, the stricture and refractory stricture rate after ESD was higher than others. Further investigation in a large cohort is necessary to clarify the indication criteria of ESD for patients with the lesion.

Impact of radiation on the incidence and management of ureteroenteric strictures: a contemporary single center analysis

Background Ureteroenteric stricture incidence has been reported as high as 20% after urinary diversion. Many patients have undergone prior radiotherapy for prostate, urothelial, colorectal, or gynecologic malignancy. We sought to evaluate the differences between ureteroenteric stricture occurrence between patients who had radiation prior to urinary diversion and those who did not. Methods An IRB-approved cystectomy database was utilized to identify ureteroenteric strictures among 215 patients who underwent urinary diversion at a single academic center between 2016 and 2020. Chart abstraction was conducted to determine the presence of confirmed stricture in these patients, defined as endoscopic diagnosis or definitive imaging findings. Strictures due to malignant ureteral recurrence were excluded (3 patients). Statistical analysis was performed using chi squared test, t-test, and Wilcoxon Rank-Sum Test, logistic regression, and Kaplan–Meier analysis of stricture by cancer type. Results 65 patients had radiation prior to urinary diversion; 150 patients did not have a history of radiation therapy. Benign ureteroenteric stricture rate was 5.3% (8/150) in the non-radiated cohort and 23% (15/65) in the radiated cohort (p = < 0.001). Initial management of stricture was percutaneous nephrostomy (PCN) in 78% (18/23) and the remaining 22% (5/23) were managed with primary retrograde ureteral stent placement. Long term management included ureteral reimplantation in 30.4% (7/23). Conclusions Our study demonstrates a significant increase in rate of ureteroenteric strictures in radiated patients as compared to non-radiated patients. The insult of radiation on the ureteral microvascular supply is likely implicated in the cause of these strictures. Further study is needed to optimize surgical approach such as utilization of fluorescence angiography for open and robotic approaches.