Comparison of Preoperative Nutritional Indexes for Outcomes after Primary Esophageal Surgery for Esophageal Squamous Cell Carcinoma

Background: This study aimed to compare the controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and geriatric nutritional risk index (GNRI) for predicting postoperative outcomes in patients with esophageal squamous cell carcinoma undergoing esophagectomy. Methods: We retrospectively reviewed the data of 1265 consecutive patients who underwent elective esophageal surgery. The patients were classified into no risk, low-risk, moderate-risk, and high-risk groups based on nutritional scores. Results: The moderate-risk (hazard ratio [HR]: 1.55, 95% confidence interval [CI]: 1.24–1.92, p < 0.001 in CONUT; HR: 1.61, 95% CI: 1.22–2.12, p = 0.001 in GNRI; HR: 1.65, 95% CI: 1.20–2.26, p = 0.002 in PNI) and high-risk groups (HR: 1.91, 95% CI: 1.47–2.48, p < 0.001 in CONUT; HR: 2.54, 95% CI: 1.64–3.93, p < 0.001 in GNRI; HR: 2.32, 95% CI: 1.77–3.06, p < 0.001 in PNI) exhibited significantly worse 5-year overall survival (OS) compared with the no-risk group. As the nutritional status worsened, the trend in the OS rates decreased (p for trend in all indexes < 0.05). Conclusions: Malnutrition, evaluated by any of three nutritional indexes, was an independent prognostic factor for postoperative survival.

Advanced Robotic Surgery: Liver, Pancreas, and Esophagus – The State of the Art?

<b><i>Background:</i></b> The trend in performing robotic-assisted operations in visceral surgery has been increasing in the last decade, also reaching the challenging field of hepatic, pancreatic, and esophageal surgery. Nevertheless, solid data about advantages and disadvantages of the robotic approach are still missing. The aim of this review is to analyze the benefit and impact of robotic surgery in the field of hepatic, pancreatic, and esophageal surgery, focusing on the comparison with the conventional laparoscopic or open approach. <b><i>Summary:</i></b> The well-known advantages of laparoscopic surgery in comparison to the open approach are also valid for robotic surgery, with the addition of a 3D-view camera, wristed instrumentation, and an ergonomic console. On the other hand, the use of a robotic system leads to longer operating time and higher costs. Randomized controlled trials comparing the robotic approach with the laparoscopic one are still missing. <b><i>Key Message:</i></b> Recent meta-analyses show promising results of the usage of robotic systems in advanced surgical procedures, like hepatic, pancreatic, and esophageal resections. Further randomized studies are needed to validate the postulated benefit.

292 PREOPERATIVE RISK STRATIFICATION IN ESOPHAGEAL SURGERY: COMPARING RISK MODELS WITH THE CLINICAL JUDGEMENT OF THE SURGEON

Numerous prediction models have been proposed to estimate the risk of complications after esophagectomy. However, these models are not commonly used in practice and surgeons generally trust on their own clinical judgment. The aim of this study is to compare the clinical judgment of the surgeons with the existing risk stratification models with regard to predicting complications after esophageal surgery. Methods Patients with resectable esophageal cancer who underwent an esophagectomy between March 2019 and January 2020 were included in this prospective study. Literature was searched to identify prediction models predicting the incidence of postoperative complications after esophagectomy. Clinical judgment of three surgeons was assessed using a standardized form where surgeons could indicate their estimated risk for postoperative complications. The best performing prediction model was compared with the judgment of the surgeons, using the Net Reclassification Improvement (NRI). A higher NRI correlates with better estimation by the surgeon and a negative NRI indicates a better prediction by the prediction model. Results Fifty-three patients were included, 36 patients (68%) developed a complication. Two risk classification models were identified in literature: Model 1 (Lagarde et al, Annals of thoracic surgery, 2008) and model 2 (Reeh et al, Medicine, 2016). Model 1 had a better discriminative ability than model 2 (Area Under the Receiver Operator Curve 0.738 versus 0.609). The NRI for the surgeons combined was −2%, meaning that model 1 outperforms the combined judgment of the surgeons. However, there was a large difference in clinical judgment between surgeons. Figure 1 shows the NRI for all three surgeons separately. Conclusion Surgeons‘assessment does not outperform prediction models in predicting the incidence of postoperative complications after esophageal surgery. However, there is a poor agreement between surgeons regarding their risk assessment based on their clinical judgment. Some surgeons might individually outperform existing risk stratification models. Surgeon’s assessment can therefore still be important when counseling patients about the risks of esophageal surgery in addition to risk stratification models.

201 POSTOPERATIVE OUTCOMES OF MINIMALLY INVASIVE ESOPHAGEAL SURGERY FOR ESOPHAGEAL CANCER IN A SINGLE CENTER

The aim if this study is to evaluate the safety and feasibility of minimally invasive esophageal surgery for esophageal cancer in a small volume center. Methods The medical records of patients who had undergone minimally invasive esophageal surgery (VATS Ivor Lewis operation with laparoscopic gastric mobilization) for their esophageal cancer between June 2017 and September 2019 in our institute were reviewed retrospectively. Perioperative outcomes including postoperative morbidities and mortalities were evaluated. Results A total of 31 patients were included in this study. The mean operation time for laparoscopic gastric mobilization were 111.3 minutes and those for VATS Ivor Lewis operation were 235.5 minutes. Seven patients underwent Neoadjuvant therapy. Half of the cases were stage I, however, operation could be performed in more advanced cases. There was no conversion to open procedure. Overall complication rates were 49.1%, and complication more than Grade III in Clavien-Dindo classification were 16.1%. Overall postoperative morality was 6.4%. Two patients died at 42 and 47 postoperative days due to acute respiratory failure, and one patient. Conclusion Minimally invasive esophageal surgery for esophageal cancer could be feasibly performed even in advanced cases. Postoperative pneumonia should be carefully managed to prevent postoperative mortality.

779 USE OF INDOCYANINE GREEN TO ASSESS THE CORRECT VASCULARIZATION OF GASTROPLASTY IN MCKWEON ESOPHAGECTOMY

Cervical anastomostic leakage in esophageal surgery is one of the most serious complications and its incidence is 10–30% according to series. ndocyanine green is being used in multitude of surgical procedures in colorectal and hepatobiliary surgery. In this video we try to prove its usefulness to assess the adequate vascularization of the gastroplasty with the aim of reducing anastomotic leak due to not-well perfusion. Methods A left lateral cervicotomy was performed and proximal esophagus was divided. Then a handsewn purse-string suture was performed and the anvil of CEA 25 stapler was introduced into the esophagus. Gastroplasty was performed with endoGIA section by minilaparotomy. An intravenous infussion of Indocyanine green was used to assess the vascularization "in situ" of the gastroplasty. The gastroplasty was pull up through the retrosternal space and when the plasty was positioned in a correct way, the optimal site for the anastomosis was chosen. Mechanical T-L anastomosis with CEA 25 stapler was performed and it was covered with an omental flap. Video https://drive.google.com/file/d/1kqmNzJCdlJFOcxKBYRp0jamoHz6Gwgt7/view?usp=sharing.

Esophageal resection in Austria—preparing a national registry

Summary Background Esophageal resection is a technically challenging procedure. Despite improvements in perioperative management and outcome, it is still associated with considerably high morbidity and mortality rates even if performed in high-volume centers. This study aimed to shed light on the results of routine patient care in three representative referral centers concerning caseload and surgical and oncological outcomes. Methods This study is a retrospective, multicenter, national-wide analysis of a newly established database including perioperative and long-term outcome data from three referral centers in Austria. Results In a 6-year study period (2013–2018), 411 patients were eligible for analysis. The indication for esophageal resection was esophageal adenocarcinoma in 299 (72.7%) patients and esophageal squamous cell carcinoma in 90 (21.9%) patients. The abdominothoracic approach (70.1%) was the most common operation, followed by transhiatal extended gastrectomy (14.8%) and a thoracic-abdominal-cervical approach (8.5%). Most patients (77.9%) underwent neoadjuvant therapy (chemotherapy 45.3%, radiochemotherapy in 32.6%). A minimally invasive approach was chosen in 25.3%. Major complications and mortality were seen in 21.7% and 2.9%, respectively. The 1‑year survival rate was 84%, 3‑year survival 60%, and 5‑year survival was 52%. The pooled overall median survival was 110 months (95% CI 33.97–186.03). Conclusion This first publication of the Austrian Society of Esophageal Surgery shows that the outcome of esophageal surgery for cancer in Austria compares well with that of renowned international centers. However, a more comprehensive approach including as many national centers as possible will improve outcome research, offer quality management, and improve patient safety. The study group invites all Austrian institutions performing esophagectomy to participate in the initiative.