V-OG02 Video Demonstration Of Abdominal Lymphadenectomy In A Robotically Assisted Oesophagectomy

Background Lymphadenectomy is essential for adequate oncological clearance and accurate staging during oesophagectomy for malignant disease. Adequate lymph node clearance has implications on patient outcomes and confers a survival benefit. Abdominal lymph node clearance may be technically challenging due to the location of nodes along key structures such as the common hepatic artery and splenic vessels. Robotic assistance during abdominal lymphadenectomy permits improved 3-D visualisation and instrument articulation in a potentially constricted space. This video demonstrates a technique for robotic abdominal lymphadenectomy during oesophagectomy. Methods This video demonstrates a technique for coeliac axis lymph node clearance during the abdominal phase of an oesophagectomy, as practiced at this institution. The intention for such a video is for ongoing appraisal and refinement of robotic techniques within the unit, as well as for teaching and training. The video was edited using iOS software, and text has been used to explain each step in conjunction with the images. Results Dissection of all relevant coeliac axis nodal stations is successfully demonstrated, with the lymph nodes resected en-bloc with the specimen. Text has also been used to explain the steps seen in the video images. Conclusions Robotic assistance permits safe and adequate lymphadenectomy during minimally invasive oesophagectomy, as demonstrated in this video.

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-OGC16 Minimally Invasive Oesophagectomy: Technique and learning curve over 10 years

Background The use of minimally invasive oesophagectomy (MIO) in the treatment of patients with oesophageal malignancy has developed since its first description by Cuschieri in 1992, although mainstream uptake of this technique has not been forthcoming. Oncological resection margins were not compromised in MIO, whilst complications and two-year mortality rates improved in MIO compared to open oesophagectomy. The advantages of MIO compared to open surgery include the speed of recovery, improved return to baseline quality of life, better physical function and less pain. We present our experience of MIO including operative technique, tips, and learning curve. Methods 160 patients underwent MIO at Portsmouth Hospitals University NHS Trust between August 2010 and December 2019. After June 2016 there was a significant change in surgical technique and pathway as outlined below and this time point has been interrogated. Primary outcomes were operative duration (minutes) and both 30-day and in-hospital mortality. Secondary outcomes were length of in hospital stay (days), ITU stay, conversion to open surgery and complications. We undertake laparoscopic abdominal phase and thoracoscopic or robotic assisted thoracic phase oeasophagectomy. Dual consultant operating is standard; and we work consistently with the same group of anaesthetists and theatre staff. Results 82.5% of our 160 patients were male, median age was 67 years. Operative duration showed a steep learning curve over the first 10 cases followed by stabilisation to case 56 and then improvement. CUSUM analysis of the anastomotic leaks showed a change point at 53 cases - 30.8% vs 16.7% (p = 0.05). 30-day mortality is 1.88% and median length of stay 12 days (IQR12.75). Complications of Clavien-Dindo ≥III occurred in 35% and “perfect” outcomes in 21.25%. Conversion to open in 5.6% of cases but only 1 in the last 100 patients. Conclusions There is a learning curve associated with the adoption of a new technique. MIO can be performed safely and cost effectively with equivalent oncological outcomes with the advantage of improved quality of life. Oesophageal cancer is still poorly understood and we therefore must spend more thought on how best to give our patients good quality disease free life. Our outcome data is within existing published data and our prospectively collected data is thorough and meticulous. Though some complications are inevitable, small changes lead to marginal gains and add up to better outcomes.

P-OGC42 Hiatus Hernia following Minimally Invasive Oesophagectomy - a Single Centre Experience

Background Hiatus hernia is an established complication following oesophagectomy, with a higher incidence when a minimally invasive approach (MIO) is undertaken. Literature reports the incidence post-MIO to be vary between 4.5% -26%. There is no clear consensus on the optimum operative management of this complication. The aim of this study was to establish the incidence of hiatus hernia post MIO (HiHO) at a single hospital site, identify predisposing factors, and evaluate subsequent surgical management of this complication. Methods Single-center data were retrospectively analysed of MIOs conducted consecutively between May 2018 and October 2020. A minimum follow-up period of 6 months was required for inclusion. HiHO was defined by radiological confirmation. Data collected included patient demographics, comorbidities, risk factors for hiatus hernia and patient’s post-operative course. Statistical analyses were performed using Fischer’s exact or independent t-test as appropriate. Results 50 patients who underwent MIO were included; mean follow up of 1.92 years. 7 (14%) presented with HiHO. There was no significant difference in age or gender between patients with and without HiHO. HiHO patients had a significantly lower BMI (95% CI 1.083-8.271; P = 0.012) and were more likely to have underlying lung conditions (P = 0.029). A higher incidence of pre-existing hiatus hernia was present among the HiHO group (43% vs 21%). Of those developing HiHO, 6 (86%) were symptomatic requiring surgical reduction with crural repair of hiatus or colopexy; 2 had a recurrence of HiHO requiring subsequent colopexy. Conclusions This study represents the largest single centre analysis of hiatus hernia post minimally invasive oesophagectomy. Our results correlate with the literature, that there is a significant risk of hiatus hernia following minimally invasive oesophagectomy. This risk is increased among patients with pre-operative hiatus hernia, low BMI, and pre-existing lung conditions. Crural repair or colopexy are options for surgical management of HiHO. Colopexy may potentially prevent recurrence of HiHO. A larger study size and a consensus from experts in the field would be beneficial in guiding operative management of HiHO to improve patient outcomes.

V-OG04 Paravertebral Catheter Placement In Minimally Invasive Oesophagectomy

Background Pain control is a vital component of enhanced recovery programmes for patients undergoing an oesophagectomy. Multimodal analgesia using intrathecal diamorphine and local anaesthetic infusion catheters into the paravertebral space and rectus sheath is increasingly utilised. Multimodal analgesia can provide comparable pain relief while potentially reducing side effects associated with thoracic epidurals. This video demonstrates the placement of paravertebral catheters following thoracoscopic oesophagectomy. Methods The video demonstrates the technique for paravertebral catheter placement at the end of the thoracic phase of an oesophagectomy, as practiced at our institution. Results Once the catheter has been placed and flushed, a bolus 15-20mls of 0.25 per cent Levobupivicaine is injected. A 600mls reservoir of Levobupivicaine is attached at the end of the procedure. Conclusions Paravertebral catheters provide a safe and feasible option for pain control following oesophagectomy.

Learning curve for minimally invasive oesophagectomy of oesophageal cancer and survival analysis

Purpose Minimally invasive oesophagectomy is a technically demanding procedure, and the learning curve for this procedure should be explored. A survival analysis should also be performed. Methods A total of 214 consecutive patients who underwent minimally invasive oesophagectomy were retrospectively reviewed. To evaluate the development of thoracoscopic-laparoscopic oesophagectomy and compare mature minimally invasive oesophagectomy and open oesophagectomy, we comprehensively studied the clinical and surgical parameters. The cumulative sum (CUSUM) plot was used to evaluate the learning curve for systemic lymphadenectomy. Cox proportional hazards regression analysis was performed to explore the clinical factors affecting survival. Results The bleeding volume, operation time, and postoperative mortality within 3 months significantly decreased after 20 patients. The rise point for node dissection was visually determined to occur at patient 57 in the CUSUM plots. Patients who underwent mature thoracoscopic-laparoscopic oesophagectomy had better surgical data and short-term benefits than patients who underwent an open procedure. Cox proportional hazards regression analysis showed that the maximum diameter of the tumour cross-sectional area and the number of positive nodes significantly influenced survival. Conclusions The results suggest that thoracoscopic-laparoscopic oesophagectomy has short-term benefits. There was no evidence that it was associated with a significantly better prognosis for patients with oesophageal cancer. ClinicalTrials Gov ID: NCT04217239; January 2, 2020 retrospectively registered.

1096 Robot-Assisted Minimally Invasive Oesophagectomy: Comparing the Geography of Research Publication with The Global Burden of Disease

Introduction Robot-assisted minimally invasive oesophagectomy (RAMIE) is increasingly used in the management of oesophageal tumours. It is unclear if there is equitable access to this innovative technique worldwide, specifically in areas of greatest need. This study aimed to map the geographic distribution of publications on RAMIE and compare this to global disease burden. Method Systematic searches identified all studies of RAMIE from inception to 2020. The country of origin of each study was identified. The incidence and age standardised rate (ASR) of oesophageal cancer for each country was obtained from The Global Cancer Observatory (GLOBOCAN) database. World Bank classifications of countries by income level were obtained. Results A total of 103 studies were identified. The majority (81%) were published in high-income countries, 15% in upper-middle, and 5% in lower-middle income countries. Thirty-four were published in the USA, the country with the fifth-highest incidence of oesophageal cancer worldwide, but 90th by ASR. The greatest incidence was in China (54% of global incidence) but was the source of only 15% of studies. Of the ten countries with the highest incidence, five were represented in published studies, in comparison to one of the top 10 by ASR. Conclusions There is evident disparity in the geographical distribution of published studies of RAMIE. This disparity may represent unequal access to surgical technologies, or a lack of evaluation of the technology in different healthcare settings. This may impact the generalisability of research findings. Equitable access to novel surgical technologies is ethical and can help address global disease burden.

Is Re-introducing Major Open and Minimally Invasive Surgery during COVID-19 Safe for Patients and Healthcare Workers? An International, Multi-centre Cohort Study in the Field of Oesophago-gastric Surgery

Introduction The COVID-19 pandemic has resulted in unparalleled changes to patient care, including the suspension of cancer surgery. Concerns regarding COVID-19-related risks to patients and healthcare workers with the re-introduction of major complex minimally invasive and open surgery have been raised. This study examines the COVID-19 related risks to patients and healthcare workers following the re-introduction of major oesophago-gastric (EG) surgery. Patients and Methods This was an international, multi-centre, observational study of consecutive patients treated by open and minimally invasive oesophagectomy and gastrectomy for malignant or benign disease. Patients were recruited from nine European centres serving regions with a high population incidence of COVID-19 between 1 May and 1 July 2020. The primary endpoint was 30-day COVID-19-related mortality. All staff involved in the operative care of patients were invited to complete a health-related survey to assess the incidence of COVID-19 in this group. Results In total, 158 patients were included in the study (71 oesophagectomy, 82 gastrectomy). Overall, 87 patients (57%) underwent MIS (59 oesophagectomy, 28 gastrectomy). A total of 403 staff were eligible for inclusion, of whom 313 (78%) completed the health survey. Approaches to mitigate against the risks of COVID-19 for patients and staff varied amongst centres. No patients developed COVID-19 in the post-operative period. Two healthcare workers developed self-limiting COVID-19. Conclusions Precautions to minimise the risk of COVID-19 infection have enabled the safe re-introduction of minimally invasive and open EG surgery for both patients and staff. Further studies are necessary to determine the minimum requirements for mitigations against COVID-19.

V3 Is re-introducing major open and minimally invasive surgery during COVID-19 safe for patients and healthcare workers? An international, multi-centre cohort study in the field of oesophago-gastric surgery

Introduction The Covid-19 pandemic has resulted in unprecedented and challenging changes to surgical practice, especially with the suspension of cancer surgery. There have been concerns regarding Covid-19 risk and infection to patients and healthcare workers, during major complex open surgical intervention, especially with minimally invasive surgery. This study examines the COVID-19 related risks to patients and healthcare workers following the re-introduction of major oesophago-gastric (OG) surgery. Methods This was an international, multi-centre, cohort study of open and minimally invasive oesophagectomy and gastrectomy procedures in specialist Upper GI centres, over a consecutive period of two months. Patients were recruited from nine European centres serving regions with a high population incidence of COVID-19 infections. 30-day operative morbidity and mortality data was collected for patients. All staff involved in the operative care of patients, were invited to complete a health-related survey. Results A total of 158 patients were included in the study (71 oesophagectomy, 82 gastrectomy), of which 87 patients (57%) underwent minimally invasive surgery (59 esophagectomy, 28 gastrectomy). A total of 403 staff were eligible for inclusion of which 313 (78%) completed the health survey. Non- standardised precautions to minimise against the risks of COVID for patients and staff were implemented at the centres. There were no cases of Covid-19 among patients in the post-operative period, however, two healthcare workers developed self-limiting COVID infection. Conclusion Precautions to minimise COVID-19 infection risk to healthcare staff and patients, have allowed the safe and successful reintroduction of major open and minimally invasive OG surgery.