Abstract Topic Esophageal Cancer: Oncology/Radiation Therapy Background Locally advanced esophageal cancer requires toxic chemoradiotherapy, yet no established pretreatment body composition thresholds exist to predict completion. Traditional assessment relies on subjective performance status, often overlooking occult sarcopenia. This study evaluates BIA markers against BMI to define objective cut-offs for guiding targeted prehabilitation and optimizing therapeutic resilience. Methods A retrospective cohort study analyzed patients with locally advanced esophageal cancer undergoing definitive or neoadjuvant CCRT at a provincial tertiary center in Thailand from December 2023 to October 2025. Baseline body composition was assessed using direct segmental multi-frequency bioelectrical impedance analysis immediately post-diagnosis. Patients were categorized into "Completion CCRT" (n=30) and "Non-completion CCRT" (n=11; withdrawal, loss to follow-up, early mortality) treatment groups. We compared baseline BMI, PhA, SMI, and other body composition parameters between groups using independent t-tests and Mann-Whitney U tests to identify predictors of treatment resilience. Results Forty-one patients (mean age 60.3±10.3; 95.1% male; 97.6% SCC) were included. The CCRT completion rate was 73.2% (30/41). While the Non-completion CCRT group had significantly lower weight (39.7 vs 47.5 kg, p=0.002) and BMI (15.0 vs 17.4 kg/m2, p=0.009), BIA revealed critical underlying deficits. The Non-completion group demonstrated significantly depleted Skeletal Muscle Index (5.43 vs 6.22 kg/m2, p=0.006), Fat Mass (4.4 vs 7.3 kg, p=0.033), and Basal Metabolic Rate (1132 vs 1246 kcal, p=0.003). Although Phase Angle was lower in the Non-completion group (4.68° vs 5.29°), it did not reach statistical significance (p=0.274). These findings characterize a state of severe cachexia driving treatment failure. Conclusion Baseline BIA parameters effectively identify high-risk phenotypes driving CCRT failure. While validation in larger cohorts is warranted, future research should focus on monitoring BIA dynamics following nutritional interventions. Ultimately, this study serves as a pivotal foundation for implementing targeted prehabilitation, aiming to optimize physiological resilience and ensure treatment completion in locally advanced esophageal cancer.
Abstract Topic Esophageal Cancer: Esophageal Carcinogenesis Case Submission A 58 year old man with oesophageal adenocarcinoma, presented with a 4 day history of right upper quadrant pain, jaundice, dark urine and pale stools. Laboratory tests showed a serum bilirubin of 179umol/L, alkaline phosphatase 252U/L, gamma glutamyl transferase 202U/L, alanine aminotransferase 142U/L and aspartate aminotransferase 67U/L. A contrast-enhanced CT of the abdomen and pelvis demonstrated marked intrahepatic duct dilatation with rapid tapering and nodular circumferential mural thickening of the common hepatic duct and confluence (see figure). The patient underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) which confirmed a tight segmental stricture 3cm in length at the lower two thirds of the common bile duct and an approximately 1.5cm dilation of the common hepatic bile duct (see figure). A metal stent was placed in the common bile duct. Histopathology of the brushings collected during ERCP demonstrated adenocarcinoma cells with increased nuclear to cytoplasmic ratio and hyperchromasia (see figure). Immunohistochemistry demonstrated CK7 positivity supportive of oesophageal adenocarcinoma (see figure). Current literature suggests that oesophageal carcinomas rarely metastasises to the common bile duct. To the best of our knowledge, oesophageal adenocarcinoma metastasising to the common bile duct has not been described previously. The patient presented with classical features of obstructive jaundice and a cholestatic liver enzyme derangement. Contrast-enhanced CT imaging demonstrated intrahepatic biliary dilatation with circumferential mural thickening and abrupt tapering of the common hepatic duct, features typically associated with cholangiocarcinoma. ERCP confirmed a tight segmental stricture involving the distal common bile duct with upstream biliary dilatation. Biliary decompression was achieved with placement of a self-expanding metal stent, consistent with current endoscopic management of malignant biliary obstruction. This highlights the dual diagnostic and therapeutic role of ERCP in such presentations. A key learning point from this case is the importance of tissue acquisition in patients with indeterminate biliary strictures, particularly in those with a known extra-biliary primary malignancy. Although radiologic and endoscopic findings strongly suggested primary cholangiocarcinoma, brush cytology obtained during ERCP demonstrated malignant glandular cells. Immunohistochemical analysis showing CK7 positivity supported an upper gastrointestinal origin and confirmed metastatic oesophageal adenocarcinoma. This emphasises the critical role of cytology and immunophenotyping in distinguishing primary biliary tumours from metastatic disease. Another important learning point is that metastatic disease to the bile duct, while rare, should remain part of the differential diagnosis in patients with known oesophageal malignancy. True intraductal metastasis is uncommon and is thought to occur via haematogenous or lymphatic dissemination rather than direct invasion. Failure to consider this possibility may result in misdiagnosis and inappropriate referral for surgical resection.
Abstract Topic Benign Disease: Other Case Submission A 70-year-old man presented with pericardial effusion and suspected gastric conduit–pericardial fistula secondary to gastric conduit ulceration after esophagectomy. He was diagnosed with lower thoracic esophageal cancer in 2021 and underwent neoadjuvant docetaxel/cisplatin/5-fluorouracil therapy, followed by robot-assisted esophagectomy with retrosternal gastric conduit reconstruction. He received 12 courses of adjuvant nivolumab therapy. In January 2024, he continuously used nonsteroidal anti-inflammatory drugs (NSAIDs) for right shoulder pain. He subsequently developed chest discomfort and general fatigue and visited a local clinic, where he was managed by observation. One week later, at a scheduled follow-up visit to our hospital, laboratory testing demonstrated elevated inflammatory markers and electrocardiography showed ST-segment elevation. Transthoracic echocardiography and contrast-enhanced computed tomography revealed pericardial fluid accumulation and an ulcer on the posterior wall of the gastric conduit. Based on these findings, a gastric conduit–pericardial fistula related to gastric conduit ulceration was diagnosed. Pericardial drainage was performed on the day of admission, and intravenous antibiotic therapy was initiated thereafter. Upper gastrointestinal endoscopy revealed ulcers on both the anterior and posterior walls of the gastric conduit; no clear malignant features were observed endoscopically. After drainage and medical therapy, the systemic inflammatory response improved; however, follow-up assessment suggested the persistence of an abscess cavity within the pericardial space despite ongoing drainage. Given the residual intrapericardial abscess cavity after drainage and antibiotic treatment, surgical drainage was selected. On hospital day 25, thoracoscopic pericardial window creation (pericardial fenestration) and feeding jejunostomy were performed under general anesthesia. Postoperatively, the inflammatory markers decreased further, and the clinical status stabilized. The gastric conduit ulcers showed scarring changes during follow-up, and oral intake was resumed after treatment. The pericardial drain was removed on day 52 of hospitalization, and the patient was transferred to another facility for convalescence. This case raises discussion points regarding diagnostic confirmation and step-up management of late-onset suspected microfistulas without an obvious perforation site. In particular, the case was characterized by (i) ST-segment elevation with inflammatory markers prompting cardiac evaluation, (ii) imaging findings of pericardial effusion and posterior gastric conduit ulcer in close proximity to the pericardium, (iii) absence of apparent malignant features on endoscopy, and (iv) persistence of a pericardial abscess cavity after initial pericardial drainage and antibiotics, which was ultimately managed with thoracoscopic pericardial fenestration and enteral access. The questions for the panel discussion included the following: (1) recommended diagnostic workflow to confirm a gastric conduit–pericardial fistula or microfistula in similar settings, including the role and timing of CT, echocardiography, endoscopy, and/or contrast studies; (2) criteria for escalation from pericardial drainage plus antibiotics to thoracoscopic pericardial window creation; (3) indications, feasibility, and risks of endoscopic interventions for gastric conduit ulcers when a pericardial complication is suspected; and (4) preventive strategies after esophagectomy, including long-term acid suppression and analgesic selection in patients requiring NSAIDs.
Abstract Topic Benign Disease: Esophageal Function and Motility Background Esophageal achalasia is a rare motility disorder. Surgical interventions, including Heller myotomy with Dor fundoplication (HD) and per-oral endoscopic myotomy (POEM), are performed for medically refractory cases. This study aims to evaluate the surgical techniques and clinical outcomes of both procedures in patients treated at a single institution. Methods We reviewed 68 cases of esophageal achalasia (54 HD, 14 POEM). In the HD group (mean age 50.6), 51 underwent laparoscopic surgery. HD involved a 6cm esophageal and 2cm gastric myotomy with Dor fundoplication. The POEM group (mean age 42.6) underwent circular muscle myotomy via a submucosal tunnel. Clinical efficacy was assessed using the Eckardt score and lower esophageal sphincter pressure (LESP). Postoperative reflux esophagitis was evaluated using the Los Angeles (LA) classification. Results In the HD group, the Eckardt score significantly improved from 5.6 to 1.4 (p<0.001), and LESP decreased from 22.6 to 16.3 mmHg (p=0.017). In the POEM group, the Eckardt score improved from 5.9 to 1.4 (p<0.001), and LESP decreased from 31.2 to 12.3 mmHg (p=0.002). Postoperative reflux esophagitis (Grade A or higher) was significantly more frequent in the POEM group (37.5%) than in the HD group (9.3%; p=0.029); however, all cases were effectively managed medically. Conclusion Both HD and POEM are effective treatments for esophageal achalasia, providing significant symptomatic relief and reduction in LESP. While POEM is associated with a higher incidence of postoperative reflux esophagitis, both procedures remain valuable therapeutic options.
Abstract Topic Esophageal Cancer: Barrett‘s Esophagus: High-Grade Dysplasia and Early Invasive Cancer Background In many European countries, esophageal adenocarcinoma (EAC) incidence is increasing [1]. Barrett’s esophagus(BE), strongly associated with EAC, can progress via dysplasia to early and invasive adenocarcinoma [2]. Endoscopic treatment is the mainstay for early mucosal cancer (T1a/b) but requires intense post-treatment surveillance [3]. This results in overtreatment in most, and undertreatment in only a subset of patients [4]. The ENDEAVOR consortium, with over 10 partners from 8 European countries, will execute a 5-year project to develop a risk stratification model guiding treatment and surveillance. Below, preliminary results from the pilot study. Methods A total of 60 patients with BE and a visible lesion on endoscopy will be included in this study. Patients will be evaluated for endoscopic resection, with ablation therapy as needed. Forceps biopsies, brush biopsies and blood samples are taken before and after endoscopic resection. From these samples, clonal diversity measurements for HER-2, cMYC and CEP-17 are determined. Using these results, a determination of low or high clonal diversity is made. The degree of clonal diversity will be correlated to histopathological risk factors (lymphovascular invasion, differentiation grade, invasion depth) and recurrence events. Results Ongoing recruitment is at 33 patients. The population includes 6,1% female gender, mean age 67,27 (SD 10,42) and mean BMI 27,93 (SD 5,91). Median BE segment length is C1M3, 39,3% short-segment Barrett (<3cm maximum extent), and hernia diaphragmatica was present in 46,4% of patients. Paris classification lesion types consisted of Is (7; 20,59%), IIa (15; 44,12%), IIb (6; 17,65%), IIc (4; 11,76%). There were no Ip or III lesions included so far, 2 lesions (5,88%) were not classifiable. Of the 26 endoscopic resections performed so far, en bloc resection was performed in 23/26 procedures (88,46%). Histopathology staging has been obtained for 18 specimens, of which 9 were T0 (60%), 8 were T1a (33,33%) and 1 was T1b (6,67%) (see Table 1). In the 14 patients that have undergone endoscopy after endoscopic resection, There have been no recurrences registered so far, with average follow-up time after endoscopic resection of 3,54 months. Conclusion Our population includes an important number of patients with short-segment BE. With ongoing discussion about the surveillance intervals for short-segment BE, future data on recurrence rates in this subgroup will prove valuable. Continued follow-up to detect recurrences and biomarker analysis is being conducted.
Abstract Topic Benign Disease: Esophageal Function and Motility Background Achalasia is a chronic oesophageal motility disorder causing stasis and inflammation, predisposing to structural complications and malignancy. While squamous cell carcinoma (SCC) is a recognized risk in long-standing disease, malignant transformation within an epiphrenic diverticulum is exceptionally rare. Methods A 74-year-old woman with achalasia diagnosed in 2009 after endoscopy and barium swallow underwent endoscopic dilatations before defaulting follow-up for 15 years. She re-presented with progressive dysphagia, weight loss, and severe malnutrition (BMI 12). Evaluation included repeat upper endoscopy with biopsy and cross-sectional imaging for staging. Assessment demonstrated a moderately differentiated squamous cell carcinoma arising within an epiphrenic diverticulum in a markedly dilated oesophagus, staged cT2N0M0 without distant metastases. Findings were discussed in a multidisciplinary setting to determine optimal management. Results A nasogastric feeding tube was inserted to establish enteral nutrition along with parenteral nutrition in view of her severe malnutrition. The patient was recommended for curative oesophagectomy but she declined and opted for Heller’s cardiomyotomy with Dor fundoplication to relieve obstruction and allow for oral feeding with plans for definitive chemoradiotherapy for treatment of her oesophageal SCC. Conclusion This case illustrates the progressive pathological cascade from untreated achalasia. Chronic stasis and mucosal inflammation likely contributed synergistically to both diverticulum formation and carcinogenesis. It underscores the importance of early diagnosis, timely and appropriate treatment with long-term surveillance in achalasia patients. One should maintain a high index of suspicion for malignancy in such patients presenting with worsening symptoms, even when structural complications (eg. diverticula) are known.
Abstract Topic Esophageal Cancer: Other Background Chyle leak following esophagectomy is a rare but life-threatening complication associated with significant morbidity, prolonged hospitalization, and mortality. While conventional management relies heavily on prolonged conservative measures or morbid surgical ligation, minimally invasive lymphangiographic embolization has recently emerged as a highly promising treatment alternative for these critically ill patients. Methods This prospective cohort study evaluated five consecutive patients who developed refractory chyle leaks following esophagectomy for esophageal carcinoma at a high-volume tertiary cancer centre between January 2023 and December 2024. Patients were included if they demonstrated high-output chyle leaks exceeding 500 ml per day that remained unresponsive to a strict trial of conservative management, including total parenteral nutrition, medium-chain triglyceride dietary modifications and intravenous octreotide medical therapy for at least forty-eight hours. Upon failure of conservative measures, all patients underwent targeted percutaneous or transvenous lymphangiography followed by embolization. We systematically collected and analysed clinical demographics, surgical details, precise lymphangiographic anatomical findings, catheterization techniques, specific embolic agents utilized, and overall clinical outcomes (Table 1). The primary study endpoint was defined as complete clinical resolution of the chyle leak. Secondary endpoints evaluated procedural technical success, procedure-related adverse events, hospital length of stay and long-term recurrence rates during the comprehensive postoperative follow-up period. Results All five patients initially presented with high-output chyle leaks exceeding 500 ml daily. Diagnostic lymphangiography successfully visualized and anatomically localized the exact site of the leak in all cases: the proximal thoracic duct in the chest (n=3), the distal thoracic duct in the neck (n=1), and the right lymphatic tributary duct (n=1). Catheterization was successfully achieved utilizing diverse approaches tailored to patient anatomy: percutaneous puncture of the cisterna chyli (n=2), direct percutaneous access of the proximal thoracic duct (n=2), and retrograde transvenous cannulation via the basilic vein (Image 1) for the distal thoracic duct (n=1). Embolization utilizing a precisely concentrated N-butyl cyanoacrylate (NBCA) glue mixture was technically successful in all patients. Complete clinical leak resolution and subsequent thoracic drain removal occurred at a median of three days (range 2 - 5). No severe procedure-related adverse events, embolic complications, or leak recurrences were noted over a median follow-up period of twelve months. Conclusion Lymphangiographic embolization utilizing strictly cyanoacrylate glue without coiling represents a highly safe, effective, and minimally invasive therapeutic treatment for refractory post esophagectomy chyle leaks. By completely avoiding the substantial morbidity of surgical reintervention, this novel strategy offers an immensely valuable management option. Although this prospective cohort provides robust evidence of excellent outcomes and durability over a one year follow up, larger multi-centre studies are still definitively warranted to comprehensively validate these crucial clinical interventional findings.
Abstract Topic Esophageal Cancer: Adjuvant and Neo-Adjuvant Therapies Background Esophageal cancer is the seventh cause of cancer mortality worldwide. Despite recent advances in the perioperative management of esophageal adenocarcinoma with systemic and immunotherapy, significant therapy resistance persists. New approaches are in demand, and repurposing approved drugs for other indications is an attractive and low-cost approach to address this issue. Interfering with the adaptive metabolism of cancer cells holds promise, but complexity and redundancy makes it challenging to identify specific targets. Lipid and cholesterol metabolism play a key role in cancer cell homeostasis. Statins are ubiquitous cholesterol-lowering oral agents that could have a role in esophageal malignancy. Methods With a focus on esophageal adenocarcinoma (EAC), inputs from our single center highly annotated clinical database and biobank comprising more than 400 esophageal cancer patients were integrated. We used single-cell RNA sequencing data from a select cohort and employed an artificial intelligence-driven platform called NeMoCAD (Network Model for Causality-Aware Discovery) to predict compounds capable of reversing cancer cells transcriptomic state. High-throughput drug screening and synergy assays were employed to assess the in vitro effect of statins alone or in combination with chemotherapy on a patient-derived organoid cancer model. Parallel to this, we collected retrospective data from our prospectively maintained clinical database for analysis of demographics, tumor characteristics, response to systemic therapy and survival, grouping patients by statin use status. Results: With the NeMoCAD algorithm several statins were predicted to potentially alter the transcriptomic profile of chemoresistant tumours to resemble that of normal surrounding tissues, notably simvastatin and atorvastatin. Drg screening and synergy assays showed statins alone displayed variable cytotoxicity and that overall interaction patterns with chemotherapy were additive, but yielding peak synergy scores at low concentrations. From our clinical database, 449 locally advanced EAC patients receiving curative-intent neoadjuvant chemotherapy followed by surgery were included. A quarter of patients were on cholesterol-lowering statins for cardiovascular indications (n=128). They were significantly older and had higher BMI. A 30% increase in major pathological response was seen in statin users (NS) as well as significantly improved overall survival (5-year OS 54.1% vs 40.7%, HR 0.69, p=0.019). This impact was more pronounced for those receiving current standard-of-care FLOT. Of note, lipophilic statins (e.g., Atorvastatin, Simvastatin) showed better survival outcomes than hydrophilic statins. Conclusion In EAC, statins may play a role in improving response to neo-adjuvant systemic chemotherapy and may lead to prolonged survival in this population. Our clinical observations are in accordance, with increased overall survival (HR 0.69) for statin users. Moreover, these observations validate the predictions of in silico models employed, further corroborated by in vitro synergy essays. Confirmation of these findings is planned within a phase 2 clinical trial.
Abstract Topic Benign Disease: Esophageal Function and Motility Background We developed multi-society recommendations addressing the question: should adult patients with achalasia receive botox, pneumatic dilation (PD), POEM, or Heller myotomy with fundoplication? Methods We performed a systematic review of randomized trials across PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to July 9th, 2025. We recruited an international, multidisciplinary panel including members from the AATS, CATS, EAES, and SAGES. The panel included four gastrointestinal surgeons, two thoracic surgeons, two gastroenterologists, and two patient partners. The panel prioritized outcomes for evaluation and set decision thresholds for absolute effect estimates of treatment comparisons. The panel performed a network meta-analysis, appraised the certainty of evidence, and developed recommendations using the core GRADE approach at an in-person consensus meeting. Results We identified 31 reports of 22 trials of patients undergoing Botox injections (n=137), PD (n=562), POEM (n=199), Heller myotomy alone (n=52), and Heller myotomy with fundoplication (n=665). In adult patients with achalasia with moderate-to-severe symptoms with an acceptable anesthetic risk, we suggest Heller myotomy with fundoplication over POEM, pneumatic dilations, and botox, while we suggest POEM over pneumatic dilation or botox for those with a high anesthetic risk, or who prefer to avoid surgery (both conditional recommendation). In adult patients with achalasia with mild symptoms and a high anesthetic risk, we suggest pneumatic dilation over botox, while we suggest POEM over pneumatic dilation or botox for those with an acceptable anesthetic risk (both conditional recommendation). Conclusion Treatment selection for achalasia should be individualized according to symptom severity and surgical fitness, with specific therapeutic modalities favored for each clinical scenario.
Abstract Topic Benign Disease: Iatrogenic Esophageal Disease, Perforation and Postsurgical Complications Case Submission: A 60-year-old man was brought to the emergency department in shock. He had undergone undergoing subtotal esophagectomy with mediastinoscopic assistance for esophageal cancer two years earlier. Laboratory tests showed WBC 22,700/μL, CRP 22.5 mg/dL, and hemoglobin 6.1 g/dL. Computed tomography revealed cardiomegaly, right pleural effusion, and free air within the pericardial cavity. Upper gastrointestinal endoscopy demonstrated a 5-mm perforation on the anterior aspect of the left wall of the lower gastric tube. Based on these findings, mediastinitis and purulent pericarditis secondary to gastric tube ulcer perforation were diagnosed. Laparoscopic surgery was performed with the aim of draining the mediastinal abscess through the esophageal hiatus and closing the perforation. Although careful dissection was attempted while preserving the right gastroepiploic vessels, severe adhesions prevented entry into the mediastinum, and the perforated ulcer could not be reached. Drinage of the contaminated area and creation of a jejunostomy were performed instead. On the following day, the patient remained febrile with persistent inflammation. Contrast study through the perforation site revealed direct opacification of the pericardial cavity. Under endoscopic guidance, a guidewire was advanced from the gastric perforation into the pericardial space, and an 8-Fr drainage tube was inserted. Following endoscopic drainage, the inflammatory response improved markedly. By the third week of treatment, endoscopy confirmed healing of the ulcer, allowing removal of the drainage tube and initiation of oral intake. The patient was discharged on postoperative day 28. We report a rare case of benign gastric tube–pericardial fistula after esophagectomy that was successfully treated with endoscopic drainage.
Abstract Topic Benign Disease: Esophageal Surgery Background With increasing life expectancy, more elderly patients are diagnosed with large paraesophageal hernias (PEHs). However, the optimal management of PEHs in patients aged ≥70 years remains debated because of concerns regarding operative risk, frailty, and postoperative recovery. While elective minimally invasive repair is commonly performed in younger populations, evidence describing perioperative safety, short-term outcomes, and patient-reported satisfaction in older individuals is limited. As this population continues to grow, better characterization of surgical outcomes is essential to guide shared decision-making. We therefore evaluated perioperative and short-term outcomes of PEH repair in patients aged ≥70 years at our institution. Methods We conducted an institutional review board–approved, single-center observational study of consecutive patients aged ≥70 years who underwent primary PEH repair by a single surgeon between September 2016 and June 2025. Demographic, clinical, operative, and postoperative data were collected prospectively and analyzed retrospectively. Predefined outcomes included in-hospital postoperative complications (graded by Clavien-Dindo classification), length of stay (LOS), intensive care unit (ICU) admission, 30- and 90-day readmissions, 90-day mortality, quality of life (GERD-HRQL), patient satisfaction, need for endoscopic dilation, and hernia recurrence at last follow-up. Operative variables included surgical approach, fundoplication type, mesh use, adjunct procedures, operative time, and blood loss. Mid-term follow-up data were obtained from clinic visits and standardized surveys. Logistic regression models were used to evaluate associations between clinical variables and outcomes, reporting odds ratios (ORs) with 95% confidence intervals (CIs). Statistical significance was defined as p<0.05. Results A total of 203 patients were included (74.9% female), with a median age of 76 years (maximum 96) and median BMI of 27.5 kg/m2. Non-elective surgery was performed in 16.7%. Most procedures were laparoscopic (87.1%) or robotic (11.9%), with a 1% conversion rate. Median operative time was 90 minutes and median blood loss was 25 mL. Postoperative complications occurred in 16.7% of patients, (5.9% Clavien-Dindo ≥III). Median LOS was 2 days; 5.4% required ICU admission. Thirty- and 90-day readmission rates were 7.4% and 10.9%, respectively. Ninety-day mortality was 0.5%. At a median 12-month follow-up, GERD-HRQL scores was 1, and 90.6% of patients would recommend surgery. Endoscopic dilation was required in 13.8%. Increasing age (OR 1.14, 95%CI 1.04-1.26, p=.008) and non-elective surgery (OR 7, 95%CI 2-24.6, p=.002) predicted ICU admission; non-elective surgery also predicted complications (OR 2.5, 95%CI 1.1-5.9, p=.034) and 30-day readmission (OR 5.2, 95%CI 1.7-15.6, p=.003). Conclusion Minimally invasive PEH repair is safe and effective in patients aged ≥70 years, with low mortality, short hospital stay, and high patient satisfaction. Although overall morbidity was acceptable, non-elective surgery was associated with increased ICU utilization, postoperative complications, and readmissions. These findings support consideration of elective repair in appropriately selected elderly patients to reduce adverse outcomes associated with urgent intervention. Further comparative studies incorporating younger cohorts and adjusting for comorbidities and frailty are needed to better define the independent impact of age on surgical risk and to refine patient selection strategies in this growing population.
Abstract Topic Benign Disease: Gastro-Esophageal Reflux and Hiatal Hernia Background Ambulatory reflux monitoring (wireless pH or catheter-based pH-impedance) performed off acid suppression is the gold standard for diagnosing gastroesophageal reflux disease (GERD). Barium esophagram (BE), commonly used to evaluate esophageal symptoms, routinely assesses reflux, yet its diagnostic accuracy relative to ambulatory monitoring remains unclear. Existing studies are limited, relied on outdated reflux criteria, and demonstrated poor concordance with BE-based GERD diagnoses. We aimed to determine whether BE reliably identifies GERD compared with ambulatory reflux monitoring interpreted using updated Lyon 2.0 consensus criteria. Methods Retrospective analysis of adult patients that underwent BE and ambulatory reflux monitoring (wireless pH or pH-impedance) off PPI within an 8-month interval. Patients with a history of fundoplication were excluded. Esophagram was performed with standard technique and reported by radiology, considered positive for GERD if there was reflux above the thoracic inlet with or without provocative maneuvers. Reflux monitoring studies were considered positive or negative for GERD based on Lyon consensus 2.0 recommendations. Inter-rater reliability, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and received operating characteristic (ROC) curve analysis were calculated for esophagram, with reflux monitoring diagnosis as the gold standard. Results 64 patients were included, 31 % male, mean age = 60 years, mean Body Mass Index = 26. GERD was diagnosed by esophagram in 20 patients (31%), and by reflux monitoring in 19 (30%). Compared to reflux monitoring, BE had sensitivity: 47%, specificity: 76%, PPV: 45%, NPV: 77%, and area under the ROC curve: 0.61 (Figure 1). Inter-rater reliability between BE and ambulatory reflux monitoring was poor (Cohen's Kappa = 0.226). Conclusion There was poor concordance between BE and ambulatory reflux monitoring for diagnosing GERD. BE overall had suboptimal diagnostic performance, with low sensitivity, and moderate specificity. Furthermore, the area under the ROC curve indicates limited ability to distinguish correctly between patients with and without GERD. These findings indicate that barium esophagram should not be relied upon as a diagnostic tool for GERD.
Abstract Topic Esophageal Cancer: Molecular Biology/Pathology Background B7-H3 (CD276) is an immunoregulatory molecule and emerging therapeutic target. The prognostic value of B7-H3 expression in locally advanced esophageal squamous cell carcinoma (ESCC) treated with multimodality therapy plus adjuvant pembrolizumab was unclear. We performed a post-hoc analysis of a single-arm phase II ESCC patient cohort (NCT03322267) treated with protocol-specified adjuvant cisplatin-based chemoradiotherapy (CRT) followed by pembrolizumab for post-neoadjuvant CRT esophagectomy, pathology revealing risk factors for recurrence including involved or close margins (≤1 mm), extranodal extension of involved lymph nodes, and ypN2-3 stage. Methods Patients in the study cohort with adequate surgical tissue for B7-H3 immunohistochemistry (IHC) were included. B7-H3 (clone EPR20115, Abcam) was scored by H-score. H-score values of B7-H3 IHC analyses calculated by multiplying the percentage of cells positive by 1, 2 or 3 based on expression intensity. PD-L1 combined positive score (CPS) was assessed with Dako 22C3. Relapse-free survival (RFS) and overall survival (OS) were analyzed. Cox proportional hazards models adjusted for age, performance status, post-neoadjuvant therapy pathology stage, margin status, lymphovascular invasion, perineural invasion, tumor regression grade, and PD-L1 expression. Results Twenty-four patients were evaluable (B7-H3 H-score ≥150: n=7; <150: n=17). PD-L1 CPS was similar between the B7-H3 H-score ≥150 vs <150 groups (median 5.0 vs 4.0; p=0.637). B7-H3 H-score ≥150 was associated with shorter RFS (median 4.6 vs 18.0 months; p =0.002) and OS (median 10.2 vs 19.8 months; p =0.041). In multivariable Cox model, B7-H3 H-score ≥150 independently predicted inferior RFS (p =0.039) but not OS (p =0.108). PD-L1 CPS ≥10 was not significant for RFS (p =0.253) or OS (p =0.428). Conclusion High tumor B7-H3 (H-score ≥150) identified a higher-risk subgroup with shorter RFS after multimodality therapy plus adjuvant pembrolizumab, independent of PD-L1 CPS and adverse pathologic features, supporting B7-H3 expression for risk stratification and warranting external validation.
Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly utilized for locally advanced esophageal cancer; however, its clinical utility in challenging cases such as clinical T3 borderline resectable (cT3br) or cT4b tumors remains poorly understood. We retrospectively analyzed 60 patients with cT3br/cT4b esophageal cancer who underwent RAMIE (n=22) or video-assisted thoracoscopic esophagectomy (VATS) (n=38) after preoperative chemotherapy or chemoradiotherapy between 2014 and 2024. Three-year overall survival (OS), progression-free survival (PFS), and recurrence patterns were evaluated using a multivariable Cox proportional hazards model. A high R0 resection rate was achieved in both groups (RAMIE 90.9% vs. VATS 89.5%, p=1.000). The 3-year OS (75.4% vs. 82.7%, p=0.762) and PFS (51.8% vs. 57.8%, p=0.742) did not differ significantly between groups; however, the limited number of events precluded definitive comparative conclusions. After multivariable adjustment, the adjusted 3-year OS was 84.5% for VATS and 79.7% for RAMIE, while the adjusted 3-year PFS was 62.3% and 47.2%, respectively (both p>0.05). Adjuvant nivolumab was administered exclusively in the RAMIE group (27.3% vs. 0.0%, p<0.001). RAMIE was associated with a lower, although non-significant, rate of recurrent laryngeal nerve-area recurrence (4.5% vs. 10.5%, p=0.643) and significantly higher distant lymph node involvement (18.2% vs. 0.0%, p=0.015). One-year post-recurrence survival did not differ significantly between groups (RAMIE 80.0% vs. VATS 75.0%, p=0.941). RAMIE achieved similarly high R0 resection rates and shortterm safety compared with VATS despite a numerically higher baseline tumor burden. No significant differences in 3-year survival were observed between RAMIE and VATS, although larger multicenter studies are needed to validate these findings. BACKGROUND:Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly utilized for locally advanced esophageal cancer. However, its clinical utility in challenging cases, such as clinical T3 borderline resectable (cT3br) or cT4b tumors, remains poorly understood. METHODS:We retrospectively analyzed 60 patients with cT3br/cT4b esophageal cancer who underwent RAMIE (n = 22) or video-assisted thoracoscopic esophagectomy (VATS) (n = 38) after preoperative chemotherapy or chemoradiotherapy between 2014 and 2024. Three-year overall survival (OS), progression-free survival (PFS), and recurrence patterns were evaluated. A multivariable Cox proportional hazards model was used to estimate adjusted hazard ratios. RESULTS:A high R0 resection rate was achieved in both groups (RAMIE 90.9% vs. VATS 89.5%, p = 1.000). The 3-year OS (75.4% vs. 82.7%, p = 0.762) and PFS (51.8% vs. 57.8%, p = 0.742) did not differ significantly between groups; however, the limited number of events precluded definitive comparative conclusions. After multivariable adjustment, the adjusted 3-year OS was 84.5% (VATS) vs. 79.7% (RAMIE), and the adjusted 3-year PFS was 62.3% vs. 47.2% (both p > 0.05). Adjuvant nivolumab was administered exclusively in the RAMIE group (27.3% vs. 0.0%, p < 0.001). RAMIE was associated with a lower, although non-significant, rate of recurrent laryngeal nerve-area recurrence (4.5% vs. 10.5%, p = 0.643) and with significantly higher distant lymph node involvement (18.2% vs. 0.0%, p = 0.015). One-year post-recurrence survival did not differ significantly (RAMIE 80.0% vs. VATS 75.0%, p = 0.941). CONCLUSIONS:RAMIE achieved similarly high R0 resection rates and short-term safety compared with VATS, despite a numerically higher baseline tumor burden. No significant differences in 3-year survival were observed between RAMIE and VATS. Larger multicenter studies are needed to validate these findings.
BACKGROUND:The incidence of early-onset oesophageal, junctional, and gastric adenocarcinoma, collectively known as early onset (EO) oesophago-gastric adenocarcinoma (OGA) is rising worldwide, yet its clinicopathological characteristics and oncological outcomes remain incompletely defined. This study aimed to compare the clinical profile, treatment pathways and outcomes of patients with early-onset (<55 years) and late-onset (LO) (≥55 years) OGA. METHODS:A retrospective cohort study was conducted at a UK tertiary oesophago-gastric cancer centre (2014-2025). Clinicopathological features along with postoperative outcomes and survival metrics in those patients undergoing curative-intent resection were analysed. Survival was estimated using Kaplan-Meier analysis and compared by log-rank testing. RESULTS:Among 936 patients with OGA, 138 (14.7%) patients had EO disease compared with 798 (85.3%) patients who had LO disease. The proportion of EO OGA patients increased significantly from 11.5% (60/522) to 18.9% (78/414) over the study period (p = 0.0022). Surgery with curative intent was offered to 54.3% of EO patients versus 58.8% of LO patients (p = 0.38). EO patients had a significantly lower comorbidity burden (18.7% vs 46.3%, p < 0.00001); were more frequently female (30.4% vs 18.9%, p = 0.003); and presented more often with advanced-stage disease (stage III-IV, p = 0.018). Diffuse histology predominated in EO gastric cancers compared to LO gastric cancers (64.3% vs 43.2%, p = 0.07), with signet-ring features present in 66.7% of EO cases and 85% of LO. Postoperative outcomes were broadly comparable; however, EO patients had shorter ICU stays (6.5 vs 9.4 days, p = 0.0015) in oesophageal adenocarcinoma and lower pneumonia rates in gastric adenocarcinoma (10.7% vs 40.3%, p = 0.00084). Despite comparable post-operative pathological stage and treatment, EO disease was associated with significantly inferior disease-free survival (gastric: p = 0.0033; oesophageal: p = 0.026), while overall survival was similar. Recurrence patterns differed significantly (p = 0.00028), with EO gastric cancers demonstrating a markedly higher rate of peritoneal dissemination (50.0% vs 26.3%). CONCLUSIONS:EO OGA represents a distinct entity, characterised by a higher prevalence of diffuse histology and a relative female predominance compared to its LO counterpart. The rising incidence observed in our cohort is concerning and mirrors global trends reported in recent studies, with EO patients more frequently presenting at an advanced stage of disease. Of particular concern, this patient group demonstrates inferior post-operative disease-free survival despite lower comorbidity burden and receipt of equivalent treatment regimens. As such, they appear unable to derive the survival advantage that younger age might otherwise be expected to confer. These findings highlight the need for tailored preventive, diagnostic and therapeutic strategies for this emerging patient population.
Paraconduit hiatus herniation (PHH) is an increasingly recognized complication following esophagectomy, particularly with the adoption of a minimally invasive approach. Although several prophylactic and repair strategies have been described, recurrence remains high with no clear consensus on the optimal method. In this article, we describe our experience of a novel technique for PHH repair combining hiatoplasty and liver buttress reinforcement, developed to achieve a tension-free repair using autologous tissue and avoiding the use of mesh. The technique was used for all patients presenting with PHH between April 2023 and April 2025. All procedures were performed using the novel technique under the primary care of one consultant surgeon at a tertiary esophagogastric unit. Six patients underwent seven PHH repairs during the study period. The median age was 66.5 years, and most cases (83.3%) occurred as a complication of minimally invasive esophagectomy for esophagogastric cancer. The median length of stay was 2 days (interquartile range 1-7). One patient, who presented in a compromised clinical condition, had a more complex postoperative course requiring intensive care support. The 30-day readmission rate was 14.3%. Symptom recurrence occurred in three of seven repairs (42.3%), but this was confirmed radiologically in only one case, resulting in a radiological recurrence rate of 14.3%. No in-hospital or 90-day mortality occurred. The technique proved feasible in this early single-center experience, with no associated mortality or major technique-specific morbidity and comparable recurrence rates to those reported in the published literature following PHH repair. Larger, multi-center studies with longer follow-up are required to validate its efficacy and establish its role in PHH management.
A 96-hour ambulatory pH testing is a practical tool for diagnosing gastroesophageal reflux disease (GERD) and for concurrently evaluating two conditions: dietary variation and its effect on measured acid exposure time (AET) and reported symptoms. To date, it is unknown how consuming a diet of either low or high acidity can influence pathologic GERD. This study aimed to assess the effects of high- and low-acid diets on AET and the occurrence of laryngopharyngeal symptoms (LPS) during prolonged wireless pH monitoring. A retrospective review of 208 patients who underwent 96-hour wireless pH monitoring for GERD evaluation was completed. Patients consumed a primarily high-acid diet on 1 day and a primarily low-acid diet on a separate day during the 96-hour period. Patients were considered to have pathologic GERD if esophageal AET was >6% for the time with pH <4, and were considered normal on an individual day if the AET was <4%. Pathologic GERD was found in 78 patients (37.5%), of whom the majority (55%) recorded their lowest AET during the study on their low-acid day. Only 24.7% achieved normal AET on a low-acid diet day. Mean AET on a high-acid diet, compared with a low-acid diet, decreased by 41%, from 12.51 to 7.33, with a similarly proportional decrease in patients negative for GERD. There was no significant difference between patients with and without LPS with regard to esophageal acid exposure on high- and low-acid diet days (P = 0.73, P = 0.81). A low-acid diet may be a viable lifestyle modification when used as monotherapy or adjunctively with proton pump inhibitor in patients with or without pathologic GERD.
Gastroesophageal reflux disease (GERD) is implicated as a potential cause of chronic laryngopharyngeal symptoms, including laryngitis, cough, dysphonia, and throat clearing, often grouped under laryngopharyngeal reflux (LPR). This study aimed to assess the predictive value of clinical and demographic factors for GERD in patients with LPR symptoms using multichannel intraluminal impedance-pH monitoring. Analytical cross-sectional study of 2688 adults with upper airway symptoms and suspected LPR undergoing pH-impedance monitoring between January 2019 and December 2022. Pathological GERD was defined as acid exposure time (AET) >6%, or AET 4%-6% with abnormal reflux parameters (total reflux events >80 and/or positive symptom association). Proximal reflux episodes were recorded but not used diagnostically. Multivariable logistic regression analyses identified independent predictors. Among 2688 patients (73.6% female; mean age 54.5 years), only 8.4% had pathological GERD. Independent predictors included higher body mass index, male sex, older age, heartburn, and hiatal hernia. The final model demonstrated moderate discrimination area under the curve (AUC) 0.676. Only a small proportion of patients with suspected LPR have objective GERD. Pathological reflux is better predicted by traditional GERD-related factors than by isolated laryngopharyngeal symptoms, supporting a more cautious interpretation of LPR and consideration of alternative diagnoses.
