212 USEFULNESS OF ENDOSCOPIC ESOPHAGECTOMY IN A PRONE POSITION FOR ELDERLY PATIENTS OVER 75 YEARS OLD

Surgery for esophageal squamous cell carcinoma(ESCC) is one of the most invasive surgery and high mortality rate because operation is centered on the thoracic cavity. Recently, Japan has been facing aging society, and surgery for elderly ESCC patient is increasing. In our hospital, we changed surgical position from left lateral position to prone. In this study, we investigated the surgical outcome and prognosis of ESCC operation in the patients aged ≧ 75. Methods From April 2011 to March 2019, 39 ESCC operations for patients aged ≧ 75 were performed in our hospital. We compered surgical position. We retrospectively examined clinicopathological factors, long-term prognosis, preoperative nutritional status (albmin, neutrophil and lymphocyte ratio), and operation factors (operation time, blood loss, recurrent nerve paralysis, complication, hospital stay). Results Cases in lateral position surgery were 22 and prone position were 17. The median age was 79 vs 79 years old, and the gender ratio was male: female = 16:6/14:3. No significant differences were observed in preoperative nutritional status. The operation time was 458 min vs 501 min (p = 0.126). The blood loss was 318 mL vs 195 mL (p = 0.003). The rate of recurrent nerve paralysis was 42.1% vs 29.4% (p = 0.262). The number of patients in Clavien-Dindo ≧ III complications was 40.9% vs 41.2% (p = 0.987). 3-year OS was 74.7% vs 77.3%, DFS was 78.6% vs 67.7%. Conclusion In ESCC patients aged ≧ 75, surgery in prone position was relatively safe. The blood loss and the recurrent nerve paralysis ware tend to be less. Recurrent nerve monitoring during operation and evaluation of perioperative swallowing function seemed to be the next subject.

Tracheal stenosis and recurrent nerve paralysis due to thyroid malignant lymphoma with huge chronic thyroiditis

We experienced a case of huge chronic thyroiditis with malignant lymphoma that caused dyspnea with tracheal stenosis, dysphagia with esophagus stenosis and recurrent nerve paralysis. In this case, thyroidectomy was performed and, after the surgery, there was no sign of breathing or swallowing difficulties, and it was confirmed by the postoperative computed tomography that the tracheal stenosis had improved. We considered two possible explanations for the preoperative right recurrent nerve paralysis. In the first, the right recurrent nerve could have suffered from mechanical stimulation such as compression and traction to the recurrent nerve due to enlargement of the malignant lymphoma together with chronic thyroiditis. The second possible explanation was that malignant cells had invaded neurons. We could not distinguish between the two possibilities, since this right recurrent nerve was spared and could not be examined histopathologically.

Surgical management of intrathoracic goiters: 20 years experience

Background: Surgery is necessary for intrathoracic goiters (ITG) even in asymptomatic forms considering the risks of compression and malignancy. The major problem is the adequate approach. Intrathoracic goiter’s removal can be performed via a cervical approach, whereas sternotomy might be required intraoperatively in some cases.Methods: A retrospective analysis of twenty years on 122 cases of intrathoracic goiters in a referral centre for thoracic surgery was carried out. We included secondary substernal goiters and ectopic thoracic goiters.Our aim was to define the specifities of this surgery and its outcomes. Postoperative data were examined as well as morbidity and mortality factors.Results: The most common symptoms included dyspnea, cough and dysphagia. Whereas Twenty-two patients were asymptomatic. One hundred sixteen patients underwent a successful transcervical incision without thoracic approach. Six cases of primary goiters were noted, of whom 3 were extracted via a cervical approach. Two cases showed unilateral recurrent nerve paralysis and two cases a hypoparathyroidism.Conclusions: Surgical management of intrathoracic goiter was correlated with low morbidity and mortality The cervical approach was performed in the vast majority of cases without an extra cervical procedure. Intrathoracic approaches were restricted to some selected indications.

Recurrent Nerve Palsy due to a Giant Vertebral Artery Aneurysm

Vertebral artery aneurysms are rare and challenging as they are usually asymptomatic and, therefore, often overlooked. We report the case of a 73-year-old man with a history of progressive dysphagia for 1 year. Computed tomography (CT) and computed tomography with angiography (CTA) of the cerebrum revealed a giant vertebral artery aneurysm compressing the medulla. Fiberoptic endoscopic evaluation of swallowing (FEES) revealed recurrent nerve paralysis. The patient was managed conservatively since the aneurysm was completely thrombosed.

PS01.174: AN EXAMINATION OF OUTCOMES AFTER ANTE-THORACIC ROUTE WITH RIGHT HEMICOLON RECONSTRUCTION AFTER ESOPHAGECTOMY.

Background In our institute, we usually use gastric tube for reconstruction organ after esophagectomy. When we can’t use gastric tube, we use right hemi-colon with ante-thoracic route. Previously, we reconstructed by 1-step after esophagectomy, but from 2012, we have done by 2-step for reduce postoperative complications. Methods We enrolled 15 esophageal cancer patients who underwent esophagectomy and right hemicolon reconstruction between April 2004 and December 2016. Results The average age of 15 patients is 67.3. The reasons of using right hemicolon are as follows; post gastrectomy 13, stomach double cancer 2. The reasons of gastrectomy are as follows; gastric cancer 8, duodenum cancer 1, gastric ulcer 4. The average duration from gastrectomy to esophagectomy is 12.5 year. We reconstructed by 1-step for 5 patients, and after 2012, we reconstructed by 2-step for 10 patients. Anastomotic leakages were found in 2 cases (40.0%) in 1-step reconstruction group, and 3 cases (20.0%) in 2-step reconstruction group. In 1-step reconstruction group, 1 case occurred multiple anastomotic leakages and DIC, and another 1 case was found necrosis of reconstructive colon. In 2-step reconstruction group, we found 1 case of major leakage and 1 case of recurrent nerve paralysis and 2 cases of postoperative pneumonia. However, there were no case of tracheotomy. The incidence of pneumonia did not differ between the two groups. And the term of postoperative oral intake tend to shorter in 2-step reconstruction group (P = 0.06). 2 severe postoperative complications (Clavian-Dindo V or IVa) cases were found in 1-step reconstruction group, on the other hand, 2 cases severe complications (CD IIIa) in 2-step reconstruction group. Conclusion In the case of using right hemicolon as a reconstructive organ, 2-step reconstruction approach is useful and superior from the viewpoints of postoperative complications. Disclosure All authors have declared no conflicts of interest.

PS01.125: SURGICAL APPROACH FOR THE ELDER ESOPHAGEAL CANCER

Background Recently the number of elder patients who have esophageal cancer has been higher in Japan. Because the anesthesia and surgical technique are developing day by day, we can choose surgery as radical therapy for esophageal cancer in elder patients. But the percentage of complication after operation in elder person still should be higher compared to young person. We present the problems and the risks of surgery for elder esophageal cancer in our institution. Methods 61 patients (over 75 years old) who had esophageal cancer underwent esophageal resection from 1998 to 2016 in Osaka Medical College, Japan. We divided these patients to 3 groups: open surgery; Group A, none open surgery (trans hiatal approach); Group B, VATS (Video-Assisted Thoracic Surgery); Group C, and assessed the amount of blood loss and surgical time during operation and the frequency of complication after operation. Results Average age of patient in Group B was significantly higher than other groups (Group A: 78.7 y. o., Group B: 81.3 y. o., Group C: 77.5 y. o.). Surgical time in Group C (526.5 ± 20.7min) was significantly longer than other groups (Group A: 385.5 ± 17.9min, Group B: 297.1 ± 27.4min). Blood loss during operation in Group B tended to be less than other groups (Group A: 575.4 ± 105.4mL, Group B: 320.4 ± 61.0mL, Group C: 317.6 ± 80.3mL). The complication after surgery occurred in 27 patients (44.3%) in whole groups, including pneumonia (48.8%), anastomotic leakage (18.6%), recurrent nerve paralysis (16.3%), empyema (7.0%), ischemia of gastric tube and/or small intestine (4.7%), deep venous thrombosis (4.7%). According to surgical approach, the occurring frequency of pneumonia (Clavien-Dindo classification Grade III and more) after operation in Group A (28.6%) was higher than other group (Group B: 8.3%, Group C: 9.5%), but more recurrent nerve paralysis was occurred in Group C (33.3%) compared to other groups. Conclusion Lung diseases including pneumonia, particularly in elder patient, are one of the most critical and sometimes become a fatal complication after esophageal cancer surgery. VATS seems to be more safe and useful approach in elder esophageal cancer resection, but needs to be care for recurrent nerve paralysis. Disclosure All authors have declared no conflicts of interest.