BOLUS

Food bolus impaction can be a manifestation of chronic untreated inflammation in those with underlying eosinophilic esophagitis (EoE). The eosinophil predominant inflammation of the esophagus is associated with a higherprevalenceoffibrosiswhenitremainsundetectedanduntreated.Non-malignantfoodbolusimpactionisstronglyassociatedwithanunderlyingdiagnosisofEoE,butoutsideofgastroenterologyandotheresophagealinterestedspecialiststhereremainspoorunderstandingofhowtodiagnoseandmanagethiscondition. We conducted a retrospective study of patients presenting to a tertiary emergency unit with esophageal food bolus impaction between Novem-ber 2018 and May 2021. Electronic attendance records and the endoscopy database were examined to determine the associations between demograph-ics, comorbidities, endoscopic findings, biopsy findings and follow up. We also evaluated the effect of the pandemic on food bolus management with statistical analysis undertaken using IBM SPSS software. Of the 938 patients who presented to the emergency department with food Our findings highlight significant shortcomings in the management of those presenting emergently with food bolus impaction and possible undiagnosed EoE. There need for clear management pathways to aid risk-stratification, discharge planning and endoscopic practices in the diagnosis of EoE. We therefore propose an algorithm for food bolus management to facilitate early endoscopy, effective diagnosis, and appropriate follow-up, ensuring optimal management for patients with non- malignant dysphagia requiring emergency admission for resolution of food impaction.

Food bolus impaction can be a manifestation of chronic untreated inflammation in those with underlying eosinophilic esophagitis (EoE). The eosinophil predominant inflammation of the esophagus is associated with a higher prevalence of fibrosis when it remains undetected and untreated. Nonmalignant food bolus impaction is strongly associated with an underlying diagnosis of EoE, but outside of gastroenterology and other esophageal interested specialists there remains poor understanding of how to diagnose and manage this condition.
We conducted a retrospective study of patients presenting to a tertiary emergency unit with esophageal food bolus impaction between November 2018 and May 2021. Electronic attendance records and the endoscopy database were examined to determine the associations between demographics, comorbidities, endoscopic findings, biopsy findings and follow up. We also evaluated the effect of the pandemic on food bolus management with statistical analysis undertaken using IBM SPSS software.
Of the 938 patients who presented to the emergency department with food bolus impaction, 83.6% were sent home with no follow up. Only 7.2% went on to have an endoscopy. In those with macroscopic evidence of inflammation, only 35.8% of patients had the correct number of biopsies taken to establish a histological cause for their symptoms. 1.6% of patients demonstrated histological evidence of EoE, of whom 80% were male and 20% female. The COVID-19 lockdown did not negatively impact access to endoscopy with mean wait time improving from 121-days prior to lockdown compared to 69-days during lockdown, p < 0.01.
Our findings highlight significant shortcomings in the management of those presenting emergently with food bolus impaction and possible undiagnosed EoE. There remains a need for clear management pathways to aid risk-stratification, discharge planning and endoscopic practices in the diagnosis of EoE. We therefore propose an algorithm for food bolus management to facilitate early endoscopy, effective diagnosis, and appropriate follow-up, ensuring optimal management for patients with nonmalignant dysphagia requiring emergency admission for resolution of food impaction.

THE MEDIASTINOSCOPIC RADICAL ESOPHAGECTOMY WITH A TRANS-BICERVICAL APPROACH USING INTRAOPERA-TIVE NERVE MONITORING (IOMN)
Yutaka Tokairin 1,2 , Kagami Nagai 2 , Hiroyuki Shiobara 1,2 , Masayuki Ando 1 1. Department of Surgery,Toshima Hospital Tokyo Metropolitan Health And Hospitals Corporation,Japan and 2.Department of Gastrointestinal Surgery,Tokyo Medical and Dental University,Japan We developed 'mediastinoscopic esophagectomy with lymph node dissection' (MELD), performed under pneumomediastinum via a trans-bicervical and transhiatal approach using cadavers. A clinical trial on the feasibility and safety of MELD showed it to be useful for complete mediastinal lymph node dissection. We report the indications and novel aspects of MELD.
MELD was indicated for patients of thoracic esophageal cancer without bulky primary lesions or lymph node metastases. MELD was performed in 16 patients. First, 101R and part of the 106recR lymph nodes were dissected in open surgery. After attaching an APS electrode for intraoperative nerve monitoring (IOMN) to the right vagus nerve, open surgery was changed to the pneumomediastinal method. The dorsal side of the esophagus was dissected along the visceral sheath. The 106tbL lymph nodes and the106recR lymph nodes were dissected using a right trans-cervical pneumomediastinal approach. The 106recL lymph nodes were dissected using a left trans-cervical pneumomediastinal approach.
The median pneumomediastinal operation time was 320 minutes. The median amount of bleeding was 230 mL, and the median postoperative hospital stay was 16 days. Regarding complications, eight patients developed recurrent laryngeal nerve palsy (right, n = 3; left, n = 2; bilateral, n = 3), but no patients required conversion to thoracotomy, and no leakage, pneumonia, or operative deaths occurred. After incorporating the use of IOMN, the incidence of recurrent laryngeal nerve palsy was drastically reduced recurrent laryngeal nerve palsy was drastically decrease.
Previous clinical trials shown that MELD can retrieve the mediastinal lymph nodes at the same level as thoracoscopic esophagectomy. The incidence of recurrent laryngeal nerve palsy was reduced by IONM; thus, MELD is considered a feasible procedure for radical esophagectomy.

POSTOPERATIVE CHEMORADIATION FOR LOCAL ADVANC ED ESOPHAGEAL SQUAMOUS CELL CARCINOMA WITH LOW MEAN PLATELET VOLUME Qifeng Wang, Lei Wu, Jie Zhu, Wenjie Ni, Xiao Chang, Zefen Xiao, Yongtao Han
To develop mean platelet volume (MPV) as a biomarker to predict prognosis and guide postoperative chemoradiation (POCRT) in patients with locally advanced esophageal squamous cell carcinoma (LA-ESCC).