54th Annual Meeting - Society for Surgery of the Alimentary Tract

Transcription

THE SOCIETY FOR SURGERY
OF THE ALIMENTARY TRACT
54th Annual
Meeting
May 17-21, 2013
Orange County Convention Center
Orlando, Florida
ABSTRACT SUPPLEMENT
Table of Contents
Schedule-at-a-Glance ............................................................................................................. 2
Sunday Plenary, Video, and Quick Shot Session Abstracts.................................................... 6
Monday Plenary, Video, and Quick Shot Session Abstracts ................................................ 22
Tuesday Plenary Session Abstracts ....................................................................................... 50
Sunday Poster Session Abstracts .......................................................................................... 59
Monday Poster Session Abstracts ....................................................................................... 112
Tuesday Poster Session Abstracts ....................................................................................... 166
THE SOCIETY FOR SURGERY
OF THE ALIMENTARY TRACT
PROGRAM BOOK ABSTRACT SUPPLEMENT
FIFTY-FOURTH ANNUAL MEETING
Orange County Convention Center
Orlando, Florida
May 17–21, 2013
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Schedule-at-a-Glance
DDW CCS:
Therapeutic
Approaches in
NAFLD
Other
DDW CCS:
Controversies in
Barrett's
Esophagus
MAINTENANCE OF CERTIFICATION COURSE:
Evidence Based Treatment of Colorectal Diseases
6:30 AM
6:45 AM
7:00 AM
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208ABC
RESIDENTS & FELLOWS RESEARCH CONFERENCE
(by invitation only)
300
SATURDAY, MAY 18, 2013
DDW CCS:
Endoscopic
Evaluation & Mgt
of IBD
FRI, MAY 17, 2013
2
54TH ANNUAL MEETING • MAY 17–21, 2013 • ORLANDO, FL
SUNDAY, MAY 19, 2013
300
303ABC
304AB
Exhibit
Hall
Other
OPENING SESSION
3
CONTROVERSIES IN
GI SURGERY
DEBATES A: HIPEC;
Synch Colorectal Liver
Mets
STATE-OF-THE-ART
CONFERENCE: Evolving
Management in Pancreatic
Cancer
PLENARY SESSION III
DDW CCS:
Bariatric Surgery as
Tx of Metabolic
Syndrome
GUEST ORATOR
MEET-THEPROFESSOR
LUNCHEON
PRESIDENTIAL
PLENARY B
(PLENARY SESSION II)
DDW CCS: Mgt
of Benign Liver
Lesions
PRESIDENTIAL
ADDRESS
POSTER SESSION I (authors available @ posters 12:00 PM - 2:00 PM)
DDW
COMBINED
RESEARCH
FORUM: IBD
PRESIDENTIAL
PLENARY A
(PLENARY SESSION I)
VIDEO SESSION I
6:30 AM
6:45 AM
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5:45 PM
308D
4
DDW CCS: Mgt
of Sx Risk in
Patients with
Cirrhosis
WRITERS
WORKSHOP
1: Writing
MEET-THEPROFESSOR
LUNCHEON
DDW CCS:
Post-Op
Complications in
IBD Patient
CLINICAL
WARD
ROUNDS I:
Trans-Anal
Surgery for
Rectal CA
BREAKFAST
WITH THE
EXPERT
MONDAY, MAY 20, 2013
Exhibit
303ABC
304AB
Hall
Achalasia Treatment:
Botox, Balloon, Lap
Myotomy or POEM
VIDEO
SESSION
III
POSTER SESSION II (authors available @ posters 12:00 PM - 2:00 PM)
CONTROVERSIES IN
GI SURGERY
DEBATES B:
Resectable Pancreas
Adenocarcinoma;
Nissen Fundoplication
STATE-OFTHE-ART
LECTURE
DDW CCS:
CLINICAL
WARD
ROUNDS II:
Cysts of the
Pancreas
VIDEO SESSION II:
BREAKFAST AT
THE MOVIES
PUBLIC
POLICY &
ADVOCACY
PANEL
308D
SSAT/AHPBA JOINT
SYMPOSIUM:
Parenchymal
Preservation in Hepatic
Resection for
Metastatic Colorectal
CA
PLENARY
SESSION IV
300
QUICK
PLENARY
SHOTS
SESSION
SESSION V
III
SSAT/ASCRS
QUICK
JOINT
ANNUAL
SHOTS
SYMPOSIUM:
BUSINESS
Mgt of
SESSION
MEETING
Diverticular
II
Disease
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5:30 PM
5:45 PM
QUICK
SHOTS
SESSION I
Other
.
5
WRITERS
WORKSHOP
2: Reviewing
BEST OF DDW
MEET-THEPROFESSOR
LUNCHEON
DDW CCS:
Pancreatic
Necrosis
DDW CCS:
Early
Pancreatic
Cancer
BREAKFAST
WITH THE
EXPERT
Other
DDW CCS: GE
Junction
Tumors
HEALTH CARE
& QUALITY
OUTCOMES
PANEL
SSAT/SAGES JOINT
LUNCHEON SYMPOSIUM:
Mgt & Rescue from Complex Upper
GI Surgery Complications
POSTER SESSION III (authors available @ posters 12:00 PM - 2:00 PM)
SSAT/ISDS JOINT
B'FAST
SYMPOSIUM: Mgt of
GI Leaks
303ABC
PLENARY SESSION VII
6:30 AM
6:45 AM
7:00 AM
7:15 AM
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PLENARY
SESSION VI
308D
TUESDAY, MAY 21, 2013
Exhibit
304AB
Hall
SSAT PLENARY, VIDEO, AND
QUICK SHOT ABSTRACTS
Printed as submitted by the authors.
indicates a paper that is also being presented at the Residents & Fellows Research Conference.
Participation in and attendance at this conference is by invitation only.
/
indicates a video presentation scheduled during a Plenary Session.
Sunday, May 19, 2013
8:00 AM – 9:00 AM
303ABC
PRESIDENTIAL PLENARY A
(PLENARY SESSION I)
/199
benign lesions. E3 and E4 were expressed at extremely low
levels in all patients. Compared to IPMN alone, E6 levels
were significantly higher in PDA (p = 0.0036). There were
no significant differences between E6 levels in IPMN and
Normal sera (p = 0.59). Using a logistic regression model,
we found that for each increasing unit of log E6 COL6A3,
patients are 9.5 times more likely to harbor a cancer rather
than a benign lesion, 95% CI (2.4, 38.1), p = 0.002. The area
under the ROC curve, AUC, was 0.72. Knocking down E3
or E4 or E6 with isoform-specific siRNA resulted in reduced
PDA cell migration and invasion and concomitant reduction of the expression of several inflammation and angiogenesis-related genes, such as MMP-9, OPN, MCP-1 and
VEGF. Interestingly, knocking down any of the 3 isoforms
resulted in increased expression of TNF-alpha.
Clinical Significance of Serum COL6A3 Isoforms in
Pancreatic Ductal Adenocarcinoma
Christopher Y. Kang, Dierdre Axell-House, Pranay Soni,
Galina Chipitsyna, Konrad Sarosiek, Mazhar Al-Zoubi, Hwyda A.
Arafat, Charles J. Yeo
Surgery, Thomas Jefferson University, Philadelphia, PA
INTRODUCTION: Type VI collagen (COL6) forms a
microfibrillar network associated with type I collagen fibrils
and constitutes a major component of the prominent desmoplastic reaction in pancreatic ductal adenocarcinoma
(PDA). We have demonstrated recently that a subunit of
COL6, COL6A3, is expressed in high levels in PDA tissue.
We also showed that COL6A3 gene undergoes tumor-specific alternative splicing to produce 3 isoforms E3, E4 and
E6 that are tumor tissue-specific. The aim of this study is to
investigate the diagnostic value and clinical significance of
circulating COL6A3 isoforms mRNA in PDA.
CONCLUSIONS: Our data show for the first time the
potential clinical significance of circulating E6 COL6A3 levels in the diagnosis of pancreatic malignancy. Our in vitro
data suggests a role for COL6A3 isoforms in PDA progression and metastatic potential.
METHODS: Serum samples were obtained from patients
that underwent pancreatic resection at a single institution
between 2006 and 2009. COL6A3 levels in the sera from
patients with pathologically confirmed PDA (n = = 40),
intraductal papillary mucinous neoplasms (IPMN) (n = 20),
and chronic pancreatitis (n = 10) were analyzed by real time
PCR using isoform-specific primers for E3, E4 and E6. In
addition, sera from age-matched healthy volunteers were
analyzed (n = 30). The prediction levels for malignancy
were determined by the area under the receiver operating
characteristic curve (AUC). In vitro, wound healing, cell
proliferation and soft-agar colony formation assays evaluated the functional impact of each isoform in PDA cells
(MIAPACA-2 and ASP-C-1) transfected with isoform-specific
siRNA. A panel of inflammation- and invasion/angiogenesis-related genes was also evaluated.
/200
Treatment Sequencing for Resectable Pancreatic
Cancer: Influence of Early Metastases and Surgical
Complications on Multimodality Therapy Completion
Rates and Survival
Ching-Wei D. Tzeng1, Daniel E. Abbott2, Jeffrey E. Lee1,
Peter W. Pisters1, Jason B. Fleming1, Jean-Nicolas Vauthey1,
Matthew Katz1
1. Department of Surgical Oncology, The University of Texas MD
Anderson Cancer Center, Houston, TX; 2. Surgical Oncology,
University of Cincinnati, Cincinnati, OH
INTRODUCTION: Multimodality therapy (MMT) is important to the long-term survival of patients with resectable
RESULTS: Circulating E6 mRNA levels were significantly pancreatic adenocarcinoma (PDAC), but its completion can
(p = 0.006) elevated in PDA patients when compared to all be hindered by early cancer progression or by treatment
6
/
METHODS: A cost model was created from a third-party
payer perspective over a 10-year period. Average wholesale
unit prices of generic and name-brand PPIs were obtained
from the 2012 Micromedex Redbook®. Low-dose (20 mg
daily) generic PPI and high-dose (40 mg twice daily) namebrand PPI costs were used as the low-end and high-end
PPI costs, respectively. The cost of 24-hour pH monitoring
and manometry was obtained from 2012 Medicare fees.
Manometry was necessary to determine esophageal function and for appropriate positioning of the pH probe. A
cohort of 100 patients who underwent pH monitoring at
an academic institution was retrospectively reviewed for
type of GERD symptoms and duration of PPI use prior to
pH monitoring. The sensitivity of 24-hour pH monitoring
by literature review ranged from 30% to 96%. The cost of
unnecessary PPIs was subtracted from the cost of pH monitoring for all patients to evaluate the cost-effectiveness.
Among all patients, those who completed MMT lived longer than those who did not (36 vs. 11 mo, p < 0.001). The
median OS durations of all NT and SF patients (NT 28 vs.
SF 21 mo, p = 0.082), the subset in each cohort who completed MMT (NT 36 vs. SF 36 mo, p = 0.565), and the subset
in each cohort who did not complete MMT (NT 11 vs SF 13
mo, p = 0.325) were not statistically different.
The rate of PMC did not differ between NT and SF groups
(19% vs. 17%, p = 0.782). SF patients with no PMC had a
71% (31/44) MMT completion rate vs. 25% (2/8) after PMC
(p = 0.014). When resected NT patients suffered PMC, there
was no significant decrease in OS (36 vs. 30 mo, p = 0.934),
in contrast to the negative effect of PMC in SF patients (26
vs. 10 mo, p < 0.001).
RESULTS: The weekly cost of PPIs ranged from $29.06
to $107.70, and the cost of 24-hour pH monitoring was
$690. The cost of PPI therapy reaches equivalence with pH
monitoring after 6.4 to 23.7 weeks, depending on the PPI
regimen. Patients who experienced esophageal and extraesophageal GERD symptoms reported a median of 208 and
7
Sunday
Abstracts
CONCLUSIONS: Completion of multimodality therapy
is strongly associated with improved survival of operable
patients with resectable PDAC. Even in the highly selected
cohort evaluated in this study, early cancer progression
METHODS: We retrospectively evaluated all patients and PMC negatively impacted MMT completion rates and
with PDAC at our institution from 2002–2007, who had OS, particularly among SF patients. Thus, NT sequencing
1) a radiographically resectable pancreatic head tumor, 2) remains a valuable alternative to SF sequencing for tumor
a performance status (PS) and comorbidities suitable for biology evaluation and patient selection.
immediate surgery, and 3) a carbohydrate antigen (CA)
201
19-9 <1000 U/ml. MMT was defined as resection before or
after completion of planned pre- or post-operative therapy. Early Referral for 24-Hour Esophageal pH Monitoring
Postoperative major complications (PMC) were defined as
Is More Cost-Effective Than Prolonged Use of
Clavien Grade ≥3. Disease progression was considered early
when it developed within 3 months in SF patients or prior Proton Pump Inhibitors in Patients with Suspected
to planned resection in NT patients. Reasons for and rates Gastroesophageal Reflux Disease
1
1
2
of failure to complete MMT, 90-day PMC, and overall sur- David Kleiman , Toni Beninato , Brian P. Bosworth ,
4
3
Laurent Brunaud , Thomas Ciecierega , Carl V. Crawford2,
vival (OS) were compared between the two cohorts.
2
1
1
RESULTS: 112 NT and 58 SF patients met inclusion cri- Brian G. Turner , Thomas J. Fahey , Rasa Zarnegar
1.
Surgery,
New
York
Presbyterian
Hospital
–
Weill
Cornell Medical
teria. 92/112 (82%) NT and 33/56 (59%) SF patients with
College,
New
York,
NY;
2.
Medicine,
New
York
Presbyterian
complete follow-up completed MMT (p < 0.001). NT
patients did not complete MMT due to early progression (n Hospital – Weill Cornell Medical College, New York, NY; 3.
= 13, including 8 nontherapeutic laparotomies) and PS (n = Pediatrics, New York Presbyterian Hospital – Weill Cornell Medical
7). SF patients did not complete MMT due to early progres- College, New York, NY; 4. Surgery, University Hospital Nancy,
sion (n = 10), PMC (n = 6), and PS (n = 3); 4 SF patients also Brabois, France
underwent nontherapeutic laparotomy due to metastases.
BACKGROUND: Gastroesophageal reflux disease (GERD)
affects nearly 25% of adults, but the diagnostic algorithm
remains controversial. Most guidelines recommend an
empiric 8-week trial of proton-pump inhibitors (PPIs), but
many patients remain on PPIs for much longer periods.
Twenty-four hour esophageal pH monitoring can help rule
out GERD and avoid the unnecessary cost and risks of prolonged PPI use. We hypothesized that performing pH monitoring promptly after an 8-week PPI trial would be a more
cost-effective strategy than prolonged courses of PPIs.
complications. We sought to compare the influence of each
of these factors on the MMT completion rates of operable
patients with resectable PDAC treated with either a neoadjuvant (NT) or surgery-first (SF) sequencing strategy.
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52 weeks of PPI use, respectively, prior to referral. The cohort
was prescribed a total of 21,411 weeks of PPIs beyond the
initial 8-week trial, 32% of which were for patients who had
a negative 24-hour pH monitoring study and were therefore
unnecessary. If the sensitivity of pH monitoring was 100%,
performing pH monitoring on all patients after an 8-week
PPI trial would have saved between $1,966 and $7,285 per
patient over 10 years. This strategy remains cost-effective
as long as the sensitivity of pH monitoring is above 35%
(Figure 1). In this model, since patients with extra-esophageal GERD symptoms were referred a median of 156 weeks
sooner than patients with esophageal symptoms, the cost
savings were less (Table 1).
Risk Factors Associated with 30-Day Readmissions in
Major Gastrointestinal Resections
Kristin N. Kelly, James C. Iannuzzi, Aaron S. Rickles,
Veerabhadram Garimella, John R. Monson, Fergal Fleming
Surgical Health Outcomes & Research Enterprise, Division of
Colorectal Surgery, Department of Surgery, University of Rochester
Medical Center, Rochester, NY
PURPOSE: Preventable readmissions represent a major
burden on the health care system and by risk stratifying
patients resources can be directed to prevent these costly
complications. This study examines patient characteristics,
surgical factors, and postoperative complications associated
with 30-day readmissions in gastrointestinal (GI) resections.
METHODS: Inpatients undergoing major GI surgery
were selected from the 2011 ACS National Surgical Quality Improvement Program prospectively collected database.
Procedures were classified into esophageal, gastric, small
bowel, large bowel, liver, and pancreatic resections using
Common Procedural Terminology codes. Postoperative
complications were divided into pre- and post-discharge
groups by comparing time to complication and discharge.
Operative times were grouped by 75th percentile (≥4 hours).
Univariate analysis using Chi-square, Mann Whitney-U,
and Student’s T-test were used to compare patient comorbidities, surgical characteristics, and postoperative complications with 30-day unplanned readmission rates. Factors
with a p < 0.1 were included in multivariate logistic regression. Odds ratios (OR) and 95% confidence intervals (CI)
are reported and p-value < 0.05 was considered statistically
significant.
Table 1: Estimated Range of Cost Savings Over 10-Years
(Per Patient) of Performing Early 24-Hour pH Monitoring
Across the Range of Reported Sensitivity for Diagnosing GERD
30% Sensitivity(1)
All patients
(2)
–$100.31 to $1,495.45
96% Sensitivity(1)
$1,196.99 to $6,303.43
RESULTS: For 43,894 patients undergoing GI resection, the
overall 30-day unplanned readmission rate was 12.0% ranging from 11.4% for colorectal resections to 15.7% for pancreatic resections. Median postoperative length of stay was
longer in the readmission group (7 vs. 6 days p < 0.0001).
Major predictors of 30-day readmissions included pre-discharge major complications (OR = 1.28; CI: 1.14,1.44, p <
0.0001), preoperative steroid use (OR = 1.62; CI: 1.39,1.89,
p < 0.0001), operative time ≥4 hours (OR = 1.61; CI:
1.45,1.78, p < 0.0001) and discharge to a facility other than
home (OR = 1.48; CI: 1.28,1.70, p < 0.0001). Other factors
associated with increased readmission included dependent
functional status, open surgery, pulmonary comorbidity,
neurologic comorbidity, higher ASA score, diabetes, and
preoperative anemia (table 1). Post-discharge major and
minor complications were highly correlated with 30-day
readmission rates (OR = 59.3; CI: 52.2,67.3, p < 0.0001 and
OR = 6.3; 95% CI: 5.8,6.9, p < 0.0001) and not included in
the final model.
Esophageal
–$59.57(2) to $1,646.44
$1,327.37 to $6,786.61
symptoms
Extra-esophageal –$299.23(2) to $758.25
$560.47 to $3,940.09
symptoms
(1)Range of savings from low-dose generic PPI to high-dose name-brand PPI,
(2)Negative values reflect additional cost over 10-years.
CONCLUSIONS: Most patients are maintained on PPIs for
periods greatly surpassing the cost-equivalence point with
24-hour esophageal pH monitoring. Early referral for pH
monitoring after a brief empiric PPI trial may result in substantial cost savings for patients with both esophageal and
extra-esophageal GERD symptoms.
8
Table 1: Factors Associated with Unplanned 30-Day Readmissions Following GI Resection
% Readmitted
18.6 v 11.5
15.4 v 12.8
15.1 v 11.6
13.1 v 9.1
14.9 v 11.1
15.2 v 11.9
14.2 v 11.5
15.8 v 11.8
13.5 v 9.9
12.8 v 11.9
13.8 v 11.6
13.5 v 11.3
Adjusted OR
1.62
1.61
1.48
1.46
1.28
1.26
1.22
1.24
1.17
1.16
1.13
1.11
95% CI
1.39, 1.89
1.45, 1.78
1.28, 1.70
1.30, 1.63
1.14, 1.44
1.06, 1.51
1.03, 1.45
1.01, 1.51
1.06, 1.30
0.98, 1.38
1.01, 1.27
1.01, 1.22
p-Value
<0.0001
<0.0001
<0.0001
<0.0001
<0.0001
0.01
0.02
0.037
0.002
0.077
0.032
0.024
could inform resource utilization and post-operative care
to help prevent readmissions in select high-risk GI surgical
patients.
CONCLUSIONS: Unplanned 30-day readmissions represent a major medical and financial concern, but some may
be foreseeable and thus preventable. Although previous
studies have identified major complications as a strong risk
factor for readmissions, this might represent an overestimate of the risk due to confounding by including post-discharge complications that may in fact cause, not predict,
readmissions. This model provides insight into factors that
Logistic regression model also controlled for age, hepatic
insufficiency, cardiac comorbidity, renal insufficiency,
wound class, smoking, bleeding disorder, chemotherapy/
radiation, weight loss, preoperative sepsis, and LOS.
8:00 AM – 9:30 AM
203AB
DDW COMBINED RESEARCH FORUM
(AGA-ACCREDITED) IBD
203
205
Mesenchymal Stem Cell Transplantation Improves
Chronic Colitis-Associated Cholangitis Through
Inhibiting the Activity of LPS/TLR4
Intestinal Barrier Dysfunction Measured with Confocal
Endomicroscopy in Macroscopically Normal Mucosa
Can Predict Requirement for Treatment Escalation
X. Zhang1, G. Niu1, L. Liu1, H. Li1, J. Guo1, J. Song1, Y. Liu1,
S. Chen2
1. Department of Gastroentology, The Second Hospital of Hebei
Medical University, Shijiazhuang City, China; 2. Division of
Pediatric Infectious Diseases and Immunology, Burns and Allen
Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA
K. Liu1, J. Mill1, B. Wong2, C.P. Selinger1, V.C. Kariyawasam1,
N. Merrett1,3, R.W. Leong1, 2
1. Gastroenterology and Liver Services, Bankstown and Concord
Hospitals, Concord, NSW, Australia; 2. Faculty of Medicine, The
University of New South Wales, Sydney, NSW, Australia;
3. Gastroenterology and Liver Services, University of Western
Sydney, Sydney, NSW, Australia
204
IL-10-Producing Mucosal B Cells Attenuate T CellMediated Colitis Through Induction of Tr-1 Cells
Y. Mishima1, B. Liu1, C. Karp2, R.B. Sartor1
1. CGIBD, University of North Carolina, Chapel Hill, NC;
2. Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
9
Sunday
Abstracts
Risk Factor
Preoperative Steroid use
Operative time (4 hrs vs. <4hrs)
Discharge Destination (Facility vs. Home)
Open Surgery
Pre-discharge Major Complication
Neurologic Comorbidity
Pulmonary Comorbidity
Dependent Functional Status
ASA (3/4 vs 1/2)
Pre-discharge Minor Complication
Diabetes
Preoperative Anemia (HCT < 36)
206
Link Between VEGF Expression, Angiogenesis and
Inflammation in Pediatric Crohn’s Disease
Jennifer L. Knod1, Kelly M. Crawford1, Mary R. Dusing1,
Artur Chernoguz1, Margaret H. Collins2, Jason Frischer1
1. Division of Pediatric General and Thoracic Surgery, Cincinnati
Children’s Hospital Medical Center, Cincinnati, OH; 2. Division
of Pathology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, OH
PURPOSE: Early-onset Crohn’s disease (CD) accounts for
25% of cases but is distinct from adult-onset CD by a more
severe disease activity index, increased immunosuppressant
requirement, and more extensive intestinal involvement.
The pathogenic link between chronic inflammatory diseases and angiogenesis prompted investigations into its role
in inflammatory bowel disease. We hypothesize that VEGF
driven angiogenesis plays a significant role in Crohn’s disease inflammation.
METHODS: Pediatric patients (n = 13), ages 12 to 16, at
our institution having undergone resection involving the
terminal ileum for CD were compared to controls (n = 5)
with non-inflammatory indications for resection. Additionally, from each Crohn’s pathology specimen, inflamed and
non-inflamed ileum were obtained for comparison. Samples were evaluated for inflammation using the Crohn’s
Histology Index of Severity (range 0–13) and for microvessel density by quantitative endothelial cell immunohistochemistry using CD31. Corresponding tissues were assessed Figure 1: Inflammation score (range 0–13) of inflamed pediatric Crohn’s
for VEGF-A mRNA and protein expression by RT-PCR and disease ileum increased compared to both non-inflammed Crohn’s
Western blot respectively. Results expressed as mean ± SEM diseae and control. Results expressed as mean ± SEM (*P < 0.001).
were analyzed for significance (P ? 0.05) by ANOVA and Student’s t-test.
RESULTS: Inflammation scores were significantly increased
(Figure 1) between inflamed CD and controls (5.8 ± 0.7 vs
0.62 ± 0.38, P < 0.001), and between paired inflamed and
non-inflamed ileum (5.8 ± 0.7 vs 1.2 ± 0.6, P < 0.001).
Increased microvessel density was observed in both
inflamed and non-inflamed CD groups compared to controls (inflamed 24,955 ± 3,202 μm2, non-inflamed 18,719
± 2,050 μm2, control 9,032 ± 1,474 μm2), with statistical
significance (P = 0.008) only present between inflamed CD
and control subjects (Figure 2). Expression of tissue VEGFA mRNA was upregulated in CD (CD 8.5 ± 2.51 vs control
2.32 ± 0.58, P = 0.034), and was associated with an increased
trend in VEGF-A protein levels (VEGF/GAPDH, CD 3.96 vs
control 2.20, P = 0.53).
CONCLUSION: Angiogenesis is associated with pediatric
Crohn’s disease as observed by increased microvessel density that correlates with greater inflammation in resected
ileal specimens. At the molecular level, we demonstrate
elevated VEGF transcription and protein levels, which
implicates a VEGF pathway for angiogenesis associated
inflammation in early-onset Crohn’s disease. Further investigations regarding mechanism of angiogenesis, its relationship to inflammation, and effectiveness of anti-angiogenic
Figure 2: Microvessel density (MVD) in pediatric Crohn’s disease ileum
therapies are warranted.
(inflamed and non-inflamed) increased compared to control, detected by
CD 31 quantitative immunohistochemical staining. Results expressed as
mean ± SEM (*P = 0.008).
10
PRESIDENTIAL PLENARY B
(PLENARY SESSION II)
CONCLUSIONS: PVE is safe and effective in inducing
hypertrophy in patients with small FLR and allows 2/3 of
patients with inadequate FLR the opportunity for curative
resection.
363
Safety and Efficacy of Portal Vein Embolization
Before Planned Major Hepatectomy: An Institutional
Experience of 358 Patients
Junichi Shindoh1, Ching-Wei D. Tzeng1, Thomas Aloia1,
Steven Curley1, Giuseppe Zimmitti1, Steven Y. Huang2,
Armeen Mahvash2, Sanjay Gupta2, Michael J. Wallace2,
Jean-Nicolas Vauthey1
1. Surgical Oncology, University of Texas MD Anderson Cancer
Center, Houston, TX; 2. Diagnostic Radiology, University of Texas
MDAnderson Cancer Center, Houston, TX
364
Gastric Emptying, Ensuing GLP-1 Release and Insulin
Sensitivity After Partial Pancreaticoduodenectomy:
Improved Glycemic Control in Cases Without Pylorus
Preservation (Whipple Procedure)
Johannes Miholic1, Marlene Wewalka2, Stefan Harmuth1,
Jens J. Holst3
1. Department of Surgery, Medical University of Vienna, Vienna,
Austria; 2. Gastroenterology, Department of Internal Medicine
III – Medical University of Vienna, Vienna, Austria; 3. The
Panum Institute, Department of Medical Physiology, University of
Copenhagen, Copenhagen, Denmark
INTRODUCTION: Portal vein embolization (PVE) induces
hypertrophy of the future liver remnant (FLR) in patients
with unfavorable tumor distribution and low calculated
standardized FLR (sFLR). We sought to evaluate the safety
and efficacy of PVE.
METHODS: We evaluated 358 consecutive patients who
underwent PVE before intended major hepatectomy from
1995–2012. Diagnoses, morbidity, degree of hypertrophy
(DH), and post-PVE resectability were evaluated in the
whole study period and compared over time.
OBJECTIVE: Investigate the relationship between gastric
emptying, postprandial GLP-1 and insulin sensitivity after
pancreaticoduodenectomy (PD).
BACKGROUND: Abnormal glucose regulation is highly
prevalent in patients with pancreatic neoplasm, and
resolves in some after PD, the cause of which is unclear. The
procedure is carried out with pylorus preservation (PPPD)
or with distal gastrectomy (Whipple procedure). Accelerated gastric emptying, and ensuing enhanced release of
glucagon-like peptide-1 (GLP-1) conceivably play a role
in glucose metabolism after PD. Any procedure associated
with accelerated gastric emptying might improve glycemic
control. It was the purpose of this study to shed light on the
relationship between gastric emptying, GLP-1 and glycemic
control after PPPD and the Whipple procedure.
RESULTS: The diseases treated included colorectal liver
metastases (CLM, 217, 61%), hepatocellular carcinoma (49,
14%), extrahepatic biliary cancers (31, 9%), neuroendocrine
metastases (25, 7%), intrahepatic cholangiocarcinoma (13,
3%), and others (23, 6%). Right PVE alone was performed in
31% of cases; due to tumor distribution and to the necessity
of resecting segment IV, right PVE with segment IV PVE was
required in 66% of patients. The first-session PVE success
rate was 98%. Post-PVE complications occurred in 12/358
patients (3%), with portal vein thrombosis occurring in
6 (2%) patients. Median pre-PVE standardized FLR (sFLR)
was 19% (inter-quartile range, IQR, 15.0–25.9). Median
post-PVE sFLR was 30% (IQR, 22.5–38.2). Of 358 patients
who underwent PVE, 282 (79%) were taken to the operating room with 240/358 (67%) undergoing curative hepatectomy. Post-hepatectomy major complications occurred
in 62/240 (26%) patients, with postoperative hepatic insufficiency (PHI) in 20/240 (8%) and a 90-day liver-related
mortality rate of 9/240 (4%). Over the 18-year study period,
the rate of PVE performed for CLM increased from 39%
before 2005 to 78% in 2010–12. The use of preoperative
chemotherapy and long-duration (>12 weeks) chemotherapy increased from 26% to 86% and from 16% to 43%,
respectively, in that time frame (all p < 0.001). However,
despite increased preoperative chemotherapy usage, PHI
and 90-day liver-related mortality rates improved over the
last decade (11% and 4%, respectively before 2010 vs. 3%
and 3%, in 2010–12).
METHODS. A 75 g oral glucose tolerance test was carried out
in tumor free subjects, 13 having undergone PPPD, and in 13
after the Whipple procedure (Table1). Gastric emptying was
measured by the paracetamol absorption method. Plasma
concentrations of glucose, insulin, GLP-1, and paracetamol
were measured at baseline, 10, 20, 30 60, 90, 120, 150, and
180 minutes. Homeostasis model assessment-estimated insulin resistance (HOMA-IR) and oral glucose insulin sensitivity
were calculated from glucose and insulin concentrations.
RESULTS. Patients with Whipple procedure as compared
to PPPD had accelerated gastric emptying (p = 0.01) which
correlated with early (0–60 min.) integrated GLP-1 (AUC30;
r2 = 0.61; p = 0.02) and insulin sensitivity (r2 = 0.41; p =
0.026), and inversely with HOMA insulin resistance (r2 =
0.17; p = 0.033). 2 of 13 Whipple patients (15%) as compared to 7 of 13 after PPPD (54%) had postload glucose
11
Sunday
Abstracts
10:15 AM – 11:00 AM
303ABC
METHODS: A cost-effectiveness decision tree was created using TreeAge (Figure 1). Assigned probabilities were
derived from published literature. The decision point compared extended duration thromboprophylaxis with low
molecular weight heparin for 21 days after discharge to
inpatient-prophylaxis alone, with base case assumptions
(Table 1) based on an abdominal oncologic resection without complications in a 45 year-old male. The end points
were pulmonary embolism or deep vein thrombosis with
attendant costs and assigned effectiveness evaluated by
Quality Adjusted Life Years (QALY). Willingness to pay was
set at $50,000/QALY. Sensitivity analyses were performed to
assess uncertainty within the model, with particular interest in the threshold for cost-effectiveness based on VTE
incidence.
concentrations (i.e. 120 minutes postmeal) ≥200 mg/dl (p <
0.05). None of 13 (0%) after Whipple procedure but 4 of 13
(31%) after PPPD had fasting glucose concentrations ≥126
mg/dl (p < 0.05).
CONCLUSIONS. Gastric emptying was accelerated after
Whipple procedure as compared to patients who have
undergone pylorus preserving PD, resulting in higher postprandial GLP-1 concentrations and insulin sensitivity and
improved glycemic control.
Age (yr)
Interval (mo)
Gastr. Emptying (Integr.parac.
30 min)
Early integ. GLP-1 (30 min)
Fasting glucose (mg/dl)
Insulin resistance (HOMA-IR)
Insulin sensitivity (OGIS 180)
Whipple
61 (32–70)
PPPD
62 (48–66)
P-Value
NS
31 (7–199)
495 (309–860)
19 (5–107)
319 (230–601)
NS
0.01
2880 (920–9205)
91 (75–123)
0.6 (0.22–1.75)
488 (310–568)
1740 (340–3215)
108 (83–170)
0.8 (0.6–5.8)
406 (265–500)
0.03
0.02
0.02
0.009
/365
Extended Duration Thromboprophylaxis CostEffectiveness in Abdominal Surgery
J.C. Iannuzzi1, A.S. Rickles1, J.G. Dolan2, F. Fleming1,
J.R. Monson1, K. Noyes1
1. Surgical Health Outcomes & Research Enterprise, Division of
Colorectal Surgery, Department of Surgery, University of Rochester
Medical Center, Rochester, NY. 2. Community and Preventative
Health, University of Rochester Medical Center, Rochester, NY
Figure 1: Decision Tree.
RESULTS: Given base case assumptions with VTE probability of 4%, extended duration thromboprophylaxis had an
incremental cost effectiveness ratio of $8123/QALY, which
was considered cost-effective. The results were robust to
sensitivity analysis with the highest uncertainty associated
with VTE incidence and medication cost. The threshold for
the relative cost-effectiveness was a VTE incidence exceeding 2.53%.
BACKGROUND: Post-discharge thromboprophylaxis is
the practice of prescribing antithrombotic therapy for 21
days after discharge, commonly used in surgical patients
who are at high risk for venothromboembolism (VTE).
Multiple consensus guidelines recommend extended duration thromboprophylaxis (EDTPPX) after major abdominal
oncologic resections based on randomized clinical trials
demonstrating a significant reduction in VTE events after
surgical discharge in these patients. While the National
Comprehensive Cancer Network suggests all major abdominal oncologic resections receive EDTPPX, the American
College of Chest Physicians suggests an individualized
risk assessment, with only high risk patients undergoing
oncologic resections suggested to receive EDTPPX, however, high risk is not currently defined. The threshold for
high risk ought to be informed by when it is cost-effective
to provide EDTPPX, which has not previously been established. In order to further inform current guidelines this
study sought to determine the VTE incidence threshold for
the cost-effectiveness of low molecular weight heparin for
4 weeks after surgery as compared to inpatient prophylaxis
only.
12
CONCLUSIONS: Given the base case assumptions,
extended prophylaxis is more cost effective than inpatient
prophylaxis alone, and the threshold for its use should be
cases where the estimated VTE risk exceeds 2.53%. These
findings should inform future guidelines’ definition of
“high risk” and individualized risk scores should be developed to predict patient likelihood of post-discharge VTE.
These results can lead to specific individualized EDTPPX
application.
Table 1: Baseline Model Assumptions and Sensitivity Analysis
Utility (Range)
N/A
0.84 (0.7–0.931)
0.76 (0.6–0.89)
0.98 (0.9–.099)
1
2:00 PM – 4:00 PM
300
VIDEO SESSION I
437
439
Robotic Assisted Median Arcuate Ligament Release
Endoscopic Removal of a Laparoscopic Adjustable
Gastric Band That Is Eroded
Martin J. Dib, Mark P. Callery, Marc Schermerhorn,
A. James Moser
Surgery, BIDMC, Boston, MA
40-year-old female with chronic abdominal pain and preoperative aortography consistent with median arcuate
ligament syndrome. Ports and a laparoscopic liver retractor are placed. After docking the robot, the left gastric vein
is divided. The left gastric artery is encircled with a vessel
loop to apply inferior traction and identify the common
hepatic artery of the celiac trunk. The left lateral border of
the celiac trunk is dissected. Hook cautery and LigaSure is
used to divide the left crus of the diaphragm. Finally, circumferential skeletonization of the aorta at the entrance of
the celiac trunk is achieved.
Aurora D. Pryor, Dana A. Telem, Joshua Karas,
Georgios Spentzouris, Eleanor Fallon, Jonathan Buscaglia
Surgery, Stony Brook University Medical Center, Stony Brook, NY
This is a case of a 52-year-old male with history of morbid
obesity status-post Laparoscopic Band at an outside hospital complicated by port infection and band erosion. Following port removal, the patient presented for removal of
the laparoscopic band. Due to the extent of the intra-gastric
band erosion, total endoscopic removal was attempted succesfully. This case highlights the mechanism of endoscopic
removal of the band, challenges encountered, and techniques to navigate these obstacles. The patient tolerated
removal of the band, was started on a liquid diet immediately, and was discharged on post-operative day one.
438
440
Enucleation of Hepatic Neuroendocrine Tumor
Metastases
Totally Laparoscopic Left Colonic Resection with
Intracorporeal Anastomosis
Nicholas N. Nissen, Vijay G. Menon
Cedars-Sinai Medical Center, Los Angeles, CA
Laura Doyon, Celia M. Divino, Scott Q. Nguyen, Edward Chin
Surgery, The Mount Sinai School of Medicine, New York, NY
Neuroendocrine tumors (NET) represent a unique type of
hepatic metastasis. These tumors tend to be well encapsulated and generally carry a favorable prognosis. Many of
these patients will require repeated hepatic interventions
over a period of several decades. Surgical enucleation of
hepatic NETs is a technique that is not often employed
but that holds great potential for preservation of maximal
hepatic parenchyma, while carrying a low risk of injury
to underlying vascular and biliary structures. This video
describes the application of enucleation to patients with
NET metastases and addresses patient selection, surgical
techniques and management of complications.
13
This video demonstrates two complementary laparoscopic
cases, each focusing on techniques for intracorporeal anastomosis. The first is an elective sigmoid resection for history
of uncomplicated diverticulitis. It uses an end-to-side intracorporeal anastomosis performed with a circular stapler.
The second is a left hemicolectomy, performed for descending colon cancer. It employs a side-to-side intracorporeal
anastomosis performed with a linear stapler and sewn common enterotomy. Totally laparoscopic colonic resection
with intracorporeal anastomosis can facilitate resection
in obese patients, as well as improve cosmesis and wound
complications by reducing incision length for extraction.
Sunday
Abstracts
Variable
Baseline Probability
Sensitivity Range
Cost ($,2010)
Cost Range ($)
VTE
0.04
0.001–0.3
N/A
N/A
DVT
0.923
0–.0923
10,804
3371–22,748
PE
0.077
0.077–1
16,644
6443–25,554
LMWH
0.22
0.22–0.7
885.99
357–885.99
No VTE
0.96
0.7–0.999
680
0–680
VTE = Venothromboembolism, DVT = Deep Vein Thrombosis, PE = Pulmonary Embolism, LMWH = Low Molecular Weight Heparin
441
443
Laparoscopic Central Pancreatectomy and
Pancreaticogastrostomy for the Management of
a Proximally Migrated Pancreatic Stent
Laparoscopic Repair of a Large Right Sided Morgagni’s
Hernia
1
2
David Lawrence1, Yuhsin V. Wu2, Michael J. Rosen1,2
1. Case Western Reserve University, Cleveland, OH; 2. Surgery,
University Hospitals, Cleveland, OH
2
Marc G. Mesleh , Frank Lukens , Michael B. Wallace ,
Horacio J. Asbun1, John Stauffer1
1. General Surgery, Mayo Clinic Jacksonville, Jacksonville, FL;
2. Gastroenterology, Mayo Clinic Jacksonville, Jacksonville, FL
Morgagni’s hernias are rare congenital anterior diaphragmatic hernias for which the optimal method of repair is
A 43 year old female had a pancreatic stent placed during unknown. This video presents a morbidly obese patient with
ERCP for elevated LFTs. The stent migrated proximally into oxygen dependent chronic obstructive pulmonary disease
the pancreas and was unable to be retrieved with multiple and a Morgagni’s hernia that compresses her entire right
endoscopic attempts. After several episodes of pancreatitis, lung. Omentum and colon are seen herniating through
she was evaluated for surgical retrieval. A laparoscopic cen- the 10x15cm defect. Through a laparoscopic approach the
tral pancreatectomy was performed to remove the stent, and intra-abdominal contents were reduced, the defect primarily closed, and re-enforced with mesh. After the repair, the
a pancreaticogastrostomy was created for reconstruction.
patient had significant improvements in pulmonary status.
Laparoscopic repair with mesh re-enforcement is a viable
442
and easily accomplished approach for Morgagni’s hernia
Difficult Diverticulits and Failed Anastomosis: Troubles repair.
and More Troubles
Barry Salky
Surgery, Mount Sinai Hospital, New York, NY
This is a 68 year old female with mulitiple episodes of
diverticulitis documented on CT scans. Dyspareunia is a
recent symptom. This video demonstates several technical challenges assoiciated with chronic diverticulitis. After
completion of the descending rectal anastomosis, a leak
was detected and the video demostrates one technique of
recovery in a difficult clinical situation.
2:00 PM – 4:45 PM
308D
PLENARY SESSION III
staging system, lymph node ratio (LNR), and overall survival (OS) from date of diagnosis were analyzed. Median
follow-up was 19 months (range, 1–211 months).
445
Modern Chemotherapy Mitigates Adverse Prognostic
Effect of Regional Nodal Metastases in Stage IV
Colorectal Cancer
RESULTS: The number of positive regional nodes and LNR
correlated with the presence of multiple sites of distant
Yun Shin Chun , Steven Cohen , John H. Donohue ,
metastases (p < 0.001). Survival was significantly associBarbara Burtness1, Michael J. Hall1, David M. Nagorney2
ated with number of positive nodes and LNR, with median
1. Fox Chase Cancer Center, Philadelphia, PA; 2. Mayo Clinic,
OS of 36 months with negative regional nodes, compared
Rochester, MN
to 17 months with ≥7 positive nodes (p < 0.001). Among
BACKGROUND: In colorectal cancer, the involvement 315 patients treated with modern oxaliplatin- or irinoteof regional lymph nodes with metastasis is an established can-based chemotherapy after colorectal resection, survival
prognostic factor. However, the impact of the number of was not significantly associated with number of positive
positive regional nodes on patient outcome with stage IV regional nodes (p = 0.072) or LNR (p = 0.34). The number
of regional nodal metastases correlated with OS among 249
disease is not well-defined.
patients who underwent resection of liver metastases but
METHODS: A retrospective review was performed of 869 lost prognostic significance in the subset of 105 patients
patients at two tertiary referral centers with synchronous who underwent hepatectomy with perioperative modern
stage IV colorectal cancer who underwent resection of their chemotherapy.
primary tumors. Associations between number of positive
regional lymph nodes stratified by the 7th edition AJCC
1
1
2
14
Sunday
Abstracts
CONCLUSIONS: In stage IV colorectal cancer, increasing
number of positive regional lymph nodes and LNR correlate with multiple sites of distant metastases and poorer survival. The number of metastatic regional lymph nodes loses
prognostic significance with modern chemotherapy, particularly in patients undergoing resection of liver metastases.
/447
Night Time Is Not the Right Time: Increased Risk of
Complications After Laparoscopic Cholecystectomy at
Night
446
Uma R. Phatak, Curtis J. Wray, Debbie Lew, Richard Escamilla,
Winston M. Chan, Tien C. Ko, Lillian S. Kao
Surgery, University of Texas Health Science Center, Houston, TX
Evidence from a large national database has shown that
performance of non-emergent general surgery procedures
at night does not predispose patients to increased morbidity or mortality. However, these results may not be generalizable to high risk populations of medically underserved
patients. We hypothesized that performance of laparoscopic
cholecystectomy (LC) at night in such a population would
be associated with increased post-operative complications.
Totally Laparoscopic Cytoreductive Surgery and
Hyperthermic Intraperitoneal Chemotherapy for
Mucinous Adneocarcinoma of the Appendix
Cherif Boutros, Nader Hanna
Division of Surgical Oncology, University of Maryland,
Baltimore, MD
Open cytoreductive Surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) has emerged as the procedure
of choice for mucinous adenocarcinoma of the appendix
(MAA), however is associated with substantial morbidity.
We present a case of a totally laparoscopic R0- CRS-HIPEC
for MAA. CRS included: right hemicolectomy, omentectomy, cholecystectomy, bilateral salpingo-oopherectomy,
excision of the round and falciform ligaments and stripping of the peritoneum of the right diaphragm; followed
by HIPEC through single inflow and outflow catheters. OR
time was 380 mns and EBL was 100 mL. There was no postoperative morbidity. The patient was discharged home on
postoperative day 8.
15
We conducted an IRB approved single center retrospective
review of consecutive LC patients between October 2010
and May 2011 at a safety-net hospital in Houston, TX.
Data were collected regarding demographics, date and site
of diagnosis (defined as first imaging study demonstrating gallstones), number of biliary-related admissions and
emergency room (ER) visits between diagnosis and surgery,
length of stay (LOS) for each admission, dates and types of
procedures, dates and types of imaging studies, and 30-day
postoperative complications (bile leak/biloma, common
bile duct injury, retained stone, superficial surgical site
infection, organ space abscess, pneumonia, readmission,
and death). We defined “night” as 7PM to 7AM. Statistical
analyses were done using STATA 12 (College Station, TX).
During the 8-month period, 580 patients received LC and hazards. We compared survival of patients with thrombosis
incision times were available for 549. Of these 38% (n = of the mesenteric venous system to that of patients with
208) were elective and 62% (n = 341) were non-elective. A patent reconstructions.
majority were female (n = 460, 84%) and Latino (n = 456,
83%). There were 196 LC performed at night of which 186
were non-elective and 10 were elective. Of the 353 daytime
LCs, 198 were elective and 155 were non-elective. There
were 35 complications in 22 patients (4 elective, 18 nonelective). Multivariate analysis revealed age (OR 1.05, 95%
CI 1.01 to 1.08, p = 0.003) and LC at night (OR 3.1, 95% CI
1.3 to 7.6, p = 0.012) to be associated with increased risk of
complications. The predicted probability of a complication
increased three fold for older patients who received LC at
night (Figure).
Age and performance of LC at night were predictive of an
increased risk of complications among medically underserved patients treated at a high volume safety net hospital with limited resources. Restricting performance of LCs
to the daytime in high risk patients, such as the elderly,
may lead to improved outcomes in this challenging clinical
setting.
Predicted probability of complication after LC at night by age.
/448
Short-Term But Not Long-Term Patency of Venous
Reconstruction During Pancreatic Resection Predicts
Survival
Irmina Gawlas, Irene Epelboym, Megan Winner,
Joseph DiNorcia, Yanghee Woo, James A. Lee, Beth Schrope,
John A. Chabot, John D. Allendorf
Department of Surgery, Columbia University, New York, NY
BACKGROUND: Pancreatic surgery with concomitant
vascular reconstruction is being performed with increasing frequency, and offers the benefits of surgical resection
to patients with locally advanced disease. The technique
is not standardized, however, and the short and long-term
patency rates and the clinical significance of thrombosis of
a reconstructed venous system are unknown.
RESULTS: Between 1994 and 2011, 203 pancreatic operations requiring venous reconstruction were performed. Of
these, 106 (52.2%) included resection of the portal vein (PV),
59 (29.1%) included the superior mesenteric vein (SMV)
only, and in 38 (18.7%) patients, the confluence of the PV
and SMV was resected. Segmental resection was performed
in 131 (64.5%), and 72 (35.5%) underwent tangential resecMETHODS: We reviewed clinical and operative character- tion. Ninety-seven veins (47.8%) were repaired primaristics as well as follow up records of patients who under- ily, 67 (33.0%) were repaired using a venous interposition
went pancreatic resections requiring venous resection and graft, and 34 (16.8%) were repaired using an autologous
reconstruction from 1994 to 2011. We sought to identify vein patch. Acute thrombosis occurred in 9 (4.4%) cases,
predictors of acute (occurring within 30 days) thrombosis and was significantly associated with increased perioperaof the venous reconstructions using logistic regression, and tive mortality (22.2% versus 4.6%, p = 0.023). After excludpredictors of late loss of patency using Cox-proportional ing cases of perioperative mortality, acute thrombosis was
16
449
Simultaneous Surgical Resection of Primary and
Metastatic Carcinoid and Neuroendocrine Tumors Is
Both Safe and Effective
Nicholas N. Nissen1, Vijay G. Menon1, Edward M. Wolin2,
Run Yu2, James M. Mirocha3, Alagappan Annamalai1,
Deepti Dhall4, Ashley Wachsman5, Marc L. Friedman5,
Steven D. Colquhoun1
1. Hepatobiliary and Pancreatic Surgery, Cedars-Sinai Medical
Center, Los Angeles, CA; 2. Carcinoid and Neuroendocrine
Tumor Program, Cedars-Sinai Medical Center, Los Angeles, CA;
3. Biostatistics, Cedars-Sinai Medical Center, Los Angeles, CA;
4. Pathology, Cedars-Sinai Medical Center, Los Angeles, CA;
5. Radiology, Cedars-Sinai Medical Center, Los Angeles, CA
INTRODUCTION: Management strategies for patients
with carcinoid and neuroendocrine tumors (CNETs) generally include removal of the primary tumor and cytoreduction (CR) of metastatic tumor burden, both to improve
survival and control symptoms. Patients with synchronous
presentation of primary tumors and hepatic metastases
present a unique challenge. We reviewed our experience
with simultaneous surgical removal of primary abdominal
CNETs and hepatic metastases.
Progression Free Survival Related to Type of Cytoreductive Treatment.
CONCLUSION: To our knowledge this series represents the
largest single center report of simultaneous resection of primary abdominal CNETs and hepatic metastases in the literature. Our results demonstrate that this surgical approach
is safe and effective in expert hands. In patients undergoing near total hepatic CR, which made up almost half of
our series, no additional hepatic treatments were required
PATIENTS: Forty-seven patients underwent simultaneous over the next year, which in turn demonstrates the effective
hepatic resection and removal of either small bowel carci- consolidation of treatments into a single surgical endeavor.
noid (n = 32) or pancreatic NET (n = 15) by two experi- In remaining patients, resection of the primary tumor comenced hepatobiliary surgeons as part of a multidisciplinary bined with partial hepatic CR combined with postoperative
CNET treatment group. Surgical details are shown in the hepatic therapy was equally effective. A multidisciplinary
Table. In 22 patients, surgery was undertaken with a goal of and multimodal approach is essential in these patients.
near total surgical CR, while in 25 patients partial surgical
CR was performed as part of a plan to include postoperative
hepatic arterial or ablative therapy. Tumor progression was
categorized using RECIST criteria.
17
Sunday
Abstracts
RESULTS: Nineteen patients had carcinoid syndrome and
all had dramatic improvement after surgery, with complete
resolution in 11 (58%) cases. Overall there were 8 complications of Clavien grade >2 including bile leak requiring ERCP
(n = 2) and repeat laparotomy (n = 4). There was no 30-day
mortality. Median length of stay was 7 days. Overall survival for the entire cohort at 1, 3 and 5 years was 95%, 82%
and 82%, while the progression free survival at 1, 3 and 5
years was 77%, 37% and 28%. In the 22 patients undergoing near total surgical CR, no patient required repeat
hepatic intervention within 12 months. In the 25 patients
undergoing partial surgical CR, 18 (72%) went on to receive
postoperative hepatic treatments within 12 months. Progression free survival was similar in patients whether they
underwent total CR or partial CR with staged hepatic treatCONCLUSIONS: Acute thrombosis of the reconstructed ment. Patients who failed to undergo postoperative hepatic
portal venous system after pancreatic surgery is clinically therapy (n = 7) were at increased risk of progression comsignificant; it is associated with increased perioperative pared either to patients with near total CR (HR = 3.10, P =
mortality, and even when non-fatal, is associated with 0.044) or partial CR and staged liver treatment (HR = 3.37,
decreased survival. Late loss of patency occurs in one-third P = 0.029) (Figure).
of patients but does not affect survival.
associated with decreased median survival (7.1 versus 15.9
months, p = 0.011) and increased hazard of death (HR 8.6,
CI 3.7–19.9, p < 0.001). These events were more common
in cases of total or subtotal resection compared to Whipple
or distal resections (22.2 versus 2.7%, p < 0.001). Longterm follow-up imaging was available for 138 patients at a
median of 11.7 months. Of these, 43 (31.2%) experienced
a loss of patency of the portal venous system at a median
of 9.5 months; the majority of these were associated with
tumor recurrence. Independent predictors of late loss of
patency were age under 65 (HR 2.2, CI 1.2–4.1, p = 0.015)
and segmental resection (HR 3.3, CI 1.5–7.2, p = 0.002).
Later loss of patency was not associated with decreased
median survival (18.1 versus 16.8 months, p = 0.455) or
increased hazard of death (HR 1.3, CI 0.8–2.1, p = 0.375).
>0.8). MRE accuracy for inflammation, thickening, stenosis, abscess and fistula were all above 85% in per-patient
analysis. In 68/75 cases (90.7%) both approach and strategy
were correctly predicted by MRE. Conversely, in 7/75 cases
(9.3%, 3 false positives: 2 enterocolic fistulas and 1 anastomotic stricture; and 4 false negatives: 3 enteric fistulas with
colon, duodenum and bladder and 1 enteromesial abscess)
surgical strategy (type of resection or strictureplasty, n = 5)
and/or surgical approach (conversion from laparoscopy to
open surgery, n = 2) changed due to discordance with MRE
findings.
Variables Associated with Simultaneous Resection
Type of Primary Surgery
Small Bowel Resection
Right Hemicolectomy
Segmental or Distal Pancreatic Resection
Pancreaticoduodenectomy
Type of Liver Surgery
Major Resection of 3 or more segments
Segmental Resection (1 or 2)
Multiple Wedge Resections and Enucleations
Largest Liver Tumor size (cm)
No. of liver lesions resected;
Grade; High: Intermediate: Low: N/s
Differentiation; Poor: Well: N/s
Positive Lymph nodes (%)
R0 Resection (%)
Bilobar Resection (%)
21
12
11
3
9
11
27
4.9 (mean); 3.5 (median);
0.6–17 (range)
5.5 (mean); 3 (median);
1–28 (range)
4.3%: 27.7%: 51.1%: 17%
4.3%: 82.9%: 12.8%
78.6%
57.4%
55.3%
CONCLUSION: Preoperative MRE correctly predicts surgical strategy in the majority of patients undergoing surgery
for complicated CD. MRE is especially valuable before laparoscopic surgery, since unrecognized lesions may lead to
conversion to open surgery.
451
Tumor Size Does Not Dictate Prognosis After Resection
for Hepatocellular Carcinoma: Results from a Large
Western Series
Michael D. Kluger1,2, Andrea Belli2, Alexis Laurent2,
Daniel Azoulay2, Daniel Cherqui1,2
1. Division of Hepatobiliary Surgery and Liver Transplantation,
New York-Presbyterian Hospital Weill Cornell Medical College,
New York, NY; 2. Service de Chirurgie Digestive et Hépatobiliaire,
Hôpital Henri Mondor, Assistance Publique-Hôpitaux de Paris –
Université Paris-Est, Créteil, France
450
Value of Preoperative Magnetic Resonance Enterography
to Predict Surgical Findings and to Guide Decisions in
Crohn’s Disease: A Prospective Study
Antonino Spinelli1,2, Gionata Fiorino3, Piero Bazzi1,2,
Cristiana Bonifacio4, Matteo Sacchi1, Sarah De Bastiani1,
Andrea Gatti1, Alberto Malesci2,3, Luca Balzarini4,
Laurent Peyrin-Biroulet5, Marco Montorsi1,2, Silvio Danese3
1. Department of Surgery, Istituto Clinico Humanitas, Rozzano
Milano, Italy; 2. Dip. di Biotecnologie Mediche e Medicina
Traslazionale, Università degli Studi di Milano, Milano, Italy;
3. Department of Gastroenterology, Istituto Clinico Humanitas,
Rozzano Milano, Italy; 4. Department of Radiology, Istituto
Clinico Humanitas, Rozzano Milano, Italy; 5. Department of
Hepato Gastroenterology, University of Nancy, Nancy, France
INTRODUCTION: Operative management remains the
gold standard approach for hepatocellular carcinoma
(HCC). Resection is the preferred treatment in patients
without cirrhosis, with transplantation being the best
option for decompensated cirrhotics. This study evaluated
underlying liver disease, operative factors and histopathological characteristics on overall and recurrence-free survival in 313 patients undergoing liver resection for HCC at
a single Western center.
METHODS: Patients who underwent liver resection for
HCC between 3/89 and 9/10 were studied. Patients were
not excluded based on tumor size, extent of fibrosis, or
etiology of underlying liver disease. As indications for
treatment are mostly based on tumor size, patients were
stratified by diameter: <50 mm, 50–100 mm and >100 mm.
Patients with Child’s A cirrhosis, no esophageal varices, and
a platelet count ≥100 × 10^9/L were directed toward resection. Kaplan-Meier and Cox regression methodology were
utilized.
BACKGROUND: Surgery is still required for many patients
with Crohn’s disease (CD). Intraoperative detection of new
lesions is common and may lead to a change in the planned
approach (laparoscopic or open surgery) and strategy (type
of resection or strictureplasty). Whether magnetic resonance enterography (MRE) can be used to optimize surgical planning and to guide decision-making in CD patients
undergoing surgery is currently unclear.
METHODS: Seventy-five consecutive patients with complicated CD who were candidates for surgery were prospectively enrolled. MRE was performed according to
a standardized protocol within 30 days before surgery.
Two experienced radiologists blindly and independently
assessed MRE images. Radiological findings were correlated
with intraoperatively detected lesions. Analysis included
MRE accuracy (per-segment and per-patient) and change in
surgical strategy due to discordance with MRE findings.
RESULTS: 36% had tumors <50 mm, 36% had tumors
50–100 mm, and 28% had tumors >100 mm. Patients with
larger tumors were more likely to have normal underlying
liver parenchyma: 43% >100 mm, 15% 50–100 mm and 1%
<50 mm (p < 0.001). 77% underwent an open and 23% a
laparoscopic procedure (p < 0.001). Major hepatectomies
comprised 56%, anatomic resections 87%, and R0 88% of
resections. There was no significant difference in Clavien
3–5 complications among the groups (p = 0.78), 16% overall. This rate decreased in the second decade of our experience. For example, the mortality rate between 3/89 and
RESULTS: Surgery was performed laparoscopically in 39/75
pts (52%; conversion to open surgery 6/39, 15%). Concordance rate among observers was excellent (kappa value
18
Sunday
Abstracts
12/99 was 14%, and 5% through 9/10 (p < 0.008). Median
overall survival was 60 months, with 1- and 5-year overall survival rates of 76% and 50%. On multivariate analyses, intra-operative transfusion (HR = 2.60), cirrhosis (HR
= 2.42), salvage transplantation (HR = 0.23), poorly differentiated tumor (HR = 2.04), satellite lesions (HR = 1.68),
microvascular invasion (HR = 1.48), and AFP > 200 (HR =
1.53) were significant predictors of survival. Median time to
recurrence was 20-months, with 1- and 5-year recurrencefree survival rates of 61% and 28%. By multivariate analyses
intra-operative transfusion (HR = 2.15), poorly differentiated tumor (HR = 1.87), cirrhosis (HR = 1.69) and microvascular invasion (HR = 1.71) independently impacted
recurrence-free survival.
CONCLUSION: It is demonstrated that resection is a safe
and readily available treatment for any size HCC in properly
selected patients in the modern era of liver surgery. Tumor
size did not independently impact recurrence or survival
on multivariate analyses, whereas tumor histopathology
and background parenchyma did. The current investigation adds to a growing body of literature supporting that
HCC tumor biology and the condition of the non-tumor
parenchyma should be given greater consideration in considering resection in this era of organ shortage.
Table 1: Clinical Characteristics, Operative Details and Pathologic
Characteristics of Patients with HCC Undergoing Resection
Figure 1: Overall and recurrence-free survival among patients resected
for hepatocellular carcinoma stratified by tumor size.
19
/452
453
Analysis of a Single-Series Learning Curve for Peroral
Esophageal Myotomy (POEM)
Peroral Endoscopic Myotomy (POEM) Feasible as
Reoperation Following Heller Myotomy
Amy K. Yetasook1, Jin-cheng Zhao1,2, Woody Denham1,2,
John G. Linn1, Michael B. Ujiki1,2
1. Minimally Invasive Surgery, NorthShore University
BACKGROUND: Peroral esophageal myotomy (POEM) is a HealthSystem, Evanston, IL; 2. Department of Surgery, University
novel endoscopic operation for the treatment of achalasia. of Chicago, Chicago, IL
The operator learning curve for POEM and patient factors Peroral Endoscopic Myotomy (POEM) is a promising new
associated with operative difficulty are not known.
treatment for achalasia. We present three cases of recurrent
METHODS: A single-institution prospective POEM out- achalasia after failed therapy with reoperation by POEM.
comes database was analyzed. All POEM procedures were Additionally, we also demonstrate our technique with
performed conjointly by the same two surgeons. Associa- a patient who underwent POEM after failed endoscopic
tions between preoperative patient variables (series case intervention and laparoscopic Heller myotomy (LHM) with
number, gender, age, BMI, ASA class, prior treatment with reoperation by POEM. This case series illustrates feasbility
dilation or Botox, symptom duration, manometric pres- of completing a peroral minimally invasive approach in the
sures, achalasia subtype) and operative outcomes (proce- management of recurrent achalasia.
dure time, tunnel length, myotomy length, number of clips
used for closure, EBL, mucosal perforation, need to decom454
press pneumoperitoneum) were tested using bivariate linear correlation. To assess for changes in efficiency over the Idiopathic Pulmonary Fibrosis and Gastroesophageal
course of the series, the total procedure time and the time Reflux: Implications for Treatment
required for each individual procedural step (submucosal Marco E. Allaix1, P. Marco Fisichella2, Fernando A. Herbella1,
access, tunnel creation, myotomy, and mucosal closure) Marco G. Patti1
were tested for best fit to linear, logarithmic, and exponen1. Department of Surgery, Center for Esophageal Diseases,
tial regression curves using case number as the dependent
variable. A subgroup analysis of treatment-naïve patients University of Chicago Pritzker School of Medicine, Chicago, IL;
2. Department of Surgery, Swallowing Center, Loyola University
was secondarily performed.
Chicago, Stritch School of Medicine, Maywood, IL
RESULTS: 30 patients underwent POEM, of which 26 were
treatment-naïve. Preoperative symptom duration was posi- BACKGROUND: While the pathogenesis of idiopathic
tively associated with increased operative time (r^2 = .55, pulmonary fibrosis (IPF) is multifactorial, it has been shown
p < .01). Prior achalasia treatment and EGJ resting pressure that the prevalence of abnormal reflux (GERD) is very high,
were both positively associated with operative time at a and that antireflux surgery may affect the progression of
trend level (p = .08 for both). Case number correlated nega- this disease.
tively with the number of clips required for closure (r^2 = AIMS: The aims of this study were to compare in a group of
–.51, p < .01), whereas duration of symptoms was positively
patients with GERD and a group of patients with GERD and
correlated with clip number (r^2 = .40, p < .05). Case numIPF: a) the clinical presentation; b) the esophageal function
ber correlated negatively, whereas duration of symptoms
as defined by high resolution manometry; and c) the reflux
correlated positively, with occurrence of a mucosal perforation, both at a trend level (p = .06 and .07). Myotomy profile by dual sensor pH monitoring.
length proximal to the EGJ increased over the course of the PATIENTS AND METHODS: We compared the clinical
series (r^2 = .44, p = .02), whereas there was no change presentation, the esophageal function and the reflux profile
in myotomy length distal to the EGJ. Total procedure time in 80 patients with GERD and in 22 patients with GERD
and time to perform tunnel creation, myotomy and muco- and IPF.
sal closure did not change over the course of the series. SubRESULTS: Data are expressed as mean ± SD.
mucosal access time decreased over the course of the series
(r^2 = .22, p < .01) with best fit to a logarithmic curve. CONCLUSIONS: The results of this study show that in
In treatment-naïve patients only, mucosal closure time patients with GERD and IPF: a) heartburn is present in less
decreased over the series (r^2 = .17, p = .03) with best fit to than 60% of patients; b) with the exception of a weaker
an exponential curve.
UES, the esophageal function is preserved; and c) proximal
CONCLUSIONS: In this POEM series, the time needed to reflux is more common, and in the supine position it is
access the submucosa and the number of clips required to coupled with a slower acid clearance. Because these factors
close the mucosotomy both decreased with experience. expose IPF patients to the risk of aspiration, antireflux surMyotomy length proximal to the EGJ increased with expe- gery should be considered early in the course of the disease.
rience. Total procedure time did not change over the course
of the series, and may not be an important marker of procedural skill for POEM. Longer symptom duration and prior
endoscopic treatment may result in increased operative
difficulty.
Ezra N. Teitelbaum, Byron F. Santos, Fahd O. Arafat,
Nathaniel J. Soper, Eric S. Hungness
Northwestern University, Chicago, IL
/
20
GERD + IPF
(22 Patients)
61.3 ± 8.9
13 (59.1)
13 (59.1)
20.5 ± 11.9
14 (63.6)
P Value
0.098
0.143
0.028
0.807
0.810
6 (7.5)
7 (31.8)
0.008
9.7 ± 6.6
0.9 ± 1.1
85.3 ± 65.2
42.4 ± 67.1
12.7 ± 13.6
2.5 ± 6.9
137.5 ± 112.4
169.9 ± 406.8
0.149
0.047
0.006
0.008
10.5 ± 12.8
0.5 ± 1.2
181.1 ± 270.1
47.6 ± 72.3
8.6 ± 17.1
2.9 ± 7.6
171.5 ± 259.9
899.1 ± 1668.1
0.569
0.007
0.882
<0.001
/455
Laparoscopic Heller Myotomy Can Be Used as Primary
Therapy for Esophageal Achalasia Regardless of Age
sigmoid-shaped mega-esophagus (stage 4) were excluded.
Symptoms were scored using a detailed questionnaire for
dysphagia, regurgitation, and chest pain; barium swallow,
endoscopy, and esophageal-manometry were performed,
before and 6 months after the treatment. Patients were classified in three age brackets: group A (≤45 years), group B
(45–70) and group C (≥70). Treatment was defined as a failure if the postoperative symptom-score was >10th percentile
of the preoperative score (i.e. > 8).
RESULTS: We consecutively performed the LHD as primary treatment in 514 achalasia patients, 272 (53%) in
group A, 208 (40.4%) in group B and 34 (6.6%) in group C.
The mortality was nil; the conversion and morbidity rates
were both 1.2% with no-difference in the 3 groups.
Group C patients had higher preoperative symptom scores
(p = 0.02), while the symptom duration was similar in all
groups. At a median follow-up of 40 months (IQR 15–80),
the median of symptom scores was significantly lower after
surgery (18 [IQR 14–20] vs 0 [IQR 0–3]; p < 0.0001). The
median of resting LES pressure decreased from 27 mmHg
(IQR 19–36) to 11 mmHg (IQR 8–14) (p < 0.001) and the
residual LES pressure from 10 mmHg (IQR 5–17) to 3 mmHg
(QR: 1–5) (p < 0.001). No statistically significant differences
emerged between the 3 groups in any of these aspects.
Mucosal tears occurred in 16 patients (3%): 5 (1.8%) in
group A; 8 (3.9%) in group B; and 3 (8.9%) in group C (p
= 0.06). The postoperative hospital stay was slightly longer for group C (p = 0.06). The treatment failure rate was
quite similar: 31 failures in group A (11.4%), 19 in group B
(9.1%) and 2 in group C (5.9%) (p = 0.55) (table). The failures were seen more in manometric-pattern III (22.2%, p =
BACKGROUND: Laparoscopic Heller-Dor (LHD) surgery is 0.002). All the patients whose surgical treatment failed were
the current treatment of choice for patients with esopha- treated with pneumatic dilations. The overall success rate
geal achalasia, but elderly patients are generally referred of this combined treatment was therefore 98.4% (507/515).
for less invasive treatments (pneumatic-dilations or botu- Postoperative 24-hour pH-monitoring was abnormal in 16
linum-toxin injections). The aim was to assess the effect of patients (6.6%): 7 patients were in group A, 6 in group B
age on the surgical outcome of patients receiving laparo- and 3 in group C (p: n.s.).
scopic Heller-Dor as primary treatment.
DISCUSSION: LHD is often performed in old patients as
METHODS: We evaluated the patients who underwent sur- a “last resource”, after other treatments have failed. Given
gery from 1992 to January 2012 . Patients who had already our high success and low complication rate, this study supbeen treated for esophageal achalasia and patients with ports the use of LHD as the first treatment of achalasia in
elderly patients with an acceptable surgical risk.
Renato Salvador1, Mario Costantini1, Francesco Cavallin1,
Elena Finotti1, Cristina Longo1, Michela Di Giunta1,
Nicola Passuello1, Loredana Nicoletti1, Giovanni Capovilla1,
Stefano Merigliano1, Ermanno Ancona1, Giovanni Zaninotto1
1. Department of Surgical and Gastroenterological Sciences,
Clinica Chirurgica 3, University of Padova, Padova, Italy
Table: Postoperative Findings in the Three Groups. Data Are Shown as Median and IQR (in Brackets)
Postoperative symptom score
Postoperative chest pain score
LES resting pressure (mmHg)
LES residual pressure (mmHg)
Esophageal diameter (mm)
Mucosa tear
Postoperative hospital stay (days)
Failures
Group A (45 Yrs)
n = 272
0 (0–3)
0 (0–0)
10 (8–13)
3 (1–5)
20 (18–27)
5 (1.8%)
3 (3–4)
31 (11.4%)
Group B (45–70 Yrs)
n = 208
0 (0–3)
0 (0–0)
12 (8–17)
3 (2–6)
22 (20–25)
8 (3.9%)
3 (3–4)
19 (9.1%)
21
Group C (70 Yrs)
n = 34
0 (0–3)
0 (0–0)
10 (7–14)
2 (1–4)
22 (20–25)
3 (8.9%)
3 (3–6)
2 (5.9%)
p Value
0.89
0.11
0.07
0.21
0.95
0.06
0.06
0.55
Sunday
Abstracts
Age (years)
Gender (male), N (%)
Heartburn, N (%)
LES pressure (mmHg)
Normal peristalsis,
N (%)
Hypotensive UES,
N (%)
% time <4, total Distal
Proximal
Acid clearance, total
(seconds) Distal
Proximal
% time <4, supine
Distal Proximal
Acid clearance, supine
(seconds) Distal
Proximal
GERD
(80 Patients)
55.7 ± 15
31 (38.8)
67 (83.8)
19.9 ± 9.7
51 (63.8)
Monday, May 20, 2013
7:30 AM – 9:15 AM
303ABC
VIDEO SESSION II: BREAKFAST AT THE MOVIES
507
510
Laparoscopic Enucleation of Benign and Low Grade
Hepatic Lesions
Transanal Minimally Invasive Surgery Assisted Single
Incision Low Anterior Resection with Total Mesorectal
Excision (TAMIS Assisted LAR TME) in a Cadaver Model
Nicholas N. Nissen, Vichin Puri, Vijay G. Menon
Elisabeth C. McLemore1, Alisa M. Coker1, Bikash Devaraj1,
Jeffrey
Chakedis1, Ali Maawy1, Tazo Inui1, Mark A. Talamini1,
Enucleation is a technique which can be applied to benign
1
2
3
and low grade lesions of the liver such as select neuroendo- Santiago Horgan , Michael R. Peterson , Patricia Sylla ,
1
crine tumors (NET), cysts, hemangiomas and focal nodular Sonia Ramamoorthy
hyperplasia. The benefits of enucleation include the preser- 1. Surgery, UC San Diego, La Jolla, CA; 2. Pathology, UC
vation of maximal hepatic parenchyma, as well as the low San Diego, La Jolla, CA; 3. Surgery, Massachusetts General,
likelihood that underlying vascular or biliary structures will Boston, MA
be compromised. A laparoscopic approach to enucleation
not only offers the benefits of minimal access surgery, but The purpose of this video is to demonstrate the feasibility
also allows simultaneous access to multiple regions of the of an innovative technique for the surgical management of
abdomen. This may be ideal for managing certain scenarios rectal cancer: trans anal minimally invasive surgery assisted
such as the patient with distal pancreatic NET and synchro- low anterior resection with total mesorectal excision
(TAMIS assisted LAR TME) in a cadaver model. Trans anal
nous liver metastases. Illustrative cases are shown.
LAR via natural orifice translumenal endoscopic surgery
(NOTES) has been reported in cadaveric series using rigid
508
transanal platforms. This procedure has not been described
using a combination of a single incision laparoscopy and
Use of Fluorescence Angiography During 2-Field
TAMIS trans anal endoscopic platform. Herein, we describe
Minimally Invasive Esophagectomy
the first cadaveric series of TAMIS assisted laparoscopic LAR
C. Daniel Smith, Steven P. Bowers
with TME.
Surgery, Mayo Clinic Florida, Jacksonville, FL
This video depicts the use of fluorescence angiography
using the SPY technology to assess the perfusion of the gastric conduit during 2-field minimally invasive technology.
The SPY allowed real-time visualization of the perfusion of
the gastric conduit and subsequent esophagogastrostomy.
The tip of the conduit was found to have poor perfusion
based on the fluorescence imaging and was resected. The
distal end of the gastric conduit at the anastomosis showed
good perfusion.
511
Central Pancreatectomy with Pancreatogastrostomy for
Traumatic Transection of the Pancreas
Farzad Alemi, Jonathan Carter, Carlos U. Corvera
Surgery, UCSF, San Francisco, CA
509
A 22 year-old man sustained abdominal trauma resulting
in complete transection of the pancreas at the neck of the
gland. Pancreatic ascites and mesenteric hematoma was
found at exploration. Given the normalcy of the distal
pancreatic remnant, a central pancreatectomy and pancreatogastrostomy was done. The operation entailed 1)
partial mobilization of the distal pancreatic remnant, 2)
cannulation and stenting of the pancreatic duct, 3) opposing anterior and posterior gastrotomies, and 4) a two-layer,
interrupted anastomosis. The proximally transected segment was treated with biologic adhesive and wide drainage.
Postoperatively the patient exhibited normal digestion and
glucose homeostasis.
Surgical Treatment Options for Delayed Gastric
Emptying
Nathan Lytle, Juan Toro, Ankit Patel, Jahnavi Srinivasan,
S. Scott Davis, Edward Lin
Surgery, Emory University, Atlanta, GA
Delayed gastric emptying is a common problem that is
seen by both gastroenterologists and general surgeons.
Poor gastric emptying from outlet obstruction or diabetic,
post-surgical, and idiopathic gastroparesis can be difficult
to treat. This video demonstrates four surgical options for
treatment. Gastric stimulator, duodenojejunostomy, pyloroplasty, and distal gastrectomy are shown demonstrating
technique, and indications for each are discussed.
22
512
513
Laparoscopic Hilar Resection with Roux-en-Y
Hepatico-Jejunostomy
Robotic Assisted Laparoscopic Total Proctocolectomy
with Ileal Pouch Anal Anastomosis
Juan Toro, Nathan Lytle, Ankit Patel, S. Scott Davis,
Edward Lin, Juan M. Sarmiento
Mehraneh D. Jafari, Alessio Pigazzi, Michael J. Stamos
Surgery, University of California, Irvine, Orange, CA
9:45 AM – 11:00 AM
308D
PLENARY SESSION IV
addition, data on hospital setting (teaching-research hospitals vs. community hospitals) were collected and analyzed.
The Cochran-Armitage test for trend was used to assess
changes in treatment over time.
587
Trends in the Surgical Treatment of Pancreatic
Adenocarcinoma
Siavash Raigani1, John Ammori2, Julian Kim2, Jeffrey Hardacre2
1. Department of Surgery, CWRU School of Medicine, Cleveland,
OH; 2. Department of Surgery, University Hospitals Case Medical
Center, Cleveland, OH
RESULTS: 47, 086 patients with stage 1–2 pancreatic adenocarcinoma were included in the analysis. Between 2003–
2009, the use of surgery alone as first course treatment of
stage 2 disease decreased significantly at both teachingINTRODUCTION: Multiple prospective, randomized trials research hospitals and community hospitals by nearly 25%
have demonstrated that the addition of adjuvant therapy (p < 0.0001 for both cases). In the same period, the use of
after surgical resection of pancreatic cancer improves sur- chemotherapy in addition to surgery as treatment of stage
vival compared to surgery alone. However, the optimal type 1 and 2 disease increased two-fold at both types of hospiof adjuvant therapy, chemotherapy alone or chemotherapy tals (p < 0.0001 for all cases). Treatment with surgery plus
combined with chemoradiation therapy, remains con- chemoradiation decreased significantly for both stages in
troversial. Our aim was to determine whether the type of both hospital settings by approximately 30% (p < 0.05 for
adjuvant therapy for pancreatic cancer given in the United all cases). Non-surgical treatment for stage 2 disease was
States has changed by examining treatment trends using surprisingly high and significantly increased over time (p
< 0.0001 for both), ranging from approximately 30–37%
the National Cancer Data Base.
at teaching-research hospitals and 40–49% at community
METHODS: The National Cancer Data Base (NCDB) is a hospitals.
national oncology outcomes database for over 1,500 Commission on Cancer-accredited cancer programs. Patients CONCLUSION: Data from the NCDB from 2003–2009
diagnosed with stage 1–2 pancreatic adenocarcinoma illustrate changes in the adjuvant treatment of pancreatic
between 2003–2009 were selected from the NCDB Hospital cancer. There is an alarmingly high rate of non-surgical
Comparison Benchmark Reports. Attention was paid to the therapy for stage 1 and 2 disease. The use of chemotherinitial treatment regimen, such as surgery alone, surgery apy alone as adjuvant therapy increased whereas the use of
plus chemotherapy, or surgery plus chemoradiation. In multimodality therapy decreased.
23
Monday
Abstracts
This is a 38 year old female with polyposis syndrome. A
laparoscopic total colectomy is performed in a medial to
lateral fashion. The ielocolic vessels, middle colic vessels,
and inferior mesenteric vessels are divided. The four arm
Di Vinci robot is docked and a total proctocolectomy is carried out to the level of the dentate line. The distal rectum
is transected and the specimen removed through a Pfannenstiel incision. An ileal J-pouch is created and an end to
end ileo-anal anastomosis is performed. Pathology revealed
colonic polyposis with no evidence of malignancy.
Several series demonstrate the safety and feasibility of
laparoscopy for complex hepatobiliary procedures. These
reports show the results of laparoscopic liver resections for
different types of neoplasms and benign diseases such as
choledochal cysts. However, the adoption of laparoscopic
resection with common bile duct excision is still uncommon due to technical complexity and longer operative
times. We perform laparoscopic extended hepatectomies
with biliary reconstructions using minimally invasive surgical technique. In this video, we demonstrate our technique
for right and left extended hepatectomies with Roux-enY hepaticojejunostomy. This approach allows superior
visualization.
Stage 1
Surgery
Only
Percent
CochranChange
Armitage Test Between
for Trend
2003 and
p Value
2009
0.1069
–3.14%
Surgery Plus
Chemotherapy
Surgery Plus
Chemoradiation
Percent
CochranPercent
CochranChange
Armitage Test
Change
Armitage Test Between
for Trend between 2003 for Trend
2003 and
p Value
and 2009
p Value
2009
<.0001
235.48%
0.0006
–27.70%
Teaching-Research
Hospitals
Community Hospitals
0.6323
–10.86%
<.0001
261.12%
Stage 2 Teaching-Research
<.0001
–23.05%
<.0001
229.31%
Hospitals
Community Hospitals
<.0001
–23.97%
<.0001
174.81%
No Surgical Therapy includes no first course therapy, chemotherapy only and chemoradiation only
No Surgical
Therapy
CochranArmitage Test Percent Change
for Trend Between 2003 and
p Value
2009
0.162
–1.42%
0.0002
<.0001
–35.31%
–34.21%
0.145
<.0001
3.53%
16.89%
<.0001
–30.35%
<.0001
15.94%
RESULTS: The overall incidence of adenocarcinoma of the
esophagus and the gastric cardia increased from 13.4 per
million in 1973 to 51.4 per million in 2009, a nearly 400%
increase. Jointpoint analysis demonstrated that the yearly
increase in incidence has slowed somewhat from 1.27 per
million before 1987 to 0.97 between 1987–1997 and 0.65
after 1997. Stage-specific analyses suggests, that incidence
of early stages has actually declined after 2001 with a yearly
decrease of 0.22. The percentage of patients diagnosed with
early cancer declined after 2000 and remained under 2.5%
through the study period. Regression analysis showed a
substantially higher correlation of incidence of adenocarcinoma of the esophagus and the gastric cardia with population (r2 = 0.95) than with time (r2 = 0.65).
588
Does the Incidence of Adenocarcinoma of the
Esophagus and Gastric Cardia Continue to Rise in
the 21st Century?
Attila Dubecz1, Norbert Solymosi2, Michael Schweigert1,
Rudolf J. Stadlhuber1, Hubert J. Stein1, Jeffrey H. Peters3
1. Surgery, Klinikum Nurnberg, Nuremberg, Germany;
2. Faculty of Veterinary Science, Szent Istvan University, Budapest,
Hungary; 3. Division of Thoracic and Foregut Surgery, Department
of Surgery, University of Rochester School of Medicine and
Dentistry, Rochester, NY
BACKGROUND: The rising incidence and histologic
change to adenocarcinoma in esophageal cancer over
the past four decades has been among the most dramatic
changes ever observed in human cancer. Recent reports
have suggested that its increasing incidence may have plateaued over the past decade. Our aim was to examine the
latest trends in esophageal adenocarcinoma incidence and
analyze its correlation with time and population density.
CONCLUSION: The incidence of esophageal adenocarcinoma continues to rise in the 21st century in the United
States. A significant linear correlation of incidence with
total population was found.
PATIENTS AND METHODS: We used the Surveillance
Epidemiology and End Results (SEER) database of the
National Cancer Institute to identify all patients with adenocarcinoma of the esophagus and gastric cardia between
1973 and 2009. Both overall and stage specific trends in
incidence were analyzed using joinpoint regression. The
correlation of incidence with time and total population
within the geographic areas covered by SEER was analyzed
by linear regression.
24
589
590
Reoperative Intervention in Patients with Mesh at
Hiatus Is Associated with High Morbidity and High
Incidence of Esophageal Resection: Single Center
Experience
Influence of Ethnicity on the Efficacy and Utilization
of Bariatric Surgery in the United States
25
Monday
Abstracts
Ranjan Sudan1, Deborah Winegar2, Steven Thomas3,
John M. Morton4
Kalyana C. Nandipati, Maria Bye, Se Ryung Yamamoto,
1. Department of Surgery, Duke University Medical Center,
Pradeep K. Pallati, Tommy H. Lee, sumeet K. mittal
Durham, NC; 2. Department of Clinical Affairs, LipoScience,
Raleigh, NC; 3. Department of Biostatistics and Bioinformatics,
Creighton University, Omaha, NE
BACKGROUND: Increasing use of mesh for hiatus repair Duke University, Durham, NC; 4. Department of Surgery, Stanford
during anti-reflux surgery has been reported. Re-operative University, Palo Alto, CA
intervention with previously placed mesh is technically BACKGROUND: In the US more blacks than whites are
more challenging. The aim of this study is to present a severely obese (26% vs. 15%) and suffer from hypertension
single Center experience with reoperative intervention in (40% vs. 27%). Prior studies examining the influence of
patients with previous mesh at hiatus and outcomes in this race on bariatric surgery have been from single-institution
subset of patients.
or small cohorts. This is the first study to examine dispariMETHODS: After Institutional review board approval pro- ties in national patterns of utilization and the influence of
spectively maintained database was retrospectively queried ethnicity on outcomes after Roux-en-Y gastric bypass surto identify patients who underwent re-operative interven- gery (RYGB) from the large multi-institutional prospective
tion between 2003 to 2012 and had mesh placed at a previ- database for the American Society for Bariatric and Metaous hiatal hernia procedure. Patient charts were reviewed bolic Surgery.
and variables collected included demographics, indications, METHODS: All research-consented white, black or Hisoperative details (initial and reoperative) and postoperative panic patients undergoing RYGB between 6/2007 and
complications.
10/2011 and eligible for one year of follow-up were
RESULTS: Twenty-six patients met inclusion criteria included. Other races were excluded. Descriptive statistics
and form the cohort for the study. There were 14 females were used for demographic information. Multivariate logiswith a mean age of 58.3 + 29.2 years. Synthetic mesh was tic and normal regression models examined relationships
placed in 15 (58%) patients, while the remaining 11 had between race and outcomes, controlling for age, gender,
bio-prosthetic mesh. Mean duration of re-operative inter- baseline BMI and comorbid conditions. Races were comvention since the last surgery was 22 (1–52) months. Dys- pared using a t-test for continuous variables and Pearson
phagia (57%) was the most common presentation while 4 chi-square test for categorical variables. Reported p-values
patients had mesh erosion. Recurrent hiatus hernia (2 to 7 were adjusted for the false discovery rate (FDR) to control
cm) was noted in 16 (62%) patients. Nine patients (35%) for multiple testing.
underwent redo fundoplication, 8 (31%) were converted RESULTS: The racial distribution of the 135,262 study
to Roux en Y gastrojejunostomy, 3 (12%) underwent dis- patients was 79% white, 12% black, and 9% Hispanic.
tal esophagectomy with esophago-jejunostomy, 5 (19%) Among the blacks undergoing RYGB only 15% were male
had subtotal esophagectomy with gastric pull-up and one whereas 22% of the white and Hispanic patients were
patient underwent substernal gastric pull-up for esophageal men. Compared to whites, blacks were younger (42.8 ±
bypass with interval esophagectomy. The mean operative 10.6 vs. 46.3 ± 11.6 yrs.), heavier BMI (50.2 ± 9.2 vs. 47.6
time was 250 + 70.1 min, the median blood loss was 150 ± 8.0 kg/m2 and more often hypertensive (58% vs. 53%)
ml (50–1650 ml). Reoperative intervention was performed at baseline. Although mortality rates within 30 days were
with laparoscopic approach in 50% (13/26) of the patients, equivalent for all races (0.23–0.26%), serious adverse events
laparoscopy converted to laparotomy in 12% (3/26) of the were higher for blacks (3.65%) versus whites (3.19%) and
patients, laparotomy was performed in 34% (9/26) and tho- Hispanics (2.01%). At 1 year, mean BMI decreased markedly
racotomy was performed in 1 patient. There was no post- to 35.0 ± 7.5 for blacks, 31.6 ± 6.73 for whites and 32.6 ±
operative mortality. Major complications were noted in 6 7.0 kg/m2 for Hispanics. However, the percentage decrease
patients. Mean ICU stay was 6 days and hospital stay was in BMI from baseline was lower for blacks (-30%) compared
14 days.
to whites (-34%) and Hispanics (–32%). Similarly, hyperCONCLUSION: Reoperative intervention in patients with tension decreased from 57% to 37% (blacks), 53% to 27%
mesh at hiatus is associated with a high (>35%) need for (whites) and 42% to 29% (Hispanics) but, the percentage
esophageal resection. More than half the patients also had decline was less for blacks (-35%) versus whites (–49%) and
a recurrent hiatal hernia. Caution is advised in liberal use of Hispanics (–50%). Resolution of diabetes also demonstrated
a similar pattern for blacks (59%) versus whites (65%) and
mesh for hiatoplasty.
Hispanics (61%). Racial differences in outcomes for weight
loss and major comorbid conditions persisted after adjustment for baseline characteristics (p values and odds ratios
are in Table1).
Effect of Ehnicity on Outcomes at 1 Year
Outcomes
BMI 1
Excess Body Weight (kg)
Outcomes
GERD
Diabetes
Hypertension
Obstructive Sleep Apnea Syndrome
P-value
<.0001
<.0001
P-value
0.7875
0.8914
<.0001
0.8914
Black vs. Hispanic
PPM (95% CI)
1.23 (1.04, 1.42)
2.00 (1.59, 2.42)
OR (95% CI)
1.05 (0.91, 1.20)
0.98 (0.82, 1.17)
1.66 (1.44, 1.90)
1.02 (0.86, 1.21)
CONCLUSIONS: Race exerts a significant influence on outcomes after RYGB. Despite lower efficacy in blacks, overall
benefits from RYGB were significant. Given the higher prevalence of obesity in blacks, bariatric surgery is underutilized
by this group (particularly males). Higher baseline BMI and
more frequent hypertension in blacks indicate need for earlier surgical intervention.
Outcomes are fit with a generalized linear model controlling, sex, age, current tobacco use, prior medical history,
and current BMI unless noted. Reported p-values were
adjusted with FDR. 1 The covariate BMI was replaced with
baseline BMI PPM: Predicted population marginal mean
difference.
/591
Understanding Hospital Readmissions After
Pancreaticoduodenectomy: Can We Prevent Them?
A 10-Year Contemporary Experience with 1173 Patients
at the Massachusetts General Hospital
Zhi Ven Fong, Klaus Sahora, Seefeld J. Kimberly,
Cristina R. Ferrone, Sarah P. Thayer, Andrew L. Warshaw,
Keith D. Lillemoe, Matthew M. Hutter, Carlos Fernandez-del
Castillo
General Surgery, Massachusetts General Hospital, Boston, MA
INTRODUCTION: The morbidity and mortality of pancreaticoduodenectomy (PD) have significantly decreased over
the past decades to the point that they are no longer the
sole indicators of quality and safety. In recent times, hospital readmission is increasingly used as a quality metric for
surgical performance, and has direct implications on health
care costs. We sought to delineate the natural history and
predictive factors of readmissions after PD.
METHODS: The clinicopathologic and long-term followup data of 1173 consecutive patients who underwent PD
between August 2002 and August 2012 at a single institution were reviewed. The NSQIP database was linked with our
26
P-value
<.0001
0.0155
P-value
0.0095
0.0258
<.0001
0.9332
Black vs. White
PPM (95% CI
1.77 (1.65, 1.89)
0.50 (0.14, 0.87)
OR (95% CI)
0.87 (0.79, 0.96)
1.15 (1.03, 1.28)
1.69 (1.57, 1.83)
.00 (0.89, 1.11)
Hispanic vs. White
P-value
PPM (95% CI
<.0001
0.54 (0.38, 0.71)
<.0001
–1.50 (–1.73, –1.28)
P-value
OR (95% CI)
0.0056
0.83 (0.74, 0.93)
0.0661
1.17 (1.02, 1.35)
0.7339
1.02 (0.90, 1.16)
0.7339
0.97 (0.84, 1.13)
clinical database to supplement perioperative data. Readmissions unrelated to the index admission were omitted.
RESULTS: We identified 173 (16%) patients who required
readmission after PD within the study period. The readmission rate was higher in the 2nd half of the decade when compared to the 1st half (18.6% vs 12.3%, p = 0.003), despite a
stable 7 day median length of stay. Readmitted patients were
analyzed against those without readmissions after PD. The
demographics and tumor pathology of both groups did not
differ significantly. In the multivariate logistic regression
analysis, preoperative albumin ≤3.5 (19% vs 11%, OR 1.6, p
= 0.046), multi-visceral resection at time of PD (3% vs 0.6%,
OR 11.9, p = 0.031) and a length of initial hospital stay >7
days (59% vs 43%, OR 1.6, p = 0.043) were independently
associated with readmissions. There were no postoperative
biochemical variables that were predictive of readmissions.
Fifty percent (n = 87) of the readmissions occurred within 7
days from initial operative discharge. The reasons for early
and late (>7 days) readmissions differed; ileus, delayed gastric emptying and pneumonia were more common in early
readmissions, whereas wound infection, failure to thrive
and intraabdominal hemorrhage were associated with late
readmissions. The incidence of readmissions due to pancreatic fistulas and intraabdominal abscesses were equally
distributed between both time frames.
CONCLUSION: The frequency of readmission after PD is
16%, and has been on the uptrend over the last decade.
Poor preoperative nutritional status and the complexity of
initial resection were independently associated with hospital readmissions after PD. Further efforts should be centered
on preventing early readmissions, which constitute half of
all readmissions.
9:45 AM – 11:00 AM
300
QUICK SHOTS SESSION I
594
Does Intramesorectal Proctectomy Affect Overall
Complication Rates Compared to Standard Total
Mesorectal Excision in Patients with Ulcerative Colitis?
Adenovirus-Mediated Interferon Therapy Sensitized
Chemotherapy and Radiation for Pancreatic Cancer in
Vitro and in Vivo Models
Caitlin W. Hicks1,2, Richard A. Hodin1, Lieba R. Savitt1,
Liliana Bordeianou1
1. Department of Surgery, Massachusetts General Hospital,
Boston, MA; 2. Department of Surgery, The Johns Hopkins
Hospital, Baltimore, MD
Joohee Han1, Yoshiaki Miura1, Leonard Armstrong1,
Ryan M. Ryan M Shanley2, Xianghua Luo2, Eric H. Jensen1,
Edward W. Greeno3, Selwyn M. Vickers1, Masato Yamamoto1,
Julia Davydova1
1. Surgery, University of Minnesota, Minneapolis, MN;
2. Division of Biostatistics, University of Minnesota, Minneapolis,
MN; 3. Medicine – Hematology, Oncology and Transplantation,
University of Minnesota, Minneapolis, MN
PURPOSE: In patients with ulcerative colitis (UC), intramesorectal proctectomy involves close dissection along the
rectal wall with concomitant rectal eversion (IMP/RE). In
contrast, standard total mesorectal excision (TME) involves
close dissection along the pelvic wall with an intraabdominal stapled rectal transection above the levator muscles.
Our goal was to compare surgical outcomes among UC
patients following IMP versus TME (Figure).
Interferon-D (IFND) in conjunction with chemoradiotherapy has emerged as a promising treatment for pancreatic
adenocarcinoma. However, despite encouraging survival
results (e.g. a 5-year survival rate of 55% in a phase II trial
by the Virginia Mason study group evaluating adjuvant
METHODS: All patients undergoing IPAA surgery for active chemotherapy, immunotherapy and external-beam radiaUC at a tertiary referral hospital over a 10.5-year period tion for resected PDAC), utilization of this regimen has
(09/2000-04/2011) were included in analysis. Univari- been impeded by systemic toxicity of IFND.
ate analysis (T-tests and chi square tests) and step-wise fit To circumvent these problems, we engineered a novel infecregression modeling were used to compare complications tivity-enhanced oncolytic adenoviral vectors for high-level
rates among patients undergoing IMP vs. TME procedures. targeted IFND expression (Ad-IFN). We hypothesized that
RESULTS: Of 201 patients identified for inclusion in a new therapeutic modality combining an Ad-IFN with
the study, 119 (59%) underwent IMP/RE. Age, race, gen- chemoradiation would overcome the major drawbacks of
der, smoking status, disease comorbidity, steroid or other IFN-based regimens. The adenovirus-mediated tumor-selecimmunomodulator use, surgical urgency, severity of disease tive expression of IFN will eliminate systemic toxicity of
on pathology, and surgical staging were similar between cytokine, while massive IFND expression via replicationgroups (p = ns). IMP/RE patients underwent fewer laparo- competent vector will yield an extended response. In this
scopic procedures (2% vs. 37%, p < 0.0001) based on sur- study, we combined this vector with chemo- and radiothergeon preference. On univariate analysis, IMP/RE patients apy and analyzed its therapeutic ability in vitro and in vivo
had fewer total perioperative complications (0.9 ± 0.1 vs. models.
1.4 ± 0.1, p = 0.02), but no differences in abdominal sepsis, The in vitro assays revealed that combination of Ad-IFN
post-operative length-of stay, or hospital readmissions (p = with chemotherapeutics (5-FU, gemcitabine, cisplatin) and
ns). However, in a step-wise regression model accounting X-ray radiation killed human and hamster pancreatic canfor age, co-morbidities, disease severity, pre-operative medi- cer cells significantly better than either of the single treatcations, operative technique, and follow-up time (mean 5.5 ments. Furthermore, we established pancreatic tumors in
± 0.2 years), both anastamotic leak rate [OR –0.56 (95% CI immunocompetent hamsters and discovered that combi0.33, 0.99); p = 0.04] and overall post-operative combined nation of Ad-IFN with either 5FU or radiation (8 Gy and
pouch-related and infectious complications were lower in 20 Gy were tested) resulted in remarkable tumor shrinkage
the IMP/RE group (2.0 ± 0.2 vs. 2.6 ± 0.2, p = 0.03).
and was significantly superior to radiation and 5-FU alone
CONCLUSIONS: IMP/RE appears to be associated with or both of these combined. The triple-therapy (Ad-IFN+Xfewer overall post-operative complications than TME in ray+5-FU) outperformed all treatment groups. The evaluapatients with UC. This may be a reflection of smaller free tion of the survival rate also showed statistically significant
space within the pelvis and/or the ability to invert the rec- improvement in groups treated with dual (Ad-IFN+X-ray)
tal stump staple line during concomitant rectal eversion. and triple (Ad-IFN+X-ray+5-FU) therapies versus convenHowever, further studies on functional and long-term out- tional approaches (radiation or/and 5FU).
comes are needed.
27
Monday
Abstracts
592
596
Our results support the impact of Ad-mediated IFND to
sensitize chemotherapy and radiation for pancreatic cancer. This strategy may expand clinical use of the robust and
promising IFN-based multimodal therapy to meet the pressing continued need for PDAC treatment.
Laparascopic Pyloroplasty: A Promising Treatment for
Refractory Gastroparesis
595
Katie Farah, Elie Aoun, Elizabeth Dovec, Sheri A. Mancini
The Western Pennsylvania Allegheny Health System,
Pittsburgh, PA
INTRODUCTION: Gastroparesis is a chronic debilitating
digestive disorder characterized by a delay in gastric emptying. Nausea, vomiting, abdominal pain, and bloating
are characteristic of the disease and significantly affect the
patient’s quality of life. Medical therapy is limited to very
John S. Bolton, William C. Conway
few agents most of which are limited by their side effect
Surgery, Ochsner Clinic, New Orleans, LA
profile. Various surgical techniques for the treatment of
INTRODUCTION: With the increasing use of minimally gastroparesis are invasive, not as effective, and have high
invasive esophagectomy (MIE) and early hospital discharge, complication rates. We describe our experience with lapathe timing and role of postoperative contrast swallow study roscopic pyloroplasty as a therapeutic alternative for the
(SS) has become increasingly problematic. We systemati- treatment of gastroparesis.
cally evaluated a policy of delayed SS and oral intake after PATIENTS AND METHODS: 22 patients with refractory
MIE until the second postoperative week, approximately gastroparesis were enrolled in this prospective study and
one week after hospital discharge.
underwent minimally invasive pyloroplasty. Pre- and postMETHODS: Between Sept 2007 and October 2012, 143 operative gastric emptying study (GES), Gastroparesis Carconsecutive patients undergoing MIE were evaluated for dinal Symptom Index (GCSI©2003 Johnson & Johnson),
inclusion in the study. Patients with obvious clinical or and complications were recorded.
radiographic leak by d 7 were excluded from the study. Our RESULTS: 21 patients underwent laparoscopic pylorostudy group consisted of 30 patients (Late Eaters) whose SS plasty and one patient was converted to open laparotomy.
and po intake were intentionally delayed (20 patients) until The mean duration of the procedure was 106 ± 25 minutes.
a week after hospital discharge or were delayed by postop The average length of stay was 2.9 ± 1.2 days. There were
events (10 patients) which made early SS and institution or no major complications linked to the surgical procedure. At
oral feeds impractical. The study group was compared to a one month follow up, 16/22 (72.7%) patients noted overcontrol group who were deemed ready to have SS done and all improvement in their symptoms. At six months, 19/22
po intake started while in the hospital on postop day 5-7. (86.3%) patients showed improvement in their GES. The
Primary endpoints studied were the anastomotic leak rate GES results normalized in 18/22 (81.8%) patients at one
(ALR) and the hospital length of stay (LOS).
year. The T1/2 decreased from 392 to 110 minutes (p =
0.001). Significant improvements were noted on all items
RESULTS: Data are shown in Table 1.
of the GCSI score at one year post-operative visit (Table 1).
CONCLUSION: After MIE, a policy of early hospital discharge nil per os, delaying SS and resumption of oral intake Gastroparesis Cardinal Symptom Index (GCSI) Pre and
to about two weeks postoperatively, significantly reduces Post-Op Data
hospital LOS and anastomotic leak rate. Early institution or
Symptom
Pre-Op Score
Post-Op Score
p- Value
oral feeds after MIE appears to increase ALR.
Planned Delay of Contrast Swallow Study and Oral
Intake After Minimally Invasive Esophagectomy
Reduces the Anastomotic Leak Rate and Hospital
Length of Stay
Nausea
Retching
Vomiting
Fullness
Unable to finish a meal
Feeling full
Loss of appetite
Bloating
Stomach visibly bigger
Table 1
Early Eaters
(n = 91)
Late Eaters
(n = 30)
Postop Day on which
SS Done and Oral Intake Anastomotic Hospital Length
Begun (Median)
Leak Rate
of Stay
D6
22% (20/91)
D8
D12
3% (1/30)
D6
p < 0.05
p < 0.05
p < 0.05
4.45
3.00
3.14
4.73
4.41
4.68
4.41
4.73
3.73
1.41
0.55
0.64
2.32
1.55
2.05
1.36
2.05
1.45
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
CONCLUSION: Laparoscopic pyloroplasty is an effective,
minimally invasive, and safe surgical alternative in patients
with refractory gastroparesis who either fail or are intolerant of medical therapy. While our results are very promising, larger studies are needed to further evaluate its role.
28
597
Limitations of NSQIP in Reporting Complications for
Patients Undergoing Pancreactectomy: Underscoring
the Need for a Pancreas-Specific Module
Irene Epelboym, Irmina Gawlas, James A. Lee, Beth Schrope,
John A. Chabot, John D. Allendorf
Surgery, Columbia University Medical Center, New York, NY
BACKGROUND: Administrative databases are used with
increased frequency for reporting hospital-specific and
nationwide trends and outcomes after various surgical procedures in order to improve quality of surgical care. NSQIP
is a risk-adjusted case-weighted complication tracking initiative that reports 30-day outcomes from more than 400
academic and community institutions in the United States
alone. However, the accuracy of reported events specific to
pancreatic surgery has never been reported in depth.
METHODS: We retrospectively reviewed a randomly
selected subset of patients, the information on whose postoperative course was originally reported through NSQIP.
Preoperative characteristics, operative data, and postoperative events were recorded after review of electronic medical
records including physician and nursing notes, operative
room records and anesthesiologist reports. We compared
categorical variables using chi-square or Fischer’s exact test
and continuous variables using Student’s t-test.
CONCLUSIONS: NSQIP data is an important and valuable tool for evaluating quality of surgical care, however
pancreatectomy-specific postoperative events are often misclassified, underscoring the need for a hepatopancreatobiliary-specific module to better capture key outcomes in this
complex and unique patient population.
29
Monday
Abstracts
RESULTS: Between 2006 and 2010, 316 pancreatectomy
cases were reported to NSQIP by our institution. Two hundred and forty-nine were reviewed in detail, among them
145 (58.2%) Whipples, 19 (7.6%) total pancreatectomies,
65 (26.1%) distal pancreatectomies, and 15 (6.0%) central
or partial resections. Median age was 65.7, males comprised
41.5% of the group, and 74.3% of patients were Caucasian. Overall rate of complications reported by NSQIP was
44.0%, compared with 55.0% in our review, however discordance was observed in 73 (29.3%) cases (p < 0.001),
including 24 cases of reporting a complication where
there was not one, and 49 cases of missed complication.
Most frequently reported event was postoperative bleeding requiring transfusion (22.7%), however true incidence
of postoperative bleeding was actually 19.0%, with NSQIP
missing 27 (57.5%) and incorrectly reporting 36 (64.3%), p
< 0.001. Four procedures unrelated to the index operation
were recorded as reoperation events. While a pancreas-specific module does not yet exist, NSQIP reports a 7.6% rate
of organ-space surgical site infections; when compared with
our institutional rate of Grade B and C postoperative fistula
(8.8%), we observed discordance 6% of the time, p<0.001.
Delayed gastric emptying, a common post-pancreatectomy
morbidity, was not captured at all. Additionally, there were
significant inaccuracies in reporting urinary tract infections, postoperative pneumonia, wound complications,
and postoperative sepsis, with discordance rates of 4.4%,
3.2%, 3.6%, and 6.8%, respectively.
598
Chimeric Antibodies to CEA Improve Detection of
Human Colon Cancer in Orthotopic Mouse Models
respectively compared to 72.5, 60.1, and 80.5 for M-Ab (p <
0.001). The Chi-Ab demonstrated improved specificity as
evident by the lower signal intensity in normal human tissue samples compared to M-Ab (normal colon tissue: 4.3 vs
5.4; normal pancreas tissue: 1.5 vs 2.7) indicating decreased
binding of Chi-Ab. The chimeric CEA antibody was also
accurate in labeling human colon cancer in mouse xenografts enabling improved detection of tumor margins for
more effective resection, increasing the R0 resection rate
from 86% to 96%.
Cristina A. Metildi1, Sharmeela Kaushal1, George A. Luiken2,
Mark A. Talamini1, Robert M. Hoffman1,3, Michael Bouvet1
1. Surgery, University of California San Diego, La Jolla, CA;
2. OncoFluor, San Diego, CA; 3. AntiCancer, Inc., San Diego, CA
Positive surgical margins after colorectal cancer surgery
are strong predictors for higher local recurrence rates and
poor overall survival. Currently, no real-time, reliable detection assays for positive surgical margins at the time of surgery exist. We have previously shown improved detection
and resection of primary pancreatic cancer with a mousederived fluorophore-conjugated antibody against the tumor
antigen CEA in open laparotomies in mouse models. The
aim of this study was to demonstrate improved sensitivity
and specificity of a new chimerized antibody against CEA
in detection of CEA-expressing colon cancer for improved
resection in xenograft mouse models.
The chimeric form of our fluorophore-conjugated CEA antibody has more effective labeling of human CEA-expressing
cancer in tissue arrays and in our xenograft mouse models
of human colon cancer. The improved sensitivity and specificity of the chimeric fluorophore-conjugated antibody is
clinically translatable.
The top left panel is an illustration of the steps required
to convert a mouse antibody to a human antibody. Before
fully humanizing the antibody, we tested the chimeric antibody on normal tissue and CEA-expressing colon tissue
Mouse models of human colon cancer were established with samples, comparing its labeling sensitivity and specificity
fragments of a CEA-expressing patient colon tumor. Two to the mouse antibody. The bottom left panel shows that a
to four weeks after implantation, mice were randomized brighter signal is obtained by labeling the tumor with the
to fluorescence-guided surgery (FGS) or bright-field surgery chimeric antibody, as compared to the mouse antibody.
(BS). Mice in the FGS group received tail vein injections of Also, there is less labeling on normal tissue with the chithe chimeric anti-CEA-Alexa-488 antibody 24 hours prior meric antibody. The two panels on the right illustrate the
to resection. Pre- and postoperative images were obtained improved detection of CEA-expressing colon tumor in our
to assess for completeness of resection. Mice were then fol- mouse models with the chimeric antibody.
lowed for 6 months postoperatively to assess for recurrence
and overall survival. At termination, all tumor lesions were 599
harvested and evaluated histologically. The chimeric antibody was also tested on frozen tumor and normal tissue Endoscopic Submucosal Dissection for Early Neoplasia
of the Foregut: A North American Perspective
arrays comparing it to the mouse antibody.
Jonathan Cools-Lartigue, Lorenzo E. Ferri
Surgery, McGill University, Montreal, QC, Canada
INTRODUCTION: Endoscopic resection as an organ sparing option in the management of early cancers of the foregut is becoming increasingly accepted. In North America,
endoscopic mucosal resection (EMR) is the technique primarily employed. However lesions greater than 1 cm frequently require piecemeal resection with EMR, resulting
in a high rate of local recurrence. Endoscopic Submucosal
Dissection (ESD) allows for the en-bloc removal of larger
tumors, however there is very limited data of this procedure
in North America. We present our experience as one of the
only centers in North America routinely performing ESD
for neoplasia of the foregut.
The chimeric antibody directed against CEA demonstrated
improved sensitivity and specificity in labeling CEAexpressing tumor compared to the mouse antibody. The
fluorophore conjugation efficiency to the chimeric CEA
antibody (Chi-Ab) was 2-fold higher than the mouse CEA
antibody (M-Ab). On frozen tumor tissue arrays, the signal
intensity of the Chi-Ab was significantly brighter compared
to the M-Ab indicating improved binding to tumor tissue. For colon, pancreas and lung tumor samples, the signal intensity with the Chi-Ab was 94.1, 85.3, and 106.1,
METHODS: A prospectively maintained database of all
patients with early neoplasia of the foregut managed in
a busy North American centre was reviewed for patients
undergoing ESD. Patient characteristics, endoscopic/postendoscopy outcomes, pathologic features, and oncologic
outcomes were captured. Data presented as median(range).
30
RESULTS: From 5/2009–11/2012 twenty patients (74
(38–85)yrs: 16M/4F) underwent ESD for neoplasia in the
gastric antrum (10), body (2), cardia (6), or esophagus (2).
General anesthesia was performed in the majority (19/20)
and endoscopy time was 75 (30–330) minutes. The first
5 cases were longer than the last 15 (235(132–330) vs 75
(30–240) minutes). Median lesion size was 2.25 (0.6-5) cm
CONCLUSION: In this study, CAW concentrated mainly in
surgical specimen extraction sites, and port-related complications were uncommon.
and most underwent en-bloc resection (18/20). Perforation
occurred in 3 patients, which was repaired by endoscopy (2)
or by laparoscopy (1). Bleeding requiring repeat endoscopy
occurred in 1 pt. Length of stay was 2 (1–7) days, there were
no re-admissions. Final pathology revealed invasive cancer
in 13 (ADC = 9, SCC = 3, NET = 1: T1a = 9, T1b = 3, T2 = 1))
and adenoma with dysplasia in 7. Complete resection (R0)
was achieved in 18/20, the 2 incomplete resection cases
underwent laparoscopic resection. There is no evidence of
recurrence at 5 (1–41) months follow-up.
601
BACKGROUND: At present, advantages of laparoscopic
colorectal surgery (LCRS) over a conventional approach
have been demonstrated, mostly due to a reduced morbidity and hospital stay. This has encouraged the development
of new minimally invasive techniques like single incision
laparoscopic surgery, which are thought to have further
benefits over LCRS especially due to reduction of the number of incisions on the abdominal wall. However, there is
only few information available regarding complications on
the abdominal wall (CAW) after LCRS.
pared to a case control group of 86 patients without postoperative leaks. Only anastomoses distal to the splenic flexure
and created by employing an EEA stapler were included,
as those anastomoses are testable via beta-dine, air-leak,
rigid sigmoidoscopy, and doughnut observation. Air-tests
and beta-dine tests for left hemicolectomies were excluded.
Patient demographics, surgical procedures, reoperations,
pathologic findings, and outcomes of the intraoperative
tests were reviewed. All statistical analyses were performed
using SPSS v20 software.
PURPOSE: To analyze CAW in patients undergoing LCRS.
Table 1
Intraoperative Testing Following EEA Stapling, and the
Implications for Postoperative Anastomotic Leaks
METHODS: Patients were selected from our prospectively
maintained database of LCRS, operated between July 2007
and July 2012. Following a standardized protocol, the surgical specimen was extracted using an Alexis retractor to protect surgical site, and incisions of 10 mm were sutured both
aponeurosis and skin, while 5 mm incisions only had skin
closure. Patients with anastomosis leak and/or deep surgical
site infection were included. Information of demographic,
operative and follow-up data was analyzed using chi square
and t of Student tests.
RESULTS: In 455 patients that underwent LCRS during
the above-mentioned period, 16 (3.7%) had ≥ 1 CAW. Eight
patients (1.9%) had an incisional surgical site infection
(SSI), six (1.4%) had an abdominal wall hematoma, three
(0.7%) presented an incisional hernia, and two (0.5%) had
a covered evisceration during early follow-up. Frequency of
CAW was similar in patients operated secondary to diverticular disease and those with malignancy. Every SSI, hematoma and incisional hernia developed in surgical specimen
extraction site, with no significant differences between
periumbilical and suprapubic incision (SSI p = 0.15; Hematoma p = 0.990; Incisional hernia p = 0.08). Two out of three
patients with incisional hernia had a prior SSI. When analyzing morbidity associated with ports, there was 1 (0.08%)
covered evisceration in 1,180 incisions of 5 mm ports, and
another one in the 890 incisions of 10 mm ports (0.11%).
Test Result
Positive Air-Leak Positive
Beta-dine Incomplete
Doughnuts Positive Rigid
Sigmoidoscopy
Negative Air-Leak
Negative Beta-dine
Complete Doughnuts
Negative Rigid
Sigmoidoscopy
Post-Operative Leak
(Number Of Patients)
1010
No Post-Operative Leak
(Number Of Patients)
2120
25 9 43 15
66 29 81 13
Table 2
Test
Sensitivity (%)
Air-Leak
3.85
Beta-dine
0.0
EEA Doughnut
2.27
Integrity
Rigid
0.0
Sigmoidoscopy
31
Specificity
(%)
97.06
96.67
97.59
Positive
Predictive
Value (%)
33.33
0.0
33.33
Negative
Predictive
Value (%)
72.53
76.32
65.32
100
-
46.43
Monday
Abstracts
Jake G. Prigoff, Adam C. Fields, Sapna Rustagi,
Celia M. Divino
CONCLUSIONS: Although technically challenging, endo- Mount Sinai School of Medicine, New York, NY
scopic submucosal dissection for neoplastic lesions of the INTRODUCTION: Anastomotic leaks will occur in roughly
upper GI tract is effective, feasible, and can be safely applied 3-10% of surgical procedures that include an end-to-end
in a North American setting.
anastomosis (EEA). To prevent leaks, surgeons evaluate
the doughnuts removed from the autosutures and perform
maneuvers to assess the viability of the anastomosis includ600
ing air-leak tests, beta-dine leak tests, and rigid sigmoidosHow Frequent Are Complications of the Abdominal
copies. This study will evaluate the efficacy of these tests to
Wall After Laparoscopic Colorectal Surgery?
determine if they are valid.
Alejandro J. Zarate, Camila Estay, Udo Kronberg,
METHODS: A cohort of 44 surgical patients (ages 18–92;
Claudio Wainstein, Francisco López-Köstner
25 male) who presented to The Mount Sinai Medical Center
Colorectal Unit, Clinica las Condes, Santiago, Chile
between 2005 and 2012 with anastomotic leaks were com-
RESULTS: The procedures included low anterior resection
(50.0%), left hemicolectomy (15.9%), sigmoid resection
(29.5%), and ilio-anal pull through (13.6%). Procedures of
the control group were equivalent ±7%. Beta-dine and airleak tests, as well as doughnut observation, were more likely
in the control group, and rigid sigmoidoscopies less likely.
Table 1 displays the true positives, true negatives, false positives, and false negatives. Table 2 has their corresponding
sensitivities and specificities.
histopathological diagnosis. Available published data
seems to indicate that there is an incongruency between
sonographic diagnosis and the actual surgical pathology of
gastric subepithelial lesions with a reported accuracy that
ranges between 20% and 84%.
CONCLUSIONS: A combination of EEA doughnut integrity and an air-leak test show the highest predictive value.
However, the high rates of false negatives and corresponding low sensitivities of these tests show their inability to
correctly identify the patients who will ultimately have
anastomotic leaks.
METHODS: Patients who underwent endoscopic mucosal
resection for a suspected subepithelial lesion were retrospectively identified from 2009 to 2012 at two university
hospitals. The diagnosis made at the time of the endoscopic
ultrasound prior to EMR was compared with the diagnosis
made from the specimen obtained after EMR.
602
RESULTS: Twenty-three patients (12M, 11F) with a mean
age of 58yrs (range 36–82 yrs) were identified who underwent both EUS and EMR for subepithelial lesions of the GI
tract. The location of the lesions were: esophagus 1, stomach 13, duodenum 6, rectum 3. EUS based diagnosis was
only 61% accurate when compared with the histopathological diagnosis obtained via EMR. (Table 1)
AIM: To compare the diagnosis suggested by sonographic
evaluation of various subepithelial lesions throughout the
GI tract with the histological description of tissue specimens obtained by endoscopic mucosal resection (EMR).
The Pathologic Diagnosis of Subepithelial Lesions of
the GI Tract Based Solely on Sonographic Features
Correlates Poorly with Histopathological Diagnosis
Obtained by Mucosal Resection
Andrew Jatskiv1, Gabriel H. Lee1, Laura Rosenkranz1,
Sandeep Patel1, Kenneth Sirinek2
1. Medicine, UTHSCSA, San Antonio, TX; 2. Surgery, UTHSCSA,
San Antonio, TX
CONCLUSION: Except for the rectum, there is poor correlation between the sonographic and histopathological
diagnosis of subepithelial lesions of the GI Tract. Based on
these findings, clinical decision making protocols that rely
BACKGROUND: Subepithelial lesions are incidentally solely on endoscopic sonographic findings for pathologic
found during routine endoscopy of the gastrointestinal diagnosis are flawed and may lead to unnecessary surgical
(GI) tract. Endoscopic ultrasonography (EUS) has become procedures. All subepithelial lesions of the GI Tract should
the preferred non-invasive technique in evaluating these undergo endoscopic mucosal resection for a definitive hissubepithelial lesions. It is assumed that it provides valuable topathological diagnosis to direct appropriate treatment.
information such as size, echotexture, layer of origin and
features of invasion which may correlate with a particular
EUS Diagnosis
Duplication Cyst
Histologic Diagnosis
Granular Cell Tumor
Age
36
Sex
F
Stomach (13)
Carcinoid
Carcinoid
Carcinoid
Carcinoid
Carcinoid
Carcinoid
Granular Cell Tumor
Granular Cell Tumor
Granular Cell Tumor
Inflammatory nodule
Pancreatic Heterotopia
Pancreatic heterotopia
Carcinoid
Carcinoid
Carcinoid
Carcinoid
Oxyntic Gastric Mucosa
Gastric Adenoma
Granular Cell Tumor
Lipoma
GIST
48
82
59
60
46
55
61
54
81
63
63
44
71
F
F
M
M
F
M
M
M
F
F
F
F
M
Duodenum (6)
Carcinoid
GIST
Carcinoid
Carcinoid
Carcinoid
Leiomyoma
Ectopic Salivary gland tissue
Carcinoid
44
75
58
52
54
51
F
M
M
F
M
M
Rectum (3)
Carcinoid
GIST
Carcinoid
GIST
73
47
61
M
F
M
Esophagus (1)
32
603
Characteristics of Early-Onset Colorectal Cancer
Kidist Yimam, Richard E. Shaw, Christine Wong,
Joyce Louie, Edward W. Holt, Michael S. Verhille,
Taehyun P. Chung, Michael Abel
California Pacific Medical Center, San Francisco, CA
BACKGROUND: Colorectal cancer (CRC) diagnosed at
or before age 50 (early-onset) is increasing in the United
States. Early-onset CRC is associated with more advanced
stage disease at diagnosis compared to CRC diagnosed at or
after 50 years of age (late-onset).
PURPOSE: To compare the occurrence of early-onset and
late-onset CRC at our center from 2000 to 2011 and identify characteristics associated with early-onset CRC.
METHODS: We retrospectively studied all patients diagnosed with CRC at our center from January 2000 to January 2011 using our cancer registry database. Patients were
defined as early-onset or late-onset CRC based on age at
diagnosis. Additional variables were recorded including
demographic data, personal or family history of CRC or
other cancers, alcohol and tobacco use, tumor location by
colonic subdivision and tumor stage at diagnosis. Univariate analysis (Pearson’s Chi-square or Kendall’s tau-b tests)
was used to identify factors associated with early onset CRC.
Multivariate analysis (Cox proportional hazards regression)
determined independent predictors of early-onset CRC.
RESULTS: We identified total 2,147 patients, of these,
1,057(49.2%) were male, 1,898 (88.4%) had late-onset
CONCLUSION: Patients with early-onset CRC had more
rectal tumors, more advanced stage disease at diagnosis and
a higher rate of recurrence. These patients more frequently
had a family history of CRC but less frequently had a history of smoking. Early-onset CRC is an aggressive disease
that portends a poor prognosis. Further work is merited to
identify additional risk factors for this disease.
10:00 AM – 11:00 AM
304AB
VIDEO SESSION III
604
605
Robotic Assisted Single Incision Ileocolic Resection
Using Standard Robotic Instrumentation and a
Single Incision Laparoscopy Surgery (SILS) Port
Dual-Scope Endoscopic Resection of Benign GE
Junction Tumors (with Video)
Edwin O. Onkendi1, Larissa Fujii2, Michael J. Levy2,
Christopher J. Gostout2, Juliane Bingener1
1. Surgery, Mayo Clinic, Rochester, MN, Rochester, MN;
2. Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN,
We present a representative case from our initial experi- Rochester, MN
ence with robotic single incision colectomy. This ileoco- Surgical resection for benign subepithelial tumors near
lic resection was performed in a 20 year old female with the gastroesophageal junction is difficult, often leading to
medically refractory fibrostenotic Crohn’s disease. The per- esophagectomy. Here we demonstrate the feasibility of a
ceived advantages of robotic single incision surgery over novel technique of dual endoscopic resection using retrolaparoscopic single incision surgery are: improved visual- flexed standard adult upper endoscope and second smaller
ization, a surgeon-controlled camera platform, and wristed caliber (baby) endoscope to resect benign GE junction leioinstrumentation.
myomas (2-6 cm size) in four patients.
Jennifer Hrabe, Anthony R. Cyr, John W. Cromwell,
John Byrn
Surgery, University of Iowa, Iowa City, IA
Maneuvering the small caliber endoscope allowed off-axis
retraction of the mass while the adult endoscope was used
to carry out the dissection from the submucosal tissue. Our
experience highlights the feasibility of this minimally invasive approach by enabling triangulation using endoscopic
tools.
33
Monday
Abstracts
CRC and 249 (11.6%) had early-onset CRC. 1,447 patients
(67.4%) were Caucasian, 111 (5.2%) African American, and
589 (25.4%) Asian. Tumor was located in the appendix in
21 (1%), cecum in 275 (12.8%), ascending colon in 207
(9.6%), hepatic flexure in 102 (4.8%), transverse colon in
134 (6.2%), splenic flexure in 79 (3.7%), descending colon
in 90(4.2%), sigmoid colon in 431 (20.1%), rectosigmoid
junction in 166 (7.1%), and rectum in 592 (27.7%). At
diagnosis, 170 patients (7.9%) had carcinoma in situ, 553
(25.8%) stage I, 57 (24.1%) stage 2, 489 (22.8%) stage 3,
and 291 (13.6%) stage 4. The prevalence of early-onset CRC
increased from 11.4% to 16% during the study period (p
= 0.157). Patients with early-onset CRC had more rectal
tumors than patients with late-onset CRC (48.6% vs. 33.3%,
p < 0.001), higher rate of recurrence (34.7% vs. 23.6%, p <
0.001), and more advanced tumor stage at diagnosis (p <
0.001). Independent predictors of early-onset CRC included
1st (aOR 1.8 (1.1–2.9), p = 0.016) and 2nd (aOR 5.4 (2.9–
10.1), p < 0.001) degree family history of CRC and receiving
chemotherapy (aOR 3.5 (2.44–5.43), P < 0.001). History of
smoking, cancer in sigmoid colon, and stage 1 and 2 diseases were less associated with early-onset CRC on the multivariate analysis.
606
607
Pass the Courvoisier’s: Laparoscopic Extrahepatic Bile
Duct Resection with Roux-en-Y Hepaticojejunostomy
eTAMIS: Transanal Minimally Invasive Surgical
Submucosal Excision of a Large, Circumferential,
Rectal Adenoma with Endoscopic Visualization
Rebecca Kowalski1, Niket Sonpal2, Jennifer Montes1,
Paresh C. Shah1
1. Surgery, Lenox Hill Hospital, Northshore-LIJ Health System,
Hofstra Medical School, New York, NY; 2. Medicine, Lenox Hill
Hospital, Northshore-LIJ Health System, Hofstra Medical School,
New York, NY
Elisabeth C. McLemore, Alisa M. Coker, Peter T. Yu,
Garth R. Jacobsen, Mark A. Talamini, Sonia Ramamoorthy,
Santiago Horgan
Surgery, UC San Diego, La Jolla, CA
TECHNICAL POINTS ADDRESSED: Transanal endoluminal surgical techniques can be employed to safely and
completely remove a large, circumferential rectal adenoma.
This video demonstrates the benefits of combining endoscopic visualization and submucosal injection with minimally invasive endoluminal surgery using a soft, disposable
transanal access platform.
We present an 82 year old man with obstructive jaundice,
dark urine and pale stools. On presentation his total bilirubin was 12.4. CT of the abdomen and pelvis showed dilated
intrahepatic and common bile ducts with a 1.4 x 2.3 × 2.0
cm mass at the junction of the gallbladder neck and cystic duct. He underwent laparoscopic extrahepatic bile duct
resection with Roux-en-Y hepaticojejunostomy. Pathology
demonstrated a 2.5 × 1.5 x 1.0 cm moderately-differentiated
adenocarcinoma of the gallbladder with 4 negative lymph
nodes. Staging was determined to be T2 N0 (Stage II).
CASE HISTORY: A 51 year old female was found to have
a circumferential rectal mass extending from 3cm to 11 cm
on flexible endoscopy and non-invasive transrectal ultrasound (uT0N0). Final pathology revealed a 8.5 × 6.2 × 1.5
cm tubulovillous adenoma with high grade dysplasia and
negative margins.
2:00 PM – 3:00 PM
303ABC
QUICK SHOTS SESSION II
RESULTS: 664 patients (m:f = 136:526; median age 44.2
years [range 18–66], average BMI 45.6 [range 33.1–76.9])
Is Esophago-Gastro-Duodenoscopy Prior to Roux-en-Y
underwent preoperative EGD. In 341 cases no abnormalities
Gastric Bypass Mandatory?
were found (A), 115 patients had findings that did not have
Usha K. Coblijn, Arvid Schigt, Sjoerd D. Kuiken,
consequences (B1), 112 patients needed HP eradication
therapy (B2), 87 patients needed preoperative treatment by
Pieter Scholten, Sjoerd M. Lagarde, Bart A. van Wagensveld
proton pump inhibitors (B3), and 6 patients needed follow
Sint Lucas Andreas Ziekenhuis, Haarlem, Netherlands
up EGD prior to surgery (C). For one patient the operation
BACKGROUND and study aims: Roux-Y Gastric Bypass
was cancelled because preoperative EGD showed Barrett’s
is one of the most frequently used techniques in surgery
esophagus with carcinoma (D). When all abnormalities
for morbidly obese patients. Postoperative anatomy is
are taken into account, baselines show a significant differaltered by exclusion of the remnant stomach which makes
ence for age, gender, hypertension and alcohol consumpthis organ inaccessible for future Esophago-gastro-duodetion. The number of performed EGD’s to find one serious
noscopy (EGD). There is no consensus about preoperative
abnormality (requiring a follow up EGD and/or postponing
assessment of the stomach. Some institutions choose to
or cancelling the operation) is 94,5. The estimated costs of
investigate the future remnant stomach by EGD, others do
one EGD (including personnel costs but without sedation,
not. Aim of the present study is to quantify the yield of preadmission and possible complications) is approximately
operative EGD in a bariatric center of excellence.
385 US dollar.
METHODS: Patients, who were planned for laparoscopic
CONCLUSION: Based on our results and those in literature
Roux-Y Gastric Bypass (LRYGB) from December 2007 until
it can be concluded that routine assessment by EGD prior to
August 2012, were all screened by EGD in advance. These
laparoscopic Roux-Y Gastric Bypass should be abandoned.
files were retrospectively reviewed for EGD outcome, coIn this selected series, risk factors for abnormalities are age,
morbidities, medication and other patient characteristic.
gender, hypertension and alcohol consumption. The numAll these data were analyzed using a statistical program.
ber of EGD’s needed to perform to find one abnormality
A two sided P value of <0.05 was considered statistically
that requires treatment is high, with equal high costs.
significant.
707
34
709
Upper Endoscopy Prior to Bariatric Surgery: Do Visual
Findings Accurately Predict Mucosal and Anatomical
Pathology?
Perioperative Blood Transfusion Reduces Survival
in Patients with Pancreatic Adenocarcinoma: A
Multi-Institutional Study of 698 Patients
Craig D. Kolasch, Kristian T. Dacey, Eric Boyle,
Amanda Walters, Keith S. Gersin, Dimitrios Stefanidis,
Timothy Kuwada
Carolinas Medical Center, Charlotte, NC
Jeffrey M. Sutton1, David Kooby2, Gregory C. Wilson1,
Dennis J. Hanseman1, Shishir K. Maithel2, David J. Bentrem3,4,
Sharon M. Weber5, Clifford S. Cho5, Emily Winslow5,
Charles R. Scoggins6, Robert C. Martin6, Hong Jin Kim7,
Nipun Merchant8, Alex Parikh8, Daniel E. Abbott1,
Michael J. Edwards1, Syed A. Ahmad1
1. Surgery, University of Cincinnati College of Medicine, Cincinnati,
OH; 2. Surgery, Emory University School of Medicine, Atlanta, GA;
3. Surgery, Northwestern University Feinberg School of Medicine,
Chicago, IL; 4. Surgery, Jesse Brown Veterans Affairs Medical
Center, Chicago, IL; 5. Surgery, University of Wisconsin School of
Medicine and Public Health, Madison, WI; 6. Surgery, University
of Louisville School of Medicine, Louisville, KY; 7. Surgery,
University of North Carolina School of Medicine, Chapel Hill, NC;
8. Surgery, Vanderbilt University School of Medicine, Nashville, TN
BACKGROUND: Evaluation of upper GI mucosa and anatomy is important prior to bariatric surgery. Esophagogastroduodenoscopy (EGD) can diagnose H.pylori infection (HP),
mucosal inflammation and hiatal hernia (HH). HP can be
treated preoperatively and the degree of GERD and HH may
influence the choice of bariatric procedure. Mucosal biopsy
adds to the cost of EGD and some endoscopists do not “routinely” biopsy for HP if the gastric mucosa appears normal.
The goal of this study was to determine the relationship
between gross visual findings on EGD and histopathology.
We also examined the ability of EGD to accurately diagnose
hiatal hernia.
INTRODUCTION: In this multi-institutional study of
patients undergoing pancreaticoduodenectomy (PD) for
pancreatic adenocarcinoma, we sought to identify factors
associated with a perioperative blood transfusion requirement. In addition, we investigated the hypothesis that
receiving blood transfusion reduces long-term survival in
this patient population.
METHOD: A retrospective review of prospectively collected data of a single surgeon (TSK) series of laparoscopic
non revisional bariatric procedures at a center of excellence
between 2010-2012. Preoperative EGD was performed on
all patients. Patients without a gastric biopsy were excluded
from analysis. Endoscopic appearance (gross) was considered positive if there were any signs of inflammation or
hiatal hernia. The gross and histological appearances were
compared. Biopsy results (histology) and laparoscopic evaluation of the hiatus were considered the gold standard Sensitivity (SS) and specificity (SP) of the gross EGD appearance
were calculated.
METHODS: A retrospective chart review was performed
across six high-volume institutions to identify patients
who underwent PD between 2005 and 2010. Data collection included patient demographics, perioperative factors, transfusion status, and survival data. For statistical
RESULTS: There were 274 patients in the study group. analysis, patients were then grouped according to whether
Mean age and BMI were 42.8 and 43.3 respectively. The they received 0, 1-2, or >2 units of packed red blood cells
majority of the patients were female (88%). Procedures (pRBCs).
included: 189 laparoscopic gastric bypass, 69 laparoscopic RESULTS: Among 698 patients identified, 168 (24%)
sleeve gastrectomy and 16 laparoscopic adjustable gastric required blood transfusion. 105 (15%) received 1–2 units
bands. There were 57 HH confirmed at the time of surgery and 63 (9%) received >2 units (range 0–25 units). Patient
(20%). Preoperative EGD identified 21 of these (SS = .37, SP demographics associated with an increased transfusion
= .86). H. pylori was identified in 34 patients (12.5%); 19 of requirement included age, smoking status, and heart disthese patients had gross inflammatory changes on EGD (SS ease (all p < 0.03). Operative variables associated with an
= .56, SP = .58). Gross gastric inflammatory changes were increased transfusion requirement included operative time,
identified in 63/125 patients that had histological gastritis estimated blood loss, tumor size, and R1/R2 margin status
(SS = .50, SP = .64). There were 12 patients with histological (all p < 0.03). Postoperative complications were not associGERD, 8 of these patients had grossly inflamed esophageal ated with transfusion requirement. However, those patients
mucosa (SS = .67, SP = .24).
who received transfusions experienced a longer length of
CONCLUSION: EGD prior to bariatric surgery can provide stay (p = 0.0009) as well as increased rate of readmission
important information that may alter preoperative inter- within 90 days (p = 0.002). The median survival of patients
ventions and influence the choice of bariatric procedure. who received >2 units of pRBCs was significantly less than
Our findings suggest that the gross appearance during EGD those who received either 0 or 1–2 units (10.2 months vs.
is unreliable for detecting histological inflammation, infec- 18.4 or 18.9 months, p = 0.0002). A multivariate model
tion (HP) and HH. Thus, we recommend routine gastric including margin status, nodal involvement, tumor size,
biopsies to maximize H. pylori detection during EGD. Fur- and transfusion status identified the transfusion of >2 units
thermore, if the presence of a hiatal hernia could change of pRBCs as an independent predictor of reduced survival
a procedural recommendation, a complimentary upper GI (HR 1.56, p = 0.03).
evaluation should be considered.
35
Monday
Abstracts
708
tiveness of modern chemotherapeutic regimens and the
high operative mortality in this population, further studies
are needed to evaluate the role of and timing of resection of
the primary tumor.
CONCLUSIONS: This multi-institutional study represents
the largest series to date analyzing the effects of pRBC transfusion in patients undergoing PD for pancreatic adenocarcinoma. The transfusion rate in this series is less than what
has been previously reported. Our data confirm that blood
transfusion confers a negative impact on long-term survival
in this patient population. These results can be utilized as a
benchmark for future studies.
711
710
Transplant Versus Resection for the Management of
Hepatocellular Carcinoma in the Post-2006 MELD
Exception Era at a Single Institution in the Southeast
UNOS Region
Trends in Resection and Chemotherapy in Patients
with Stage IV Colorectal Cancer
Malcolm H. Squires1, Steven Hanish2, Sarah B. Fisher1,
Cristen Garrett2, David Kooby1, Juan M. Sarmiento3,
Gabriela Vargas1, Kristin Sheffield1, Abhishek Parmar1,2,
Kenneth Cardona1, Stuart J. Knechtle2, Maria C. Russell1,
Yimei Han1, Taylor S. Riall1, KImberly M. Brown1
Joseph F. Magliocca2, Andrew B. Adams2, Charles A. Staley1,
1. General Surgery, University of Texas Medical Branch, Galveston, Shishir K. Maithel1
TX; 2. General Surgery, USCF East Bay, Oakland, CA
1. Department of Surgery, Division of Surgical Oncology, Winship
INTRODUCTION: Patterns and trends in the use of mod- Cancer Institute, Emory University, Atlanta, GA; 2. Department
ern chemotherapeutic regimens, primary tumor resection, of Surgery, Division of Liver Transplantation, Emory Transplant
and the relative timing of chemotherapy and resection in Center, Emory University, Atlanta, GA; 3. Department of Surgery,
older patients with stage IV colorectal cancer (CRC) have Division of General and GI Surgery, Emory University, Atlanta, GA
not been evaluated.
BACKGROUND: Optimal management of hepatocellular
METHODS: We used Texas Cancer Registry-Medicare carcinoma (HCC) in the post-2006 MELD (Model for End
linked data (2001–2007) to identify patients 66 and older Stage Liver Disease) exception era remains controversial
with stage IV colorectal cancer (N = 3,343). Time trends and is regionally dependent. We compared outcomes for
in resection of the primary tumor and receipt of chemo- patients undergoing liver transplant versus resection at a
therapy were determined. We defined chemotherapy regi- single institution in a UNOS region with short wait times
mens as “standard” (5-fluorouracil (5-FU)/leucovorin (LV)) for organ availability.
or “modern” (oxaliplatin or irinotecan plus 5-FU/LV or
METHODS: All patients who underwent resection of
bevacizumab).
HCC between 1/00 and 8/12 were identified. Inclusion of
RESULTS: The mean age of patients was 76.9 ± 7.2 years, patients who underwent transplant was limited to those
53.3% were female, and 80.9% were white. 87.7% of can- after 1/06, when the MELD exception policy for HCC based
cers were in the colon and 25.7% of tumors were poorly dif- on the Milan criteria (MC) was universally incorporated
ferentiated histologically. Liver metastases, lung metastases, into UNOS organ allocation. Primary outcomes were overand carcinomatosis were documented in 72.8%, 32.3% and all survival (OS) and recurrence-free survival (RFS).
36.3% of patients, respectively. 37.4% were treated with
both chemotherapy and resection, 26.4% had resection RESULTS: 259 patients were identified, of whom 133
only, 11.8% had chemotherapy only, and 24.4% had no underwent transplant and 126 underwent resection. Transtreatment. Resection of the primary tumor was performed plant patients had a higher incidence of hepatitis C (67% vs
in 63.8% of patients, of which 24.3% were emergent. After 29%, p < 0.001), a greater median raw MELD score (15 vs 8,
excluding emergent procedures, resection decreased from p < 0.001), and smaller tumor size (2.4 vs 7.0 cm, p < 0.001).
59.9% to 53.0% between the early (2001–2002) and late All 133 patients who underwent transplant met MC, while
(2006–2007) study periods (P = 0.007). In patients undergo- 37 (29%) who underwent resection met MC. Of these 37
ing elective resection and chemotherapy (N=1015), resecpatients, 26 had preserved liver function with a raw MELD
tion was done prior to chemotherapy in 88.5% of patients. score ≤8. Median follow-up time was 30 mos. Median wait
30-day post-operative mortality for all patients undergoing time to transplant was 55 days (1-321); no patients dropped
resection of the primary tumor was 13.5% and 10.7% for off the waitlist while awaiting an organ.
elective resection. Chemotherapy was given to 49.2% of Transplant compared to resection was associated with
patients and was stable over time. However, in patients who improved OS (median not reached (MNR) vs 28.7 mos, p
received chemotherapy, the use of oxaliplatin or irinotecan < 0.001) and greater RFS (MNR vs 17.4 mos, p < 0.001).
plus 5-FU/LV increased from 53.3% in 2001 to 89.7% in When compared to the 37 patients within MC who under2007 (P < 0.0001). After approval of bevacizumab for meta- went resection, transplant demonstrated a trend towards
static CRC in 2004, its use increased from 0.5% to 30.8% improved OS (MNR vs 57.4 mos, p = 0.065) and greater
from 2001–2004 and from 30.8% to 55.8% from 2004-2007 RFS (MNR vs 35.2 mos, p < 0.001; Figure). Of these 37
(P<0.0001).
patients who underwent resection, 11 (30%) have underCONCLUSIONS: In patients with stage IV colorectal can- gone salvage procedures for recurrence of HCC versus only
cer, modern chemotherapeutic regimens have been rapidly 4 (3%) transplant patients. Compared to resection patients
adopted over the last decade. Concomitantly, there has within MC with a raw MELD score ≤8 (n = 26), transplant
been a decrease in resection rates. Given the increased effec- demonstrated similar OS (MNR vs 57.4 mos, p = 0.84) but
36
CONCLUSION: Our results demonstrate relatively high
rates of recurrence when performing a single stage ventral
hernia repair in a contaminated field with biologic mesh.
Permacol and Alloderm showed similar results in this series.
This rate is significantly higher than typically reported in
literature, likely due to longer follow-up and relatively high
patient acuity, and calls into question the cost-effectiveness
of the use of biologic mesh in a single stage repair for conCONCLUSION: In a region with short wait times for organ taminated recurrent hernias vs the older approach of using
availability, liver transplant is associated with improved a lightweight absorbable synthetic with a second-stage
survival compared to resection for HCC. For patients definitive repair.
within Milan criteria, transplant appears to confer an onco- Table 1: Characteristics of Patients Undergoing Hernia Repair with
logic advantage as well, even in those with preserved liver Biologic Mesh in an Infected Field
function. For patients within Milan criteria with hepaOverall
Alloderm
Permacol
p-Value
titis C, transplant is associated with improved survival
and decreased recurrence when compared to resection. N
41
21
20
—
Transplant should be considered for all patients meeting Gender, Males
39%
30%
48%
0.248
Milan criteria, particularly those with hepatitis C, when Age, years
58.7 (11)
56.8 (8)
60.7 (14)
0.094
being managed in a region with short wait times for organ Mesh positioning
78/20/2
62/33/5
95/5/0
0.037
availability.
(%underlay/inlay/
onlay)
Length of stay, days
6.1 (2)
6.8 (2)
5.4 (2)
Recurrenc rate
41.5%
47.6%
35%
Interval to recurrence,
10.4 (7)
9.0 (7)
12.4 (8)
months
Duration of follow-up,
16.1 (15)
17.0 (15)
15.3 (16)
months
Data presented as means (SD), or percentages where indicated
712
Biologic Mesh in a Contaminated Field: Infected Mesh
Removal and Hernia Repair in a Single-Stage
Jeffrey Mino, Rosebel Monteiro, Steven Rosenblatt
General Surgery, Cleveland Clinic, Cleveland, OH
PURPOSE: High rates of recurrence and infectious complications are associated with the repair of hernias with synthetic mesh in a contaminated surgical field. Biologic mesh Table 2: Mesh Positioning and Recurrence Rates:
is believed to reduce the rates of these complications. We Permacol vs. Alloderm
compared the performance of two widely available biomaOverall
Alloderm
terials, Permacol and Alloderm, in a single-stage procedure
N
41
21
of infected mesh removal and hernia repair.
METHODS: All patients who underwent a single-stage
incisional hernia repair with replacement of an infected
synthetic mesh by a biologic mesh were identified. Data
retrieved included patient demographics, details of current
hernia repair with biologic mesh, post-operative complications, and hernia recurrence.
37
Underlay
Recurrence (%)
Inlay
Recurrence (%)
Onlay
Recurrence (%)
32
10 (31.3)
8
7 (87.5)
1
0 (0)
13
4 (30.8)
7
6 (85.7)
1
0 (0)
0.024
0.412
0.370
0.790
Permacol
20
19
6 (31.6)
1
1 (100)
0
0 (0)
Monday
Abstracts
RESULTS: Forty-one incisional hernia repairs met our
inclusion criteria. Alloderm was used in 21 (51.2%) cases
and Permacol was utilized in 20 (48.8%) cases. Seventeen
patients (41.5%) developed a recurrent hernia at a mean
interval of 10.4 months from surgery. Hernias repaired with
Alloderm recurred in 47.6% (10 of 21) patients, while Permacol repairs recurred in 35% (7 of 20) of cases (p = 0.412).
Infectious complications necessitating surgical intervention developed in 9 cases (22%). Hernias repaired using the
bridging technique revealed an 87.5% recurrence rate (7 of
8), while underlay fixation of the mesh with native fascial
reapproximation led to recurrence in only 31.3% of the
cases (10 of 32).
greater RFS (MNR vs 17.6 mos, p < 0.001). For patients
with hepatitis C, those undergoing transplant (n = 89) had
improved outcomes compared to the 19 patients who met
MC and underwent resection (OS: MNR vs 47.9 mos, p =
0.04; RFS: MNR vs 16.2 mos, p < 0.001).
713
714
Predictors of Bile Duct Injury During Laparoscopic
Cholecystectomy: Experience from Two Hospitals
Molecular Pathological Phenotypes and Outcome in
Pancreatic Ductal Adenocarcinoma
Curtis J. Wray1, John A. Harvin1, Uma R. Phatak1,
Lillian S. Kao1, Tien C. Ko1, Taylor S. Riall2
1. Surgery, University of Texas Medical School at Houston,
Houston, TX; 2. Surgery, University of Texas Medical Branch,
Galveston, TX
Nigel B. Jamieson1, Mohamed A. Mohamed1, Karin Oien2,
Fraser Duthie2, Euan J. Dickson1, Ross Carter1, Colin McKay1
1. West of Scotland Pancreatic Unit, Glasgow University
Department of Surgery, Glasgow Royal Infirmary, Glasgow,
Lanarkshire, United Kingdom; 2. Department of Pathology,
Southern General Hospital, University of Glasgow, Glasgow, United
Kingdom
INTRODUCTION: Bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) are a devastating complication. Due to the infrequent occurrence of BDIs, predictive INTRODUCTION: Individuals with pancreatic ductal
factors are not well-understood. We hypothesized increased adenocarcinoma (PDAC) demonstrate a generally poor outage is a risk factor for BDI.
come following resection. Molecular profiling has previMETHODS: IRB-approved review of LC at two safety- ously enhanced the identification of phenotypic subtypes
net hospitals from 2005-2011. LC cases were coded elec- of ampullary adenocarcinoma. Furthermore an intestinal
tive (same day surgery) or non-elective (admitted through subtype of PDAC has been described however the prognosemergency room). Morbidity/mortality conferences, hospi- tic impact of this variant has not been described in detail.
tal records and prospective data were used to identify BDIs. We sought to better characterize the intestinal subgroup of
The Strasberg classification was used to define BDI. We cre- PDAC and assess the impact on outcome.
ated a multivariate regression model to identify predictors METHODS: We assessed the potential clinical utility of
of BDI.
molecular pathological phenotypes defined using a comRESULTS: 2896 LCs (n = 2370 female n = 526 male) were bination of histopathology and protein expression (CDX2
performed at two hospitals. 52% of cases were elective. 120 [caudal-type homeodomain transcription factor 2]—an
cases were converted to an open operation. Males had a intestinal marker and MUC1—a pancreaticobiliary marker)
higher mean age (years) than females (47 ± 15 vs 39 ± 14, assessed by immunohistochemistry (Figure 1) in 95 patients
p = 0.01). 40 BDIs were identified. The most common BDI who underwent operative resection for PDAC by pancreatiwas type A (N = 27, women = 14 vs men = 13), followed by coduodenectomy at a single institution over a 12 year time
E3 (N = 4), D (N = 4), E2 (N = 3) and C (N = 2). Predictors of period. A tissue microarray was used with at least 4 cores
BDI included: Age (OR 1.44, 95%–CI 1.10-1.89), male gen- evaluated for each tumor for protein expression analysis in
der (OR 3.07 95%–CI 1.83–5.12) and non-elective operation addition to whole section analysis of tumor morphology.
(OR 5.11 95%–CI 1.16–22.5). The predicted probability of Care was taken to exclude all other periampullary maligBDI increased with advancing ages, but more so for men nancies from the analysis.
who underwent non-elective LCs (see graph).
RESULTS: In addition to prognostic impact of T stage,
lymph node status, resection margin status, perineural invasion and vascular invasion, a small proportion of tumors
had features of an intestinal histological subtype (13%) and
a more favorable prognosis. CDX2 and MUC1 expression
were significant prognostic variables. Patients with CDX2
negative tumors had a significantly shorter survival (Hazard
ratio [HR] = 2.77, 95%CI: 1.5–5.2, P = 0.002 as did those
with MUC1 positive tumors (HR = 2.89, 95%CI: 1.7–4.9, P
< 0.0001 – no survivors at 24 months). Patients with CDX2
negative/MUC1 negative tumors had an intermediate outcome (Figure 1). In a multivariate analysis lymph node
involvement, vascular invasion, positive MUC1 expression
and loss of CDX2 expression were independent predictors
of poor outcome.
CONCLUSION: Morphological determination of intestinal subtype of PDAC has clinical relevance. Furthermore
maintenance of CDX2 expression identifies a group of
PDAC patients with a relatively good outcome while MUC1
expression identified patients with a very poor outcome.
When combined histopathological and molecular criteria
define clinically relevant phenotypes of PDAC with significant implications for prognostication, current therapeutic
strategies and may facilitate future trial design.
CONCLUSIONS: The risk of major or minor BDIs is significant in older males undergoing non-elective LCs. Increased
risk of BDIs, due to increase age and emergency surgery,
should be risk factors considered when discussing the need
and timing of elective LC, especially with male patients.
Earlier referral and interventions aimed at decreasing the
percentage of emergency LCs may decrease the incidence
of BDIs.
38
develop VTE after discharge. We aim to characterize the risk
of post-discharge VTE after colorectal surgery and risk factors that may suggest the need for the consideration of an
extended postoperative VTE prophylaxis beyond the hospital phase.
METHODS: The ACS-NSQIP dataset from 2005–2007 was
used to identity patients undergoing colectomy or proctectomy. Patients who developed deep venous thrombosis or
pulmonary embolism were identified and sorted into pre or
post discharge events. Univariate and multivariate analysis
was done to identify risk factors for post-discharge VTE.
Figure 1. Kaplan-Meier survival curves demonstrating stratification of
the 95 patient PDAC cohort according to CDX2 and MUC1 expression
assessed by immunohistochemistry.
715
Venous Thromboembolism (VTE) After Colorectal
Surgery: Making the Case for Continuing Prophylaxis
After Discharge in High-Risk Patients
CONCLUSION: A substantial fraction of overall VTE (DVT
and PE) occurs post-discharge in patients undergoing
colorectal resection, this risk higher in patients with higher
ASA class, on perioperative steroids and undergoing open
surgery and reoperation. These findings strongly support
the consideration of extension of VTE prophylaxis to the
post-discharge (at home) period after colorectal resection in
patients with these identified risk factors.
Vikram Attaluri, Jeffrey Hammel, Pokala R. Kiran
Department of Colorectal Surgery, Cleveland Clinic, Cleveland, OH
PURPOSE: SCIP measures target prophylaxis for venous
thromboembolism (VTE), during the hospital phase for
patients undergoing surgery; some patients nevertheless
Univariate Analysis for Post-Discharge VTE
Variable
Age <70 yrs Age >70 ys
Female Male
Colectomy Proctectomy
Laparoscopic Open
No Resident Resident
No Metastatic Cancer Metastatic Cancer
No Steroid Use Steroid Use
No Sepsis SIRS Sepsis Septic Shock
No Operation within 30 days Operation
within 30 days
No emergency surgery Emergency surgery
ASA Class 1-No Disturb 2-Mild Disturb 3-Severe
Disturb 4-Life Threat 5-Moribund
Overall N=30900
20150 (65.2%) 10750 (34.8%)
15961 (51.7%) 14936 (48.3%)
28328 (91.7%) 2572 (8.3%)
8966 (29.2%) 21764 (70.8%)
7044 (22.9%) 23679 (77.1%)
29410 (95.2%) 1490 (4.8%)
28437 (92.0%) 2463 (8.0%)
26460 (85.6%) 2729 (8.8%)
826 (2.7%) 885 (2.9%)
23421 (96.6%) 819 (3.4%)
No Post-Discharge VTE
20018 (99.3%) 10672 (99.3%)
15855 (99.3%) 14832 (99.3%)
28131 (99.3%) 2559 (99.5%)
8924 (99.5%) 21596 (99.2%)
6980 (99.1%) 23533 (99.4%)
29213 (99.3%) 1477 (99.1%)
28263 (99.4%) 2427 (98.5%)
26287 (99.3%) 2702 (99.0%)
818 (99.0%) 883 (99.8%)
23269 (99.4%) 808 (98.7%)
Post-Discharge VTE
132 (0.66%) 78 (0.73%)
106 (0.66%) 104 (0.70%)
197 (0.70%) 13 (0.51%)
42 (0.47%) 168 (0.77%)
64 (0.91%) 146 (0.62%)
197 (0.67%) 13 (0.87%)
174 (0.61%) 36 (1.5%)
173 (0.65%) 27 (0.99%)
8 (0.97%) 2 (0.23%)
152 (0.65%) 11 (1.3%)
p Value
0.47
0.73
0.26
0.004*
0.009*
0.35
<0.001*
0.049*
25904 (83.8%) 4996 (16.2%)
1047 (3.4%) 14338 (46.4%)
12591 (40.8%) 2692 (8.7%)
220 (0.71%)
25733 (99.3%) 4957 (99.2%)
1042 (99.5%) 14256 (99.4%)
12483 (99.1%) 2678 (99.5%)
219 (99.5%)
171 (0.66%) 39 (0.78%)
5 (0.48%) 82 (0.57%)
108 (0.86%) 14 (0.52%)
1 (0.45%)
0.34
0.037
* significant
39
0.019*
Monday
Abstracts
RESULTS: 30,900 patients undergoing laparoscopic and
open resection of the colon and rectum for benign and
malignant conditions were identified. 567 patients developed DVT with 149 (26%) diagnosed post-discharge. 232
cases of pulmonary embolism were identified with 82
(35%) diagnosed post-discharge. Factors associated with the
post-discharge risk for VTE included open vs. laparoscopic
surgery (0.77% vs. 0.47%, p < 0.05), no resident vs. presence
of resident (0.91% vs. 0.62%, p < 0.05), steroid use (1.5%
vs. 0.61%, p < 0.05), reoperation (1.3% vs. 0.65%, p < 0.05),
BMI > 30 (p < 0.05) and higher ASA class (p < 0.05).
2:00 PM – 3:45 PM
308D
PLENARY SESSION V
independent function (OR-1.92, p < 0.001), and intraoperative transfusion≥4 units (OR-2.14, p < 0.001). Independent
factors associated with mortality included: anesthesia risk
score > 3 (OR-2.27, p = 0.025), age ≥ 80 (OR-2.83, p < 0.001),
lack of independent function (OR-2.89, p = 0.002), and
intraoperative transfusion ≥4 units (OR-2.80, p = 0.003).
778
Morbidity and Mortality After Pancreaticoduodenectomy in Patients with Borderline
Resectable Type C Clinical Classification
Ching-Wei D. Tzeng1, Matthew Katz1, Jason B. Fleming1,
Holly M. Holmes3, Jeffrey E. Lee1, Peter W. Pisters1,
Jean-Nicolas Vauthey1, Gauri R. Varadhachary2, Robert A. Wolff2,
James Abbruzzese2, Thomas Aloia1
1. Department of Surgical Oncology, The University of Texas
MD Anderson Cancer Center, Houston, TX; 2. Department of GI
Medical Oncology, The University of Texas MD Anderson Cancer
Center, Houston, TX; 3. Department of General Internal Medicine,
The University of Texas MD Anderson Cancer Center, Houston, TX
BACKGROUND: We previously described the clinical
classification of patients with resectable pancreatic tumor
anatomy but marginal performance status (PS) or reversible comorbidities as “borderline resectable type C” (BR-C
for condition/comorbidity). This study was designed to
analyze the nationwide incidence and risk factors for postpancreaticoduodenectomy (PD) morbidity/mortality in
patients who could be classified as BR-C.
METHODS: All elective PDs were evaluated in the 2005–10
ACS-NSQIP database. BR-C was defined by the following:
age ≥ 80, lack of independent function, pulmonary disease,
ascites/varices, recent myocardial infarction/angina, stroke
history, steroid use, weight loss >10%, and/or preoperative
sepsis. Clinical variables potentially associated with 30-day
morbidity/mortality were analyzed, with a focus on the
development of postoperative major complications defined
as: pneumonia, re-intubation/ventilation >48 hr, renal failure, cardiovascular event, sepsis, re-operation, dehiscence,
organ space infection, and venous thromboembolism.
RESULTS: Of 8,266 PDs, 3,033 (36.7%) involved patients
with BR-C classification. Analysis of preoperative variables
determined that BR-C patients were more likely to have
abnormal preoperative lab values (albumin, liver function
tests, leukocytosis, coagulation, hematocrit, uremia, creatinine, all p≤0.002) and need for preoperative hospitalization (23.6% vs. 12.3%, p < 0.001). Despite similar operative
times (≥360 min in 47.2% BR-C vs. 49.2% non-BR-C, p =
0.081), BR-C patients were more likely to suffer major
complications (30.8% vs. 25.9%, p < 0.001) and mortality
(4.1% vs. 2.3%, p < 0.001). In addition, BR-C patients with
major complications suffered a 50% higher mortality rate
compared to non-BR-C patients with major complications
(11.5% vs. 7.7%, p < 0.001). For BR-C patients, multivariate analysis identified the following risk factors for major
complications: albumin < 3.5g/dL (odds ratio, OR-1.24, p
= 0.036), dyspnea (OR-1.71, p < 0.001), preoperative sepsis
(OR-1.89, p = 0.001), age ≥ 80 (OR-1.56, p < 0.001), lack of
CONCLUSIONS: These data confirm that a large number
of medically high-risk patients are being treated with PD.
These BR-C patients were at higher risk for and less able
to be rescued from major morbidity, with higher rates of
mortality from potentially reversible risk factors. These data
suggest the need for optimization of comorbidities and for
increased utilization of prehabilitation to address nutritional and conditioning deficits before PD.
779
Value of Frailty and Nutritional Status Assessment in
Predicting Perioperative Mortality in Gastric Cancer
Surgery
Juul Tegels, Michiel de Maat, Karel Hulsewé,
Anton G. Hoofwijk, Jan H. Stoot
Surgery, Orbis Medical Center, Sittard-Geleen, Netherlands
40
BACKGROUND: Reported perioperative mortality in gastric cancer surgery is relatively high (4–16%). This may
be due increased patient age and poor condition related
to advanced tumor stage at time of diagnosis. Comorbidity and age are currently the main factors associated with
the risk of surgical mortality however their predictive
value is limited. Better preoperative evaluation tools have
become warranted for better patient selection and preventing unnecessary surgery related mortality. The aim of the
METHODS: Three hundred and fifteen patients who
underwent laparoscopic anti-reflux surgery at the University of Nebraska Medical Center between 2002 and 2012
METHODS: Patients in our hospital are screened for frailty were included in this study. Patient data including pre and
at admission using a scoring questionnaire to assess their post-operative studies and symptom questionnaires were
GFI (Groningen Frailty Indicator) which entails Activities of prospectively collected and the database was used to anaDaily Living, self-perceived physical and mental fitness and lyze postoperative outcomes. Statistical analysis includmultipharmacy. Further, nutritional status is assessed using ing multivariate regression models were used to compare
SNAQ (Short Nutritional Assessment Questionnaire). We patient factors and their effect on outcomes.
evaluated in a retrospective analysis whether these scores RESULTS: A total of 302 Nissen fundoplications, 24 redo
were associated with 30-day mortality considering standard fundopliations, 11 Toupet and 2 Dor procedures were performed. Mean BMI was 31%. The median follow up was
clinicopathological parameters.
RESULTS: From January 2005 to September 2012 180 68 (6–130) months. There were 3 reoperations (0.9%) for
patients underwent surgery for gastric cancer with an over- recurrent symptoms. Mesh was used in 210 cases where
all 30-day mortality of 8.3%. Complete GFI and SNAQ hiatal hernia was larger than 2 cm. Median preoperative
scores were available in 127 (71%) and 160 (89%) cases DeMeester score was 60.5 which decreased to 6 (p < 0.05).
respectively. Univariate analysis showed a cumulative mor- Heartburn (N = 264) improved in 245 (92%), regurgitation
tality risk in association with increasing GFI score (P < (N = 264) improved in 256 (97%) and dysphagia (N = 253)
0.001). Patients with a GFI ≥ 3 (n = 30, 24%) had a mortal- improved in 227 (89%). Atypical presentation such as pulity rate of 23.3% versus 5.2% in the lower GFI group (OR monary and throat symptoms only, improved in 82% of
4.0, 95% CI 1.1 to 14.1, P = 0.03). This was independent patients. Radiographic studies were available in 60% of the
from patient age, ASA classification, tumor stage and type patients with mean follow up of 1.5 years with evidence
of surgery. SNAQ score ≥1 (n = 98, 61%) was associated with of overall recurrence of 7% (21% in hiatal hernia >5 cm).
a mortality rate of 13.3% versus 3.2% in the group that Of those with recurrence over 91% were asymptomatic at
scored 0 (OR 5.1, 95% CI 1.1 to 23.8, P = 0.04). This was follow up. Male gender, advanced age, size of hiatal hernia,
also independent for patients age, type of surgery, tumor and preoperative BMI are independent predictors of worse
stage and ASA classification. Patients who were in the group outcomes.
study was to investigate the additional value of frailty and
nutritional status assessment for predicting perioperative
performance.
DISCUSSION: This is the first study that shows a significant relation between gastric cancer surgical mortality and
geriatric frailty as well as nutritional status using a simple
scoring questionnaire. This information may be of value in
781
the preoperative decision making for selecting patients who
Retroesophageal Fundic Wrap Incarceration: A Late
would optimally benefit from surgery for gastric cancer.

Complication After Nissen Fundoplication
Margaret M. McGuire, Erik G. Lough, Donald R. Czerniach,
John J. Kelly, Philip Cohen
Surgery, University of Massachusetts, Worcester, MA
780
Long Term Patient Outcomes After Laparoscopic
Antireflux Procedures
This video illustrates the laparoscopic treatment of a late
retroesophageal fundic wrap incarceration in a patient who
had undergone laparoscopic Nissen fundoplication. Our
patient presented to the emergency room 3 years after a
Nissen fundoplication with epigastric pain, back pain and
early satiety. Imaging revealed gastric outlet obstruction.
Endoscopy showed a friable mucosa with patchy necrosis.
On laparoscopic exploration the fundic wrap was found
incarcerated, due to rotation beyond 360 degrees through
the retroesophageal space, and lying on top of the greater
curve of the stomach. After dissection and reduction of the
wrap the incarcerated portion was necrotic and required
resection.
Anton Simorov, Ajay Ranade, Jeremy P. Parcells,
Dmitry Oleynikov
Surgery, UNMC, Omaha, NE
BACKGROUND: Laparoscopic antireflux surgery with or
without large hiatal hernia has been shown to have good
short term outcomes. However, limited data are available
on long term outcomes of greater than 5 years. The aim
of this study is to review functional and symptomatic outcomes of anitreflux surgery in a large tertiary referral medical center.
41
Monday
Abstracts
CONCLUSIONS: Antireflux surgery is effective in controlling symptoms of reflux and correction of hiatal hernia in
long term follow up of greater than 5 years. The durability
of this procedure can be affected by large hiatal hernia and
high BMI and male sex. Overall patients were very satisfied
with the operation even after 10 years of follow up.
of both GFI ≥3 and SNAQ ≥1 (n = 25, 19%) had a mortality
rate of 28% versus 6% in the remaining patients (OR 6.1,
95% CI 1.7 to 22.4, P = 0.006). This finding was also independent for patients age, type of surgery, tumor stage and
ASA classification.
782
783
The Association of Proton Pump Inhibitor Use on the
Incidence of Erosive Esophagitis
Pancreatic Morphological Changes in a Long-Term
Follow-Up After First Episode of Acute Alcoholic
Pancreatitis
Steven P. Bowers1, Armando Rosales-Velderrain1,2,
Marc G. Mesleh1, Horacio J. Asbun1, John Stauffer1, Eric J. Lam1,
Mauricia Buchanan1, Jeffrey Ferrell1, Li-Ling Iem1,
Ross F. Goldberg1, C. Daniel Smith1
1. Surgery, Mayo Clinic, Florida, Jacksonville, FL; 2. General
Surgery, Cleveland Clinic Florida, Weston, FL
BACKGROUND: Erosive esophagitis (EE) is experimentally and epidemiologically linked to Barrett’s esophagus
(BE) and esophageal adenocarcinoma (EAC). The authors
speculated that the increased availability of proton pump
inhibitor (PPI) medications may alter the epidemiology of
erosive reflux disease.
Jussi Nikkola2, Irina C. Rinta-Kiikka1, Sari Raty1, Johanna
Laukkarinen1, Riitta Lappalainen-Lehto1, Satu Järvinen1,
Hanna Seppänen1, Isto Nordback1, Juhani Sand1
1. Department of Gastroenterology and Alimentary Tract Surgery,
Tampere University Hospital, Tampere, Finland; 2. School of
Medicine, University of Tampere, Tampere, Finland
OBJECTIVE: Long-term morphological changes induced
by a single episode of alcohol pancreatitis are not known.
Our aim was to study these morphological changes in secretin stimulated MRCP (S-MRCP) after the first episode of
alcohol associated acute pancreatitis, and to evaluate the
METHODS: Between 1991 and 2009, 18,000 inhabitants risk factors and the possible protective factors that might be
of Olmsted County, Minnesota were identified by the Roch- associated with later chronic findings.
ester Epidemiology Project as having undergone diagnostic PATIENTS AND METHODS: In this prospective followupper endoscopy (EGD). A review of medical records was up study S-MRCP-imaging was performed for 44 (41 M, 3F,
performed on a random 10% sample of cases. Incidence of mean age 46 (25–68) years) patients who survived their first
EE was calculated based on the initial EGD of each case, and episode of alcohol associated pancreatitis. Pancreatic morwas correlated with demographic and medical history data. phology was evaluated at 3 months, and at 2, 7 and 9 years
RESULTS: Of the 1792 records reviewed, the incidence of after hospitalization. Recurrent attacks of pancreatitis were
EE was 22.3% (by LA Classification: Grade D, 0.9%; Grade studied and pancreatic function was monitored by laboC, 2.8%; Grade B, 6.8%; Grade A, 11.8%). EE was associ- ratory tests. Patients’ alcohol consumption was evaluated
ated strongly with male gender, but not with patient age or with questionnaires, laboratory markers and self-estimated
obesity. PPI use history among cases significantly increased alcohol consumption via interview. Smoking and BMI were
throughout the study, from 7% in the period 1991–1997 annually recorded.
to 25% in 1998–2003 to 42% in the period 2004–2009. RESULTS: At 3 months 32% of the patients had norRates of EE in the time periods were 26%, 22%, and 21% mal findings in S-MRCP, 52% had acute and 16% chronic
respectively. Cases with history of PPI use had significantly changes. At seven years, S-MRCP was performed to 36
lower incidence of EE (PPI use, 18%; no PPI use, 26%; p patients, with normal findings in 53%, the rest (47%) hav= 0.004, Fisher’s exact test), despite higher likelihood of ing chronic findings. Pancreatic cyst was present in 36%,
reflux-related complaints. Including analysis of 1354 sub- parenchymal changes in 28% and atrophy in 28% of the
sequent EGD in 676 cases, 7.5% of all cases had finding of cases. 7/36 (19%) patients demonstrated new chronic findendoscopically suspected esophageal metaplasia (ESEM) on ings after two years. There were no changes in the panany EGD; BE/EAC was found in 3.5% of all cases. ESEM and creas in the attending patients between 7 and 9 years (18
BE/EAC were each present at initial EGD or followed EE in patients). If chronic changes were present at 3 months after
90%.
diagnosis, they would show in later S-MRCPs also. 45%
CONCLUSIONS: Early treatment of reflux symptoms of the patients who had only acute findings at 3 months
with PPI medication may be protective of development resolved to normal in 7 years, but the rest (55%) showed
of erosive esophagitis and may decrease the likelihood of chronic changes later on. 22% of the patients who attended
future development of Barrett’s esophagus and esophageal the seventh year S-MRCP had gone through a recurrent episode of acute pancreatitis (mean 22 (2–60) months), and 8%
adenocarcinoma.
had a clinical diagnosis of chronic pancreatitis. At 7 years,
88% of patients with recurrences had chronic findings in
S-MRCP versus 36% with non-recurrent pancreatitis (p =
0.02). 6 (17%) patients maintained abstinence through the
follow-up (mean 8.7 (7–9.1) years), but even one of these
developed pancreatic atrophy. Out of the non-abstinent
patients who didn’t have recurrences, 4/22 (18%) developed
new findings in the follow-up S-MRCP (NS). Heavy smoking didn’t show correlation to increased chronic changes
compared to non-smoking in univariate analysis.
CONCLUSIONS: Morphological pancreatic changes
increase with recurrent episodes of acute pancreatitis. However, even a single episode of acute alcoholic pancreatitis
may induce chronic morphological changes in a long-term
follow-up.
42
/784
were directly attributable to pancreatic fistula. Increasing
FRS scores (0–10) correlated well with CR-POPF development (p < 0.001), with an area under the curve of 0.716.
When segregated by FRS risk groups, CR-POPFs occurred
in Low, Moderate and High Risk patients 6.6%, 12.9% and
28.6% of the time respectively (figure). Clinical outcomes
including complications, length of stay, and readmission
rates, also increased across risk groups (Table).
A Multi-Institutional External Validation of the Fistula
Risk Score for Pancreaticoduodenectomy
Benjamin C. Miller1, John D. Christein2,
Stephen W. Behrman3, Jeffrey A. Drebin1, Wande B. Pratt4, Mark
P. Callery4, Charles M. Vollmer1
1. Hospital of the University of Pennsylvania, Philadelphia, PA; 2.
University of Alabama, Birmingham Medical Center, Birmingham,
AL; 3. University of Tennessee Health Science Center, Memphis,
TN; 4. Beth Israel Deaconess Medical Center, Boston, MA
Variable
Patients, n (% Total)
POPF, n (%)
ISGPF Classification, n (%)
No fistula
Grade A
Grade B
Grade C
CR-POPF, n (%)
Any complication, n (%)
Length of stay, median
Readmission, n (%)
Negligible Risk (0 points)
63 (10.6)
1 (1.6)
62 (98.4)
1 (1.6)
–
–
–
32 (50.8)
8
10 (15.9)
Risk Profile (Model Score)
Low Risk (1–2 Points) Moderate Risk (3–6 Points)
166 (27.9)
302 (50.9)
19 (11.4)
90 (29.8)
147 (88.6)
8 (4.8)
9 (5.4)
2 (1.2)
11 (6.6)
97 (58.4)
9
24 (14.5)
43
212 (70.2)
51 (16.9)
29 (9.6)
10 (3.3)
39 (12.9)
216 (71.5)
10
51 (16.9)
High Risk (7–10 Points)
63 (10.6)
32 (50.8)
p-Value
–
<.001
31 (49.2)
14 (22.2)
15 (23.8)
3 (4.8)
18 (28.6)
54 (85.6)
11
21 (33.3)
<.001
<.001
<.001
<.001
<.001
<.001
<.001
<.001
Monday
Abstracts
BACKGROUND: Accurate prediction of postoperative
pancreatic fistula (POPF) after pancreaticoduodenectomy
(PD) would help tailor optimal intra- and postoperative
management of this morbid complication. Distinct risk
factors for ISGPF clinically relevant fistulas (CR-POPF),
previously identified as small duct size, soft gland texture,
high-risk pathology, and increased blood loss, are best discerned intraoperatively. The Fistula Risk Score (FRS), a 10
point scale derived at a single institution, relies on weighted
influence of these four variables and has been shown to
effectively predict (area under the curve of 0.942) CR-POPF
development and its consequences. External validation of
this tool would confirm its universal applicability.
CONCLUSION: This multi-institutional experience conMETHODS: From 2001–2012, 594 PDs with pancreatojeju- firms the Fistula Risk Score as a valid tool for predicting the
nostomy reconstruction were performed by four pancreatic development of CR-POPF in patients undergoing pancresurgical specialists at three institutions. POPFs, when they aticoduodenectomy. Patients devoid of any risk factors did
occurred, were graded by ISGPF standards as biochemical not develop a CR-POPF, and the rate of CR-POPF approxi(Grade A) or clinically relevant (Grades B and C). The FRS mately doubles with each subsequent risk zone. The lower
was calculated for each patient and clinical outcomes were value of the area under the curve in this analysis is attributevaluated across four discrete categories (Negligible Risk, able to the decreased rate of CR-POPF observed in the high
0 points; Low Risk, 1–2 points; Moderate Risk, 3–6 points; risk group (29% vs. 89% originally). This difference might
High Risk, 7–10 points). Receiver operator curve analysis be ascribed to variations in operative technique, postoperative management styles, patient characteristics, and a larger
was performed to judge model validity.
sample size in the current study. Despite this, the FRS is
RESULTS: 142 patients developed any sort of POPF, of validated as an accurate prediction tool, with widespread
which 68 were CR-POPF (11.4% overall: 8.9% Grade B, applicability, which can be readily translated into common
2.5% Grade C). There were 21 overall deaths, six of which practice.
4:00 PM – 5:00 PM
308D
QUICK SHOTS SESSION III
Preexisting comorbidities such as chronic renal insufficiency and inflammatory bowel need to be considered in
predicting adverse outcomes after minimally invasive
colorectal surgery, while ASA was not sufficient as a riskadjustment factor.
785
Impact of Key Factors of Enhanced Recovery Pathway
and Preexisting Comorbidities on Complications and
Length of Stay Following Colorectal Surgery
Marianne Huebner1,2, David W. Larson1, Robert R. Cima1,
Elizabeth Habermann1
1. Surgery, Mayo Clinic, Rochester, MN; 2. Statistics, Michigan
State University, East Lansing, MI
786
Impact of a Standardized Surgical Safety Checklist on
Operative Efficiency, Direct Operative Cost and Patient
BACKGROUND: Patient and case complexity influence Outcomes Following Laparoscopic Incisional Hernia
colorectal surgery outcomes. Success using enhanced recov- Repair
ery pathways (ERP) after surgery requires assessing both
Claire L. Isbell, Rahila Essani, Harry T. Papaconstantinou
patient-factors risk adjustment as well as compliance with
Surgery, Scott & White Memorial Hospital, Temple, TX
pathway elements.
METHODS: During 2011, 535 minimally invasive colorec- INTRODUCTION: The Surgical Safety Checklist (SSC) has
tal surgery patients enrolled in an ERP protocol at a single been introduced as a proven tool to significantly improve
institution were reviewed. Patient comorbidities at admis- patient safety and outcomes through effective communicasion and compliance with key ERP elements were captured tion of the surgical team. It has been suggested that the SSC
using billing data and prospectively-collected data, respec- can reduce healthcare associated cost through reduction
in postoperative complications. However, the impact of a
tively. The association of American.
SSC on operating room (OR) cost is not known. This study
Society of Anaesthesiologists Physical Status classification compares outcomes and direct OR costs for laparoscopic
(ASA), comorbidities, and ERP element compliance were incisional hernia repair (LIHR) before and after implemenconsidered in logistic regression models to predict length tation of a standardized SSC.
of stay (LOS). A prolonged LOS was defined as 9 days or
longer. Competing risk models were used to examine the METHODS: In September 2010, our institution impleimpact of factors on in-hospital outcomes. Surgery was mented a standardized SSC. We retrospectively reviewed
the initial state, discharge the endpoint, and occurrence of all patients that underwent LIHR at our hospital for 1-year
prior (PRE) and 1-year after (POST) implementation. Democomplications a time-dependent intermediate state.
graphic data included age, sex, BMI, ASA score and previous
RESULTS: Compliance with the ERP protocol diet and fluid laparotomy. Measures of OR efficiency and cost included
management was 76%. Surgical complications occurred in operative times (OT), implant cost and total direct OR cost
16% of the patients, with Ileus being the most common (TDORC). There was no change in vendor contract pric(12%), and 9% of the patients had a prolonged LOS. The ing during the timeframe of this study. Outcomes included
majority of patients had at least one comorbidity, includ- length of hospital stay (LOS), and 30-day morbidity and
ing inflammatory bowel diseases (IBD, 36%), chronic renal mortality rates. Statistical analysis by student’s t-test and
insufficiency (5%) heart disease (9%), diabetes (9%), or Fisher’s exact test where appropriate.
COPD (11%). An ASA score 3 or 4 was present in in 19%.
Chronic renal insufficiency, IBD, conversion to open, and RESULTS: A total of 154 patients were identified; 79 PRE
non-compliance with ERP diet/fluid protocol were risk fac- and 75 POST group. There were no significant differences
tors for occurrence of complications (c-index = 0.74) and between groups for age (p = 0.9), gender (p = 0.7), BMI (p =
prolonged length of stay (c-index = 0.78). Using ASA in 0.7), ASA score (p = 0.4) and previous laparotomy (p = 0.9).
place of other comorbidities or excluding diet/fluid compli- Although mean OT was 12 min shorter in the POST group,
ance reduced the predictive value of the models (c-index the difference was not significant (176.1 vs. 164.5; min p =
0.67 for complications and 0.70 for prolonged LOS). In a 0.2). However, was a significant reduction in implant cost
competing risk model chronic renal insufficiency, IBD, ($2081 vs. $879; p = 0.02) and TDORC ($3630 vs. $2463; p
non-compliance with diet/fluid ERP protocol were predic- = 0.03) in the POST group. There was no difference in LOS
(1.5 vs.1.6 days p = 0.8), surgical site infection rate (2.5% vs.
tors of a longer LOS.
4%; p=0.9, total complication rates (18.1% vs. 12.8%; p =
CONCLUSION: In the era of ERP diet/fluid management 0.4), readmission (3.8% vs. 9.3%; p = 0.28) and reoperation
compliance leads to predictably earlier recognition and rates (3.8% vs. 5.3%; p = 0.9) between groups. There was
treatment of complications and thus shorter LOS. one death reported in the study.
44
CONCLUSIONS: Our data indicate that implementation of
a standardized SSC is associated with a significant reduction
in implant cost and TDORC for patients undergoing LIHR.
We speculate that these cost savings are a direct result of an
improvement in effective communication between surgical
team members regarding special equipment and implant
needs for these complex cases. Further studies are required
to determine the impact of our SSC on direct OR cost at an
institutional level.
787
Molecular Predictors of Recurrent Hepatocellular
Cancer: Role of Cancer Stem Cells
RESULTS: Sphere forming Hep3B cells were successfully
induced and confirmed to contain CSCs morphology. Compared to the regular cultured Hep3B cells, Hep3B sphere
cells demonstrated significantly higher surface antigens.
BACKGROUND: Recurrence rates after either resection of CD44 was expressed by 74.25% of CSC vs. 59.79% regular
hepatocellular carcinoma (HCC) or liver transplantation Hep3B cells (difference of 24.46%, p value = 0.029). With
occur in 25 to 75% of patients. HCC recurrence has been regards to EPCAM expression the CSC cells expressed 1.6%
thought to be driven by cancer stem cells (CSCs). Under- versus 0.51% expressed by regular Hep 3b cells (p value =
standing the role CSCs play in HCC recurrence will provide 0.02). This enhanced expression dropped down to near
the important information to improve prognosis and better baseline when the Hep3B sphere re-cultured in standard
nutrient rich medium. CD44 and EPCAM expression was
define adjuvant therapy.
noted at 60.1% and 0.6%, which was not significantly difAIM: To demonstrate that HCC cells can dedifferenti- ferent compared to regular Hep3b cells (p = 0.87 and 0.8)
ate into CSCs, which contribute to HCC is an important but was significantly lower compared to CSC cells (p =
resource.
0.03 and 0.0.05). In the orthotpoic injection liver, Hep3B
sphere demonstrated a significantly higher tumor proliferation rate compared to non-sphere Hep3B cells. The tumor
weights are as follows: 389 mg ± 65 (Hep3B sphere) vs 94
mg ± 32 (Hep3B cells).
Prejesh Philips, Xuanyi Li, Yan Li, Suping Li,
Erik M. Dunki-Jacobs, Robert C. Martin
Surgical Oncology, University of Louisville, Louisville, KY
CONCLUSIONS: Hep3B cells show the capacity of CSC
induction in nutritionally stressed phase. Hep3B derived
CSC can not only differentiate into HCC cells when supplied with nutrient rich medium, but also form tumor
when inoculate into mouse liver. The study is on the way to
investigate the signaling such as Wnt pathway to evaluate
the clinical relevant biomarkers of CSCs in HCC patients.
Hep3B expression of CD 44 (sphere forming) left (FITC +ve 74.25%)
versus control Hep3B cells right (59.79%).
45
Monday
Abstracts
METHOD: The capacity of CSC sphere formation was
tested in a human HCC cell line, Hep3B (derived from
an 8-year-old black patient). The CSC sphere condition
medium was the DMEM/F12 medium (1:1) supplied with 20
ng/ml of EGF and 20 ng/ml of bFGF. Flow cytometery were
performed using CSCs surface antigens (including, CD133,
CD90, CD44, and EpCAM). To test the ability of CSCs for
tumor formation, an orthotopic model was developed using
nude BALB-B/C. Tumor inoculation were performed using
Hep3B cells and Hep3B CSCs at 2 × 106 per injection. The
mice were assessed for tumor formation at 4 weeks. Flow
cytometery were performed in the cells isolated from tumor
tissue to test CSCs surface antigens mentioned above.
788
789
Long-Term Quality of Life After Oesophagectomy for
Cancer: Comparison of Cervical Versus Mediastinal
Anastomoses
Surgery for Gallbladder Cancer in the US: Greater Need
for Radical Cholecystectomy and Maximal Lymph
Node Clearance
John M. Bennett1, Justin C. Wormald2, Marc Van Leuven1,
Michael P. Lewis1
1. General Surgery, Norfolk and Norwich University Hospital,
Norwich, Norfolk, United Kingdom; 2. Norwich Medical School,
Norwich, Norfolk, United Kingdom
Thuy B. Tran, Vijay G. Menon, Nicholas N. Nissen
BACKGROUND: Gallbladder cancer (GBC) is an uncommon cancer with poor overall survival and frequent local
and metastatic relapse. GBC is often identified incidentally
BACKGROUND: With recent improvements in neoadju- after cholecystectomy, in which case reoperation with porvant therapy and earlier diagnosis, long-term survival after tal lymph node dissection (LND) is frequently performed.
oesophagectomy for adenocarcinoma is becoming more The value of LND both for its staging and therapeutic value
frequent. With longer survival the quality of life (QOL) continues to be debated. In particular, the optimal extent of
of patients post resection has thus become a greater prior- lymph node clearance is unclear.
ity. There has been extensive debate focusing on the long METHODS: The Surveillance, Epidemiology, and End
term effects of different sites for surgical anastomosis. We Results (SEER) database was queried for patients diagnosed
aimed to examine if long-term post-oesophagectomy QOL with GBC. Overall survival was analyzed using the Kaplanis affected by the site of the surgical anastomosis.
Meier method and compared using Log rank testing. Cox
METHOD: Following local ethics Committee approval proportional hazard modeling was used in multivariate
QORTC C-30 and OG-25 QOL questionnaires were sent to analysis to identify predictors of survival using age, type
patients who had survived post-oesophagectomy patients of surgery (simple vs radical cholecystectomy), adjuvant
for greater than 3 years. The data was analysed in subsets treatment, stage, and number of lymph nodes examined.
dependant on the site of oesophago-gastric anastomosis In addition, the contribution to survival of minimal LND
– either thoracic or cervical. No patients in either group (min-LND; 1–3 LN removed) vs maximal LND (max-LND;
underwent formal pyloroplasty. Data was analysed using >3 LN removed) was evaluated separately within each of
the student’s t-test on SPSS statistical software. QORTC tumor Stages I-IIIB. Predictors that patients would undergo
C-30 data was compared against the reference tables for max-LND were also evaluated.
oesophageal cancer pre-treatment.
RESULTS: A total of 12,962 patients with gallbladder canRESULTS: A total of 60 patients responded (82%) with a cer were identified. We included 11,113 patients without
median time post-surgery of 6.1 years (range 3–12 years). distant metastases in our analysis. Multivariate analysis
Cervical and thoracic anastomosis subgroups were equiva- of Stage I-IIIB GBC demonstrated that strong predictors
lent in terms of age at time of surgery, time post op and can- of improved survival are early tumor status, negative LNs
cer stage. No significant QOL difference was noted between and adjuvant treatments (p < 0.001 for all). Predictors of
cervical or chest anastomosis groups for any functional or worse overall survival are simple cholecystectomy (HR 1.74;
symptom score, especially focusing on dysphagia (OG25, p < 0.001) and minimal LND (HR 2.56; p < 0.001). When
p = 0.24), odynophagia (OG 25, p = 0.68) and swallowing evaluated by tumor stage, the extent of LN removal did not
problems (OG25, p = 0.73). The patients’ overall general significantly affect mean overall survival of Stage I GBC.
health (QL2) score was 72.0 ± 19.43 compared with 71.2 ± In contrast, the extent of LND for GBC was significantly
22.4 for the general population (QORTC reference tables). associated with improved overall survival of patients with
Functional indices and symptom scores are improved for Stage II (T2N0), Stage IIIA (T3N0) and Stage IIIB (T1-3,N1)
our cohort compared to the QORTC oesophageal cancer disease (p < 0.01 for all; see Table).
reference baseline except symptom scores for diarrhoea and Comparison of Survival by Stage and Extent of Lymph Node
dyspnoea which worsen post-operatively.
Dissection
DISCUSSION: There is no significant difference in QOL
Stage
Minimal LND – OS
Maximal LND – OS
p Value
scores between oesophagectomy patients with cervical or
I
50.5 mo
58.2 mo
0.196
thoracic anastomosis long term post-surgery. QOL in longII
40.8
mo
57.4
mo
<0.001
term survivors after oesophagectomy compares favourably
IIIA
27.2 mo
43.2 mo
0.01
with QORTC reference data for both pre-treatment oesophIIIB
21.2 mo
31.9 mo
<0.001
ageal cancer and baseline general population data in our
cohort, possibly due to the absence of pylorplasty. Further OS – Overall Survival, LND – Lymph Node dissection, mo – months.
prospective QOL data collection is required to elucidate any Overall Survival of Stage II Disease Related to Extent of Lymph Node Dissection
long-term differences between the two anastomosis sites.
46
790
Factors Associated with Healing of the Perineal Wound
After Proctectomy in Crohn’s Disease Patients
Faisel Elagili, Scott A. Strong, Pokala R. Kiran
Colorectal surgery, Cleveland Clinic, Cleveland, OH
PATIENTS AND METHODS: Data for patients with CD
who underwent total proctocolectomy or proctectomy
with end ileostomy from 1995–2012 were reviewed. Perineal wound healing was classified as follows: Early healing
The likelihood that max-LND was performed was predicted (within 12 weeks), delayed healing (between 12 weeks and
by younger age (p < 0.001), as well as T4 tumor status com- 6 months) and persistent sinus (unhealed >6 months).
pared to T1-3 (p < .001). No LNs were recovered in 74%, RESULT: For 139 patients (63% female), mean age 41 ±
60% and 50% of patients with Stage I, II and III disease 13 years, perineal wound healed by 12 weeks in 74 (53%)
respectively.
patients, delayed healing occurred in 36 (25.9%) patients,
CONCLUSIONS: This is the largest population-based study and in 29 (20.9%) patients, there was a persistent sinus. Perof patients with GBC in the literature. Not surprisingly, ineal dissection was either intersphincteric or extrasphincearly tumor stage and adjuvant therapy correlate with sur- teric depending upon the extent of perineal Crohn’s/sepsis,
vival. In addition we found radical cholecystectomy and extensive disease managed by leaving the wounds open.
maximal LND correlate with survival even in node negative Factors associated with a significantly greater risk for peripatients (Stage II and IIIA). Our results support an approach neal sinus were age (p < 0.001), surgical management of
of radical cholecystectomy and extensive LN dissection for perineal wound by open drainage (p = 0.04), high fistula
Stage II and III disease, and also suggest that many patients (p=0.01), preoperative perineal sepsis/disease (p = 0.001)
in the US with GBC are currently surgically undertreated. and smoking at time of surgery (p = 0.03). On multivariThese patients may not be receiving the best chance for ate analysis, the only factor associated with delayed healing
control of an otherwise difficult disease. Finally, the finding and persistent sinus was preoperative perineal sepsis and
that LND benefits patients with N0 disease raises questions disease (P = 0.001).
about current methods of LN analysis.
CONCLUSION: The perineal wound after proctectomy or
proctocolectomy for CD is associated with poor healing
and poses a particular challenge for patients with extensive preoperative perineal disease or sepsis. These findings
support a preoperative discussion that examines potential
outcomes and the consideration of measures such as the
initial creation of a defunctioning ostomy, control/drainage of local sepsis and appropriate medical treatment prior
to proctectomy in CD patients considered to be at high risk
for perineal wound problems.
47
Monday
Abstracts
BACKGROUND: For patients with Crohn’s disease (CD)
undergoing proctectomy with or without colectomy and
end ileostomy, while the procedure may relieve debilitating symptoms and improve quality of life, postoperative
perineal wound complications can be a persistent problem.
The aim of our study is to assess perineal wound healing
in patients with CD who undergo proctectomy or proctocolectomy with end ileostomy and to evaluate the influence
of various factors including types of perineal dissection on
eventual wound healing.
791
CONCLUSIONS: Patients with increased esophageal acid
exposure at both the proximal and distal probes tended to
Dual Probe pH Monitoring Is Not Useful in Patients
have more severe reflux disease with hernias larger than
with Reflux Disease and Respiratory Symptoms
3 cm in size, erosive esophagitis and Barrett’s esophagus.
Stephanie G. Worrell, Steven R. DeMeester, Evan T. Alicuben,
Isolated abnormal proximal acid exposure was uncommon,
Christina L. Greene, Daniel S. Oh, Jeffrey A. Hagen
and was not associated with different symptoms. These
findings suggest that dual probe pH monitoring does not
Keck School of Medicine of Univeristy of Southern California,
significantly improve the ability to detect patients with
Los Angeles, CA
reflux disease that might be related to respiratory symptoms
INTRODUCTION: The etiology of respiratory symptoms compared to standard pH monitoring in the distal esophasuch as cough, hoarseness, and asthma is often multi-fac- gus. Consequently, there is little added benefit to monitor
torial. Gastroesophageal reflux can cause or contribute to patients with a dual probe pH system.
these symptoms. Typically pH monitoring is done to identify patients in whom reflux may be related to respiratory
symptoms. A dual probe study has been recommended for 792
these patients based on prior studies showing that approxi- Hospital Center Effect for Laparoscopic Colectomy
mately 17% will have abnormal acid exposure only at the Among Elderly Stage I-III Colon Cancer Patients
proximal probe. The aim of this study was to determine Zhiyuan Zheng2, Nader Hanna1, Eberechukwu Onukwugha2,
the frequency of isolated abnormal proximal acid exposure,
Kaloyan A. Bikov2, C. Daniel Mullins2
and to evaluate symptoms and endoscopic findings associ1.
Surgery, University of Maryland School of Medicine, Baltimore,
ated with distal versus proximal acid reflux.
MD; 2. Pharmaceutical Health Services Research Department,
METHODS: We reviewed the records of all patients that University of Maryland School of medicine, Baltimore, MD
had dual probe pH testing from January 1999 to November 2012. Only patients with complete foregut evaluation OBJECTIVE: To investigate hospital level variation in
including endoscopy, video esophagram, and motility were short-term laparoscopic colectomy outcomes among stage
included. Increased esophageal acid exposure was defined I-III elderly colon cancer patients.
as a DeMeester composite score of >14.76 in the distal probe BACKGROUND: Surgical outcomes are associated with
and >16.4 in the proximal probe. Dual probe pH catheters patient and surgeon characteristics. If outcomes are also
with sensors spaced 10, 15 or 18 cm apart were selected impacted by the specific hospital where the surgery occurs,
such that the proximal probe would be as close as possible there is a hospital center effect (HCE). Previous studies of
to the upper esophageal sphincter in each patient.
laparoscopic colectomies focus on patient, provider and
RESULTS: From 425 total patients 256 (60%) had increased hospital characteristics, ignoring potential HCE.
esophageal acid exposure on dual probe pH testing. Pre- Subgroup Analyses for Hospital Center Effect on Short-Term
senting symptoms in these patients were heartburn (73%),
Outcomes of Laparoscopic Colectomy
regurgitation (60%), cough (54%), hoarseness (50%), or
asthma (24%). The location of abnormal reflux was at the
Not Affiliated
distal probe only in 133 patients (31%), at the proximal
High Volume Colorectal Affiliated with with Medical
probe only in 11 patients (3%) and at both probes in 112
Hospitals (≥30) Surgeons Medical School
School
patients (26%). There was no significant difference in the N of Hospitals
43
119
196*
281
prevalence of cough, hoarseness or asthma based on loca- N of Patients
1661
1020
2397
2220
tion of the abnormal acid exposure. Abnormal acid expo- MIRR for LOS 1.24 (<0.001) 1.62 (<0.001) 1.21 (<0.001) 1.46 (<0.001)
sure at both the proximal and distal probes was most likely (P-value)
to occur in patients with a hiatal hernia larger than 3 cm MOR for
1.96 (0.004)
NA
2.09 (0.022)
1.63 (0.132)
in size [Table].
In-hospital
Mortality
(P-value)
* There are 12 hospitals who changed their medical school affiliation during
the study period. Therefore, these hospitals appeared in both affiliated and not
affiliated with medical schools.
METHODS: The Surveillance, Epidemiology and End
Results (SEER)-Medicare dataset was used to identify stage
I-III colon cancer patients in 2003 to 2007 with laparoscopic colectomies. Multilevel model regressions were utilized to study potential HCE for length of stay (LOS), 30-day
re-hospitalization, and in-hospital mortality, adjusting for
patient, surgeon and hospital level characteristics. To quantify the impact of HCE, we calculated median instantaneous
rate ratio (MIRR) for LOS and median odds ratio (MOR)
for in-hospital mortality and 30-day re-hospitalization.
Sensitivity analyses were also conducted for high volume/
medical school affiliated hospitals and colorectal surgeons.
48
793
Usefulness of Bowel Sound Auscultation: A Prospective
Evaluation
Seth Felder, Zuri A. Murrell, Phillip Fleshner
Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
METHODS: Using an electronic stethoscope (3M Littmann
Model 3200) with sound amplification capabilities and a
computer Bluetooth interface, bowel sounds of healthy volunteers (n = 10), patients with a CT diagnosed mechanical
small bowel obstruction demonstrated by a transition point
and confirmed at surgery (n = 10), and patients with postoperative ileus (n = 10) were recorded for 30 seconds while
lying in the supine position. The bowel sounds were transferred into a computer and then replayed randomly through
high definition speakers to study physicians blinded to the
clinical scenario. A total of 45 recordings were played consecutively, with 15 of the recordings duplicated. A survey
was taken just prior to the recording playback assessing
each physician’s perceived level of expertise interpreting
bowel sounds. Study physicians were instructed to categorize the patient recording as normal, obstructed, ileus, or
not sure.
Joint impact of HCE and selected patient level characteristics on LOS (A)
and in-hospital mortality (B).
RESULTS: Study physicians (n = 28) included 4 medical
students on a surgical service, 8 surgical interns, 4 senior
surgical residents, and 12 surgical attendings. Most participants (64%) stated they rarely listened to bowel sounds
in their training or clinical practice. Almost all (96%)
responded they knew what normal bowel sounds should
sound like, but were less confident in what obstructive
bowel sounds should sound like (71%). Study participants
correctly diagnosed the clinical scenario in a median of
11 (range, 5–16) of the 45 recordings (23%). A median of
2 (range, 0–22) responses were ‘not sure.’ Normal bowel
sounds were correctly identified 29% of the time with a
positive predictive value (PPV) of 22%. Obstructive bowel
sounds were correctly identified 24% of the time with a PPV
of 26%. Postoperative ileus was correctly identified 20% of
the time with a PPV of 39%. No difference was found in
diagnostic accuracy between levels of training. For participants responding he/she was ‘always able’ to identify
normal or obstructive bowel sounds if present, accuracy of
diagnosis was 32% and 29%, respectively. Fixed-marginal
inter-observer kappa value was only 0.17.
RESULTS: The multilevel analyses based on 4,617 patients
from 465 hospitals documented significant HCEs for LOS
(MIRR = 1.36; p < .001) and in-hospital mortality (MOR =
1.72; p = 0.037), but no HCE for 30-day re-hospitalization.
For patients with CCI = 3+, MIRR rose to 2.27 for LOS and
MOR rose to 6.87 for in-hospital mortality. The sensitivity
analyses confirmed our findings. HCE was significant for
LOS in all subgroup analyses, and was significant for inhospital mortality for high volume/medical school affiliated hospitals.
CONCLUSION: HCE is an important source of variation
for laparoscopic colectomy short-term outcomes, and it is
still significant when patient, provider and hospital level
characteristics are adjusted. HEC exists for both LOS and inhospital mortality. The findings are robust to high volume/
medical school affiliated hospitals and colorectal surgeons.
HCE is a potential area to improve the quality of care for
stage I-III laparoscopic colon cancer patients.
CONCLUSION: Auscultation of bowel sounds is not a useful clinical practice when trying to differentiate normal
versus ileus versus obstruction. Based on our results, the listener usually arrives at an incorrect diagnosis, and the low
inter-observer agreement further suggests the inaccuracy of
utilizing bowel sounds for clinical purposes. Routinely listening to bowel sounds should be abandoned.
49
Monday
Abstracts
BACKGROUND: Although the auscultation of bowel
sounds is considered an essential component of an adequate physical examination, its clinical value remains
largely unstudied and subjective. The aim of this study was
to determine whether an accurate diagnosis of mechanical small bowel obstruction, postoperative ileus, or normal
controls is possible based on bowel sound characteristics.
Tuesday, May 21, 2013
8:00 AM – 9:30 AM
308D
PLENARY SESSION VI
0.007) and MODS manifestations (P = 0.005). These findings held in the subgroup with biliary bacteria; and HDL
independently correlated with illness severity even among
patients with bacterial-laden CBD stones.
858
Plasma Lipids and Biliary Infections: Decreased Levels
of HDL Are Associated with More Severe Biliary
Infections: A Multivariate Analysis
Lygia Stewart1,2, Gary Jarvis3, Lawrence Way1
1. Surgery, UCSF, San Francisco, CA; 2. Surgery, SF VA Medical
Center, San Francisco, CA; 3. Infectious Disease and Laparotory
Medicine, SF VA Medical Center, San Francisco, CA
We, and others, have previously identified factors associated
with severe biliary infections: biliary bacteria, age, sex, choledocholithiasis, pigment stones. Recently we reported that
a low/normal BMI was associated with more severe biliary
infections. To understand this association, we studied correlations between plasma lipid levels and biliary infections.
METHODS: 475 patients with gallstones were studied; 410
men, 65 women; average age 62 (range 17–104). Gallstones,
bile, and blood (as applicable) were cultured, Stone type
recorded. Illness severity was classified as: none (no inflammatory manifestations), SIRS (fever, leukocytosis), severe
(abscess, cholangitis, empyema), or MODS (bacteremia,
hypotension, organ failure). Using bivariate and multivariate analysis, we examined associations between lipid levels
(HDL, LDL, Triglycerides – obtained prior to the acute illness) and: BMI, biliary bacteria, bacteremia, gallstone type,
illness severity. In the multivariate analysis we used factors
associated with biliary infections (age, sex, biliary bacteria, CONCLUSION: This study demonstrates the importance
pigment stones, choledocholithiasis).
of plasma lipids to biliary infections. Increased LDL levels
RESULTS: On bivariate analysis (Table), BMI correlated favored cholesterol (rather than pigment) gallstone formawith HDL and Trig (P < 0.003). LDL inversely correlated tion, and were more often associated with a sterile biliary
with biliary bacteria (P = 0.002) and pigment stones (P = tract. HDL levels, however, seemed to dictate the course
0.0001); while HDL and LDL inversely correlated with bac- of the biliary infection; patients with low HDL levels had
teremia (P < 0.03). HDL and LDL inversely correlated with significantly more severe biliary infections. Even among
increasing infection severity (P < 0.02) and MODS mani- patients with bacterial-laden CBD stones, those with high
festations (P < 0.006). On Multivariate analysis of factors HDL levels had a mild illness, while those with low HDL
associated with pigment stones and biliary bacteria, LDL levels more often had MODS manifestations. This data suginversely correlated with pigment stones (P = 0.001) and gest that HDL may be protective in biliary infections; and
biliary bacteria (P = 0.017). Multivariate analysis of factors that patients with biliary infections and low HDL levels
associated with biliary infection severity revealed HDL as may need a more aggressive clinical approach. This is the
the most important lipid (Figure); only HDL inversely inde- first study to demonstrate the importance of plasma lipid
pendently correlated with biliary infection severity (P = levels to the severity of biliary infections.
50
Bivariate Analysis: Lipids and Biliary Infections
Stone Type
Pigment
Cholesterol or Mixed Chol
Biliary Bacteria
Bacteria
Sterile
Bacteremia
Sterile blood
Present
None
Bacteremia
MODS findings (pts with biliary bacteria)
MODS findings (pts with bacterial-laden CBD stones)
Present
None
859
Laparoscopic-Assisted ERCP After Gastric Bypass
Surgery for Choledocholithiasis
Gastric bypass is common in the United States and is often
performed without synchronous cholecystectomy. The
resultant rapid weight loss can lead to gallstones in up
to 40% of patients, some of whom will develop choledocholithiasis. Treatment of choledocholithiasis after gastric
bypass is problematic because the long Roux limb is impossible to navigate with a standard side-viewing endoscope
passed through the mouth.
We demonstrate a simple technique to perform ERCP after
gastric bypass by laparoscopically providing access to the
gastric remnant. The purpose is to familiarize surgeons and
endoscopists with the technique, as many will encounter
patients such as this in everyday practice.
238
237
39
436
72
42
43
36
43
35
166
42
65
45
33
46
NS
0.017
0.0001
0.005
101
116
85
109
89
105
86
103
P value
0.0001
0.002
0.006
0.006
0.074
Triglycerides
mg/dl
P Value
156
NS
164
150
174
131
163
149
150
153
151
0.046
NS
NS
NS
in mice have been difficult to establish due to the technical difficulty and high mortality associated with esophageal
surgery in such small animals. The limited mouse models
that have been described lack adequate molecular characterization to confirm the development of Barrett’s metaplasia. We now describe the development and characterization
of Barrett’s-like columnar metaplasia in mice that have
reflux esophagitis induced by esophagojejunostomy (EJ).
METHODS: To induce reflux, we performed EJ in twenty
C57Bl/6 mice weighing 15 to 33 grams. At various time
points thereafter, the distal esophagus was removed, paraffin-embedded, sectioned, and mounted on slides, which
were stained with H&E and with Alcian blue. Immunohistochemistry was performed to determine expression of
Sox-9 (a columnar cell transcription factor expressed in
human Barrett’s metaplasia) and the columnar cell cytokeratin (CK) 18. CK14 (an esophageal squamous cell cytokeratin) was used as a control. We evaluated the specimens
for squamous basal cell and papillary hyperplasia typical of
reflux esophagitis, as well as for columnar metaplasia.
RESULTS: Procedural mortality was 40% for the first 10
animals, but dropped to 20% for the next 10 animals.
At 13 weeks after EJ, erosive esophagitis with prominent
Development and Characterization of a Surgical, Mouse squamous basal cell and papillary hyperplasia was present in all animals. Columnar metaplasia, with goblet
Model of Reflux Esophagitis and Barrett’s Esophagus
cells that stained with Alcian blue, developed by week 34.
Thai H. Pham1, David H. Wang2, Robert M. Genta3,
The columnar metaplasia expressed CK18, but not CK14.
Rhonda F. Souza2, Stuart J. Spechler2
Intense expression of Sox-9 was detected in areas of colum1. Surgery, North Texas VAMC; UT Southwestern Medical Center,
nar metaplasia. In the squamous epithelium close to the
Dallas, TX; 2. Medicine, North Texas VAMC; UT Southwestern
EJ anastomosis, furthermore, Sox-9 expression was seen in
Medical Center, Dallas, TX; 3. Pathology, North Texas VAMC; UT
scattered basal cells, whereas squamous epithelium further
Southwestern Medical Center, Dallas, TX
from the anastomosis did not exhibit Sox-9 expression.
INTRODUCTION: To study the molecular mechanisms CONCLUSIONS: EJ can be performed successfully in
underlying how reflux esophagitis causes Barrett’s metapla- C57Bl/6 mice, causing reflux esophagitis and, later, goblet
sia, an appropriate animal model is desirable. A number of cell-containing columnar metaplasia that expresses CK18
surgical, rat models of GERD and Barrett’s esophagus are and Sox-9. These data suggest that this surgical, mouse
available, but genetic engineering of rats is not accom- model recapitulates the phenotypic and molecular changes
plished readily. In contrast, constitutive and conditional seen in human Barrett’s esophagus. Thus, we have estabtransgenic mice as well as knockout allele mice can be lished a relevant and genetically-modifiable model for
engineered readily and, therefore, mouse models would be studying the molecular pathogenesis of Barrett’s esophagus.
highly advantageous for studying the molecular pathogenesis of GERD and Barrett’s esophagus. Surgical reflux models
860
51
Tuesday
Abstracts
Jonathan Carter, Jennifer Kaplan, Steve Elliott,
Stanley J. Rogers, John P. Cello
Department of Surgery, UCSF, San Francisco, CA
HDL
LDL
N mg/dl P Value mg/dl
244
42
NS
96
231
43
120
/861
(normal, smooth shift, unilateral narrowing, bilateral narrowing without collaterals, bilateral narrowing with collaterals). Findings were correlated to the need for venous
resection at pancreatectomy and to the presence of histologic venous invasion.
A Standardized Radiographic Assessment of the TumorVein Interface Predicts the Need for Venous Resection
and the Presence of Histologic Venous Invasion in
Borderline Resectable Pancreatic Cancer
RESULTS: 266 patients underwent pancreaticoduodenectomy and met inclusion criteria, of whom 99 required concomitant resection of the SMV-PV. Greatest sensitivity for
predicting SMV-PV resection was achieved by an interface
threshold of abutment (sensitivity 91.9%, negative predictive value 87.9%), whereas excellent specificity was reached
with a threshold of encasement (97.6%, positive predictive value 89.7%). Among patients who underwent venous
BACKGROUND: Venous resection may be required to resection, vessel encasement was associated with a 78.3%
achieve complete resection of pancreatic cancers (PC). We rate of histologic SMV-PV invasion; this rate increased to
have previously shown that histologic invasion of the supe- 90% when the vein was occluded. The Ishikawa system,
rior mesenteric vein-portal vein (SMV-PV) is associated with while more detailed, offered no advantage in predicting the
poor prognosis following resection. Using high-definition need for SMV-PV resection and was less accurate in predictmultidetector computed tomography (CT), we sought to ing histologic venous invasion. Subset analyses performed
evaluate the ability of two commonly-used sets of radio- for patients who received neoadjuvant chemoradiation and
graphic criteria to predict the need for SMV-PV resection for those who did not yielded similar findings.
at pancreatectomy and the histologic presence of SMV-PV CONCLUSIONS: A simple radiographic classification
invasion.
system that categorizes the extent of the tumor-SMV-PV
METHODS: All patients who underwent pancreaticoduo- interface accurately predicts the need for SMV-PV resecdenectomy for PC between 2004 and 2011 at the authors’ tion at pancreatectomy, and correlates with the pathologic
institution were identified. Preoperative pancreatic protocol involvement of the resected vein. To assist in treatment
CT images were re-reviewed to characterize the interface planning, a standardized description of this anatomic relabetween the tumor and SMV-PV (no interface, abutment tionship should be routinely performed for patients with
[≤180 degrees], encasement [>180 degrees], occlusion) and borderline resectable tumors.
the appearance of the SMV-PV using Ishikawa criteria
Hop S. Tran Cao1, Aparna Balachandran2, Huamin Wang3,
Jason B. Fleming1, Jeffrey E. Lee1, Peter W. Pisters1, Matthew Katz1
1. Surgical Oncology, U.T. MD Anderson Cancer Center, Houston,
TX; 2. Diagnostic Radiology, U.T. MD Anderson Cancer Center,
Houston, TX; 3. Pathology, U.T. MD Anderson Cancer Center,
Houston, TX
Correlation of Radiographic Assessment of Tumor-Vessel Relationship to Surgical and Pathologic Outcomes
Tumor-Vessel Interface*
Vessel Appearance**
Radiographic-Surgical Correlation
CT cut-off
0
1
2
3
1
2
3
4
5
Number of patients
Sensitivity
Specificity
PPV
NPV
Accuracy
266
N/A
N/A
N/A
N/A
N/A
200
91.9
34.7
45.5
87.9
56.0
39
35.4
97.6
89.7
71.8
74.4
11
10.1
99.4
90.9
65.1
66.2
266
N/ A
N/A
N/A
N/A
N/A
166
85.9
51.5
51.2
86.0
71.8
96
66.7
82.0
68.8
80.6
76.3
30
27.3
98.2
90.0
69.5
71.8
29
27.3
98.8
93.1
69.6
72.2
Radiographic-Pathologic Correlation
CT value
0
1
2
3
1
2
3
4
5
Number of venous resection
8
56
25
10
14
19
39
0
27
Histologic venous invasion (%)
33.3
64.6
78.3
90.0
54.5
52.9
69.7
-84.6
CT – computed tomography; PPV – positive predictive value; NPV – negative predictive value. *Tumor-SMV-PV interface scale – 0: no interface, 1: abutment (180°),
2: encasement (>180°), 3: occlusion. **SMV-PV appearance based on the Ishikawa system –1: normal, 2: smooth shift, 3: unilateral narrowing, 4: bilateral narrowing
without collaterals, 5: bilateral narrowing or occlusion with collaterals.
52
/862
/863
Depth of Submucosal Tumor Infiltration and Its
Relevance in Lymphatic Metastasis Formation for T1b
Squamous-Cell and Adenocarcinomas of the Esophagus
High Resolution Manometry Classifications for
Idiopathic Achalasia in Patients with Chagas Disease
Esophagopathy
Michael F. Nentwich1, Katharina von Loga1,2, Matthias Reeh1,
Guido Sauter2, Thomas Rösch3, Jakob R. Izbicki1,
Dean Bogoevski1
1. General, Visceral and Thoracic Surgery, University Clinic
Hamburg-Eppendorf, Hamburg, Germany; 2. Department of
Pathology, University Clinic Eppendorf, Hamburg, Germany;
3. Clinic for Interdisciplinary Endoskopy, University Clinic
Eppendorf, Hamburg, Germany
Fernando P. Vicentine1, Fernando A. Herbella1,
Luciana C. Silva1, Marco E. Allaix2, Marco G. Patti2
1. HSP – Unifesp, São Paulo, Brazil; 2. University of Chicago
Pritzker School of Medicine, CHicago, IL
BACKGROUND: Surgical resection for early esophageal
carcinoma has been challenged by less invasive endoscopic
approaches. As lymph node involvement, one of the major
factors influencing patients’ overall survival cannot be
assessed by endoscopic resection, selecting patients in need
for surgical intervention according to their risk of lymphatic spread is mandatory.
OBJECTIVE: The aim of this study was to evaluate submucosal layer thickness, depth of submucosal tumor infiltration and tumor length as well as lymphatic invasion in T1b
esophageal carcinomas for its predictiveness on lymphatic METHODS: We studied 86 patients with achalasia: 45
patients with CDE (54% females, mean age 55.8 ± 14.7
metastasis formation.
years) and 41 patients with IA (58% females, mean age 49.0
METHODS: Histopathological specimens following sur- ± 19 5 years). All patients underwent a HRM when Chicago
gical resection for T1b esophageal carcinomas were re- and Rochester classifications for achalasia were applied and
evaluated for overall submucosal layer thickness, depth a barium esophagram to measure esophageal dilatation.
of submucosal tumor infiltration, tumor length as well as
lymphatic and vascular infiltration. A ratio of overall sub- RESULTS: The Chicago classification was present in IA:
mucosal layer thickness and depth of submucosal tumor Chicago I: 32%, Chicago II: 66% and Chicago III: 2%; In
infiltration was calculated and this proportion of submuco- CDE: Chicago I: 49%, Chicago II: 51% and Chicago III: 0%
sal invasion was used to form sub-categories either in thirds (p = 0.178). The Rochester classification was present in IA:
or in halfs of total submucosal gauge. Influence of submu- Rochester I: 2%, Rochester II: 66% and Rochester III: 32%;
cosal invasion as well as tumor length on lymphatic metas- In CDE: Rochester I: 0%, Rochester II: 51% and Rochester
III: 49% (p = 0.178). CDE patients had more pronounced
tasis formation and overall survival was assessed.
degrees of esophageal dilatation (p < 0.0001). The degree of
RESULTS: A total of 67 Patients with pT1b tumors were esophageal dilatation did not correlate with neither classianalyzed, including 36 adenocarcinomas (53.7%) and 31 fication (p = 0.2); however, an indirect correlation between
squamous-cell carcinomas (46.3%). Lymph node involve- esophageal body pressure amplitude and the degree of
ment was seen in 20.9% (14/67) patients. Overall mean esophageal dilatation was noticed (p = 0.001). In 9 (10%)
thickness of submucosal layer was 5.07 mm (SD 1.53 mm). patients the HRM pattern changed during the test from
Overall proportion of submucosal infiltration was calculated Chicago I to II.
as 64.79% (SD 29.2%). Comparison of overall proportion
of submucosal infiltration between patients with (62.81%, CONCLUSION: Our results show that: (a) HRM classificarange 17–97%) and without (65.31%, range 2–99%) lymph tions for IA can be applied in patients with CDE and (b)
node involvement did not show significant differences (p = HRM classifications did not correlate with the degree of
0.698 Mann-Whitney-U). On log-regression models, only esophageal dilatation. The secondary findings of our study
the presence of lymphangioinvasion and tumor length suggest that HRM classifications may reflect esophageal
was significantly associated with positive lymph node repletion and pressurization instead of muscular contraction. The correlation between manometric findings and
involvement.
treatment outcomes for CDE needs to be answered in a near
CONCLUSION: As depth of submucosal tumor infiltration future.
did not correlate with the formation of lymph node metastases and in regard of the risk of lymphatic spread in these
cases, surgical resection is warranted whenever the tumor
invades the submucosal layer.
53
Tuesday
Abstracts
BACKGROUND: Idiopatic achalasia (IA) and Chagas disease esophagopathy (CDE) share several similarities; however, some differences between the 2 diseases have been
noticed. The comparison between IA and CDE is important
to evaluate if treatment options and their results can be
accepted universally. High-resolution manometry (HRM)
has proved a better diagnostic tool compared to conventional manometry. The study of IA patients with the aid of
HRM allowed the creation of new classifications of the disease with apparent correlation with treatment outcomes, as
proposed by the Chicago and Rochester groups. The clinical
application of HRM parameters in patients with CDE is still
elusive. This study aims to evaluate HRM classifications for
idiopathic achalasia in patients with CDE.
9:30 AM – 12:00 PM
308D
PLENARY SESSION VII
911
910
Does Preoperative Imaging Accurately Predict Main
Duct Involvement in Intraductal Papillary Mucinous
Neoplasm
Spleen Preserving Laparoscopic Distal Pancreatectomy
for a Solid Pseudopapillary Tumor in a Male Patient
(This Video Demonstrates Technical Details of a Rare
Tumor of the Pancreas in a Male Patient. Only Few
Cases Have Been Reported in Males)
Morgan R. Barron1, Joshua A. Waters1, Janak A. Parikh1,
John DeWitt2, Mohammad A. Al-Haddad2, Eugene P. Ceppa1,
Michael G. House1, Nicholas J. Zyromski1, Attila Nakeeb1,
Henry A. Pitt1, C. Max Schmidt1
1. Surgery, Indiana University School of Medicine, Indianapolis,
IN; 2. Gastroenterology, Indiana University School of Medicine,
Indianapolis, IN
Bestoun H. Ahmed, Reginald L. Griffin, Ziad Awad,
Carmine Volpe, Michael S. Nussbaum
Surgery, University of Florida College of Medicine/Jacksonville,
Jacksonville, FL
A 31-y-old patient had a blunt abdominal trauma. CT scan
showed an incidental tumor in the body of the pancreas.
EUS-guided cytology was Solid pseudopapillary tumor.
Patient in right semi-lateral position. Division of gastrocolic
omentum. Release of splenic flexure of the colon. Transection of the body of the pancreas after separating splenic
vessels. Separation of the pancreas from the vessels. Extraction of the specimen in a pouch. Operative time: 170 minutes. Blood loss: 50 ml. Tolerated food on day 2. Discharged
on day 4. Pathology: 6x5 cm tumor like FNA result with
METHODS: Data regarding all patients undergoing resecclear margins .In conclusion: Laparoscopic spleen preservtion for IPMN at a single, academic institution between
ing approach is feasible in the management of this tumor.
1992 and 2012 were gathered prospectively. Retrospective analysis of imaging, clinical, and pathologic data was
912
undertaken. Preoperative classification of IPMN type was
based on cross-sectional imaging (CT or MRI).
High Fat Diet Enhances Villus Growth During
OBJECTIVE: Main pancreatic duct (MPD) involvement
is a well-demonstrated risk factor for malignancy in intraductal papillary mucinous neoplasm (IPMN). Preoperative
radiographic determination of IPMN type (main, mixed, or
branch) is relied upon heavily in preoperative oncologic
risk stratification. We hypothesize that preoperative radiographic assessment of MPD involvement in IPMN is an
accurate predictor of pathologic MPD involvement.
/
RESULTS: Three-hundred and sixty four patients underwent resection for IPMN. Of these, 335 had adequate data
on both radiographic and pathologic parameters for comparison. Of 184 suspected branch duct (BD) IPMN, 35
(19%) demonstrated MPD involvement on final pathology.
Of 84 mixed-type (MT) IPMN 16 (19%) demonstrated no
MPD involvement. Of 68 suspected main duct (MD) IPMN
13 (19%) demonstrated no MPD involvement. Of 35 of 184
(19%) that had a suspected BD IPMN but were found to
have MPD involvement on pathology, 12 (34%) had invasive carcinoma. Alternatively, in patients with suspected
MD or MT IPMN who ultimately were found to have no
main duct involvement on pathology 2 (7%) demonstrated
invasive carcinoma.
Adaptation After Massive Small Bowel Resection
CONCLUSION: In resected IPMN, MPD involvement has
been demonstrated as an independent risk factor for invasive cancer. Preoperative radiographic IPMN type correlates
with final pathology in 81% of patients. In addition, risk of
invasive carcinoma correlates with pathologic presence (or
absence) of main duct involvement. Consequently, preoperative imaging for oncologic risk stratification may over or
under weigh risk in up to one in five patients.
METHODS: C57/Bl6 mice, aged 6–8 weeks, underwent
a 50% proximal SBR or sham operation (bowel transection with reanastomosis alone) and then provided a standard rodent liquid diet (LD) ad lib. After a typical period
of adaptation (7 days), SBR and sham-operated mice were
randomized to receive either LD or HFD (42% kcal/fat)
for an additional 7 days. Mice were individual caged, and
food intake and feces output were measured daily. Mice
were then harvested, and small intestine was collected for
analysis.
Pamela M. Choi, Raphael C. Sun, Jun Guo,
Christopher R. Erwin, Brad Warner
Department of Pediatric Surgery, Washington University,
St. Louis, MO
54
BACKGROUND: Adaptation is a compensatory process
following small bowel resection (SBR) that results in villus growth and enhanced mucosal surface area. In prior
studies, High Fat Diet (HFD) had been shown to enhance
adaptation responses if fed immediately following SBR. The
purpose of this study was to determine if HFD could further
enhance villus growth after resection-induced adaptation
had already taken place.
METHODS: Prospectively collected clinicopathologic and
perioperative data on adult patients undergoing liver resection between 1/1/2003–7/31/2011 were retrospectively
reviewed to assess incidence of and risk factors for postoperative VTE within 30 days. Risk factors for PP were analyzed using multivariable logistic regression.
/913
Age 60 years
Pharmacologic prophylaxis
Late/None
Early (Day 2–5)
Immediate (Day 0/1)
Major hepatectomy
EBL 600 cc
Peak INR 1.5
Pharmacologic Prophylaxis, Postoperative INR, and
Risk of Venous Thromboembolism After Hepatectomy
Hari Nathan, Matthew J. Weiss, Ronald P. DeMatteo,
Peter J. Allen, T.P. Kingham, Yuman Fong, William R. Jarnagin,
Michael D’Angelica
Department of Surgery, Memorial Sloan-Kettering Cancer Center,
New York, MD
Ref.: Referent
INTRODUCTION: Pharmacologic prophylaxis (PP) against
venous thromboembolism (VTE) is often withheld after
hepatectomy due to bleeding risk or perceived coagulopathy related to INR and platelet count, but its role has been
inadequately studied. We sought to characterize VTE risk
and define the role of PP after hepatectomy.
55
3.06
1.65–5.70
Ref.
0.63
0.78
1.19
2.09
3.03
0.29–1.35
0.42–1.45
0.63–2.22
1.18–3.69
1.58–5.79
0.001
0.4
0.6
0.01
0.001
Tuesday
Abstracts
RESULTS: Of 2198 patients undergoing hepatectomy,
median age was 60 years, and 49% were female. Median
BMI was 27, preoperative chemotherapy was given to 997
patients (45%), and a history of prior VTE was present in 67
patients (3%). Major hepatectomy (MH, defined as ≥4 segments) was performed in 716 patients (33%) and another
concomitant organ resection in 556 (25%). EBL was ≥600 cc
in 580 patients (27%), and liv±er steatosis was noted in 142
(18%). Median peak INR within 7 days after surgery was 1.4
(peak INR ≥1.5 in 32%), and median platelet count nadir
was 154k (platelet nadir <100k in 12%). PP was started on
Figure 1: Villus Height Measurements after SBR or Sham Operations.
day 0/1 (immediate) in 815 patients (37%), day 2–5 (early)
RESULTS: There were no differences in caloric intake or in 481 (22%), and later or never (late/none) in 902 (41%).
stool output between any of the groups. However, Sham Use of any (immediate or early) PP was less common with
mice had increased weight gain compared to SBR mice MH (50% vs 63%, P < 0.001), EBL ≥ 600 cc (54% vs 61%, P
independent of diet. As shown in Figure 1, adaptation = 0.002), and peak INR ≥ 1.5 (54% vs 62%, P = 0.001). VTE
occurred in both SBR groups, however the SBR/HFD had occurred in 57 patients (overall: 2.6%; immediate: 2.2%;
significantly increased villus height compared to SBR/LD. early: 1.9%; late/none: 3.3%; P = 0.2). VTE was associated
When compared to their sham counterparts, there was a with age ≥60 (3.9% vs 1.3%, P < 0.001), MH (4.2% vs 1.8%,
102.3% increase in villus height in the HFD group com- P = 0.001), EBL ≥ 600 cc (4.8% vs 1.7%, P < 0.001), and peak
pared to only 42.6% in the LD group. Real-Time PCR was INR ≥ 1.5 (5.2% vs 1.5%, P < 0.001), but not gender, BMI,
performed from mRNA of isolated intestinal villus cells, preoperative chemotherapy, history of VTE, other organ
and CD36 expression was markedly elevated after high fat resection, liver steatosis, or nadir platelet count <100k (all
diet (greater than 50-fold) in the SBR/HFD group compared P > 0.05). There was no significant time trend in VTE incidence. On multivariable analysis, age, EBL, and peak INR
with SBR/LD mice.
remained significant predictors of VTE (Table).
CONCLUSION: While a week-long exposure to increased
enteral fat alone did not affect villus morphology in sham- CONCLUSIONS: Counterintuitively, higher INR, but not
operated mice, HFD significantly increased villus growth in use of postoperative PP, was associated with VTE within 30
the setting of resection-induced adaptation. These data sup- days after hepatectomy. INR alone may not be an accurate
port the clinical utility of enteral fat in augmenting adap- indicator of coagulation status after hepatectomy. The role
tation responses in patients who have been subjected to of PP after hepatectomy requires prospective validation.
massive SBR. Increased expression of CD36 suggests a posMultivariable Logistic Regression Analysis of Risk Factors for VTE
sible mechanistic role in dietary fat metabolism and villus
growth in the setting of short gut syndrome.
Variable
Odds Ratio
95% CI
P-Value
/914
Table 1: Outcomes of Patients with Curative Esophagectomy Alone
Compared to Those with Esophagectomyand Lung Resection. Data
Presented as Median (Range) and N (%). * = p < 0.05
Clinical Significance of Incidental Pulmonary Nodules
in Esophageal Cancer Patients
Amin Madani1,2, Lorenzo E. Ferri1,2, Jonathan Spicer1,2,
David S. Mulder2
1. General Surgery, McGill University, Montreal, ON, Canada;
2. Thoracic Surgery, McGill University, Montreal, QC, Canada
Incidental pulmonary nodules are frequently identified during staging investigations for esophageal cancer
patients. However, the clinical significance of such nodules
is unclear and may bias treatment decisions towards palliative options. This study is aimed to determine the value of
an aggressive surgical approach in patients with esophageal
cancer and incidental pulmonary nodules.
Esophagectomy
Only (E)
(N = 275)
Age
62 (43–78)
Gender (% M)
73%
Smoking History
130 (47%) *
Pulmonary Complications 70 (25%)
Anastamosis Leak
26 (9%)
Overall Complications
151 (55%)
Estimated Blood Loss
310 mL (100–3500)
Length of Stay
11 days (5–185)
Operative Time
285 min (100–600)
Post-Operative Mortality 9 (3%)
Esophagectomy and
Lung Resection (EL)
(N = 33)
65 (24–91)
76%
25 (77%) *
6 (19%)
2 (6%)
15 (45%)
300 mL (150–2000)
10 days (7–86)
310 min (220–510)
1 (3%)
From 2005–2012, a prospectively entered institutional
clinical database of esophageal cancer patients was accessed
to identify patients with incidental pulmonary nodules.
915
Those patients who underwent combined esophageal and
lung resection (EL) were compared to those who had esoph- Internal Hernia After Laparoscopic Roux-en-Y Gastric
agectomy alone (E) in terms of demographics, tumor char- Bypass
acteristics and peri-operative outcomes. Fishers exact and
Ayman Obeid1, David M. Breland1, Richard Stahl1,
MWU-test determined significance (*p < 0.05).
Ronald H. Clements2, Jayleen M. Grams1
During the study period, 424 patients were treated for 1. Surgery, University of Alabama at Birmingham, Birmingham,
esophageal cancer, of which 93 (22%) had lung nodules. AL; 2. Surgery, Vanderbilt University, Nashville, TN
Of these, 29 (31%) were treated non-surgically either due to
their poor performance status or extra-pulmonary distant INTRODUCTION: Although laparoscopic Roux-en-Y gasmetastasis on CT and/or PET. The remaining 64 patients tric bypass (LRYGB) has decreased morbidity compared to
had no evidence of extra-pulmonary metastasis and under- the open approach, it was initially associated with a higher
went neo-adjuvant therapy (35 (55%)) followed by curative rate of internal hernia (IH). This study investigated the
en-bloc esophagectomy (with lung resection, 33 (50%), or impact of mesenteric defect closure on the rate and characwithout lung resection, 31 (47%) as per a tumor board con- teristics of IH after LRYGB.
sensus). Of 33 lung resections, there were 27 benign lesions METHODS: Retrospective review was conducted on all
(mostly granulomas or fibrotic scars), 4 primary stage I lung patients undergoing LRYGB from 2001–2011. Only patients
cancers and 2 metastases (1 esophageal cancer and 1 renal who had all defects closed (DC) or all defects not closed
cell carcinoma). Of the 31 patients with lung nodules who (DnC) were included. Patients with an incidentally idenunderwent curative esophagectomy without lung resec- tified IH during another operation were excluded. Data
tion, only 1 (3.2%) showed interval size increase on fol- collected included demographics, clinical presentation,
low-up imaging (median 9 months (3–40)). A total of 308 operative details, and postoperative course. Data were anapatients underwent a curative esophagectomy, of which lyzed using SPSS (version 16) statistical software.
33 had a combined esophagectomy and wedge lung resection (EL) and 275 had an esophagectomy alone (E). There RESULTS: Of 1160 patients who underwent LRYGB from
were no differences in age or gender, but the EL group had 2001–2011, 914 met inclusion criteria [DC = 663 (72.5%)
more smokers (EL:25 (77%) vs E:130 (47%) *). There was no patients and DnC = 251 (27.5%)]. Median follow-up was
difference in pulmonary complications, anastomotic leak, 24.3 (range 0.5–93.3) vs 31.7 months (range 0.5–131) in DC
overall complications, operative time, blood loss, length-of- vs DnC, respectively (p < 0.0001). A total of 46 patients
(5%) developed a symptomatic IH [25 (3.8%) in DC vs 21
stay, or post-operative mortality (Table 1).
(8.4%) in DnC group, p = 0.005]. This remained statistically
The presence of incidental pulmonary nodules in the significant on multivariate analysis (p = 0.0098, OR 0.44;
absence of extra-pulmonary metastases in esophageal can- 95% CI 0.24–0.82). Nineteen patients (42.2%) presented for
cer patients are rarely distant metastases, and should not emergent or urgent repair and 26 (57.8%) for elective repair.
bias caregivers towards palliative therapy. In addition, The most common symptom was chronic post-prandial
should a nodule be of uncertain etiology, resection of lung abdominal pain (53.4%), followed by abdominal pain with
nodules during the esophagectomy is safe.
nausea ± vomiting (35.6%), acute abdominal pain ± nausea and vomiting (8.8%), and an acute abdomen (2.2%).
/
56
(10%), or high (13%). Positive margins for EMR, LR, and PD
were identified in 66%, 29% and 3%, respectively. Median
follow-up was 27 months. The 3 year recurrence-free survival (RFS) rate was 83% and there were no differences in
RFS between the three different treatment groups. Tumors
were smaller in the EMR group (p = 0.005) and more likely
to have a positive margin compared to the LR and PD group
(p < 0.001). In all patients, RFS was better in low grade
tumors as compared to those that were high or intermediate (p = 0.04). Negative margin status and negative lymph
nodes were not associated with better RFS. Morbidity after
EMR, LR, and PD was 0%, 24%, and 41% respectively.
Median time to presentation from LRYGB was 16.6 (range
3.1–71.9) vs 33.5 months (range 10–103) in the DC vs DnC
group, respectively (p < 0.001). At the time of IH repair there
was no significant difference in BMI or % EWL between
the two groups. All patients underwent CT scan which
was consistent with IH in 26 patients (57.5%), suggestive
in 7 (15.6%), showed small bowel obstruction in 4 (8.9%),
and was negative in 8 (17.8%). The majority of IH repairs
were performed laparoscopically (86.7%) vs open (13.3%).
Intra-operatively, 71 herniation sites were identified. In the
DC group, there were 23 (67.6%) pseudo-Peterson’s and 11
(32.4%) meso-mesoenteric defects. In the DnC group, there
were 5 (13.5%) mesocolic, 15 (40.5%) Peterson’s, 2 (5.4%)
pseudo-Peterson’s, and 15 (40.5%) meso-mesenteric defects.
Median OR time was 104 minutes (range 75–180). Median
length of stay was 1 day (range 0.5–32). One patient who
presented in extremis died after being hospitalized elsewhere for 3 days with the incorrect diagnosis. One patient
had IH recurrence 11.5 and 14.2 months after initial repair.
Table I
CONCLUSIONS: Complications of IH can be devastating
and closure of mesenteric defects during LRYGB significantly lowers IH rate. A high index of suspicion must be
maintained since symptoms may be nonspecific and imaging may be negative in nearly 20% of patients.
/916
EMR
(n = 12)
0.6 + 0.5
LR
(n = 35)
1.8 + 1.4
CONCLUSIONS: EMR, LR, and PD are all effective treatment approaches for duodenal neuroendocrine tumors.
Tumor grade is associated with recurrence-free survival but
not lymph node or margin status. When feasible, a less
aggressive surgical approach to treat duodenal neuroendocrine tumors should be considered.
Tumor Grade, Not Extent of Resection, Is Associated
with Recurrence-Free Survival in Patients with
Duodenal Neuroendocrine Tumors
Brian Untch, Laura H. Tang, Keisha Bonner, Kevin K. Roggin,
Michael D’Angelica, Ronald P. DeMatteo, William R. Jarnagin,
T.P. Kingham
Surgery, Memorial Sloan-Kettering Cancer Center, New York, IL
917
BACKGROUND: Duodenal neuroendocrine tumors are
rare and few studies exist to guide surgical management.
Endoscopic mucosal resection (EMR), local duodenal resection (LR), and pancreaticoduodenectomy (PD) are typically
performed as primary treatment. This study identifies factors associated with recurrence after resection.
Laparoscopic Pancreas Sparing Segmental Resection of
the Distal Duodenum for GIST
Robert Sung, Diana J. McPhee, Paresh C. Shah
Lenox Hill Hospital, New York, NY
This is a laparoscopic pancreas sparing, segmental resection
of the distal duodenum for a GIST. A 65 year old female
METHODS: A retrospective, single institution review was presented with GI bleeding, the diagnosis and initial bleedperformed between 1987 and 2011 on patients with a patho- ing control were done endoscopically. Imaging confirmed
logic diagnosis of duodenal neuroendocrine tumor. Biopsy location and vascular supply. We begin with an extended
and surgical specimens were independently reviewed by a Kocher maneuver to the ligament of Treitz. The tumor is
pathologist. Tumor grade was assigned based on WHO 2010 identified and the duodenum freed from the superior mesenteric vessels. An extraserosal dissecton off the pancreas is
criteria (KI-67 and/or mitoses per high power field).
RESULTS: Seventy-seven patients with a median age of done using ultrasonic shears. The jejunum is divided at the
60 had resectable duodenal neuroendocrine tumors. Based ligament, the duodenum divided just distal to the ampulla.
on pathologic review, there were 9 somatostatinomas, 18 A two-layer handsewn anastomosis is created. Patholgastrinomas, and 49 not otherwise specified. In the entire ogy demonstrated a 3.9 cm low-grade GIST with negative
group, 12 underwent EMR, 35 had LR, and 30 underwent margins.
PD (Table). Tumors were graded as low (77%), intermediate
57
Tuesday
Abstracts
PD
(n = 30) p Value
1.9 + 1.1
0.005
18/28
Low Grade Tumor*
9/10 (90%)
28/33 (84%)
NS
(64%)
Positive Resection Margin 8/12 (66%)
9/31 (29%) 1/30 (3%) <0.001
18/29
Positive Lymph Nodes
NA
5/17 (29%)
0.03
(62%)
Recurrence
1/12 (8%)
6/35 (17%) 5/30 (17%)
NS
*pathology specimens were unavailable for review of grade in 6 patients
Variable
Tumor Size (cm)
/919
918
Overexpressing TNF-alpha in Pancreatic Ductal
Adenocarcinoma Cells and Fibroblasts Modifies
Cell Survival and Reduces Fatty Acid Synthesis via
Downregulation of Sterol Regulatory Element Binding
Protein-1 and Activation of Acetyl COA Carboxylase
Does Resident Experience Affect Outcomes in Complex
Abdominal Surgery?
Mazhar Al-Zoubi, Galina Chipitsyna, Konrad Sarosiek,
Christopher Y. Kang, Charles J. Yeo, Hwyda A. Arafat
Daniel Relles1, Richard Burkhart1, Michael J. Pucci1,
Jocelyn Sendecki2, Renee Tholey1, Ross E. Drueding1,
Patricia K. Sauter1, Eugene P. Kennedy1, Jordan M. Winter1,
Harish Lavu1, Charles J. Yeo1
1. Surgery, Thomas Jefferson University, Philadelphia, PA;
2. Biostatistics, Thomas Jefferson University, Philadelphia, PA
INTRODUCTION: The effect of TNF-D on pancreatic
tumorigenesis is controversial due to the differential signaling pathways initiated after binding its receptors TNFR1
and TNFR2. TNFR1 activation by TNF-D leads to cell apoptosis, whereas TNFR2 signaling is believed to be involved
in cell survival through the activation of NF kappa B. TNFDgene delivery has been suggested as a potentially useful
therapeutic approach to improve gemcitabine treatment
of pancreatic ductal adenocarcinoma (PDA), but its exact
mechanism of action is not clearly understood. Although
TNF-D has been shown to increase the expression of the
lipogenesis promoting enzyme, fatty acid synthase (FAS) in
liver steatosis, its impact on de novo lipogenesis in tumor
cells has not been determined. In this study, we investigated
effect of TNF-D on fatty acid synthase (FAS) in PDA cells and
in fibroblasts as part of the tumor micro-environment.
BACKGROUND: For complex abdominal operations, the
influence of provider and hospital volume on surgical outcomes has been described. The impact of resident experience is less well understood.
METHODS: We reviewed perioperative outcomes after
pancreaticoduodenectomy (PD) at a single high-volume
center between 2006 and 2012. Resident participation and
outcomes were collected in a prospectively maintained
database. Resident experience was defined as post-graduate
year (PGY) and number of PDs performed.
METHODS: PDA cells (MIAPACA-2 and AsPC-1) and the
fibroblast cell line, hTERT-BJ were transfected with TNFD
gene by lentivirus-vector transduction. Control cells were
transfected with the empty vector. FAS mRNA and protein were analyzed by real time PCR and Western blotting, respectively. Total- and phospho-AMPK, total- and
phospho-Acetyl CoA carboxylase (ACC), FAS, and LKB/
STK11 were analyzed by Western immunoblotting. The
effects of TNF-D on sterol regulatory element binding protein-1, SREBP-1, the transcription factor responsible for
FAS transcription, LKB1/STK11 (a tumor suppressor and
the established upstream regulator of AMPK) and ACC (the
downstream target of AMPK and the rate-limiting enzyme
of fatty acid synthesis) were evaluated by real time PCR.
MTT and Wound healing assays were used to determine cell
survival and migration, respectively.
RESULTS: Twenty-nine residents and four attending surgeons completed 681 PDs. The overall complication rate
was 44%; PD-specific complications (defined as pancreatic
fistula, delayed gastric emptying, bile leak, abscess, and
wound infection) occurred in 28% and were significantly
more common when the first assistant was a PGY 4 rather
than a PGY 5 or 6 (44% vs. 27%, p = 0.016). Logistic regression demonstrated that as residents perform more cases,
PD-specific complications decrease (OR = 0.97, p < 0.01).
For a resident’s first case, the predicted probability of a PDspecific complication is 27%; this rate decreases to 19% by
case 15 (Figure 1).
RESULTS: TNF-D significantly (P < 0.05) reduced PDA
and fibroblast cell survival and migration. This was associated with significant reduction of FAS mRNA and protein
expression levels in PDA cells (P = 0.02) but not the fibroblasts. Cells overexpressing TNF-D also showed significantly
(p < 0.05) reduced SREBP-1 and ACC. Reduction of FAS
by TNF-Dwas inhibited when either SREBP-1 or ACC was
knocked down by siRNA. No significant differences were
seen in AMPK phosphorylation in cells that overexpress CONCLUSIONS: We highlight the impact of resident
involvement in complex abdominal operations, demonTNF-D.
CONCLUSION: Our data demonstrate a previously unknown strating that as residents build experience with PD, patient
involvement of TNF-D in PDA and microenvironment lipo- outcomes improve. This is consistent with volume-outcome
genesis and suggest that targeted introduction of intratu- relationships for attending physicians and high-volume
mor TNF-D can have the potential as a novel therapeutic hospitals. Complex cases provide unparalleled learning
opportunities and remain an important component of suranti-lipogenic agent in human PDA.
gical training. Maximizing resident repetitive exposure to
complex surgical procedures benefits both the patient and
the trainee.
58
POSTER SESSION DETAIL
Printed as submitted by the authors.
8 indicates a poster featured in a Poster Tour (ticketed session with complimentary but limited registration):
Sunday, May 19, 2013, 11:00 – 11:45 AM: Esophageal and Stomach
Monday, May 20, 2013, 11:00 – 11:45 AM: HPB
Tuesday, May 21, 2013, 11:00 – 11:45 AM: Small Bowel and Colon-Rectal
indicates a Poster of Distinction.
Sunday, May 19, 2013
Authors available at their posters to answer questions 12:00 PM – 2:00 PM; posters on display 8:00 AM – 5:00 PM.
12:00 PM – 2:00 PM
West Hall A
POSTER SESSION I
(NON-CME)
Su1794
Effect of Instrument Type on Transanal Endoscopic
Microsurgery (TEM) Learning Curves
Ezra N. Teitelbaum, Fahd O. Arafat, Brittany Lapin,
Anne M. Boller
Northwestern University, Chicago, IL
BACKGROUND: The transanal endoscopic microsurgery
(TEM) proctoscope is used to resect benign and early-stage
malignant rectal tumors, and has received recent attention
as a potential platform for transanal natural orifice surgery.
No study has evaluated the effectiveness of different instrumentation types for TEM surgery. We tested whether learning curves for surgical novices using a TEM proctoscope
would be improved with the use of scissors with shaft articulation. Additionally, we compared TEM and laparoscopic
learning curves for the same task.
METHODS: Medical students were randomized into three
study groups: laparoscopic (LAP), TEM rigid (TEM-R), and
TEM articulating (TEM-A). All groups completed the Fundamentals of Laparoscopic Surgery (FLS) circle-cut task
10 times. The LAP group completed the task using an FLS
box-trainer and a standard laparoscopic grasper and rigid
laparoscopic scissors. The TEM-R group completed the task
using the same instruments but through a TEM procto- Procedure time versus run number.
scope within a custom TEM box-trainer. The TEM-A group
59
Sunday
Poster Abstracts
completed the tasks using the same grasper but with scissors
capable of shaft articulation up to 85 degrees. Outcomes
were the standard FLS metrics of time and error (deviation
as a percentage of total circle area). Instrument switches
between hands and TEM position adjustments were also
recorded. Overall group outcomes were compared using
t-tests. Mixed models were used to compare changes over
the 10 runs.
Basic: Colon-Rectal
RESULTS: 33 subjects were randomized, 11 to each group.
Overall mean task time was shorter for the LAP group than
both the TEM-R and TEM-A groups (200 vs. 362 and 417
seconds; p < .001) (See Figure). Subjects in all three groups
showed improvement in time over the 10 runs (coefficient
estimates –33, –62, and –61; p < .001 for each group). The
LAP group made fewer errors than the TEM-R group, but
not the TEM-A group (7% vs. 10% vs. 8% circle area; p =
.02 LAP vs. TEM-R). The LAP and TEM-A group made fewer
errors over time (coefficient estimates –0.6 and –0.7; p < .01
for both), whereas the TEM-R group had a trend towards
increased errors (coefficient estimate 0.4; p = 0.1). The LAP
group switched instruments between hands during fewer
runs than both the TEM-R and TEM-A groups (9% vs. 30%
vs. 24% of runs; p < .01). The TEM-A group adjusted the
proctoscope position during fewer runs than the TEM-R
group (36% vs. 54% of runs; p = .01).
Expression intensity ranged from weak to strong, whereas
VEGFR3 and EGFR showed only weak expression in esophageal samples. PDGFRD expression was observed in esophageal and gastric samples. Specimen showed intermediate to
strong expression. PDGFRE expression was seen in esophageal, gastric and colonic samples. Intensities varied from
weak to strong. KGFR was expressed in all intestinal samples
and revealed expression intensities from weak to strong.
CONCLUSIONS: A LAP approach results in faster circle-cut
task times than a TEM approach. While times were similar, TEM procedures using articulating scissors may result in
fewer errors and less need to adjust proctoscope position as
compared with rigid scissors. These results can be used to
develop specific curricula and training strategies for TEM
surgery.
Su1796
CONCLUSION: Our results reveal a high expression rate
of growth factor receptors in the rat intestine and facilitate
methodic experimental studies on gastrointestinal anastomotic healing in rat models using the positive impact of
specific growth factors.
Basic: Pancreas
Histone Deacetylase Inhibition (HDAC) by Vorinostat
Sensitizes Pancreatic Cancer Cells to TRAIL Induced
Cell Death
Basic: Esophageal
Rohit Chugh, Vikas Dudeja, Osama Alsaied, Sulagna Banerjee,
Veena Sangwan, Ashok Saluja, Selwyn M. Vickers
Surgery, Basic and Translational Research Lab, Minneapolis, MN
INTRODUCTION: Pancreatic cancer is one of the most
lethal human malignancies with five-year survival of less
than 5% because of its resistance to most conventional chemotherapies like gemcitabine and other novel anti-cancer
therapies like TRAIL. Histone deacetylase (HDAC) inhibitors
are a new and promising drug family with strong anticancer activity. The aim of the current study was to evaluate
whether inhibition of histone deacetylase sensitizes pancreatic cancer to TRAIL induced cell death.
Su1795
Growth Factor Receptors in the Gastrointestinal Tract
of the Rat: New Targets for Improved Anastomotic
Healing?
Daniel G. Drescher, Laura Kulzer, Carl Christoph Schimanski,
Hauke Lang, Ines Gockel
University of Mainz, Mainz, Germany
METHODS: Highly aggressive metastatic pancreatic cancer
cell lines (S2VP10, Capan-1) were treated with the HDAC
BACKGROUND: Anastomotic leakage after gastrointestinal inhibitor, Vorinostat (0–5μM), TRAIL (0–40 ng/ml) or a comsurgery is a significant cause of morbidity and mortality. bination of Vorinostat and TRAIL for 12–72 h. The effect on
In particular, esophagogastric and colorectal anastomoses cell viability was evaluated using a WST-8 cell viability assay
are vulnerable to leakage, resulting in an increased need (Dojindo Labs), apoptosis (caspase 3, 8 and 9 activation)
for reoperation and a high risk of subsequent anastomotic was evaluated using Caspase Glo assay kit (Promega).
stenosis formation and fistula. Studies in well-established
experimental rodent models showed a positive impact RESULTS: HDAC inhibition markedly increased TRAIL
of growth factors on anastomotic wound healing. So far, induced cell death in both pancreatic cancer cell lines evalmethodic investigations on the expression profile of growth uated. Viability, data expressed as % of Control (untreated
cells), mean ± SEM. S2VP10 (48 h): Vorinostat (5μM) – 64.5
factor receptors in the gastrointestinal tract do not exist.
± 0.1%, TRAIL (20 ng/ml) – 95.13 ± 0.825%, Vorinostat
MATERIAL AND METHODS: We investigated the co- (5μM) + TRAIL (20 ng/ml) – 41 ± 0.8%. HDAC inhibition
expression pattern of vascular growth factor receptor markedly augmented Caspase 3 activation in response to
(VEGFR1-3), epidermal growth factor receptor (EGFR), plate- TRAIL. Caspase 3, data expressed as % of Control, mean
let-derived growth factor receptor (PDGFRD/E) and kerati- ± SEM. S2VP10 24 h: Vorinostat (5μM) – 206.1 ± 12.07%,
nocyte growth factor receptor (KGFR) in the rat intestine. TRAIL (20 ng/ml) – 159.6 ± 1.2%, Vorinostat (5μM) + TRAIL
Additional, IHC staining was applied for confirmation of (20 ng/ml) – 2187.4 ± 77.62%.
expression and analysis of growth factor receptor localisation.
CONCLUSION: Inhibition of Histone deacetylases sensiRESULTS: VEGFR1-3, EGFR, PDGFRD/E and KGFR expres- tizes pancreatic cancer cells to TRAIL induced apoptosis and
sion in rat intestinal samples revealed varying transcription cell death. Combination of HDAC inhibition and TRAIL has
intensities. VEGFR1 expression was observed in all samples immense potential to emerge as novel therapeutic strategy
and varied from intermediate to strong. VEGFR2 expres- against pancreatic cancer.
sion was found in esophageal, gastric and colonic samples.
60
Su1797
Clinical: Biliary
Concepts for the Periampullary Carcinoma Enigma
from Clinico-Pathologic Analysis of 198 Patients
Su1590
Peter Bronsert1, Ilona Kohler1, Martin Werner1, Frank
Makowiec2, Laura H. Tang3, Ulrich T. Hopt2, Tobias Keck2,
Ulrich F. Wellner2
1
Pathological Institute, University of Freiburg, Freiburg, Germany;
2
Department of Surgery, University of Freiburg, Freiburg, Germany;
3
Department of Pathology, Memorial Sloan-Kettering Cancer Center,
New York, NY
Laparoscopic Cholecystectomy in Patients on
Clopidogrel: Is It Safe?
Richard Frazee, Stephen Abernathy
Surgery, Scott & White Healthcare, Temple, TX
CONCLUSIONS: Our results demonstrate that there should
be a change in the pathological management of making
diagnoses in periampullary carcinomas. By multivariate
analysis, traditional parameters as tumorlocation, TNM
classification lost their prominence as a source of prognosticating survival of periampullary carcinoma. Therefore,
we recommend comprising the histological subtype and
our adjusted histological grading for a better valuation of
survival.
61
Sunday
Poster Abstracts
BACKGROUND: Clopidogrel is a common antiplatelet
medication for patients with coronary, peripheral, and cerebrovascular disease. Many surgeons recommend cessation
AIMS: Periampullary adenocarcinomas comprise pancre- of Clopidogrel prior to surgery to avoid bleeding complicaatic ductal (PDAC), distal bile duct (DBDAC), ampullary tions. Clopidogrel cessation however, is associated with an
(AMPAC) and duodenal (DUOAC) adenocarcinoma. The increased risk of thrombotic events up to 3 months after
epithelia of these anatomical structures share a common cessation. We review our experience with laparoscopic choembryologic origin from the foregut. While there seem to lecystectomy in patients who remained on Clopidogrel in
be significant differences regarding tumor biology, the clas- the perioperative period.
sification, grading, staging and treatment of these entities
remains a matter of substantial debate. Due to the anatomi- METHODS: An IRB approved retrospective review of
cal complexity of the periampullary region, there is still patients having laparoscopic cholecystectomy from 2008–
considerable debate on how carcinomas and their precur- 2012 while on Clopidogrel was performed. Patient demosor lesions arising in this region should be classified. Our graphics, indication for surgery, ASA score, operative time,
study aimed at a detailed analysis of clinical, pathological conversion to open cholecystectomy, estimated blood loss,
and immunohistochemical parameters for assessment of length of stay, morbidity and mortality were reviewed.
tumor biology and identification of prognostic factors after RESULTS: Thirty-one patients (13 women and 18 men)
resection of periampullary carcinomas.
underwent laparoscopic cholecystectomy while on ClopiMATERIAL AND METHODS: 198 patients who had resec- dogrel. Sixteen were performed in an elective setting and
tion of periampullary adenocarcinoma from 2001 to 2011 fifteen were done as emergency/urgent operations. ASA
were identified. All tissue samples were processed by a stan- score was 2 in four patients (13%), 3 in twenty-four patients
dardized protocol for pathological workup of pancreatoduo- (77%), and 4 in three patients (10%). Two patients (6%)
denectomy specimen. Archived Hematoxylin-Eosin stained were converted from laparoscopic to open cholecystectomy
slides were reevaluated by three experienced pathologists due to indistinct anatomy in acute cholecystitis. Average
for accuracy of diagnosis. For the growthpattern, three operating time was 71 minutes (27–129 minutes). Average
typical subtypes were defined: intestinal, pancreatobiliary, estimated blood loss was 48 ml (1–300 ml). Morbidity was
mixed intestinal-pancreatobiliary and Poorly-differentiated experienced in 22.5% of patients, and two 30 day mortalicarcinomas. Additionally for immunohistochemical sub- ties occurred (6%) secondary to cardiovascular complicatyping of the growth pattern CK7, CK20 and CDX2 staining tions. Length of stay averaged 3 days (outpatient – 15 days).
were performed for each slide. Furthermore we established CONCLUSIONS: Laparoscopic cholecystectomy performed
a modified tumorgrading system.
on patients taking Clopidogrel did not produce clinically
RESULTS: 127 patients had PDAC, 39 had AMPAC, 23 significant operative blood loss. Conversion to open chohad DBDAC and nine had a DUOAC. The distribution of lecystectomy, morbidity and mortality were higher in this
subtypes was significantly different among the carcinoma patient population but appear to be more related to patient
groups. Tumor location, histological subtype and grading comorbidities than the effects of the Clopidogrel. Recomwere highly significant predictors of survival (p < 0.001). In mendations for Clopidogrel cessation prior to laparoscopic
accordance, a high CK7 expression and a low CDX2 expres- cholecystectomy should be reconsidered.
sion, which characterize PB differentiation, were significant
predictors of poor survival. Only histological subtype, grading and lymph node ratio were found to represent independent predictors of survival in multivariate analysis.
Su1591
Su1592
Diagnostic Accuracy of Preoperative MultidetectorRow Computed Tomography Imaging in Predicting
Microscopic Curative Resection of Hepatobiliary
and Pancreatic Malignancy: A Prospective
Multi-Institutional Study
Elevated Perioperative Serum CA 19-9 Level Is an
Independent Predictor of Poor Outcome in Patients
with Resectable Cholangiocarcinoma
Naru Kondo, Yoshiaki Murakami, Kenichiro Uemura,
Takeshi Sudo, Yasushi Hashimoto, Hayato Sasaki, Kenjiro Okada,
Taijiro Sueda
Surgery, Hiroshima University, Hiroshima, Japan
Kazuaki Shimada1, Yoshito Takeuchi2, Masaru Konishi3,
Tatsushi Kobayashi4, Akio Saiura5, Kiyoshi Matsueda6,
Tsuyoshi Sano7, Hideyuki Kanemoto8, Katsuhiko Uesaka8
1
Hepatobiliary and Pancreatic Surgery, National Cancer Center
Hospital, Tokyo, Japan; 2Diagnostic Radiology, National Cancer
Center Hospital, Tokyo, Japan; 3Division of Digestive Surgery,
National Cancer Center Hospital East, Kasiwa, Japan; 4Diagnostic
Radiology, National Cancer Center Hospital East, Kasiwa, Japan;
5
Gastrointestinal Surgery, Cancer Institute Hospital, Japanese
Foundation for Cancer Research, Tokyo, Japan; 6Diagnostic Radiology,
Cancer Institute Hospital, Japanese Foundation for Cancer Research,
Tokyo, Japan; 7Gastroenterological Surgery, Aichi Cancer Center
Hospital, Tokyo, Japan; 8Hepato-Biliary-Pancreatic Surgery, Shizuoka
Cancer Center Hospital, Tokyo, Japan
BACKGROUND: Prognosis of cholangiocarcinoma is still
unsatisfactory, and identification of predictive marker of
survival after surgical resection is important to establish the
perioperative therapeutic strategy for cholangiocarcinoma.
Impact of perioerative serum carbohydrate antigen 19-9
(CA19-9) levels on survival of patients with resectable cholangiocarcinoma is still unclear.
PURPOSE: The purpose of this study was to investigate whether perioerative serum CA19-9 levels can predict survival of patients underwent surgical resection for
cholangiocarcinoma.
PURPOSE: To assess the accuracy of preoperative diagnosis of hepatobiliary and pancreatic malignancy with multidetector-row computed tomography (MDCT) to predict
microscopic curative resection.
METHODS: One hundred and six patients with cholangiocarcinoma including 33 with intrahepatic, 48 with perihilar and 25 with distal cholangiocarcinoma who underwent
surgical resection between 2002 and 2012 were eligible for
this study. Preoperative biliary drainage was performed for
the patients with obstructive jaundice. Preoperative serum
CA19-9 levels were measured after biliary drainage, and
postoperative serum CA19-9 levels were measured about 4
weeks after operation. The relationships between clinicopathological factors including perioperative serum CA19-9
levels and overall survival (OS) were analyzed with univariate and multivariate analyses.
DESIGN AND SETTINGS: Prospective observational study
of hepatobiliary and pancreatic malignancy resected
between November 2007 and December 2008, in 5 Cancer
Center Hospitals in Japan.
PARTICIPANTS: 271 consecutive patients with highly
suspected and potential resectable hepatobiliary and pancreatic malignancy undergoing MDCT judged fit for lapa- RESULTS: Preoperative CA19-9 levels were significantly
higher in patients with moderately and poorly differentirotomy were studied.
MAIN OUTCOMES MEASURES: Sensitivity and specific- ated adenocarcinoma than in those with well differentiated
ity of MDCT predicting a microscopic curative resection adenocarcinoma (P = 0.009), and in patients with UICC
based on the histopathological examination of presence or stage I/II than those with III/IV (P = 0.008). In contrast,
there was no significant difference between postoperative
absence of tumors at the margin of the specimen.
CA19-9 and any other clinicopathological factors. UnivariRESULTS: 164 patients of 217 macroscopic resectable ate analysis revealed postoperative adjuvant chemotherapy
patients (75.6%) with hepatobiliary and pancreatic malig- (P = 0.03), residual tumor factor status (P = 0.01), pathonancy underwent microscopic curative resection. MDCT logical differentiation (P = 0.02), UICC pT stage (P = 0.009),
predicted clear margin resections in 146 patients (89.0%). lymph node metastasis (P < 0.001) and UICC final stage
Sensitivity for prediction of microscopic curative resection (P = 0.001) were significantly associated with OS. In addiby MDCT in perihilar cholangiocarcinoma, gallbladder car- tion, differences in OS were significant between groups
cinoma, middle/lower bile duct carcinoma, and pancreatic divided on the basis of two preoperative CA19-9 cutoff valcarcinoma was 64.7% [CI,52.3–78.9%], 90.9% [CI,90.9– ues (37 and 200 U/ml), and three postoperative CA19-9 cut97.29%], 95.5% [CI,97.7–99.1%], and 89.7% [CI,86.3– off values (37, 100 and 200 U/ml). In multivariate analysis,
93.1%], respectively. On the other hand, specificity was no postoperative adjuvant chemotherapy (odds ratio [OR],
30.8% [CI, 14.5–49.3%], 0%, 33.3% [CI, 14.4–42.4%], and 3.02: 95% confidence interval [CI], 1.54–5.89; P = 0.001),
36.4% [CI, 21.5–51.6%], respectively.
lymph node metastasis (OR, 3.96; 95% CI, 1.91–8.48; P <
CONCLUSIONS: Expert radiologists in hepatobiliary and 0.001), preoperative CA19-9 (≥200 IU/ml) (OR, 2.27; 95%
pancreatic disease could not predict microscopic curative CI, 1.10–4.61; P = 0.03) and postoperative CA19-9 (≥37 IU/
resection in patients with perihilar cholangiocarcinoma. ml) (OR, 6.88; 95% CI, 3.36–14.41; P < 0.001) were identiEven if MDCT predict a possibility of surgical margin posi- fied as independent predictors for OS.
tive resections, surgery seems to be not always contraindi- CONCLUSION: Perioperative serum CA19-9 levels predict
cated in hepatobiliary and pancreatic malignancy, because the survival of patients with resectable cholangiocarcithe accurate preoperative diagnosis with MDCT has still noma, and they may contribute to establishment of new
remained difficult.
therapeutic strategy, as perioperative treatment can be optimized based on its value.
62
Su1593
Su1594
Stapling the Cystic Duct During Laparoscopic
Cholecystectomy Results in Increased Rates of
Unintended Post-Operative ERCP
Diagnostic Utility of Magnetic Resonance
Cholangiopancreatography (MRCP) in Patients
with Intermediate Probability of Cholidocholithiasis
Irene Epelboym2, Florita Martin1, Megan Winner2,
Zachary L. Gleit2, Michael D. Kluger1,2
1
Division of Hepatobiliary Surgery and Liver Transplantation, New
York-Presbyterian Hospital Weill Cornell Medical College, New York,
NY; 2Surgery, Columbia University Medical Center, New York, NY
Hari P. Sayana, Dany Jacob, Mir Fahad Faisal, An-Lin Cheng,
Sreenivasa S. Jonnalagadda
University of Missouri Kansas City School of Medicine, Kansas City, MO
BACKGROUND: Since the advent of laparoscopic cholescystectomy in 1987, there have not been noteworthy changes
in technique for ligation and transection of cystic artery and
duct: metal clips and sharp transection. Laparoscopic staplers (LS) have been suggested as a safe alternative in severe
inflammation or when the cystic duct appears too wide for
complete clip occlusion. We hypothesized an increased rate
of adverse postoperative events following use of LS.
BACKGROUND: Patients with symptomatic cholelithiasis and suspected choledocholithiasis can be risk stratified
into a low (<10%), intermediate (10–50%) or high probability (>50%) of having CBD stone disease based on clinical
predictors. Guidelines recommend laparoscopic cholecystectomy for patients with low probability of common bile
duct (CBD) stone, pre-operative Endoscopic retrograde
cholangiopancreatography (ERCP) for high probability of
CBD stone and pre-operative Endoscopic ultrasound (EUS)
or Magnetic resonance cholangiopancreatography (MRCP)
or Intra-operative cholangiography (IOC) for intermediate
probability of cholidocholithiasis. In patients with intermediate probability, ERCP is often deferred due to its potential
complications and MRCP is commonly performed as EUS
is not widely available. However, the diagnostic utility of
MRCP in this sub set of patients is not well defined in clinical practice.
METHODS: All patients who underwent laparoscopic
cholecystectomy for biliary colic, cholecystitis, pancreatitis or choledocholithiasis at our institution were identified
using billing records. Operative notes were reviewed for use
of LS. A 2:1 control group was selected using propensity
score matching on age, gender and operative diagnosis.
Presenting features, operative characteristics and postoperative outcomes were analyzed. Continuous variables were
compared using Student’s t-test. Categorical variables were
compared using chi-square or Fisher’s exact test. Prediction
models were constructed using logistic regression.
63
Sunday
Poster Abstracts
METHODS: Charts of all patients admitted with symptomatic cholelithiasis that had cholecystectomy and underwent
prior MRCP for cholidocholithiasis between the periods of
Jan 2007 and Oct 2012 at an academic tertiary referral center were reviewed. Of these, patients who met the criteria
RESULTS: Between 1997 and 2009, LS was used in 58 for intermediate likelihood of CBD stone and underwent
(0.9%) of 6272 patients. These were matched to 116 patients preoperative MRCP, IOC or pre/post-operative ERCP were
in whom cystic duct was divided between metal clips (MC). included in the study. Patients with any intrinsic liver disDifferences in age, gender, race, ASA status, admission ease, or hepato-biliary malignancy or <18 years of age were
diagnosis, as well as in presence of leukocytosis, hyperbili- excluded. Pertinent demographic, clinical, biochemical and
rubinemia, or elevation in pancreatic enzymes were not sta- ultrasound parameters were collected by three investigators.
tistically significant (p > 0.05) between LS and MC groups,
though LS was used more often in acute compared with RESULTS: Of a total of 330 patients, 125 met the inclusion
elective cases (40% vs. 24%, p = 0.05). Compared with MC, criteria for intermediate probability and were included in
average intraoperative blood loss (50 vs 25 ml, p < 0.001) final analysis. Mean age of all patients was 52 ± 21 years
and postoperative length of stay (2 vs 1 day, p = 0.016) with 37% males (n = 46). Eighty four patients had IOC and
were both significantly greater for LS. When intraoperative sixty patients had ERCP. MRCP was positive for CBD stone
cholangiography (IOC) was attempted, successful cannula- in only 26.4% of patients (n = 33/125). CBD stone was prestion was achieved in only 2 of 8 (25%) LS cases, versus 28 ent in 33% (n = 41/125) patients as confirmed by either
of 31 (90%) controls (p < 0.001). Patients in the LS group IOC (n = 11/84) or ERCP (n = 32/60). False positive rate of
required post-operative ERCP for clinically evident post- MRCP was 36% (12/33) and false negative rate was 21% (n
operative choledocholithiasis at twice the rate of those in = 20/92). Sensitivity and specificity of MRCP in detection of
the MC group (p = 0.009). Controlling for preoperative and impacted stone was 51% and 85% respectively. Positive predemographic factors, LS remained the only statistically sig- dictive and negative predictive values were 63% and 78%
nificant predictor of requiring postoperative ERCP (OR = respectively.
4.0, p = 0.03). There were no bile duct injuries.
CONCLUSION: MRCP has a poor sensitivity in patients
CONCLUSIONS: Stapling of the cystic duct during lapa- with intermediate likelihood of cholidocholithiasis. Intraroscopic cholescystectomy is associated with an increased operative cholangiography is recommended for definitive
need for unintended postoperative ERCP. We suspect this evaluation for a residual bile duct stone in this sub group.
is secondary to passage of stone fragments into the common bile duct after crushing by the stapler, or leaving a
remnant infundibulum/neck after incomplete dissection
and stapling. Prior to using a stapling device, we advocate
for more meticulous dissection or conversion to open cholescystectomy in order to complete the operation safely and
with minimal postoperative complications.
Su1595
and underwent either pre/post-operative endoscopic retrograde cholangiography (ERC) or intraoperative cholangiography (IOC) were included in the study. Patients with any
intrinsic liver disease, or hepato-biliary malignancy were
excluded.
Trends in Liver Biochemistries: Are They a Better
Predictors Than MRCP in Evaluation of Patients with
Intermediate Probability of Choledocholithiasis?
Hari P. Sayana, Dany Jacob, Mir Fahad Faisal, An-Lin Cheng,
Sreenivasa S. Jonnalagadda
University of Missouri Kansas City School of Medicine, Kansas
City, MO
RESULTS: Of a total of 330 patients, 125 met the criteria for intermediate risk group and were included in final
analysis. Mean age of all patients was 52 ± 21 years with
37% males (n = 46). MRCP was positive for CBD stone in
26.4% of patients (n = 33/125). CBD stone was present in
BACKGROUND: Patients with symptomatic cholelithiasis 33% (n = 41/125) patients as confirmed by either IOC (n
and suspected choledocholithiasis can be risk stratified into = 11/84) or ERCP (n = 32/60). Sensitivities, specificities,
a low (<10%), intermediate (10–50%) or high probability positive and negative predictive values and accuracy of the
(>50%) based on clinical predictors. Liver biochemistries tests were calculated for preoperative MRCP, trends in total
are the first line tests and any abnormal liver test raises sus- bilirubin alone, alkaline phosphatase (ALP) alone, AST/ALT
picion for impacted common bile duct stone. A bilirubin alone, total bilirubin in combination with ALP, total bililevel >4 mg/dl is considered a very strong predictor with rubin in combination with AST/ALT, ALP in combination
high probability of CBD stone (>50%). Likewise, bilirubin with AST/ALT, and total bilirubin in combination with ALP
level between 1.8–4 mg/dl along with dilated ducts on and AST/ALT for patients with intermediate risk group and
ultrasound is considered a very strong predictor. All other for all patients (Table 1).
abnormal liver biochemistries other than bilirubin are considered moderate predictor with low probability (<10%). CONCLUSION: The sensitivity of an upward trend in
However, predictive value of liver biochemistry trends in hepatic transaminases, alkaline phosphatase and total bilidetecting choledocholithiasis in intermediate probability rubin alone and in different combinations is low although
some of them are comparable to that of MRCP in detecting
group is not known.
CBD stone. MRCP has a high specificity in detecting CBD
METHODS: Charts of all patients admitted with symp- stone and this is matched by an upward trend in AST/ALT
tomatic cholelithiasis that had cholecystectomy and under- with a similar specificity. Thus in the intermediate group,
went work up including MRCP for CBD stone evaluation proceeding with ERC may be a better option when an
between the periods of Jan 2007 and Oct 2012 at a tertiary upward trend in the AST/ALT, ALP and/or total bilirubin are
referral center were reviewed. All patients who received pre- noted, instead of performing a more expensive alternative
operative work up for suspected CBD stone including liver diagnostic MRCP testing.
biochemistries on 2 occasions with at least 12 hours apart,
Table 1
Sensitivity
Specificity
PPV
NPV
Accuracy
MRCP
51
85
63
78
74.4
T. Bili
27
76
35
67
60
ALP
49
67
43
72
61
AST/ALT
22
83
39
68
62
Bili + ALP
52
57
38
71
56
Bili + AST/ALT
43
70
40
70
60
ALP + AST/ALT
55
60
40
60
58
Bili + ALP + AST/ALT
60
51
38
51
54
two groups based on days from surgical admission to cholecystectomy within 48 hours (Group 1) and after 48 hours
(Group 2). Patient demographic, comorbidities and outcome were compared using t-test and chi-square as appropriate. Regression models were used to adjust for patient
and operative risk factors.
Su1596
Procedure Timing in Cholecystectomy Influence
Outcome in Patients Admitted for Acute Gallstone
Disease
Muhammad Asad Khan, Roman Grinberg, John Afthinos,
Karen E. Gibbs
Staten Island University Hospital, Staten Island, NY
RESULT: Patient demographics and preoperative characteristics of patients are detailed in Table 1. Patients who had
delayed procedure (>48 hours) have generally higher postBACKGROUND: Objective of this study was to examoperative complications including pneumonia, unplanned
ine the effect of delay in cholecystectomy on outcome in
intubation, acute renal failure, MI, DVT, sepsis and bleedpatient admitted for acute gallstone disease.
ing requiring transfusion (Table 2). Delayed procedure was
METHODS: Patient with acute gallstone disease admit- related to higher incidence of re-operation (2.3 vs. 1.7),
ted inpatient between 2007–2009 were identified from require prolong postoperative stay (mean 3.6 vs. 2.4 days)
American College of Surgeons National Surgical Quality and higher cumulative morbidity (). Mortality was signifiImprovement Program (NSQIP) database using Interna- antly higher in delayed surgery group even after adjusting
tional Classification of disease (ICD-9) diagnosis codes for co-morbidities (A Something missing here?
(574-574.91) and (575–575.2). Patients were divided into
64
Su1597
Table 1: Patient Characteristics and Co-Morbidites
Duration of Surgery Within 48 Hours
Number
19484 (66.9%)
Age
51.8 ± 18
Diabetes on oral
1614 (8.3%)
hypoglycemic
Diabetes on Insulin
870 (4.5%)
BMI
30 ± 36
Smoking
3840 (19.7%)
Severe COPD
670 (3.4%)
CHF
90 (0.5%)
History of MI
69 (0.4%)
Prior PCI
829 (4.3%)
CABG
977 (5.0%)
ESRD
163 (0.8%)
Hypertension
7599 (39.0%)
Prior peripheral
189 (1%)
revascularization
Prior operation within
138 (0.7%)
30 days
Partially dependent
666 (3.4%)
Totally dependent
137 (0.7%)
Bleeding disorder
787 (4%)
Steroid Use
389 (2%)
Open Cholecystectomy 3931 (20.2%)
After 48 Hours
9621 (33.1%)
55.1 ± 19
958 (10%)
P Value
Gallbladder Perforation and Grade Do Not Affect
Survival in Patients with Incidental Gallbladder Cancer
<0.001
<0.001
732 (7.6%)
29 ± 9
1868 (19.4%)
535 (5.6%)
240 (2.5%)
86 (0.9%)
623 (6.5%)
820 (8.5%)
211 (2.2%)
4658 (48.4%)
184 (1.9%)
<0.001
0.51
0.561
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
Vadim P. Koshenkov1, Tulay Koru-Sengul2, Danny Yakoub1,
Alan S. Livingstone1
1
Surgery, University of Miami, Miami, FL; 2Epidemiology, University of
Miami, Miami, FL
239 (2.5%)
<0.001
932 (9.7%)
260 (2.7%)
926 (9.6%)
331 (3.4%)
2012 (20.9%)
<0.001
<0.001
<0.001
<0.001
0.146
INTRODUCTION: Gallbladder cancer is the fifth most
common malignancy of the gastrointestinal tract and carries a poor long-term survival, unless the disease is identified early. Most frequently, it is diagnosed incidentally
after a laparoscopic cholecystectomy for benign gallbladder
disease.
METHODS: A retrospective review was performed for
patients with incidental gallbladder cancer (IGC) at two tertiary care referral centers who underwent cholecystectomy
for symptomatic cholelithiasis or cholecystitis from 1/1996
to 8/2011. Of the 26572 gallbladders that were removed
during the study period, 67 (0.25%) harbored cancer. Clinicopathologic variables such as age, sex, grade, gallbladder
perforation and stage were assessed for impact on overall
survival.
Table 2: 30-day Moratliy and Postoperative Complications
Superficial SSI
Deep SSI
Organ space SSI
Wound Dehiscence
Pneumonia
Unplanned Intubation
Pulmonary Embolism
Failure to wean >24
hours
Acute renal failure
UTI
MI
Bleeding required
transfusion
DVT
Sepsis
Return to OR
Operative time
Days from operation to
discharge
Cumulative morbidity
Mortality
Within 48 Hours
N = 19484
353 (1.8%)
53 (0.3%)
179 (0.9%)
50 (0.3%)
192 (1%)
174 (0.9%)
31 (0.15%)
140 (0.7%)
After 48 Hours
N = 9621
142 (1.5%)
24 (0.2%)
94 (1%)
34 (0.4%)
143 (1.5%)
144 (1.5%)
31 (0.3%)
150 (1.6%)
P Value
0.039
0.804
0.653
0.162
<0.001
<0.001
0.006
<0.001
40 (0.2%)
45 (0.5%)
<0.001
173 (0.9%)
38 (0.2%)
24 (0.1%)
141 (1.5%)
25 (0.3%)
36 (0.4%)
<0.001
0.284
<0.001
31 (0.2%)
207 (1.1%)
337 (1.7%)
86.3 ± 48
2.4 ± 3.7
51 (0.5%)
168 (1.7%)
220 (2.3%)
88.6 ± 48
3.6 ± 5.4
<0.001
<0.001
0.001
<0.001
<0.001
832 (4.3%)
83 (0.4%)
696 (7.2%)
151 (0.6%)
<0.001
<0.001
DISCUSSION: In patients with IGC, advanced age, male
sex, poorly differentiated tumors and presence of gallbladder perforation did not adversely affect survival. Only
advanced stage, be it distant or locoregional, predicted a
worse overall survival.
CONCLUSION: In this retrospective study, delay in surgery was related to higher postoperative complications and
mortality in patients with acute gallstone disease. These
findings demonstrate that medical optimization of patients
should be sought expeditiously to decrease potential postoperative complications.
65
Sunday
Poster Abstracts
RESULTS: A total of 67 patients with IGC were identified.
Laparoscopic cholecystectomy was performed in 58 of these
patients. Most patients were female (70.1%), had gallstones
(91.0%), and 31 were 70 years old or older (46.3%). Tumors
were most commonly poorly differentiated (35.8%). Metastatic disease was detected in 13 (19.4%) patients, while
gallbladder perforation occurred in 16 (23.9%) patients.
Univariate analysis determined that only metastatic disease
had effect on overall survival (HR = 2.76, p = 0.006). Both
univariate and multivariate analyses failed to show the
impact of age, sex, grade, and gallbladder perforation on
overall survival. Only early T stage independently predicted
overall survival (HR = 0.06, p = 0.003).
Clinical: Colon-Rectal
Su1598
Insurance Impacts Biliary Disease: A National Study
Elizaveta Ragulin-Coyne1, Zeling Chau1, Elan R. Witkowski1,
Jillian K. Smith1, Sing Chau NG3,1, Mark P. Callery3,
Heena P. Santry1, Shimul A. Shah2, Jennifer F. Tseng3,1
1
Department of Surgery, Surgical Outcomes Analysis & Research,
University of Massachusetts Medical School, Worcester, MA;
2
Department of Surgery, University of Cincinnati, Cincinnati, OH;
3
Department of Surgery, Beth Israel Deaconess Medical Center,
Boston, MA
Su1600
Extensive Abdominal Wall Necrotizing Fasciitis
and Fournier’s Gangrene Complicating Perforated
Appendicitis
Basem Azab, John Afthinos, Karen E. Gibbs
Surgery, Staten Island University Hospital, Staten Island, NY
INTRODUCTION: While many randomized trials demonstrated the possibility of non-operative management of
uncomplicated appendicitis, appendectomy remains the
standard of care. In distinct contrast, perforated acute appendicitis is widely treated non-operatively; supported by many
prior studies. Although few reports demonstrated that Fournier’s gangren and necrotizing fasciitis are potential complicaMETHODS: Nationwide Inpatient Sample 2004–2009 tions of perforated appendicitis, we are reporting the first case
was used to identify urgent biliary disease, including acute of abdominal wall necrotizing fasciitis and Fournier’s gancholecystitis, duct obstruction, cholangitis. Insurance was grene during the non-operative management of perforated
defined as private, Medicaid, uninsured. To eliminate Medi- appendicitis in a young healthy gentleman. This case demcare confounding, patients >64 were excluded. Hospital onstrates the need for close observation and the potential for
type was defined as for-profit vs. not-for-profit. We comsignificant disease progression in complicated appendicitis.
pared procedures, including cholecystectomy (OR), interventional radiology (IR), and endoscopic (GI). We further CASE REPORT: Our patient is a 23 year-old Afro-Caribbean
analyzed hospital characteristics and length of stay (LOS). gentleman with no significant medical history. He presented with a gradual onset of diffuse abdominal pain of
Multivariable analyses were performed.
7 days duration, progressively localized to the right lower
RESULTS: 1,269,668 weighted patients were identified; abdominal region. On physical exam, the patient was nor197,644 uninsured, 244,538 Medicaid, 827,486 private. motensive, pulse 108/minute, temperature 100.1 F, mild
Uninsured patients were significantly more likely than pri- distended abdomen and right lower abdominal tenderness
vately insured patients to have no intervention; Medicaid with an elevated WBC of 20k/cc. On admission, CT of abdopatient resembled uninsured [Table]. Within OR, Unin- men and pelvis demonstrated an appendicolith, thickening
sured/Medicaid patients were more likely to undergo open of the cecum, a 5.9 × 2.6 × 14.8 cm gas and fluid containing
vs. laparoscopic cholecystectomy. Disparities were more locules in the right lower abdominal quadrant compatible
pronounced in for-profit compared to not-for-profit hospi- with perforated appendicitis. These locules were not draintals. On multivariable analysis, independent predictors for able, with the appearance of an appendicluar mass rather
receiving no procedure included older age, nonwhite, rural, than a contained abscess. The patient was admitted to the
male, for-profit hospital, lower-volume center. After mul- hospital for non-operative management which included
tivariable adjustment, uninsured patients were 1.6x more intravenous broad spectrum antibiotics and serial abdomilikely (95% CI 1.5–1.8) to undergo no procedure than pri- nal exams. On hospital-day 4, the patient developed vomvate patients.
iting, more abdominal distension, a scrotal abscess, pulse
120, fever 102 F, WBC decreased to 16k/cc. A repeat CT
Biliary Procedures and Outcomes by Insurance
demonstrated stable locules of air and fluid (mostly retroperitoneal) and diffuse.
Uninsured
Medicaid
Private
p-Value
BACKGROUND: Health care reform emphasizes insurance
coverage to improve outcomes. Biliary disease affects all
population segments, and its treatment utilizes radiology,
GI, and surgical procedures. We hypothesized that insurance affects biliary procedure rates and outcomes.
Abdominal wall edema. The patient underwent a diagnostic laparoscopy that was converted to open due to difficulty
developing an appropriate working domain. A perforated
1.0%
1.2%
1.3%
<0.0001
appendix adherent to the right pelvic side wall and an extraperitoneal purulent collection was noted. After appropriate
13.9%
14.3%
13.6%
<0.0001
abdominal washout and appendectomy, incision and drain2.2
2.4
1.9
<0.0001
age of the right hemiscrotal abscess was performed. PostopCONCLUSIONS: Treatment of biliary tract disease, includ- eratively, the patient had a protracted hospitalization course
ing cholecystectomy, varies with insurance. As health care (60 days) consistent with septic shock and multi-system
reform ensues, reimbursement becomes bundled and cen- organ failure. The patient’s condition necessitated multiple
ter/provider outcomes are increasingly scrutinized, stan- returns to the operative room for debridement of necrotizing
dardization of care to reflect best practices for all patients fasciitis involving the scrotum and most of the lower half of
his abdominal wall. The patient was also managed by the
will be essential.
burn critical care unit for extensive skin loss, received appropriate wound care (including negative pressure wound dressing), and later was covered successfully with skin grafts and
was discharged in stable condition.
No Intervention
Cholecystectomy (OR)
Interventional Radiology
(IR)
Endoscopic (GI)
LOS (median) days
11.7%
85.7%
12.4%
84.1%
8.1%
88.3%
<0.0001
<0.0001
66
Su1601
METHODS: A Pubmed literature search was performed
using key search words “robotics”, “colorectal”, “cancer”,
Robotics in Colorectal Surgery: A Paradigm Shift?
and “laparoscopic”. After exclusions, 13 studies were idenFatima G. Wilder, Advaith Bongu, Michael Demyen,
tified from 2000–2012. 6 studies were a direct comparison
Ravi Chokshi
between robotics and laparoscopic surgery for CRC and the
remaining 7 looked only at robotic surgery for CRC. The
Surgery, UMDNJ – University Hospital, Newark, NJ
series of resections were analyzed for demographics, type of
INTRODUCTION: Laparoscopic colectomy is the stanprocedure, procedure length (PL), length of stay (LOS), estidard of care for primary colorectal cancer (CRC) resections.
mated blood loss (EBL), complications, and oncologic outThe benefits of robotic techniques have been described
comes (Table 1). Non-parametric statistical analyses were
throughout the gynecologic and urologic literature, but
performed with GraphPad software (La Jolla, CA).
the data relating to colorectal cancer resections is still in its
infancy. A review of the literature and analysis of outcomes
will help us to determine the safety and oncologic value of
this technology in CRC.
Table 1. Demographics, Surgical and Pathological Data
Robotic (R) or
Male:
Author/Study Laparoscopic (L) Age** Female
deSouza
R (Hybrid*)
63
28:16
EBL
(cc)
150
LOS
(days)
5
Nodes
(Number)
14
PL
(Minutes)
347
Conversions
2
Baik (2008)
Hellan
56
58
8:1
21:18
—
200
7.4
4
20.1
13
221
285
0
1
Pigazzi (2006) R (Hybrid)
60
4:2
104
4.5
14
264
0
Kwak
R
60
39:20
—
—
20
270
0
Koh
R
61
13:8
—
6.4
17.8
316
0
Patel
R (Hybrid)
58.8
3:2
150
5.4
7
204
0
Baek
R
63.6
25:16
200
6.5
13.1
296
3
Pigazzi (2010) R (Hybrid)
62
87:56
283
8:3
14.1
297
7
Spinoglio
R
66.7
32:18
—
7.74
22.03
384
2
Choi
R
58.5
38:12
—
9.2
20.6
304
0
Baik (2009)
R (Hybrid)
Pigazzi (2006) L
60.3
70
37:19
2:4
—
150
5.7
3.6
18.4
17
190
258
0
0
Kwak
L
59
42:17
—
—
21
228
2
Bianchi
L
62
17:8
—
6
17
237
1
Baek
L
63.7
26:16
300
6.6
16.2
315
9
0 – 3 I – 15 II – 3 III –
19 IV – 1
—
8.31
22.85
266
4
0 – 4.8 I – 19.3 II – 33.7
68.8 74:86
Spinoglio
L
III – 28.9 IV – 13.3
Baik
L
63.2 34:23
—
7.6
18.7
191
6
—
I–14 II–19 III–24
Bianchi
R
69
18:7
—
6.5
18
240
0
TME
I–14 II–4 III–7 Rectal
CA
*Hybrid studies used laparoscope for early dissection (establishing pneumoperitoneum to mobilization of splenic flexure), w/ robot then used for rectal mobilization and
TME **Values reported as median; LAR – Low anterior resection, APR – abdominoperineal resection, CA – coloanal, IS – intersphinteric
67
LAR – 33 CA – 2
APR – 6
—
Sunday
Poster Abstracts
R
R (Hybrid)
Path
(Staging)
Rectal CA, stages
unspecified
I – 3 II – 6 Rectal CA
0 — 8 I – 13 II – 4
III – 13 IV – 1 All rectal
cancer
TME
Rectal CA, stages
unspecified
LAR – 54 IS –5 APR – 00 – 3 I – 16 II – 23 III –
13 IV – 4 Rectal CA
APR – 1 Anterior
I – 3 II – 6 III – 5 IV – 3
resection – 7 LAR –
No cancer found – 2
7 Ultralow anterior
resection – 5 Sigmoid
resection & rectopexy
–1
TME
I – 14 II – 4 III – 7
Rectal CA
LAR – 33 CA – 2
Rectal CA 0 – 7 I – 12
APR – 6
II – 4 III – 15 IV – 3
Unspecified number of Rectal CA 0 – 18 I – 36
IS vs APR
II – 36 III – 53
R Hemi – 18 L Hemi
0 – 3 I – 36 II – 24 III –
– 10 Rectal anterior
28 IV – 9
resection w/ total
proctectomy – 19
TME
Rectal CA 0 – 0 I – 10
II – 19 III – 19 IV – 2
TME
I – 22 II – 16 III – 18
—
Rectal CA, stages
unspecified
LAR – 52 APR – 6 IS- 1 0 – 3 I – 16 II – 23 III –
12 IV – 5
—
I – 14 II –7 III – 4
Resection
LAR – 30 APR – 8
IS – 6
TME
LAR – 22 CA- 11
APR – 6
Su1602
RESULTS: Thirteen studies were identified that directly
compared the outcomes of laparoscopic and robotic surgery
for CRC. When hybrid resections were detailed, laparoscopic methods were used only for establishing pneumoperitoneum or early dissection. There were no statistically
significant differences between the groups in age, gender
distribution, procedure length, EBL when reported, or LOS
(Table 2).
Cancer-Associated Inflammation in a Cohort of
Colorectal Cancer Patients with Inflammatory
Bowel Disease
Graeme J. Guthrie, Donald C. Mcmillan, Alan K. Foulis,
Paul G. Horgan, Campbell S. Roxburgh
Academic Department of Surgery, University of Glasgow, Glasgow,
United Kingdom
Table 2: Robotic vs Laparoscopic Outcomes
AIMS: Patients with inflammatory bowel disease (IBD) who
develop colorectal cancer (CRC) have poorer outcomes,
reasons for which remain unclear. Cancer-associatedinflammation is a key determinant of disease progression
and survival in colorectal cancer. Inflammation measured
locally and in the systemic circulation, has not previously
been examined in a cohort of Inflammatory bowel diseaseassociated colorectal cancers. The aim of the present study
was to compare clinico-pathological characteristics and
survival in those with an IBD history and those without.
Complications were reported in 10 out of the 13 papers and In particular the role of local and systemic inflammatory
were graded according to the Clavien-Dindo Scale. 100% responses in determining outcome was assessed.
of the groups had some type of complication. Of the top METHODS: Patients were identified from a database of
3 complications reported in the robotics group, 20% were colorectal cancer patients undergoing surgery between
Grade I, 90% were Grade II and 80% were Grade III. In the 1997–2009. Systemic inflammation was measured using
4 of 6 laparoscopic groups reporting, 75% of 3 most com- neutrophil:lymphocyte ratio (NLR) and Glasgow Prognosmon complications were Grade I, 50% Grade II, and 100% tic Score (GPS: C-RP and albumin). Local tumour inflammaGrade III. The most common complications in both laparo- tion was measured with the Klintrup criteria.
scopic and robotic groups were ileus, anastomotic leak and RESULTS: 755 pts were included, 57 of which had Inflamwound infection. Number of conversions at 3 approached matory bowel disease. IBD patients developed Colorectal
significance in the laparoscopic group (p = 0.06). 2 of the 13 cancer at a younger age (64 vs 70 yrs, P < 0.005). Despite
papers looked at oncologic outcomes based on recurrence similar stage and tumour location to non-IBD cancers, IBD
at follow-up. At 17 months follow-up, the recurrence rate associated tumours displayed higher risk pathology includwas 5.4% in the robotics cases and 5.5% in the laparoscopic ing poor differentiation (P < 0.001), signet ring cell patholgroup. 1 report looked specifically at long-term survival ogy (P < 0.05), serosal involvement (P < 0.005), tumour
outcomes with a reported disease-free survival of 77.9% at perforation (<0.001), and high-risk Gloucester prognostic
3 years and overall survival of 97% at 3 years in the robot- index (P < 0.001). Higher-grade local inflammation (eviics groups.
denced by Klintrup criteria: P < 0.05) and higher-grade
Robotic
Laparoscopic
p
Median age (years)
60.3 (56-69)
63.5 (59-70)
0.09
Number of Males
25 (3-87)
30 (2-74)
0.70
EBL (ml)
175 (104-283)
225 (150-300)
0.61
Nodes (number)
17.8 (7-22.03)
17.9 (16.2-22.85)
0.27
LOS (days)
6.5 (4-9.2)
6.6 (3.6-8.31)
0.78
Conversions
0 (0-7)
3 (0-9)
0.06
PL (Minutes)
285 (190-384)
247.5 (191-315)
0.27
EBL – Estimated Blood Loss; LOS – Length of Stay; PL – Procedure Length
CONCLUSIONS: Robotic colectomy for CRC is still in its
infancy. However, early data indicates that it is a safe and
feasible option in comparison to laparoscopic techniques.
Outcomes may be comparable, but there is need for longer
term follow-up and prospective data.
systemic inflammation (evidenced by NLR (P < 0.001) and
GPS, P < 0.001) were observed in IBD patients.
Median follow up was 53 months (303 deaths). IBD patients
had poorer overall survival (5-year survival 14% vs 41%, P
< 0.005). When considered with age (HR1.59, P < 0.001),
TNM stage (HR1.94, P < 0.001) and GPS (HR1.58, P <
0.001), history of IBD was an independent prognostic factor (HR1.99, P = 0.001). Even within the IBD cohort, local
inflammation (P = 0.003) and systemic inflammation (GPS,
P = 0.001) remained strong predictors of overall survival.
CONCLUSIONS: Poorer survival in Inflammatory bowel
disease-associated colorectal cancer may relate to higher
frequency of high risk pathological characteristics as well
as higher levels of cancer associated inflammation. Despite
this close association, systemic inflammation remains an
independent prognostic factor on multivariate analysis.
68
Su1604
versus 309 minutes for RAR + SR (p < 0.001, CI 60.8–135.4).
Intra-operative blood loss for RAR was 97.8 mL compared
Outcomes for Robotic-Assisted Rectopexy With or
to 87.5 mL for RAR + SR (p = 0.924, CI –77.4–89.7). ConverWithout Sigmoid Colon Resection for Rectal Prolapse
sion to open procedure occurred twice with RAR and once
with RAR + SR (p = 0.407). Length of hospitalization averHyuma Leland, Sonia Ramamoorthy, Elisabeth C. Mclemore
aged 3 days for RAR and 4 days for RAR + SR (p = 0.196, CI
Surgery, University of California, San Diego, San Diego, CA
–0.2–2.2). The mean follow up was 127 days (range 1–72
PURPOSE: Our experience in robotic-assisted rectopexy months). Eight of 10 patients with preoperative constipawith sigmoid colon resection (RAR + SR) or without sigmoid tion subjectively noted improvement with RAR versus 1 of
colon resection (RAR) was reviewed to determine if there 2 patients with RAR + SR (p = 0.455). Six of 10 patients with
was a significant difference in intra-operative or postopera- preoperative fecal incontinence had subjectively improved
tive outcomes.
symptoms with RAR versus 1 of 2 patients with RAR + SR
METHODS: We retrospectively reviewed 26 patients that (p = 1.00). Six patients in the RAR group experienced a
underwent robotic-assisted rectopexy for rectal prolapse postoperative complication (over-sedation, corneal abrafrom 2006 to 2012. Rectopexy is performed with primary sion, atrial flutter, pulmonary edema, pelvic hematoma,
suture pexy and without mesh. Continuous variables were ileus) versus 1 complication (urinary retention) after RAR +
analyzed by t-test, while Fisher’s exact test was applied for SR (p = 0.924). There were no mortalities and no complicacategorical data.
tions requiring operative intervention.
RESULTS: Twenty-two patients underwent RAR and 4
patients underwent RAR + SR. The average age for study
participants was 56 years (range 21–78 years) and consisted
of 4 men and 22 women. Recurrent rectal prolapse occurred
in 2 patients at 3 and 30 months after surgery in the RAR
group and no recurrence occurred in the RAR + SR group (p
= 1.00). The duration of surgery for RAR was 211 minutes
Recurrence
2
0
p = 1.00
Duration of Blood Loss Conversion
Surgery (Min)
(mL)
to Open
210.6
97.8
2
308.8
87.5
1
p < 0.001
p = 0.924
p = 0.407
Length of
Hospitalization
(Days)
3
4
p = 0.196
Subjective
Subjective
Improvement in Improvement in
Postoperative
Postoperative
Constipation Fecal Incontinence Morbidity Mortality
8 of 10 patients
6 of 10 patients
6
0
1 of 2 patients
1 of 2 patients
1
0
p = 0.455
p = 1.00
p = 0.924 p = 1.00
defunctioning stoma created during the original procedure.
Patient demographics and comorbidities were listed. Multivariate regression analysis was used to compare outcomes
between cases that had a defunctioning stoma and leaked
and cases that leaked but did not have a stoma.
Su1605
Anastomotic Leak Following Anterior Resection for
Rectal Cancer: Does the Presence of a Defunctioning
Stoma Reduce the Burden of a Leak?
Wissam J. Halabi1, Mehraneh D. Jafari1, Vinh Q. Nguyen2,
Joseph C. Carmichael1, Steven Mills1, Michael J. Stamos1,
Alessio Pigazzi1
1
Surgery, University of California-Irvine, Orange, CA; 2Statistics,
University of California-Irvine, Irvine, CA
RESULTS: We identified 3,099 anterior resections that
leaked. A stoma was present in 28.6% of cases, especially
in male patients (31.7% vs. 22.7% p < 0.01). When a leak
occurred, the presence of a defunctioning stoma did not
reduce mortality (OR = 1.07; 95% CI 0.51–2.27; p = 0.85).
However, the presence of a stoma was associated with an
OBJECTIVE: To examine if the presence of a defunction- increased risk of infectious complications (OR = 1.50; 95%
ing stoma performed during anterior resection for rectal CI 1.24–1.82; p < 0.01), sepsis (OR = 1.58; 95% CI 1.08–
cancer affects outcomes when an anastomotic leak occurs. 2.32; p = 0.05), an increased length of stay by 2.46 days (p
METHODS: Using the Nationwide inpatient sample 2004– < 0.01). Furthermore patients with a defunctioning stoma
2010, we performed a retrospective review of rectal cancer had lower likelihood of routine discharge (OR = 0.18; 95%
cases that underwent anterior resection. We indentified CI 0.14–0.22; p < 0.01).
cases that leaked and divided them into two group based on CONCLUSION: The presence of a defunctioning stoma
the presence or absence of a defunctioning stoma. All cases does not appear to reduce the burden of anastomotic leak
that received a stoma in response to a leak were excluded following anterior resection for rectal cancer.
from our analysis. We only included patients who had a
69
Sunday
Poster Abstracts
RAR
RAR + SR
p value
n
22
4
CONCLUSIONS: The majority of patients underwent RAR
and outcomes for RAR versus RAR + SR were not significantly different in this series with the exception of increased
operative time for RAR + SR. The recurrence rate was 8%
and the complication rate was 27% with the majority of
complications being minor complications.
Su1606
to have surgical management (78.1% vs. 94.8%, p < 0.0005)
and less likely to have appendectomy on hospital day 0 or
Delay in Management: A Nationwide Study of
1 (56.8% s. 77.6%). The presence of abscess or peritonitis
Appendicitis in Patients with Cystic Fibrosis
did not differ significantly between the two groups. For
patients who underwent surgery, CF patients were more
Allan Mabardy1, Justin Lee1, Jose L. Piscoya1, Haisar E. Dao2,
likely to undergo right colectomy or ileocecectomy (10.2%
Kevin O’Donnell1
1
vs. 2.5%, p < 0.0005), more likely to require conversion
Saint Elizabeth’s Medical Center, Boston, MA; 2Rhode Island
to an open procedure (8.5% vs. 4.4%, p < 0.0005), and
Hospital, Providence, RI
more likely to have an iatrogenic injury (3.7% vs. 0.5%,
PURPOSE: Acute appendicitis is an uncommon diagno- p < 0.0005). Significantly fewer CF patients were attempted
sis in patients with cystic fibrosis (CF). Small studies and laparoscopically (52.8% vs. 58.7%, p = 0.015). The median
case reports have shown that affected patients often have a length of hospital stay and total hospital charges were sigdelay in diagnosis and subsequent complications. Our goal nificantly higher for CF patients (4 days vs. 2 days; $23,228
was to investigate the delay in diagnosis for patients with vs. $19,251). Multivariate regression analysis demonstrated
CF who present with acute appendicitis, the factors that CF patients were more likely to be white, have public insurmight contribute to this delay, and the sequellae of delayed ance, and have admission to a teaching hospital. Patients
operative management.
with CF who had surgery during hospital day 0 or 1 were less
METHODS: Using the Nationwide Inpatient Sample data- likely to require right colectomy or ileocecectomy (7.7% vs.
base, all patients in the United States with a diagnosis of 17.7%, p = 0.005). Variables associated with prompt surgiacute appendicitis were examined during the study years cal management included the non-teaching hospital setting
2005 through 2009. Patients with a diagnosis of CF were (OR 0.446–0.964), non-urban location (0.207–0.989), and
compared to patients without CF for demographic and the absence of respiratory manifestations (OR 0.260–0.607).
procedural variables, as well as variables related to com- CONCLUSIONS: The management of appendicitis in CF
plication and cost. Patients with CF who did not undergo patients differs significantly with that of the general popusurgical management for acute appendicitis during hospital lation. CF patients are more likely to have a delay in operadays 0 or 1 were compared against those who had prompt tive management and the resulting sequellae associated
surgical management.
with a more advanced disease process. Comorbid respiraRESULTS: During the study years 2005 through 2009, tory manifestations of CF are associated with a delay in sur1,350,995 patients nationwide were admitted to the hospi- gical management, possibly due to the use of antibiotics in
tal with a diagnosis of appendicitis, and of these patients, these patients.
526 had a diagnosis of CF. Patients with CF were less likely
Appendicitis in Patient with Cystic Fibrosis
Cystic Fibrosis
Appendectomy on Hospital Day 0 or 1*
55.9%
Iatrogenic Injury**
3.7%
Ileocecectomy or Right Colectomy**
10.2%
Attempted Laparoscopic Appendectomy**
52.8%
Conversion to Open Procedure***
13.9%
Median Hospital Length of Stay*
4 days
(*) All patients included; (**) All surgical patients included; (***) All laparoscopic patients included
General Population
76.8%
0.5%
2.5%
58.7%
7.1%
2 days
OR 0.322–0.454
OR 4.862–13.652
OR 3.246–6.149
OR 0.649–0.956
OR 1.480–3.023
alpha = 0.05
AIMS: Literature about this problem is scarce, even unexisting. Therefore, we want to make a survey of proctological problems in patients under chemotherapy, and evaluate
factors that promote the development of anal disease.
Su1607
Proctological Problems in Relation to Chemotherapy
Tom Lagaert1, Bruno Vanduyfhuys1, Beatrijs Strubbe1,
Ingrid Bruggeman1, Koen Gorleer1, Pieter Hindryckx1,
Daan De Maeseneer2, Ine Moors3, StéPhanie Laurent1,
Karen P. Geboes1, Tessa Kerre3, Simon Van Belle2,
Martine De Vos1, Danny De Looze1
1
Gastroenterology, University Hospital Gent, Gent, Belgium; 2Medical
Oncology, University Hospital Gent, Gent, Belgium; 3Hematology,
University Hospital Gent, Gent, Belgium
BACKGROUND: In daily practice anal problems in patients
under chemotherapy are often seen, cause significant morbidity and are difficult to treat.
70
METHODS: From March, 15th until November 30th, 2012
all patients spontaneously reporting anal complaints at the
different departments of oncology and currently under chemotherapy, are selected for this study. Informed consent is
obtained from all patients. The following data are systematically collected: performance status (grade 0 is normal-grade
4 is severe), medical history, current oncological disease
and chemotherapy, chemotherapy-related toxicity (grade
0–4), proctological complaints, diagnosis and outcome.
RESULTS: Twenty-three people, 14 women and 9 men,
with a mean age of 50 years (range 20–80) are collected. The
main presenting symptom is anal pain (n = 21) and in 2
patients anal blood loss. Proctological diagnoses were anal
fissure (n = 12), external hemorrhoidal thrombosis (n = 3),
anal abscess (n = 2), anal ulceration (n = 2), internal hemorrhoidal bleeding (n = 2), no diagnosis (n = 2).
RESULTS: Two patients were lost during the follow up.
RNA transcripts for MMP-7 were detected in 31/57 samples
(54%). Recurrence was diagnosed in 6 out of 55 patients
(11%); 4 patients eventually died because of metastases
or peritoneal dissemination. All the 6 patients who had
relapsed were positive for MMP-7. Sensitivity and specificity of the test were 100% and 49% respectively.
Mean WHO performance status was 1,72 (range 1–4), mean
toxicity scores for respectively oral mucositis, nausea-vomiting, diarrhea and constipation are 0,76–0,88–0,94 and
1,50 (ranges 0–4). Patients were under chemotherapy for
breast cancer (n = 8), AML (n = 3), renal cell carcinoma (n
= 2), rectal carcinoma (n = 2), ALL (n = 2), MDS (n = 2),
sarcoma (n = 1), testis carcinoma (n = 1), aplastic anemia (n
= 1) and non-Hodgkin lymphoma (n = 1).
CONCLUSIONS: Positivity of MMP-7 in peritoneal cavity
samples could be a novel biomarker for predicting disease
recurrence in patients with CRC.
CONCLUSION: Anal fissure is the most frequent encountered proctological problem in patients under chemotherapy. Constipation was the most commonly seen toxicity of
chemotherapy, while oral mucositis was rarely seen in this
patient cohorte. Treatment of anal problems is most often
conservative, but preventive measures should be directed
towards prevention of constipation.
Su1609
High-Dose Circumferential Chemodenervation (HDCC)
of the Internal Anal Sphincter: A New Treatment
Modality for Uncomplicated Chronic Anal Fissure
Porter H. Glover1, James Z. Whatley1, Shou Jiang Tang1,
Eric D. Davis1, Kellen T. Jex1, Ruonan Wu1, Christopher J. Lahr2
1
Internal Medicine, University of Mississippi Medical Center, Jackson,
MS; 2Surgery, University of Mississippi Medical Center, Jackson, MS
BACKGROUND: Botulinum toxin injection into the internal anal sphincter (IAS) is gaining popularity as a second
line therapy for chronic anal fissures after patients fail medical therapy. Although lateral internal sphincterotomy (LIS)
can achieve a healing rate of 91–95%, it is associated with
fecal incontinence of 11%. The dosage of Botulinum toxin
reported in the literature ranged from 20–50 IU with no
more than 3 injection sites and results in a healing rate of
65%–73% and recurrence rate of 35%. We propose a new
injection method of high-dose circumferential chemodenervation (HDCC) of 100 IU in treating chronic anal fissure.
Su1608
Peritoneal Expression of Matrilysin Helps Identify Early
Post-Operative Recurrence of Colorectal Cancer
AIM: We evaluate the fissure healing, complication, and
recurrence rates with this new method during 6 months
study period after each injection.
BACKGROUND: Recurrence of colorectal cancer (CRC)
following a potentially curative resection is a major challenging clinical problem. Although detection of tumoral
cells within the peritoneal cavity at the time of surgery
has been proposed as useful tool to identify patients with
recurrent CRC, the overall low sensitivity of the test has
hampered its use in the management of such patients.
Matrilysin, also termed matrix metalloproteinase (MMP) -7,
is over-expressed by CRC cells and supposed to play a major
role in CRC cell diffusion and metastasis. This study was
aimed at determining whether MMP-7 is detectable in the
peritoneal cavity of CRC patients undergoing potentially
curative resection and assessing whether MMP-7 positivity
marks patients who experience CRC recurrence.
METHODS: Between 2008–2012, 75 consecutive patients
(32 Blacks, 42 Whites, 1 Native American) (50 Women,
25 Men) with complete follow-up data were included in
this study. These patients presented with uncomplicated
chronic anal fissure and underwent HDCC-IAS by a single
colorectal surgeon. HDCC is an anoscopy assisted percutaneous injection involving greater than 8 injection sites in a
circumferential technique under anesthesia. Follow up data
were obtained by chart review and office follow up.
RESULTS: Of the 75 patients, the 1st injection success
rate was 90.6% at 3 months follow-up (Table 1). A few
MATERIAL AND METHODS: Fifty-seven colorectal can- patients developed transient flatus or fecal incontinence,
cer patients undergoing elective colorectal resection were but shortly resolved. There was no major complication folprospectively enrolled from June 2009 to November 2011. lowing HDCC-IAS including hematoma, infection, flatus,
During the surgery, peritoneal cavity was flushed with fecal, and urinary incontinence after 1 month.
cold saline solution and fluid was then harvested and used
CONCLUSION: HDCC-IAS is a safe and effective method
for RNA extraction. MMP-7 RNA expression was assessed
for uncomplicated chronic anal fissure. It’s efficacy rivals
by RT-PCR using specific primers. After surgery, patients
reported LIS healing rate without the associated fecal inconunderwent a regular follow up (range 12–26 months) for
tinence. In addition, HDCC-IAS demonstrated far superior
assessing recurrence.
healing rates compared to standard injection method without increased complication rate.
Key Words: Botulinum toxin, anal fissure, injection, highdose circumferential chemodenvervation (HDCC), internal
anal sphincter, lateral internal sphincterotomy (LIS)
71
Sunday
Poster Abstracts
Cristina Fiorani, Giuseppe S. Sica, Carmine Stolfi,
Rosa Scaramuzzo, Giorgia Tema, Edoardo Iaculli, Achille Gaspari,
Giovanni Monteleone
Tor Vergata, Rome, Italy
Table 1: Treatment of Uncomplicated Chronic Anal Fissures with High-Dose Circumferential Chemodenervation (Hdcc) of the Internal Anal Sphincter
HDCC Sessions
First injection (n = 75)
Second injection (n = 16)
3rd Injection (n = 3)
4th Injection (n = 1)
5th injection (n = 1)
Healing Rate
(3 Months)
90.6%
81.3%
100%
100%
0%
Healing Rate
(6 Months)
90.6%
93.8%
100%
100%
100%
Recurrence Rate
(6 Months)
8.0%
0%
33%
100%
0%
Average Healing Time
(Weeks)
6.2
7.4
12
12
20
Complications
(After 1 Month)
0
0
0
0
0
Su1610
Su1611
Medication Use and the Risk of Diverticular
Complications: A Systematic Review
Postoperative Bleeding After Colon and Rectal Surgery
by Preoperative Diagnosis: A Nationwide Analysis
Charlotte Kvasnovsky1,2, Savvas Papagrigoriadis1,
Ingvar T. Bjarnason1
1
Department of Colorectal Surgery, King’s College Hospital, London,
United Kingdom; 2Department of Surgery, University of Maryland
Medical Center, Baltimore, MD
Nitin Kumar1, Ashok Kumar2, Christopher C. Thompson1
1
Division of Gastroenterology, Brigham & Women’s Hospital, Boston,
MA; 2Surgery, Clay County Hospital, Flora, IL
BACKGROUND: Colorectal surgery is performed for a wide
array of gastrointestinal disease, in patients with varied preBACKGROUND AND PURPOSE: Serious complications operative fitness and comorbidity rates. Postoperative outof colonic diverticula, namely bleeding and perforation, are comes, including bleeding rates, are shaped by preoperative
a source of morbidity and mortality. A variety of drugs have diagnosis in addition to operative factors.
been implicated in these complications. We present a sys- AIMS: To determine incidence of postoperative bleeding
temic review of the literature to assess the importance of after colorectal surgery and analyze outcomes in patients
this relationship.
with postoperative bleeding by preoperative diagnosis.
DATA SOURCES: A systematic review of articles using METHODS: This is a retrospective cohort study using the
PubMed and Cochrane Reviews was undertaken in August 2010 Nationwide Inpatient Sample (NIS), a nationally rep2012. Search terms included ‘diverticulitis, diverticulum, resentative inpatient database. Adult patients were included
diverticulosis, diverticular perforation, diverticular bleed, if they had ICD-9 code for gastrointestinal malignancy,
OR ‘lower GI bleed’ AND ‘acetaminophen, anti-thrombotic, ulcerative colitis (UC), Crohn’s disease (CD), ischemic colicyclooxygenase-2 inhibitors, cox-2, aspirin, amino salicylic tis (IC), diverticulitis, diverticulosis, or diverticular bleedacid, ASA, nonsteroidal anti-inflammatory drugs, NSAID, ing. Inclusion was limited to patients with ICD-9 procedure
steroid, corticosteroid, OR calcium channel’.
code for colectomy, proctectomy, or colostomy. Inclusion
STUDY SELECTION AND DATA EXTRACTION: An ini- also required ICD-9 code for intraoperative bleeding, intratial search yielded 853 results that were assessed for study operative hematoma, or lower gastrointestinal bleeding
design and topicality. A total off 23 articles were included during the postoperative period, as well as postoperative
in the review, including 74 subgroup analyses, where drug packed red blood cell transfusion. Charlson Comorbidity
usage and specific complications were clearly documented. Index was calculated for each patient. Outcomes included
Data were extracted on these topics, as well as effect mea- rate of reoperation, incidence of shock, mortality, length of
stay (LOS), and inpatient charge. Statistical significance was
sures found.
established if p < 0.05.
DATA SYNTHESIS: We performed a qualitative data synthesis with a forest plot when five or more studies compared RESULTS: 214,933 patients met inclusion criteria. Of these,
1528 (0.7%) had postoperative bleeding requiring blood
a single medication and similar patient complications.
transfusion. Charlson score for patients with postoperaRESULTS: There were increased odds of bleeding with the tive bleeding was 2.4 ± 0.2 vs 2.3 ± 0.1 in patients without
use of NSAIDs (range 2.01–12.6), acetaminophen (0–3.75), bleeding. Rate of postoperative bleeding, which was highaspirin (1.14–3.70), and steroids (0.57–5.40). There were est in patients with IC, is shown by diagnosis in Table 1.
increased odds of perforation and abscess formation with Clinical outcomes are shown in Table 2. Reoperation was
NSAIDs (1.46–10.3), aspirin (0.66–2.40), steroids (2.17– significantly more frequent after bleeding in each diagnosis
31.9), and opioids (1.80–4.51).
except diverticulosis. Shock was more frequent after bleedLIMITATIONS: Most studies did not describe duration or ing in patients who had surgery for malignancy and IC, but
dosage of medications used, nor did they systematically less frequent in patients with diverticular bleeding. Mortality was significantly more frequent after postoperative
describe the severity of diverticular complications.
CONCLUSIONS: A variety of common medications are bleeding in patients with malignancy, CD, diverticulitis,
implicated in colonic diverticular complications, rare, but and diverticular bleeding. Hospital outcomes are shown in
occasionally devastating outcome in the many patients Table 2. Length of stay was significantly longer after postoperative bleeding in patients with malignancy and diverwith diverticular disease.
ticulitis; charge was significantly higher in patients with
malignancy, CD, IC, and diverticulitis.
72
CONCLUSION: Preoperative diagnosis is associated with
significant differences in outcome in patients with postoperative bleeding after colorectal surgery. Rates of shock and
mortality are significantly increased in patients with gastrointestinal malignancy and IC. Mortality is substantially
increased in patients with CD, UC, diverticulitis, and diverticular bleeding. Further study is needed to better understand the reasons for this disparity and to develop better
management strategies.
Table 1: Rate of Postoperative Bleeding by Diagnosis
Malignancy
UC
CD
IC
Diverticulitis</b
Diverticulosis
Diverticular bleeding
* denotes statistical significance
Postoperative
Bleeding (%)
0.59
0.25
0.76
2.95
0.59
0.29
0.99
n
113,202
5572
10,032
11,735
61,405
8561
4056
Table 2: Clinical Outcomes
Malignancy
Reoperation (%)
Bleed
No Bleed
16.7 *
2.1
UC
35.7 *
3.0
0
0.79
0
1.97
7.9 (5.1–11)
8.6 (8.0–9.3)
CD
26.3 *
1.3
0
0.40
13.2 *
0.54
14 (7.0–20)
6.9 (6.6–7.2)
IC
Diverticulitis
31.2 *
14.3 *
9.3
1.6
2.89 *
0
3.13
0.30
36.1 *
8.8 *
17.2
1.20
18 (12–25)
14 (10–19) *
13 (12–14)
6.9 (6.7–7.0)
Diverticulosis
0
1.2
0
0.34
0
1.46
6.0 (4.3–7.8)
5.9 (5.7–6.1)
6.2
0*
8.46
25 *
6.43
25 (10.8–39)
11 (9.9–12)
Diverticular bleeding 60.0 *
* denotes statistical significance
Shock (%)
Bleed No Bleed
3.77 *
0.48
Mortality (%)
Bleed No Bleed
7.68 *
1.93
LOS, Days (95% CI)
Bleed
No Bleed
11 (8.3–14) *
7.5 (7.3–7.6)
Charge x1000, USD (95% CI)
Bleed
No Bleed
110 (84.0–138) *
69.6
(66.4–72.8)
96.2 (–11.4–204)
94.4
(83.2–105.6)
131 (77.0–184) *
67.7
(62.1–73.2)
255 (173–337) * 150 (139–161)
140 (97.2–183) *
65.3
(62.3–68.4)
51.6 (38.6–64.7)
52.1
(48.9–55.2)
271 (78.1–465) 129 (118–140)
Long Term Outcomes of Continent Ileostomy Created
in the Pediatric Age Group
RESULTS: 49 patients (26 male), median age 18 (12–21)
years and median body mass index 22 (16–38.6) underwent
CI. 10 (20%) patients had a CI at the time of total proctocolectomy. 12 (25%) patients underwent conversion of an
ileoanal pouch (IPAA) to a CI. The majority of the patients
(n = 39, 80%) had ulcerative colitis or indeterminate colitis
at the time of CI creation; however Crohn’s disease were
BACKGROUND/AIM: Continent ileostomy (CI) is a surdiagnosed in 4 patients postoperatively. There were no
gically created intra-abdominal pouch in patients with
intra-operative or early post-operative deaths. One patients
a permanent end ileostomy. CI is one of the few surgical
who underwent CI excision seven years after CI creation
options that may be offered to patients who were fated to
due to complicated Crohn’s disease, died ten years after CI
live with a permanent ileostomy, but want to avoid a stoma
excision. Median follow-up time was 21 (range 1–38) years.
appliance at any cost. Data about durability, clinical and
Valve slippage (33%), small bowel obstruction (25%), poufunctional outcomes of CI created in pediatric patients are
chitis (25%) and fistula (23%) were the common complicalimited. In this study, we aimed to evaluate our 36-year
tions (table). 37 patients (76%) underwent at least 1 revision
operative experience on CI in pediatric patients with a 21
procedure after CI creation. 36 (74%) patients underwent
year median follow-up.
major revision and 6 (12%) patients underwent minor reviMETHODS: Pediatric (≤21 years) * patients undergoing a sions. Median pouch intubation was 6 (range 4–10) times
CI procedure at a single institution from 1973–2009 were per day. Pouch failure occurred in 9 (18%) patients with
identified. CI revisions that required pouchotomy or re- 7 out of 9 cases being due to complications from Crohn’s
construction following total or partial excision of CI were disease.
Erman Aytac1, Victor W. Fazio1, Hasan Hakan Erem1,
Jennifer Liang1, David W. Dietz1, Marsha H. Kay2, Pokala R. Kiran1
1
Department of Colorectal Surgery, Digestive Disease Institute
Cleveland Clinic, Clevaland, OH; 2Pediatric Gastroenterology,
Digestive Disease Institute Cleveland Clinic, Clevaland, OH
73
Sunday
Poster Abstracts
defined as major and those that did not require bowel resection were defined as minor revisions. CI failure was defined
as excision of the pouch and formation of an end ileostomy.
Su1612
METHODS: A systematic review was performed on 31 published series between 1994 and 2011 describing patients
with CDI requiring surgical intervention. Of the 31 studies identified, a meta-analysis was performed on 17 studies that presented comparative data between survivors and
non-survivors of surgical CDI. Independent variable analyses were performed for age, gender, preoperative comorbidities, preoperative laboratory values, as well as surgical
management (total colectomy end ileostomy or TCEI, segmental colectomy, diverting ostomy, or non-therapeutic
laparotomy).
Primary Diagnosis, Complications and Follow-Up Details
Primary Diagnosis
Ulcerative colitis
Familial adenomatous polyposis
Indeterminate colitis
Crohn’s disease
Motility disorder
Complications
Valve slippage
Small bowel obstruction
Pouchitis
Fistula
Difficult intubation
Incontinence
Leakage
Valve prolapse
Bleeding
Afferent limb stricture
Ventral hernia
Parastomal hernia
Exit conduit stricture
Follow up functional details #
Time to first major revision after CI creation (years)
Time to first minor revision after creation of CI (years)
Time to CI excision after CI creation (years)
# Results presented as median (range)
n (%)
35 (71%)
4 (8%)
4 (8%)
4 (8%)
2 (4%)
16 (33%)
12 (25%)
12 (25%)
11 (23%)
9 (18%)
8 (16%)
8 (16%)
7 (14%)
4 (8%)
3 (6%)
3 (6%)
2 (4%)
2 (4%)
RESULTS: Based on the 31 studies included in the review,
the overall rate of surgical intervention for patients diagnosed with CDI was 1.9%. The mean age of surgical CDI
patients was 69 years, and 54% were male. 93.2% of the
patients with surgical CDI had received antibiotics prior to
diagnosis, and 59.3% were initially diagnosed with CDI inhospital. The mean WBC was 29.6 x103/μL. 49.9% required
preoperative vasopressors, and 44.5% had preoperative
respiratory failure requiring intubation. Overall, 89.2% of
patients received a TCEI for CDI. Overall mortality of surgical CDI patients was 42.5%.
Among the 17 studies included in the meta-analysis, there
were a total of 621 patients comprised of 367 (59%) survivors and 254 (40.9%) non-survivors. The mean age of nonsurvivors was 71.6 years and of survivors was 65.2 years (p =
0.001). There was no significant difference between duration of symptom onset to surgery between survivors and
non-survivors. Preoperative vasopressor requirement, respiratory failure (RF), acute renal failure (ARF), multi-organ
failure (MOF), and recent antibiotic use were independent
predictors of postoperative mortality (Table). Non-survivors
had a significantly lower preoperative albumin compared
to survivors (1.66 vs 2.28 g/dL, p = 0.04). Heart rate, WBC,
lactate, creatinine were not significantly different between
survivors and non-survivors. Finally, the initial type of surgical intervention was not predictive of survival.
2 (0.5–30)
2 (0.1–5)
5 (2–28)
CONCLUSIONS: CI is safe and durable in pediatric
patients. Development of Crohn’s disease after CI creation
seems to be a risk factor for failure. Since likelihood of further revisions is high, patients with CI should be followedup regularly.
* Council on Child and Adolescent Health. Age Limits of
Pediatrics. Pediatrics 1988;81:736.
Su1613
CONCLUSION: The initial type of surgical intervention
was not predictive of survival. Factors that were predictive
of mortality from CDI included hypoalbuminemia, septic
shock, ARF, RF, and MOF. This study suggests that expeditious surgical intervention prior to end organ failure may
lead to improved survival in fulminant CDI.
Risk Factors for Mortality for Surgical Clostridium
Difficile Colitis: A Review and Meta-Analysis
Stephanie G. Wood1, Laura Skrip1,2, Hulda M. Einarsdottir1,
Vikram Reddy1, Walter Longo1
1
Surgery, Yale School of Medicine, New Haven, CT; 2Public Health,
Yale School of Medicine, New Haven, CT
OBJECTIVE: Clostridium Difficile infections (CDI), the
most common infectious colitis, have been increasing in
incidence and severity over the last decade. Severe CDI that
requires surgical intervention is rare but mortality rate is
high and poorly prognosticated. In light of a paucity of
level I evidence available to direct clinical decision-making,
this study aims to identify factors that may predict mortality from severe CDI.
74
Table 1: Meta-Analysis of Surgical Clostridium Difficile Infection Risk Factors for Mortality
Covariate
Total Colectomy (TCEI)
Segmental Colectomy
Other Procedure (Not TCEI)
Gender
Vasopressors
Immunosuppression
Recent Surgery
Recent Antibiotic Use
CRF
Respiratory Failure
ARF
COPD
Known Cancer
MOF
Diagnosis Known Pre-Op
Organ Transplant
Recurrent c diff
No. of Studies
14
14
14
10
10
9
7
6
6
6
5
4
4
4
3
3
3
Overall Effect
(OR and 95% Confidence Interval)
1.5735 (0.8711, 2.8423)
0.6526 (0.3541, 1.2026
0.6355 (0.3518, 1.1480)
1.0017 (0.6720, 1.4932)
3.8599 (2.6063, 5.7163)
0.7736 (0.5142, 1.1639)
0.4641 (0.2381, 0.9046)
4.1599 (1.1733, 14.7486)
0.8784 (0.3886, 1.9852)
6.4230 (3.4633, 11.9121)
3.5793 (1.5789, 8.1142)
1.4037 (0.5680, 3.4690)
2.0196 (0.7804, 5.2264)
7.6396 (3.0764, 18.9715)
0.3884 (0.1034, 1.459)
0.3834 (0.1265, 1.1622)
1.1434 (0.6079, 2.1505)
P
0.13
0.17
0.13
0.99
<0.001
0.22
0.02
0.03
0.76
<0.001
0.002
0.46
0.15
<0.001
0.16
0.09
0.68
I2 Test for
Heterogeneity (%)
14.7
24.5
14.7
0.0
12.5
0.0
17.9
0.0
0.0
6.0
16.7
0.0
0.0
20.3
0.0
0.0
0.0
of postoperative packed red blood cell transfusion. Univariate logistic regression models were performed to determine
significant predictors, which were entered into multivariate logistic regression models controlling for patient demographics and hospital characteristics to obtain adjusted
odds ratios (AOR). Statistical significance was established if
p < 0.05.
Su1614
Predictors of Bleeding, Reoperation, and Mortality
After Colon and Rectal Surgery by Preoperative
Diagnosis: A Nationwide Analysis
1
Division of Gastroenterology, Brigham & Women’s Hospital,
Boston, MA; 2Surgery, Clay County Hospital, Flora, IL
75
Sunday
Poster Abstracts
RESULTS: 214,933 patients met inclusion criteria in 2010.
Mean age was 60.3 ± 0.2 years and mean Charlson score was
BACKGROUND: Colorectal surgery is performed for a
1.17 ± 0.04. 1528 patients (0.7%) had postoperative bleedwide array of gastrointestinal disease, in patients with varing requiring blood transfusion. 5439 patients (2.53%)
ied preoperative fitness. Preoperative diagnosis, in addition
required reoperation during the inpatient admission. 5715
to patient and operative factors, may influence the rate of
patients (2.66%) experienced mortality during the inpapostoperative complications.
tient admission.
AIMS: To determine predictors for bleeding, reoperation,
Adjusted odds ratios for predictors of postoperative outand mortality after colorectal surgery.
comes are shown in Table 1. Urgent or emergent admission,
METHODS: This is a retrospective cohort study using the age >65, gastrointestinal malignancy, UC, and diverticulo2010 Nationwide Inpatient Sample (NIS), a nationally rep- sis were significant predictors of postoperative bleeding.
resentative database of inpatient admissions. Adult patients Urgent or emergent admission and IC were significant prewere included if they had ICD-9 CM code for gastrointes- dictors of reoperation. Urgent or emergent admission, age
tinal malignancy, ulcerative colitis (UC), Crohn’s disease >65, and IC were significant predictors of mortality.
(CD), ischemic colitis (IC), diverticulitis, diverticulosis,
CONCLUSION: Preoperative diagnosis, patient factors, and
or diverticular bleeding. Inclusion was limited to patients
admission factors have significant association with postopwith ICD-9 CM procedure code for colectomy, proctecerative outcomes after colorectal surgery. Urgent or emertomy, or colostomy. Charlson Comorbidity Index score
gent admission, age >65, and ischemic colitis are significant
was calculated for each patient. Outcomes included postopand independent predictors of mortality. Identification of
erative bleeding, reoperation, and mortality. Postoperative
modifiable factors that increase operative and postoperative
bleeding was defined as ICD-9 CM code for intraoperative
risk in these patient groups would be of benefit in improvbleeding, intraoperative hematoma, or lower gastrointestiing patient outcomes.
nal bleeding during the postoperative period in the setting
Table 1: Multivariable Logistic Regression
Urgent/emergent
Age >65
Malignancy
UC
CD
IC
Diverticulitis
Diverticulosis
* denotes significant increase
Postoperative Bleeding
AOR (95% CI)
p value
2.8 (2.53–3.12) *
<0.01
1.1 (1.06–1.19) *
<0.01
2.4 (2.17–2.57) *
<0.01
2.0 (1.60–2.46) *
<0.01
1.1 (0.87–1.29)
0.55
1.1 (0.93–1.21)
0.41
1.1 (0.96–1.19)
0.21
1.7 (1.42–1.96) *
<0.01
Reoperation
AOR (95% CI)
2.0 (1.75–2.24) *
1.1 (0.98–1.20)
0.54 (0.46–0.63)
0.90 (0.58–1.38)
0.45 (0.29–0.69)
2.3 (1.88–2.72) *
0.44 (0.37–0.52)
0.47 (0.29–0.75)
p value
<0.01
0.13
<0.01
0.61
<0.01
<0.01
<0.01
<0.01
Mortality
AOR (95% CI)
3.6 (3.15–4.02) *
2.5 (2.24–2.79) *
0.21 (0.18–0.24)
0.49 (0.31–0.78)
0.19 (0.10–0.34)
2.1 (1.83–2.39) *
0.24 (0.20–0.29)
0.40 (0.26–0.61)
p value
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
<0.01
in 9%, and urinary retention occurred in 21%. UTI rates
were the same in stent and no stent groups (9% vs. 9%,
Risk Factors for Urinary Tract Infection in Rectal
p = 1). In multivariate analysis, females older than 65
(OR 5.2, 95% CI 1.63–16.64), higher estimated blood loss
Surgery Patients
(OR 1.9, 95% CI 1.07–3.37), and a diagnosis of depression
Janet T. Lee, Mark Y. Sun, Genevieve B. Melton,
(OR 4.7, 95% CI 1.58–14.0) were independently associated
Robert D. Madoff, Mary R. Kwaan
with UTI (model c = 0.78). UTI + patients were more likely
Department of Surgery, Division of Colon and Rectal Surgery,
to have a prolonged LOS (p = 0.04) and be discharged to a
University of Minnesota, Minneapolis, MN
rehab facility (p = 0.01), but not more likely to have associPURPOSE: Urinary tract infection (UTI) has been identi- ated major complications (p = 1).
fied as the most common hospital-acquired infection in
the United States. Studies have shown that UTIs are sig- RIsk Factors for UTI in Rectal Surgery Patients
nificantly more common after colorectal surgery, especially
Variable, n (%)
UTI + (n = 20)
UTI – (n = 204) p-value
rectal surgery, compared with other procedures. We hypothAge, mean y (SD)
59.7 (16.2)
52.6 (15)
0.05
esized that the use of ureteral stents in rectal surgery would
Female
14 (70)
96 (48)
0.10
be associated with a higher risk of UTI. We also sought to
Female age >65
6 (30)
17 (8)
0.01
examine other risk factors for UTI after rectal surgery.
Su1615
BMI >30
5 (25)
69 (30)
0.80
ASA class >3
9 (45)
62 (35)
0.359
Rectal Cancer
7 (35)
110 (54)
0.16
Inflammatory bowel disease
6 (30)
53 (26)
0.79
Depression
7 (35)
20 (10)
0.005
Diabetes mellitus
4 (20)
19 (9)
0.13
Laparoscopic surgery
3 (15)
25 (12)
0.72
Ureteral Stent
3 (15)
33 (16)
1.0
EBL* cc (95% CI)
509 [340–760]
330 [290–376]
0.05
Operative duration >300 min
12 (60)
69 (38)
0.06
Urinary retention
6 (30)
41 (20)
0.39
*EBL was analyzed after logarithmic transformation (ln) to create a normal
distribution
METHODS: All patients undergoing rectal resection at a
tertiary care medical center from 2005 to 2010 were identified using ICD-9 procedure codes. Patient and procedure
variables, UTI within 30 days of surgery, urinary retention
(defined by reinsertion of a Foley catheter), major complications, and length of stay (LOS) were identified on retrospective chart review. UTI was defined as a positive urine
culture with >105 colonies/ml urine with no more than 2
species of organisms and one of the following: fever >38
degrees C, urgency, frequency, dysuria, or suprapubic tenderness. Prolonged LOS was defined as >75th percentile and
was >10 days in this cohort. Comparisons between groups
were made with Student t tests and Fisher exact tests (alpha
= 0.05). Multivariable analysis of significant factors (p <
0.2) was performed with stepwise logistic regression. All statistical analyses were performed using SAS 9.2 (Cary, NC).
CONCLUSION: Ureteral stents are not associated with a
higher rate of UTI in patients undergoing rectal resection.
Females older than 65, a higher estimated blood loss, and a
RESULTS: We identified 223 patients during the study
diagnosis of depression were found to be independent sigperiod with age range of 18 to 96 (median 63). There were
nificant predictors of UTI. We have no clear explanation for
110 (49%) males. Ureteral stents were used in 36 cases
why depression would be associated with UTI and it should
(16%). The majority of patients had rectal cancer as the
be studied further in postoperative patients.
primary diagnosis (52%), followed by inflammatory bowel
disease (26%), and rectosigmoid cancer (5%). UTI occurred
76
Su1616
surgery, or proctectomy. A Charlson Comorbidity Index
score was calculated for each patient. Outcomes included
rate of bleeding, rate of reoperation, mortality, and inpatient charge in 2010 US dollars. Statistical significance was
established if p < 0.05.
Nationwide Analysis of Postoperative Bleeding After
Colon and Rectal Surgery over the Past Decade:
Incidence, Intervention, and Mortality
1
Division of Gastroenterology, Brigham & Women’s Hospital,
Boston, MA; 2Clay County Hospital, Flora, IL
RESULTS: 360,091 patients had surgeries meeting inclusion criteria in 2000 and 381,741 patients had surgeries
meeting inclusion criteria in 2010. Rate of postoperative
bleeding over time is shown in Table 1. Bleeding decreased
BACKGROUND: Colorectal surgery has evolved over the
significantly among all surgery types between 2000 and
past decade as the laparoscopic era has dawned. The prem2010. Reoperation rate and mortality in patients with postise of laparoscopic surgery has been that a less invasive
operative bleeding in shown in Table 2. Even as bleeding
surgical modality might lead to decreased morbidity and
rate declined, reoperation rate and mortality rate among
health care utilization.
patients with postoperative bleeding increased, especially
AIMS: To determine the change in rate of bleeding, rate of in open colectomy. However, overall mortality rate for
reoperation, mortality, and health care utilization over the patients undergoing colorectal surgery remained stable at
past decade in patients with postoperative bleeding after 0.165% in 2000 versus 0.175% in 2010 (p = 0.29).
colon and rectal surgery.
CONCLUSION: Incidence of postoperative bleeding after
METHODS: This is a retrospective cohort study using the colorectal surgery has decreased over the past decade. Lapa2000 and the 2010 Nationwide Inpatient Sample (NIS), roscopic colorectal surgery, which has a low postoperative
a nationally representative database of inpatient admis- bleeding rate, has accounted for much of the decrease; howsions. Inclusion was limited to patients with postoperative ever, a significant decrease in bleeding rates was seen after
bleeding was defined as ICD-9 CM code for intraoperative open colectomy, proctectomy, and colostomy. Although
bleeding, intraoperative hematoma, or lower gastrointesti- mortality rates have increased in patients with postoperanal bleeding during the postoperative period and postop- tive bleeding, overall mortality after colorectal surgery has
erative packed red blood cell transfusion. Adult patients been stable. Further development of minimally invasive
were included if they had ICD-9 CM procedure code for surgical techniques holds promise for further improvelaparoscopic colectomy, open colectomy, colostomy-related ments in postoperative complication rates.
Table 1: Rate of Postoperative Bleeding by Surgery Type
2000
Postoperative Bleeding (%)
–
1.27
0.57
3.19
1.50
n
79,021
191,379
49,524
61,817
381,741
2010
p Value, Bleeding Rate
Postoperative Bleeding (%)
0.20
–
1.16 *
<0.01
0.44 *
<0.01
2.13 *
<0.01
1.03 *
<0.01
* denotes statistically significant change
Table 2: Reoperation and Mortality in Patients with Postoperative Bleeding
Laparoscopic colectomy
Open colectomy
Proctectomy
Colostomy
Overall
* denotes statistically significant change
2000
—
6.8
4.5
4.4
5.8
Reoperation (%)
2010
43.8
19.5 *
22.5 *
15.2 *
27.3 *
77
P value
—
<0.01
<0.01
<0.01
<0.01
2000
—
10.7
7.4
11.9
11.0
Mortality (%)
2010
20.0
19.9 *
8.7
13.2
17.0 *
P Value
—
<0.01
0.60
0.27
<0.01
Sunday
Poster Abstracts
Laparoscopic colectomy
Open colectomy
Proctectomy
Colostomy
Overall
n
–
252,225
47,438
60,428
360,091
Clinical: Esophageal
8Su1618
8
Su1617
Restaging PET-CT After Neoadjuvant
Chemoradiotherapy Can Prevent Non-Curative
Surgical Interventions in Esophageal Cancer Patients
Most Patients with Persistent Symptoms on AcidSuppressive Therapy Do Not Have Reflux as a Cause
of Their Symptoms: a Single Center Study Using
Ambulatory Impedance-pH Study
Martinus C. Anderegg1, Roelof J. Bennink2,
Hanneke Van Laarhoven3, Jean H. Klinkenbijl1, Maarten C. Hulshof4,
Jacques J. Bergman5, Mark I. Van Berge Henegouwen1
1
Surgery, Academic Medical Center, Amsterdam, Netherlands;
Pradeep K. Pallati, Se Ryung Yamamoto, Kalyana C.
2
Nuclear Medicine, Academic Medical Center, Amsterdam,
Nandipati, Tommy H. Lee, Sumeet K. Mittal
Netherlands; 3Medical Oncology, Academic Medical Center,
Amsterdam, Netherlands; 4Radiation Oncology, Academic Medical
BACKGROUND AND AIMS: Multichannel intra-luminal Center, Amsterdam, Netherlands; 5Gastroenterlogy and Hepatology,
impedance (MII) and pH monitoring has been shown to be Academic Medical Center, Amsterdam, Netherlands
efficacious in the evaluation of patients with incomplete
BACKGROUND: Esophageal cancer is notorious for its
symptom control on proton pump inhibitor (PPI) therapy.
rapid dissemination, both locally and to distant sites. AccuThe aim of our study is to evaluate the relationship of typirate staging at the time of diagnosis is of crucial importance
cal and atypical gastroesophageal reflux (GER) symptoms
to identify patients eligible for curative treatment. For the
to frequency of acid and non-acid reflux (NAR) episodes in
vast majority of these patients the preferred strategy conpatients on PPI therapy.
sists of neoadjuvant chemoradiotherapy (nCRT) followed
METHODS: Patients with persistent GER symptoms who by esophagectomy. Given the aggressive nature of esophaunderwent 24 hour combined MII-pH monitoring while on geal tumours, it is conceivable that in a significant portion
PPI therapy form the cohort of the study. Reflux episodes of patients treated with nCRT, dissemination becomes manwere detected by impedance channels located 3, 5, 7, 9, 15, ifest during this preoperative course (interval metastasis).
and 17 cm above the lower esophageal sphincter (LES) and Since metastatic disease is an absolute contraindication for
classified into acid or non-acid based on pH data from 5 cm esophagectomy, we added a post-neoadjuvant therapy PETabove the LES. Symptom Index (SI) was considered positive CT (restaging PET-CT) to the standard work-up of patients
if >50% of specific symptom events were preceded by acid with potentially resectable esophageal carcinoma at initial
or non-acid reflux episodes within five minutes.
presentation.
RESULTS: Of 63 patients who underwent combined MII- AIM: Determine the value and diagnostic accuracy of PETpH monitoring on PPI therapy, there were 46 (75%) women CT after neoadjuvant chemoradiotherapy in identifying
and the mean age was 51.6 years (range 18–83). Fifty five patients with interval metastases preoperatively.
patients reported one or more symptoms during the study,
METHODS: From January 2011 until September 2012 all
of these 25 (39.7%) patients had a positive SI for at least
consecutive esophageal cancer patients deemed eligible
one symptom (12 with acid reflux and 16 with NAR). For
for a curative approach with nCRT and surgical resection
typical GERD symptoms, 14 (19%) had a positive SI for acid
underwent a PET-CT after completion of nCRT (median
reflux, 18 (24%) for NAR, and 43 (58%) had a negative SI.
interval 18 days). Staging at initial presentation consisted of
For atypical symptoms, 6 (14%) had a positive SI for acid
endoscopy with biopsy, endoscopic ultrasonography, exterreflux, six (14%) had a positive SI for NAR, and 32 (72%)
nal ultrasonography of the neck and a thoracoabdominal
had a negative SI.
CT scan. A PET scan was not part of the initial staging. NeoCONCLUSION: Combined MII-pH shows that about 2/3rd adjuvant therapy consisted of 5 cycles of carboplatin AUC
of patients complaining of symptoms on PPI therapy do
2, paclitaxel 50 mg/m2 and concurrent radiotherapy (41.4
not have positive symptom index to either acidic and/or
Gy). If abnormalities on restaging PET-CT were suspect of
non-acidic reflux while remaining patients can have their
metastases, histologic proof was acquired. This study was
symptoms attributable to reflux.
approved by the local ethics committee.
RESULTS: During the study period a total number of 280
new esophageal cancer patients were analysed at the outpatient clinic. Of these patients 148 underwent a restaging PET-CT. The remaining 132 patients were considered
ineligible for curative esophagectomy at initial presentation due to comorbidity, unresectable tumours or distant
78
CONCLUSION: Conversion of fundoplication to RYGB is
performed on patients with a lower than average BMI than
our typical RYGB cohort and experience significant weight
loss with improvement in comorbid disease. Complications
are similar to larger cohorts of patients undergoing RYGB.
Although ongoing therapy for acid reduction is common,
improvements in GERD symptoms were noted.
metastases (94 cases), refused to undergo surgery (12), were
operated without nCRT (13) or did not complete nCRT in
our centre (13). In 29 patients (19.6%) restaging PET-CT
showed abnormalities suspicious for dissemination requiring additional imaging and/or biopsy, resulting in 16 cases
of proven interval metastasis (10.8%) and a false-positive
rate of 8.8% for restaging PET-CT. Of the patients without
proven metastatic disease 116 patients have been operated
at this time. In 4 of these 116 cases distant metastases were
detected intraoperatively, leading to a false-negative rate of
3.4%.
Su1620
Esophageal Cancer in the Young: A Population-Based
CONCLUSION: 10.8 percent of esophageal cancer patients Analysis of 1095 Patients
1
2
1
develop detectable distant metastases during neoadjuvant Attila Dubecz , Norbert Solymosi , Michael Schweigert ,
3
1
Jeffrey
H.
Peters
,
Hubert
J.
Stein
chemoradiotherapy. To avoid non-curative resections we
advocate restaging PET-CT as part of the standard work-up 1Surgery, Klinikum Nurnberg, Nurnberg, Germany; 2Faculty of
of candidates for surgery.
Veterinary Science, Szent Istvan University, Budapest, Hungary;
3
Division of Thoracic and Foregut Surgery, Department of Surgery,
8Su1619
University of Rochester School of Medicine and Dentistry, Rochester, NY
BACKGROUND: Controversy exists about the clinical
presentation and prognosis of young patients with gastrointestinal malignancies. The aim of this study was to evaluate population-based demographics and survival of young
patients with esophageal cancer in the United States.
Conversion of Fundoplication to Roux-en-Y Gastric
Bypass: Long-Term Results
Daniel B. Leslie, Nikolaus F. Rasmus, Bridget M. Slusarek,
Barbara K. Sampson, Henry Buchwald, Sayeed Ikramuddin
Department of Surgery, University of Minnesota, Minneapolis, MN
MATERIALS AND METHODS: Patients who underwent
a conversion of fundoplication (Nissen or other) to RYGB
between 2000 and 2011 at our academic medical center
were identified. The department’s bariatric surgery database was reviewed for weight loss, the presence of GERD
symptoms and the use of GERD medications. A reflux and
heartburn questionnaire was administered to assess impact
on quality of life (GERD-HRQL) scores and to determine
postoperative GERD symptoms.
RESULTS: Percentage of young patients with esophageal
cancer is less than 2% and is declining since the 1990s.
More than fifty percent are diagnosed in metastatic stage.
Only 74% of patients with potentially resectable esophageal
cancer underwent surgery. Median cancer-related survival
(13 months vs. 11 months) and five-year survival (22% vs.
18%) was significantly higher than in older patients. Multivariate-analysis identified surgical treatment (OR: 5.046)
as the only as independent predictor of 5-year survival.
RESULTS: Twenty eight patients (female/male = 24/4) Percentage of non-white patients, distal cancer and adenounderwent laparoscopic (n = 17) or open (n = 11) surgery carcinoma were significantly higher when compared to all
by 3 different surgeons and mean weight follow-up (100%) patients.
was 3 ½ years. Average preoperative BMI and weight were CONCLUSION: Most young patients with esophageal can43.1 kg/m2 and 119 kg; 3 patients had BMI below 35 kg/ cer are diagnosed in metastatic stage in the United States.
m2. Average length of stay was 4 days. Post-revisional BMI, Survival in patients under 40 years of age is better than in
weight, and% excess weight loss were 32.0 kg/m2, 87 kg, older patients. Patients undergoing surgical treatment for
and 61%. Resolution of type II diabetes mellitus, hyperten- locoregional cancer have better survival.
sion, and hyperlipidemia were noted in 67%, 33%, and
60% of patients, respectively. No major short-term complications occurred and there were no mortalities. At least
13 patients (46%) continued to use daily acid reduction
medication treatment, and 7 patients reported ongoing
GERD symptoms (25%). Indications for GERD therapy also
include nonspecific abdominal pain, pre-RYGB history of
Barrett’s esophagitis, and documented gastrojejunal ulcer.
On a ranked scale of no symptoms (0) to incapacitating
symptoms (50), mean GERD-HRQL score was 9.5/ 50 following surgery.
79
Sunday
Poster Abstracts
METHODS: We identified 1,095 patients under 40 years
of age with cancer of the esophagus and the gastric cardia
diagnosed between 1973 and 2008 from the Surveillance,
Epidemiology, and End Results (SEER) database. Demographic variables and cancer-related survival were assessed
and compared to all patients >40 years old (n = 65,930).
Influence of available variables on survival was analyzed
with logistic regression.
INTRODUCTION: Conversion of Fundoplication to Rouxen-Y gastric bypass (RYGB) results in significant weight loss
and resolution of co-morbid illness, especially gastrointestinal reflux disease (GERD). This procedure offers alternative therapy to patients with recalcitrant GERD following
a failed fundoplication. To date, very little long-term data
exists for this revisional procedure.
Su1621
Su1622
Prevalence of Gastroesophageal Reflux in Chronic
Obstructive Pulmonary Disease Patients
Celiac Nodal Status as Determined by Laparoscopic
Gastric Ischemic Preconditioning Is Prognostic
in Locally-Advanced Esophageal Cancer and May
Determine Necessity for Completion Esophagectomy
Henrique Abrahao1, Fernando A. Herbella1,
Amilcar M. Bigatao2, Jose R. Jardim2, Luciana C. Silva1,
Fernando P. Vicentine1, Marco G. Patti3
1
Department of Surgery, Federal University of São Paulo, São Paulo,
Brazil; 2Department of Medicine, Division of Pneumology, Federal
University of São Paulo, São Paulo, Brazil; 3Department of Surgery,
University of Chicago, Chicago, IL
Sabha Ganai1,2, Michael B. Ujiki1,2, Mark Talamonti1,2,
John G. Linn1,2, Amy K. Yetasook1, Joann Carbray1,
Marco Zahedi1, Ki Wan Kim1,2, John Howington1,2
1
Surgery, NorthShore University HealthSystem, Evanston, IL;
2
Surgery, The University of Chicago Medicine, Chicago, IL
BACKGROUND: The association of gastroesophageal reflux
disease (GERD) and chronic pulmonary disorders has been
a topic of great interest recently. However, little is known
about GERD in the setting of chronic obstructive pulmonary disease (COPD). This study aims to evaluate in
patients with COPD: (a) the prevalence and the sensitivity
of symptoms to diagnose GERD; (b) the pattern of esophageal motility; and (c) the prevalence of distal and proximal
GERD.
INTRODUCTION: Laparoscopic gastric preconditioning
has theoretical benefits of reducing conduit-related morbidity by allowing time for the stomach to adapt and/or demarcate to ischemic insults prior to staged esophagectomy and
reconstruction. We hypothesized that focused pathological
assessment of celiac lymph nodes during the conditioning
interval could predict long-term outcomes after esophagectomy in patients with locally-advanced esophageal cancer.
METHODS: A single-institutional retrospective review was
conducted between 10/2008 and 11/2012, identifying 34
patients with locally-advanced (clinical Stage IIB/III) esophageal cancer who completed staged esophagectomy after laparoscopic preconditioning. Median follow-up was 9 months.
METHODS: A total of 50 patients with DPOC (as defined
by age >40 years with a FEV1/FVC below 88% of the predicted value after bronchodilator use, and no prior history
of asthma) underwent symptomatic assessment, high-resolution manometry and dual probe esophageal pH monitoring. GERD was defined by a DeMeester score >14.7. Proximal
reflux was defined by ≥1 episode of proximal reflux.
RESULTS: GERD was present in 21 (42%) of the total patients.
GERD symptoms were referred by 20 (40%) patients more
than once a month. Symptoms were not predictive of the
presence of GERD (sensitivity 71%; specificity 83%). GERD
symptoms presence, esophageal manometry and pHmonitoring according to the presence of distal GERD by pHmonitoring results are depicted in Table 1.
RESULTS: Patients were 60 ± 10 years old, 82% male, and
had a BMI of 24 ± 5 kg/m2. The median interval from preconditioning to esophagectomy was 7 days (interquartile
range, IQR, 7–8). Preoperative staging was performed with
EUS in 94% and PET in 100%, with 4 (12%) and 30 (88%)
patients having clinical Stage IIB and III disease, respectively. Ninety-one percent of lesions were located in the
distal esophagus, GE junction, and/or cardia. Histology
comprised 30 (88%) adenocarcinomas, 3 (9%) squamous
cell carcinomas, and 1 (3%) adenosquamous carcinoma.
Ninety-seven percent of patients completed neoadjuvant
therapy, with a pathologic complete response rate of 27%.
All patients had microscopically-negative margins. The
median number of lymph nodes resected was 20 (IQR
16–24), with a median of 5 (IQR 3–6) identified in the
celiac nodal packet harvested during the preconditioning
stage. Patients with positive celiac lymph nodes (32%) were
more likely to have pN2/N3 disease (3 or greater positive
nodes) than those with negative celiac nodes (64% versus
9%, p < 0.01). Median disease-free survival by celiac lymph
node status was 18.6 versus 3.7 months (HR 0.22, 95% CI
0.06–0.75, p < 0.01). Median overall survival by pN status
was 32.7 months for pN0, 12.2 months for pN1, and 5.6
months for pN2/N3 (p < 0.001). On multivariate analysis
controlling for histology, grade, pathological response to
therapy, celiac nodal status, and pT status, only pN status
remained an independent predictor of both disease-free
(p < 0.05) and overall survival (p < 0.01).
GERD + (n = 21)
GERD – (n = 29)
p
GERD symptoms
15 (71%)
5 (17%)
<0.001
hypotensive LES
8 (39%)
5 (17%)
0.1
Abnormal peristalsis
2 (9%)
8 (28%)
0.1
Abnormal amplitude
10 (48%)
4 (14%)
0.01
Proximal GERD
20 (95%)
7 (24%)
<0.001
GERD: gastroesophageal reflux disease LES: lower esophageal sphincter
CONCLUSIONS: These data show that in patients with
DPOC: 1) GERD is present in almost half of the patients; 2)
symptoms were insensitive and nonspecific for diagnosing
GERD; 3) a defective LES is not more common in patients
with GERD leading to the hypothesis that the physiopathology for GERD may be linked to the transthoracic pressure gradient in this population; 4) in 95% of the patients
with GERD, acid refluxed into the proximal esophagus. We
conclude that patients with DPOC should be screened with
pH monitoring for GERD.
80
Su1623
POEM-Based Endoscopic Treatment of Zenker’s
Diverticulum: Minimal Incision Cricopharyngeal
Myotomy (CPM)
Luke Mccrone1, Kondal R. Kyanam Kabir Baig2, Victoria
Gomez2, John D. Casler3, Timothy A. Woodward2
1
Internal Medicine, Mayo Clinic Florida, Jacksonville, FL;
2
Gastroenterology, Mayo Clinic Florida, Jacksonville, FL;
3
Otorhinolaryngology, Mayo Clinic Florida, Jacksonville, FL
BACKGROUND: Zenker’s diverticulum (ZD), a posterior
outpouching of mucosa through transverse cricophargyngeal muscle fibers, has a reported prevalence of 0.01% to
0.11%. ZD is associated with marked morbidity, with symptoms ranging from halitosis and food regurgitation to aspiration pneumonia and cachexia. Therapeutic management
of ZD has evolved from open diverticulectomy to rigid
endoscopy, and, most recently, flexible endoscopy utilizing
cricophayrngeal myotomy (CPM) with diverticulotomy.
Traditional open surgical and rigid endoscopic methods
have been associated with high rates of symptomatic resolution, with acceptable rates of recurrence. There are, however, associated complications of bleeding and perforation,
with these risks being amplified in this comorbid, aged
patient population. Building upon the per oral endoscopic
myotomy (POEM) A POEM-based minimal incision cricopharyngeal myotomy (CPM) technique has been developed, using a needle knife to dissect the cricopharyngeal
bar by way of a 8 to 10 mm incision within the confines
of the mucosa without an extended diverticulotomy (See
image).
Sunday
Poster Abstracts
CONCLUSIONS: While the AJCC 7th edition for staging of
esophageal cancer has changed the emphasis from the location of regional lymph node metastasis to the number of
positive nodes, our data suggest that esophagectomy may be
avoided in patients with positive celiac nodes after neoadjuvant therapy for locally-advanced esophageal cancer. Laparoscopic preconditioning provides an opportunity to determine
celiac nodal status prior to committing to esophagectomy.
Myotomy within minimal incision.
81
METHODS: After IRB approval, we retrospectively queried
our prospective database for patients who underwent an Ivor
METHODS: Prospectively collected cohort of patients Lewis esophagogastrectomy for esophageal cancer. We idenundergoing minimal incision needle-knife cricophargyneal tified 220 patients from May 2001 to December 2012. Pathmyotomy under monitored anesthesia care at a single cen- way one consisted of 110 patients, operated on between May
2001 and January 2007, who had contrast examination on
ter tertiary referral center.
postoperative day (POD) # 5, and if no anastomotic leak was
Subjects include patients with symptomatic ZD as demon- seen, progression of oral intake from clear liquids on POD#5,
strated by radiographic and/or endoscopic evaluation. The full liquids on POD#6 and soft solids on POD#7. They were
main outcome measurements consisted of pre- and post discharged on a soft solid postgastrectomy diet. Pathway
dysphagia scores (0–4 with 0 as no dysphagia and 4 rep- two consisted of 110 patients operated on between January
resenting severe dysphagia) and any post-procedural com- 2007 and December 2012 who had no postoperative contrast
plications, as determined by clinical review and telephone swallow, jejunal tube feedings starting POD #1 at 20 cc/hr
follow up.
advancing 10 cc/12 hours until goal and discharge NPO on
RESULTS: From January 2009 to November 2012, 8 jejunal tube feedings only for 1 month then gradual increaspatients underwent minimal incision CPM (see table). The ing oral intake and eliminating tube feedings by 6 weeks
mean age was 76 years (range 61–91 years; 63% male). postoperatively. Factors analyzed included demographics,
Improvement in dysphagia was seen in 100% of patients, length of stay, complications and weight changes.
though complete resolution was seen only in 4 patients RESULTS: Overall there were 188 (85.5%) men; median
(50%). As this was a pilot program, all patients were hospi- age was 64 years (range 32–89). Table 1 show the patient
talized overnight for observation. Excluding mild subcuta- characteristics overall and of the two pathways. Median
neous emphysema in two patients, no procedurally related length of stay was 10days (range 7–98) in pathway one and
problems. Time to follow up ranged from 2 weeks to 17 only 7 days (range 5–54) in pathway two. Complication
months.
rates were similar in the two groups: 37.2% in pathway one
and 42.7% in pathway two. The anastomotic leak rate was
Results of Cricopharyngeal Myotomy
higher in pathway one compared to pathway two: 4.5% vs.
1.8% respectively. There was no difference in the median
Dysphagia
Dysphagia
weight loss from discharge to the 6 week follow-up visit
Case
Age/Sex
Pre-Procedure
Post-Procedure Successful
between the two groups: 6.8 kg in pathway one patients vs.
1
84/Male
3
0
Yes
6.4 kg in pathway two patients.
2
68/Male
3
1
Yes
AIMS: To evaluate the efficacy of endoscopic minimal incision CPM in the treatment of Zenker’s Diverticulum.
3
70/Male
3
1
Yes
4
61/Female
2
0
Yes
5
75/Female
2
0
Yes
6
76/Male
3
1
Yes
7
83/Male
2
0
Yes
8
91/Female
4
2
Yes
Dysphagia Score: 0 = no dysphagia; 1 = able to swallow some solid foods;
2 = able to swallow only semi-solid foods; 3 = able to swallow liquids only;
4 = total dysphagia.
Patient Characteristics
Overall
Pathway 1
Pathway 2
Characteristic
(n = 220)
(n = 110)
(n = 110)
Men (%)
85.5
87.2
83.6
Median age (range)
64 (32–89)
64 (32–89)
63 (33–84)
Preop chemo/XRT (%)
69.1
61.8
76.4
Clinical Stage IIIA
53.6
51.8
55.5
Adenocarcinoma (%)
86.8
88.2
85.5
Preop chemo/XRT – Preoperative chemotherapy and radiation therapy
CONCLUSION: Minimal incision CPM is effective in management of Zenker’s diverticulum, and demonstrates effective resolution of dysphagia. In our case series, no serious
procedural or post-procedural complications occurred.
CONCLUSION: Changing the postoperative nutritional
management after an Ivor Lewis esophagogastrectomy
to no contrast swallow and delaying oral intake for one
month results in a shorter length of stay and reduced anastomotic leaks, but no change in the overall complication
rate or early postoperative weight loss.
Su1624
Postoperative Management of Nutrition After Ivor
Lewis Esophagogastrectomy for Cancer
Laura Trujillo, James Taswell, Mark Allen
Mayo Clinic, Rochester, MN
OBJECTIVES: Esophagogastrectomy is a complex operation
and the postoperative management is variable. We hypothesized that waiting 5 days postoperatively to obtain a contrast
swallow to start oral intake and then waiting until patients
were able to take sufficient oral intake before discharge prolongs hospitalization after an Ivor Lewis esophagogastrectomy. To examine this hypothesis we analyzed two methods
of management of postoperative nutrition after surgery.
82
Su1625
Su1626
High-Resolution Impedance Manometry Findings in
Patients with Epiphrenic Diverticulum
Surgical Management of Esophageal Perforation: A
10-Year Experience
Se Ryung Yamamoto, Kalyana C. Nandipati,
Pradeep K. Pallati, Tommy H. Lee, Sumeet K. Mittal
Paul Goldsmith1, Bilal Alkhaffaf1, Bart Decadt2
1
Manchester Royal Infirmary, Manchester, United Kingdom;
2
Stepping Hill Hospital, Stockport, United Kingdom
AIM: The objective of this study was to evaluate high-resolution INTRODUCTION: The management of esophageal perimpedance manometry (HRIM) findings in patients with foration and mediastinal sepsis is challenging. Treatment
esophageal epiphrenic diverticulum.
strategies differ between surgical units and as a conseMETHODS: Patients with esophageal epiphrenic diver- quence outcomes can vary widely in this patient group. We
ticulum who underwent HRIM between October 2008 and present our 10-year experience of esophageal perforation
March 2012 are included in the study. Manometric findings and evolving treatment strategy for this condition.
were compared to endoscopic (EGD) and barium swallow
(BS) findings. Patients with previous foregut surgery were
excluded.
METHODS: This was a retrospective review of all esophageal perforations including both patients with a spontaneous or iatrogenic perforation and cases of mediastinal sepsis
RESULTS: Six patients (mean age 59.0 years, 3 females) are due to anastomotic leak following cardio-esophagectomy.
included in the study. On EGD the diverticulum was 1 to Patients were grouped according to their treatment strategy.
4 cm above the gastro-esophageal junction (GEJ) and the The primary outcome measures were in-hospital death and
mouth of diverticulum was 2 to 9 cm in size. Mean lower length of stay (total hospital stay and Intensive Care Unit
esophageal sphincter pressure (LESP) and mean Integrated (ICU) stay).
relaxation pressure (IRP) were 50.7 mmHg (range 39.2 to RESULTS: In total, thirty-seven patients were included.
61.9 mmHg) and 22.4 mmHg (range 13.8 to 30.8 mmHg) Twenty-five were male with a median age of 59 (range
respectively. Achalasia was the most common abnormal- 21–80). Seven patients suffered iatrogenic perforations
ity noted in 3 patients (type I = 2 and type II = 1). Two (3 esophageal dilatations, 2 food bolus removal, 2 gastrosadditional patients had isolated EGJ obstruction with pre- copy). Eleven patients presented following spontaneous
served esophageal motility. One patient had normal IRP esophageal perforations and a further Eighteen suffered
but weak peristalsis. A break in peristalsis corresponding to anastomotic leaks following cardio-esophagectomy and
the mouth of the diverticulum could be seen in 4 patients. one leak following cardio-myotomy.
There was decreased bolus transit in three patients.
Twenty-six patients underwent surgery for their perforations compared to eleven who were conservatively managed. Surgical management involved either thoracotomy
with primary repair or creation of a controlled fistula using
a T-tube (20), cardio-esophagectomy (3) or thoracoscopic
washout (3). All patients had enteral feeding routes inserted
in conjunction with surgery. Conservative management
constituted either simple insertion of chest drains (8) or
stent placement (3).
Death following non-operative management occurred in 4
patients compared to two (36% vs 7% p < 0.05) in those
who underwent surgery.
CONCLUSION: Urgent operative management is a safe
treatment option for patients who have oesophageal perforation and are fit to undergo a surgical exploration.
Thoracotomy with repair of the perforation over a T-tube
with defunctioning gastrostomy, feeding jejunostomy and
drainage of the thorax and mediastinum, appears a safe
policy and is our preferred approach. Patients with existing esophageal pathology may be considered for emergency
cardio-esophagectomy.
83
Sunday
Poster Abstracts
CONCLUSIONS: There is a high prevalence of esophageal
outflow obstruction and primary peristaltic abnormality in
patients with epiphrenic diverticulum. This reconfirms the
need to extend the myotomy down on to the GEJ even in
patients in whom the diverticulum appears to be well above
the GEJ.
Su1627
use were collected at years 1, 2, 3, 4 and 10 post-procedure.
The data were analyzed using a repeated measures analysis
of variance to determine whether there was a significant
temporal trend in the various outcomes. Any significant
effect was sub-analyzed using a Bonferroni-adjusted multiple comparison procedure.
Sustained Improvement in GERD-HRQL, Patient
Satisfaction, and Anti-Secretory Drug Use 10-Years
After Stretta for Medically Refractory GERD
Mark D. Noar1, Patrick Squires1, Emmanuelle Noar1,2
1
The Heartburn and Reflux Center, Endoscopic Microsurgery
Associates, Towson, MD; 2School of Medicine, Tulane University,
New Orleans, LA
RESULTS: The total treated pool included 227 patients (136
females, 60%). No strictures, perforation, deaths or other
significant adverse events occurred. Complete follow-up
was available for subjects at intervals as follows: 6 months
BACKGROUND & AIMS: The Stretta procedure is an (n = 177), 1 year (n = 149), 2 years (n = 98), 3 years (n =
effective endoscopic modality for control of GERD symp- 98), 4 years (n = 94), and 10 years (n = 99). Heartburn,
toms. However, long term efficacy and safety at >10 years satisfaction, HRQL and medication use were significantly
has not been assessed. We prospectively evaluated the long- improved across the follow-up period (6, 12, 24, 36, 48, and
term efficacy of Stretta at 10-years and assessed anti-secre- 120 months; p < 10–6 for all of the outcomes) and results
tory drug use, GERD symptoms, and patient satisfaction.
were superior to those achieved for baseline drug therapy
METHODS: From 8/2000 to 9/2004, 227 patients with (see Table).
inadequate GERD symptom control despite BID PPI under- CONCLUSION: This 10-year, open, single center, prospecwent Stretta and were prospectively enrolled in this study. tive assessment of Stretta for refractory GERD demonstrates
All patients had normal esophagogastric anatomy, except a significant and sustained improvement of GERD-HQoL
16 patients with failed Nissen fundoplication and 7 with scores, patient satisfaction, and improved PPI use and valilarge (>3 cm) hiatal hernia. All procedures were performed dates the long-term usefulness of this endoscopic proceby a single endoscopist in an outpatient setting with con- dure. Patients with variant anatomy such as prior Nissen
scious sedation. Baseline and follow-up GERD-HRQL scores fundoplication or large hiatal hernia had a similar response
(0–50), heartburn (0–5), satisfaction (0–5) and medication compared to patients with normal anatomy.
Parameter
Med Scores
GERD Scores
Satisfaction Scores
Before Treatment,
off Meds
27.8 ± 10.7
1.3 ± 0.9
Before Procedure,
on Meds
8.3 ± 3.8
21.4 ± 11.5
1.9 ± 1.1
0.5 Years
4.9 ± 3.9
11.1 ± 10.0
3.4 ± 1.3
1 Year
3.8 ± 3.5
6.9 ± 7.5
3.9 ± 1.3
2 Years
3.7 ± 4.2
5.0 ± 6.9
4.3 ± 1.0
3 Years
4.6 ± 3.6
6.9 ± 8.2
3.8 ± 1.3
4 Years
4.3 ± 3.2
7.3 ± 8.5
3.8 ± 1.3
10 Years
4.7 ± 3.3
8.1 ± 9.9
3.8 ± 1.2
METHODS: A query was submitted to the Web of Science database to find all the publications in the topic of
gastroesophageal reflux in the time period between January
1954 to December 2011. A total of 18136 references were
retrieved, these records were then analyzed using bibliometric parameters.
Su1628
Bibliometric Analysis of the Scientific Publications
About Gastroesophageal Reflux Disease (GERD)
Between 1954 and 2011
Shahin Ayazi, Thomas J. Watson, Carolyn E. Jones,
Virginia R. Litle, Christian G. Peyre, Jeffrey H. Peters
Surgery, University of Rochester, Rochester, NY
INTRODUCTION: Gastroesophageal reflux disease (GERD)
is an increasingly prevalent health problem. This disease
has been the focus of the work of many researchers in the
last 50 years, these investigations has led to a transformation in the understanding and treatment of this disease.
However little is known about the characteristics and trends
of the scientific publications in this field. The aim of this
study is to present a bibliometric analysis of the scientific
publications on gastroesophageal reflux disease.
84
RESULTS: Number of publications has increased from
only two papers per year in 1954 to nearly three papers per
day in 2011, with more than 700 publications per year in
21st century. Majority of these publications are in English
(94%). United States, England and Italy are the most productive countries with 40%, 7% and 6% of the literature
respectively. Eighty percent of the literature in the field is
the result of the work of authors from 10 countries [North
America (2), Europe (6), Japan and Australia], this pattern
did not change when the publications from 2000–2011
were analyzed separately.
METHODS: A retrospective database was used to capture
the clinico-pathological data of all consecutive curative
resections of OGJ adenocarcinomas over the last 10 years in
two UK Upper GI Units. Any report with less than 12 lymph
nodes was considered inadequate and denoted as (Nx). All
cases were re-reported and re-staged according to the 7th
TNM staging rules. We compared the impact of the 7th TNM
staging rules on neo-staging. Overall survival was analysed
using the 6th and 7th TNM staging respectively. Overall survival was sub-stratified into 2 years, 5 years and 10 years
post curative resection.
Mayo clinic is the institution with the highest number of
publications (268), followed by the University of Southern RESULTS: Fifty seven (57) pathology reports confirmCalifornia (243) and Northwestern University (211). Tom ing oesophago-gastric junctional adenocarcinomas were
DeMeester, Joel Richter and Donald Castell are the most reviewed. Adequate lymphadenectomy (minimum of 12
prolific authors in this field with 194, 178 and 169 publica- nodes) was noted in 33 patients. Overall stage migration
tions respectively. Gastroenterology and American Journal was noted in 36 (63%) reports with the 7th TNM staging. Of
of Gastroenterology are the two journals with the highest those who had adequate lymphadenectomy (33), 20 reports
(60.6%) had stage migration.
number of publications about the GERD.
CONCLUSION: Parallel to the rise in the prevalence of the In terms of survival, one patient was lost to follow up and is
gastroesophageal reflux disease, there is an increase in the not included in the analysis for survival. Patients with Stage
research performed about reflux evidenced by the constant 4 disease were not operated on in this cohort.
increase in the number of scholarly work published in this 2 year survival (n = 56) using the 7th TNM staging, showed
field (Figure). Two thirds of the literature about the GERD an apparent increase in survival by 12.4% in stage 3 disease
has been published in the 21st century. Only a small frac- with a corresponding decrease in survival by 17.8% in stage
tion of GERD publications (6.3%) is supported by a funding 2 disease. 5 year survival (n = 34) using the 7th TNM staging,
agency. Majority of the literature (80%) is the result of the demonstrated 14.8% increase in survival for stage 3 disease
work of the authors from only 10 countries.
and a corresponding decrease by 17.6% for stage 2 disease.
10 year survival (n = 10) with the 7th TNM, again demonstrated a 30% increase in apparent survival for stage 3 disease and a corresponding decrease by 40% in stage 2 disease.
Su1629
For stage 1 disease, there is no significant change in 2 year,
5 year and 10 year survival.
CONCLUSION: The 7th edition of TNM staging provides
a detailed documentation of the lymphatic staging. The
apparent increase in survival in stage 3 disease appears to
be compensated for the apparent decrease in survival for
stage 2 disease. This better defined lymphatic staging does
not seem to predict survival or have a superior prognosticating ability.
Ramesh Y. Kannan, Matthew L. Davies, Carys Jenkins,
Majid Rashid, Ashraf M. Rasheed
Minimal Access Surgery, Royal Gwent Hospital, Newport,
United Kingdom
INTRODUCTION: The 7th TNM staging defines a minimum number of nodes, recommends an optimal number
for each T stage, emphasizes the prognostic importance of
number of regional nodes involved and upstages based on
the number of metastatic lymph nodes.
AIMS: To study the impact of application of 7th TNM rules
on nodal staging (N) of resected and pathologically reported
oesophago-gastric junctional (OGJ) adenocarcinomas during the last 10 years stratifying them according to the 7th
edition TNM staging and to compare against the original
staging and assess possible impact of nodal neo-staging on
survival.
85
Sunday
Poster Abstracts
The Better Definition of Nodal Staging in the 7th
Edition of TNM Manual Does Not Predict Survival
or Translates Into Better Prognosticating Ability in
Oesophago-Gastric Junctional Adenocarcinoma
Su1631
Does Surgery Have a Role in the Treatment of Small
Cell Cancer of the Esophagus?
(p < 0.001) and higher stage (p < 0.001) at diagnosis and
were less likely to undergo surgical resection (4.9% vs. 18%;
p < 0.01). In both all-comers as well as those undergoing surgical resection, univariate analyses showed a worse
survival in patients with small cell esophageal cancer.
However, multivariate analyses adjusting for age, gender,
grade, stage, race and number of lymph nodes examined
did not show a statistically significant association between
small cell histology and overall survival in both sets of
patients. Univariate analysis of patients with small cell cancer alone demonstrated a significant association of surgery
with median survival (17 months vs. 7 months; p = 0.002)
(Figure 1).
Moshim Kukar1, Adrienne Groman1, Graham W. Warren3,
Usha Malhotra2, Chukwumere Nwogu1, Todd L. Demmy1,
Sai Yendamuri1
1
Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY;
2
Medical Oncolgy, Roswell Park Cancer Institute, Buffalo, NY;
3
Radiation Medicine, Roswell Park Cancer Institute, Buffalo, NY
INTRODUCTION: Small cell cancer of the esophagus is
an uncommon malignancy with perceived poor prognosis. Due to its rarity, no large case series has been examined to guide therapeutic decisions. We examined the SEER
database to analyze factors determining outcome of this
unusual malignancy.
CONCLUSIONS: This large study of small cell esophageal
cancer confirms the clinical observation that small cell cancer of the esophagus is an aggressive disease. In addition,
we show that outcomes with this disease are associated
with stage of disease and not histology. Therefore, surgical
resection for esophageal cancer patients with this histology should be offered based on stage rather than histology
alone.
METHODS: All patients with esophageal cancer in the
SEER database from 1973–2009 were included. Characteristics of patients with and without small cell cancer were
compared. Univariate and multivariate analyses examining
the relationship of small cell histology with overall survival
(censored at 72 months) were performed in all patients as Su1632
well as those undergoing surgical resection. In addition,
only patients with small cell cancer were analyzed to exam- Dissatisfaction After Laparoscopic Heller Myotomy
ine the potential benefit of surgery.
Sharona B. Ross, Carrie E. Ryan, Benjamin L. Jacobi, Harold
Paul, Kenneth Luberice, Paul Toomey, Alexander Rosemurgy
General Surgery, Florida Hospital Tampa, Tampa, FL
INTRODUCTION: Laparoscopic Heller myotomy alleviates symptoms of achalasia; however, we have observed
a small subset of patients who are dissatisfied with their
experience. This study was undertaken to identify causes
of dissatisfaction after laparoscopic Heller myotomy and to
identify predictors of dissatisfaction following myotomy.
METHODS: With IRB approval, all patients undergoing
laparoscopic Heller myotomy at our institution from 1992
to 2012 were prospectively followed. Using a Likert scale
patients rated their frequency and severity of symptoms
before and after myotomy. Patients graded their experience
from “Very Satisfying” to “Very Unsatisfying”. Objective
outcomes were determined by esophagography/esophagoscopy. Complaints were derived from postoperative surveys,
clinic visits, and phone surveys. Median data are reported.
RESULTS: Of the 597 patients undergoing laparoscopic
Heller myotomy, 44 (7%) patients reported some level of
dissatisfaction following myotomy with follow-up at 32
months. Dissatisfied patients were more likely to have
undergone prior abdominal operations (45% vs. 28%, p
Figure 1: Patients with small cell esophageal cancer undergoing
= 0.03) and previous myotomies (16% vs. 5%, p = 0.02).
surgical resection (green line) have a better survival than those with
Dissatisfied patients also had longer postoperative lengths
no surgical resection (blue line) on univariate analyses.
of stay (2 days vs. 1 day, p = 0.01), generally because of
RESULTS: 387 of 64,799 (0.6%) patients with esophageal postoperative complications or exacerbations of preopcancer had small cell histology. Patients with small cell erative comorbidities. For dissatisfied patients, symptom
histology were similar in age and race, but had a higher frequency and severity persisted after myotomy and were
proportion of females compared to other histologies (40.6% more notable than for satisfied patients (p < 0.03 for all;
vs. 25.4%; p < 0.001). These patients also had higher grade Figure).
86
METHODS: With IRB approval, patients were prospectively followed after Heller myotomy. Patients scored the
frequency and severity of their symptoms before and after
myotomy using a Likert scale (0 = never/not bothersome
to 10 = always/very bothersome). The symptom frequency
and severity of the first 100 patients undergoing laparoscopic Heller myotomy with anterior fundoplication were
compared to the last 100 LESS patients undergoing LESS
Heller myotomy with anterior fundoplication. Median data
are reported.
Su1633
A Single Institution’s Journey with Heller Myotomy:
Is the Laparo-Endoscopic Single Site (LESS) Approach
Best?
Alexander Rosemurgy, Thara Salam, Carrie E. Ryan,
Mercedez C. Cruz, Kenneth Luberice, Harold Paul,
Sharona B. Ross
Graphs illustrate symptom frequency preoperative and postoperatively.
Figure 1a is specific for the first 100 patients undergoing laparoscopic
Heller myotomy with anterior fundoplication while Figure 1b is specific
for the last 100 patients undergoing LESS Heller myotomy and anterior
INTRODUCTION: The surgical treatment of achalasia has fundoplication.
evolved from a conventional laparoscopic Heller myotomy
to a Laparo-Endoscopic Single Site (LESS) Heller myotomy
with anterior fundoplication. This study illustrates our journey with the evolution in technology and instrumentation
and details patient outcomes along our journey.
87
Sunday
Poster Abstracts
RESULTS: 601 Heller myotomies with fundoplications
were undertaken between 1992–2012. Of these, 470 (78%)
were completed via conventional laparoscopy, 130 (21%)
via the LESS approach, and 1 (.1%) as an “open” operation.
All of the last 100 patients underwent the LESS approach
with anterior fundoplication. The frequency and severity
of all preoperative symptoms significantly improved with
Figure depicts the disparity of symptom resolution between satisfied and either the conventional laparoscopic or LESS approach;
dissatisfied patients. *denotes symptom improvement after myotomy
several postoperative symptoms had superior improve(p < 0.05).
ment with the LESS approach (e.g., vomiting, choking, p =
0.01 for each; Figures 1a, 1b). Those who underwent LESS
CONCLUSIONS: Dissatisfaction is fortunately uncommon Heller myotomy with anterior fundoplication also had a
after laparoscopic Heller myotomy. Dissatisfaction is directly decreased length of hospital stay (2 vs. 1 day, p < 0.05) and
related to persistent severe and frequent symptoms; longer no apparent scars.
lengths of stay, previous abdominal operations, and “re-do” CONCLUSIONS: Laparoscopic Heller myotomy provides
myotomies predict dissatisfaction. Patients with notable an efficacious and durable treatment for achalasia. The
comorbidities and/or previous abdominal operations, par- LESS technique offers a safe approach with equivalent or
ticularly Heller myotomy, are more likely to be dissatisfied superior symptom relief and improved cosmesis. Overall
after laparoscopic Heller myotomy should be counseled patient satisfaction and durable symptom relief promotes
preoperatively. Comorbidities should be addressed preop- laparoscopic Heller myotomy with anterior fundoplication,
eratively and for patients with previous notable abdominal particularly using the LESS approach.
operations, particularly myotomy, alternatives to laparoscopic Heller myotomy should be considered.
Su1634
Su1635
Surgical Myotomy Should Be Considered as Primary
Treatment in Elderly Patients with Achalasia
Surgical Treatment for Achalasia: A NSQIP Analysis
Stephanie G. Wood, Edward J. Hannoush, Andrew Duffy,
Robert Bell, Kurt E. Roberts
Surgery, Yale School of Medicine, New Haven, CT
Donald E. Low, Artur M. Bodnar, Sheraz R. Markar
Department of Thoracic Surgery, Virginia Mason Medical Center,
Seattle, WA
INTRODUCTION: There are multiple surgical treatment
options for Achalasia, with the laparoscopic approach
increasingly considered the treatment of choice. We review
the largest number of reported cases of laparoscopic Heller
myotomies to date, from the NSQIP database, and compare
alternative surgical treatments.
INTRODUCTION: Achalasia is a rare disease which predominantly affects patients between 25 and 55 years. Older
patients are often not considered for endoscopic management due to the perception that they are at higher risk for
surgical therapy.
METHODS: Using the American College of Surgeons
National Surgical Quality Improvement Program (NSQIP)
participant use files from 2005–2010, patients diagnosed
with Achalasia (ICD-9 530.0) who underwent a surgical
Heller myotomy, including open abdominal (CPT 43330),
laparoscopic (CPT 43279), open thoracic (CPT 43331), and
RESULTS: 99 patients underwent surgical treatment for thoracoscopic (CPT 32665) approaches. As the CPT code for
achalasia during the study period. 6 patients (1 > 70, 5 < laparoscopic Heller myotomy was created in 2009, there are
70) underwent esophageal resection and were excluded. 92 none reported before this time.
patients underwent Heller myotomy and either Toupet or
Dor fundoplication. 17 patients >70 years of age, mean age RESULTS: A total of 978 patients diagnosed with Achalasia
was 76.5, range 70–92 years, were compared to 75 patients were identified, of which 663 patients received a laparocopic
<70 years. Pre-operative weight loss was similar (mean 15.6 Heller, 239 open Heller, 16 open thoracic, and 60 thoracolbs >70 versus 18.7 lbs <70). Patients in the >70 group had scopic myotomies. Overall, 56.8% were male and mean age
higher ASA scores (2.58 versus 2.14, p = 0.01) and were more is 52 years (SD ± 16.3). There was no significant difference
likely to undergo previous endoscopic therapy (65% versus in age between groups. There was a significant difference in
60%). Patients in the >70 group were less likely to undergo total length of stay between open and laparoscopy Heller
laparoscopic surgery (35% versus 79%). Length of operation myotomy groups only, 3.45 vs 2.48 days, p = 0.015. Operaand blood loss was similar between study groups. Intraop- tive time was significantly different between the open and
erative complications were more common in patients <70, laparoscopy Heller myotomy groups only, 146.0 vs 136.27
conversions (3 versus 0), intraoperative mucosal injury min (SD ± 54.9), p 0.018. There only significant difference
(3 versus 0). Perioperative complications occurred in 13% in postoperative complications was in superficial site infecof patients <70 and 23.5% of patients >70. Complications tions, with 3 in open heller and 1 in thoracoscopic groups,
in the >70 group included transient delirium 2, C. diff coli- p = 0.025. There were no deaths reported.
tis 1 and fall 1. Median length of stay was 2 days in patients CONCLUSION: While there is no significant difference in
<70 (lap 2 versus open 4.5 days) and 4 days in patients >70 serious post-operative complications, laparoscopic Heller
(lap 2 versus open 4 days). There was no mortality in either myotomy has improved length of stay and operative times
group. Readmissions were required in one patient in each compared to open, and thoracic approaches.
cohort. At mean objective follow-up of 3.8 months, 94%
of patients >70 reported excellent (normal swallowing) or
good (occasional dysphagia but no regurgitation) results. Clinical: Hepatic
Followup was available in 12 patients >70 years at mean
29.1 months. 83% reported they ate a completely normal
diet. Residual symptoms included occasional dysphagia Su1636
34%, occasional regurgitation 8%, and periodic heartburn Difference in Outcomes Between Right and Left
42%. No patient had required additional surgical or endoHepatectomy in Patients Undergoing Hepatic Resection
scopic therapy and all patients indicated they would have
Mashaal Dhir1, Lynette M. Smith1, George Dittrick2,
the operation again.
Quan P. Ly1, Aaron R. Sasson1, Chandrakanth Are1
CONCLUSIONS: Elderly patients with achalasia can 1University of Nebraska Medical Center, Omaha, NE; 2Surgery,
undergo surgical myotomy and partial fundoplication
Nebraska Methodist Hospital, Omaha, NE
safely and with excellent results comparable to younger
patients. These older patients should be given the opportu- BACKGROUND: Several studies have documented the
nity to discuss surgical treatment with an experienced sur- safety of liver resections. Although right hepatectomy is
felt to be associated with higher mortality and morbidity,
geon at the time of their initial presentation.
data on the difference in outcomes between right and left
hepatectomy is scarce. The aim of the current study is to
analyze the difference in outcomes between right and left
hepatectomy in patients undergoing hepatic resection.
METHODS: All patients undergoing surgical treatment for
achalasia between 2001 and 2012 were entered into an IRBapproved database. Presenting characteristics and perioperative outcomes were compared in patients younger and
older than 70 years.
88
Su1639
METHODOLOGY: All patients undergoing right (primary
CPT code 47130) and left hepatectomy (primary CPT code
47125) were extracted from the National Surgical Quality Improvement Program (NSQIP) database (2005–2010).
Benign and malignant diagnoses (ICD-9 155.0, 155.1, 155.2
and 197.7) were determined from the database. The data
was analyzed to determine differences in outcomes between
right and left hepatectomy by using the chi square test or
Fisher’s exact test as appropriate.
Modified FOLFOX6 and Bevacizumab as Neoadjuvant
Chemotherapy for Patients with Potentially Curable
Bilobar Liver Metastases from Colorectal Cancer
Atsuyuki Maeda, Masatoshi Isogai, Yuji Kaneoka
Digestive Surgery, Ogaki Municipal Hospital, Ogaki, Gifu, Japan
OBJECTIVE: Even though patients with colorectal cancer
(CRC) and liver metastases have a poor prognosis, they can
benefit from perioperative chemotherapy and complete
extirpation of the disease. Oxaliplatin based chemotherapy
with bevacizumab has been widely reported to improve
outcomes with metastatic CRC. However, its impact on surgical complications and survival benefit after liver resection
remains to be determined.
RESULTS: A total of 2311 patients who underwent right
or left hepatectomy were identified of whom 1680 patients
were noted to have a malignant diagnosis. (Table 1) Patients
that underwent right hepatectomy were noted to be have a
higher mortality rate when compared to left hepatectomy
(all patients: right vs left—4.24% vs 1%, P < 0.001 and for
patients with malignancy: right vs left—4.52% vs 1.09%, P
< 0.001). Right hepatectomy was also associated with significantly higher incidence of several other complications
such as organ space infections, pneumonia, unplanned reintubation, pulmonary embolism, failure to wean off the
ventilator, renal insufficiency, urinary tract infection, blood
transfusion, deep venous thrombosis and sepsis (P value <
0.05).
RESULTS: Synchronous liver diseases were observed in 14
(73%). Although objective response to NAC was achieved
in 6 patients (32%), 16 patients (84%) underwent liver
resection. The liver surgery included 4 hemihepatecitomies,
5 sectorectomies, and 7 partial resections of the liver with
median operative time of 186 minutes and median blood
loss of 340 mL without blood transfusion. Any postoperative morbidity or morbidity was observed. One- and threeyear OS of the NAC group were 100% and 56% (MST 43
months), and those of the non-NAC group were 93% and
49% (MST 31 months), respectively (P = 0.47). DFS of the
two groups were not different (P = 0.50). Among the hepatectomized of NAC group, 10 patients (60%) developed
recurrence with median relapse free time of 16.6 months.
Initial recurrent deposits were observed in remaining liver
in 4 patients, lung in 3, lymph nodes in 3, and peritoneum
in 1 (redundant included).
CONCLUSION: The results of our study demonstrate that
mortality and morbidity after right hepatectomy remains
significantly higher than left hepatectomy.
CONCLUSION: Our data suggest that FOLFOX6 and bevacizumab can be safely administered until 4 weeks before
liver resection in patients with liver metastases from CRC
without increasing perioperative complications. Although
no contributions to OS and DFS were observed, control
of liver recurrence may be achieved. Adjuvant therapies
and further study is needed to define the survival benefit
of NAC with FOLFOX6 plus bevacizumab in patients with
potentially curable bilobar metastases from CRC.
89
Sunday
Poster Abstracts
PATIENTS AND METHODS: Nineteen patients with
potentially curable bilobar metastases from CRC were eligible for this single-center, nonrandomized trial during a
period between September 2008 and August 2012 (NAC
group). The study group consisted of 13 men and 6 women,
with median age of 63 (range 52 to 79) years. Eligible criteria included synchronous liver metastases and metastatic
liver disease developed within one year after resection of
the primary lesions. Patients received biweekly oxaliplatin,
5-fluorouracil, and folic acid (FOLFOX6) plus bevacizumab
therapy. The sixth cycle of neoadjuvant chemotherapy
(NAC) did not include bevacizumab, resulting in 4 weeks
window-time between the last administration of bevacizumab and hepatectomy. Over all survival (OS) and progression free survival (PFS) were compared with 27 patients
who underwent hepateictomies for bilober metastasis during 2002 and 2008 (non NAC group).
Su1640
Su1641
Hepatectomy for Liver Metastases from Gastric and
Esophageal Cancer: Tumor Biology and Surgical Results
Define Outcome
Portal Venous Thrombosis After Distal Pancreatectomy:
Risk Factors and Outcomes
Ashwin S. Kamath1, Michael L. Kendrick1, Michael G. Sarr1,
David M. Nagorney1, Robert Mcbane2, Michael B. Farnell1,
Kaye M. Reid Lombardo1, Florencia G. Que1
1
General Surgery, Mayo Clinic, Rochester MN, Rochester, MN;
2
Cardiovascular Diseases, Mayo Clinic, Rochester MN, Rochester, MN
Andreas Andreou1, Luca Viganò2, Giuseppe Zimmitti2,
Martin Dreyer1, Jean-Nicolas Vauthey3, Peter Neuhaus1,
Daniel Seehofer1, Lorenzo Capussotti2, Sven-Christian Schmidt1
1
Department of General, Visceral and Transplant Surgery, Charité
– Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin,
Germany; 2Department of HPB and Digestive Surgery, Ospedale
Mauriziano “Umberto I”, Turin, Italy; 3Surgical Oncology, The
University of Texas MDAnderson Cancer Center, Houston, TX
BACKGROUND: The role of hepatectomy for patients
with liver metastases from gastric and esophageal cancer
(GELM) is not well defined. The present study examined
the morbidity, mortality and long-term survival after liver
resection for GELM.
AIM: Outcomes of patients developing portal vein (PV)
thrombosis (PVT) after distal pancreatectomy (DP) are
unknown. The goal of this study was to identify risk factors for PVT and describe the long term outcomes in these
patients.
METHODS: Patients undergoing DP without repair or
reconstruction of the PV between 2001 and 2011 were
included. Patients that showed evidence of PVT on preoperative imaging were excluded from the study. Location
and extent of thrombosis was determined by postoperative
PATIENTS AND METHODS: Clinicopathological data of
CT or ultrasound imaging in all patients. Evidence of syspatients who underwent hepatectomy for GELM between
temic thrombosis (if present) in addition to PVT was also
1987 and 2012 at two European high-volume hepatobiliary
documented.
centers were assessed and predictors of overall survival were
RESULTS: In the study period, 991 patients underwent DP
identified.
and 21 (2.1%) patients were diagnosed with PVT. Pancreatic
RESULTS: Fourty-six patients underwent liver resection
neoplasm was the most frequent indication for operation
for GELM. The primary tumor was located in the stom(n = 11). Thrombus occurred in the main PV in 15 and the
ach and in distal esophagus in 40 and 6 cases, respectively.
right branch of the PV in 8 patients. Complete PV occlusion
GELM were synchronous to primary tumor in 33 patients
occurred in 9 patients with a median time to diagnosis of
and multiple in 18 patients. In 13 cases, major hepatec16 days (range 5–85 days). Seventeen patients were anticotomy (resection ≥3 liver segments) was performed. Thirtyagulated for a median duration of 6 months (range 3.3–36
day postoperative morbidity and mortality rates were 33%
months) after the diagnosis of PVT. Over a median follow
and 2%, respectively. After a median follow-up time of
up of 22 months, resolution of PVT occurred in 7 patients.
76 months (range 1–135), 1, 3 and 5 year overall survival
Predictors of non-resolution of PVT included anesthesia
rates were 70%, 40% and 27%, respectively. Outcomes
time >180 minutes (p = 0.025), DM type II (p = 0.03), BMI
were comparable between the two centers. At univariate
>30 Kg/m2 (p = 0.03), occlusive PVT (p < 0.001), or thromanalysis, primary tumor invasion of other organs (T4) (P =
bus in a sectoral branch (p = 0.02). Anticoagulation therapy
0.004), poorly differentiated carcinoma (P = 0.006), posidid not influence the frequency of thrombus resolution
tive lymph node metastases, (P = 0.006), the need for blood
and was complicated by gastrointestinal hemorrhage in 4
transfusions at hepatectomy (P = 0.02), major hepatectomy
patients. There was no mortality as a direct result of PVT or
(P = 0.017) and major posthepatectomy complications (P
anticoagulation.
= 0.001) were associated with worse overall survival after
liver resection. Independent risk factors for shorter overall CONCLUSION: PVT after distal pancreatectomy is a rare
survival identified in multivariate analysis included poorly complication. Serious complications as a direct result of
differentiated carcinoma (hazard ratio [HR] = 3.1, 95% con- PVT in this setting are uncommon and are not dependent
fidence interval [CI] = 1.17–8.15, P = 0.022), major hepa- on thrombus resolution. Although anticoagulation does
tectomy (HR = 3.0, 95% CI = 1.22–7.39, P = 0.017) and not appear to influence the rate of PVT resolution in this
major posthepatectomy complications (HR = 4.1, 95% CI = small retrospective series, we support the use of anticoagulation until larger, controlled-studies define clear advan1.31–12.57, P = 0.015).
tages or disadvantages.
CONCLUSIONS: liver resection should be considered in
selected patients with GELM. Patients with poor differentiated tumor and those who require major hepatectomy
because of more advanced disease derive the least benefit
from this approach.
90
Clinical: Pancreas
CONCLUSION: PET is a more sensitive modality for identifying metastatic disease than CT or MRI, however, it has a
lower specificity and lower positive predictive value. While
PET identified an additional 5.6% of patients with occult
metastatic disease, it is likely that unresectability would
have been established at diagnostic laparoscopy, thus not
saving an unnecessary resection. We therefore conclude
that PET has limited utility in workup of patients who
already undergo CT or MRI as part of initial staging of pancreatic adenocarcinoma.
Su1642
Positron Emission Tomography (PET) Has Limited
Utility in Preoperative Staging of Pancreatic
Adenocarcinoma
Peter Einersen1, Irene Epelboym1, Megan Winner1,
David Leung2, John A. Chabot1, John D. Allendorf1
1
Surgery, Columbia University Medical Center, New York, NY;
2
Radiology, Columbia University Medical Center, New York, NY
Su1644
Human Equilibrate Nucleoside Transporter 1
Expression Predicts Survival of Pancreatic Cancer
Patients Trated with Gemcitabine-Based Adjuvant
Chemotherapy After Resection
BACKGROUND: Utility of positron emission tomography
(PET) as an adjunctive imaging modality to CT or MRI in
evaluating resectability of pancreatic cancer is a subject of
controversy. In this study, we seek to assess the utility of PET
in identifying occult metastatic disease, as well as evaluate
predictive value of maximum standard uptake value (SUV)
with respect to tumor resectability and patient survival.
91
Sunday
Poster Abstracts
Toshiyuki Moriya1, Shigemi Fuyama2, Yukinori Kamio1,
Koichiro Ozawa1, Shigeo Hasegawa1, Masaomi Mizutani1,
Takayuki Higashi1, Moriyoshi Yokoyama1, Osamu Usuba1
METHODS: Cross sectional imaging, clinical course, oper- 1
ative outcomes, and overall survival of all patients who pre- 2Surgery, Okitama Public General Hospital, Kawanishi, Japan;
sented with pancreatic adenocarcinoma and had PET scan Pathology, Okitama Public General Hospital, Kawanishi, Japan
in workup were reviewed retrospectively. Resectability was BACKGROUND: Gemcitabine is promising adjuvant cheassessed based on established criteria. Continuous variables motherapy for patients with resected pancreatic cancer.
were compared using Student’s t-test or ANOVA. Categori- Human equilibrative nucleotide transporter-1 (hENT1) is
cal variables were compared using chi-square or Fisher’s the major transporter responsible for gemcitabine uptake
exact test. Prediction models were constructed using linear into cells. The aim of the current study is to investigate
or logistic regression where appropriate.
whether hENT1 expression can predict the survival of panRESULTS: Complete imaging and follow-up data was avail- creatic cancer patients treated with adjuvant gemcitabineable for 123 patients evaluated from 2005 to 2011. Of this based chemotherapy after pancreatic resection.
cohort, 36 patients (29%) were thought to be free of extra- METHODS: Immunohistochemical hENT1 expression was
pancreatic disease and offered resection, 21 (17%) had met- analyzed in 19 resected pancreatic cancer patients received
astatic disease, and 66 (53%) were deemed locally advanced gemcitabine-based adjuvant chemotherapy. Relationand referred for neoadjuvant therapy. PET and CT/MRI were ships between various clinicopathological factors includconcordant in 108 (88%) cases, however metastatic lesions ing hENT1 expression and patient survival were examined
were identified in 7 (5.6%) patients deemed resectable by using univariate and multivariate analysis.
CT or MRI. Among those offered immediate resection, 5
RESULTS: Sixteen (84%) patients highly expressed hENT1.
(14%) patients had occult metastatic disease identified at
Patients with low expression of hENT1 showed significantly
diagnostic laparoscopy, including 3 previously identified by
worth outcome than high expression group [2-year survival:
nonconcordant PETs and 2 missed by false negative PETs.
0% for low expression group vs. 60% for high expression
False positive PETs led to unnecessary procedures delaying
group; HR 8.72, 95% confidence interval (CI) 1.70–44.76, p
surgery for 3 (8.3%) patients who went on to resection. In a
= 0.009] (Figure), although low hENT1 expression was not
cohort of patients thought to be free of metastatic disease,
independent prognostic factor by multivariate analysis (HR
in terms of detecting metastases, overall sensitivity and
4.41, 95% CI 0.71–27.39, p = 0.111). Other prognostic facspecificity of PET were 89.3% and 85.1%, respectively, comtor was only AJCC stage [2-year survival 0% (III, IV) vs. 64%
pared with 62.5% and 93.5% for CT and 61.5% and 100.0%
(I, II), HR 6.24, 95% CI 1.35–28.85, p = 0.0192]. Tumor size,
for MRI. Positive predictive value and negative predictive
lymph node metastasis, and residual tumor (R1 vs R0) did
value of PET were 64.1% and 96.4% respectively, compared
not reach significant prognostic factor, although the trend
with 75.0% and 88.9% for CT and 100.0% and 91.9% for
was observed.
MRI. Average difference in maximum SUV of resectable and
unresectable lesions was not statistically significant (5.65 CONCLUSIONS: Low expression of hENT1 strongly indivs. 6.5, p = 0.224), nor was maximum SUV a statistically cated worth outcome of patients treated with adjuvant
gemcitabine-based chemotherapy after pancreatic resecsignificant predictor of survival (p = 0.18).
tion. Gemcitabine-based adjuvant chemotherapy may be
useful for only high expression of hENT1. The new adjuvant chemotherapy except gemcitabine might be necessary
for patients with low expression of hENT1.
Su1645
The Effect of Preoperative Renal Insufficiency on
Postoperative Outcomes Following Pancreatic
Resection: A Single Institution Experience of 1061
Consecutive Patients
Malcolm H. Squires1, Vishes V. Mehta1, Sarah B. Fisher1,
Neha L. Lad1, David Kooby1, Juan M. Sarmiento2,
Kenneth Cardona1, Maria C. Russell1, Charles A. Staley1,
Shishir K. Maithel1
1
Department of Surgery, Division of Surgical Oncology, Winship
Cancer Institute, Emory University, Atlanta, GA; 2Department of
Surgery, Division of General and GI Surgery, Emory University,
Atlanta, GA
BACKGROUND: Chronic kidney disease (CKD) is known
to adversely affect outcomes after cardiac and vascular surgery. We examined the effect of preoperative renal insufficiency on postoperative outcomes following pancreatic
resection.
METHODS: All patients who underwent pancreatic resection at a single institution between 1/2005 and 7/2012 were
identified. Creatinine clearance (CrCl) was estimated by the
MDRD (Modification of Diet in Renal Disease) formula.
Severe CKD was defined as CrCl < 30 mL/min (CKD stages
4–5). Renal function also was analyzed by using serum creatinine (sCr) dichotomized at 1.8 mg/dL. Primary outcomes
were any complication within 30 days, Clavien Class III-V
major complication, and respiratory failure. Multivariate
(MV) models for each endpoint were constructed by including all variables with a p-value ≤0.1 on univariate (UV)
analysis.
central or total pancreatectomy. The median sCr value was
0.86 (0.30–14.1). 18 patients (1.7%) had severe CKD and 31
patients (2.9%) had sCr ≥ 1.8. Complications occurred in
622 patients (58.6%), major complications in 198 (18.7%),
and respiratory failure in 48 (4.5%). Both severe CKD and
sCr ≥ 1.8 were associated with any complication, major
complications, and respiratory failure on UV analysis. On
MV analysis, severe CKD was associated with increased
complications (HR 5.5; 95% CI: 1.3–25.5; p = 0.02) and
respiratory failure (HR 6.1; 95% CI: 1.8–20.5; p = 0.03),
but not major complications. Using sCr ≥ 1.8 as a surrogate marker for renal insufficiency, patients with sCr ≥ 1.8
had increased risk of any complication (HR 3.5; 95% CI:
1.3–9.3; p = 0.01), major complications (HR 2.2; 95% CI:
1.04–4.8; p = 0.04), and respiratory failure (HR 4.7; 95%
CI: 1.8–12.6; p = 0.002, Table). Among patients undergoing
Whipple, sCr ≥ 1.8 remained associated with any complication (HR 3.6; 95% CI: 1.03–12.9, p = 0.05) and respiratory
failure (HR 3.9; 95% CI: 1.2–12.8; p = 0.03), and demonstrated a trend towards increased major complications (HR
2.3; 95% CI: 0.9–6.0; p = 0.10). Among patients undergoing distal pancreatectomy, sCr ≥ 1.8 demonstrated a trend
towards increased complications (HR 6.8; 95% CI: 0.8–54.6;
p = 0.07), was not prognostic for major complications, but
remained a significant risk factor for respiratory failure (HR
15.4; 95% CI: 2.2–106.3; p = 0.006).
CONCLUSION: Few patients with significant renal insufficiency are operative candidates for pancreatic resection.
Severe CKD (stages 4–5) is associated with increased risk of
complication and respiratory failure, but may be of limited
clinical utility. Serum creatinine ≥1.8 mg/dL may serve as a
useful surrogate marker of renal insufficiency and identifies
patients at significantly increased risk of any complication,
RESULTS: 1061 patients were identified; 709 underwent major complication, and respiratory failure after pancreatic
pancreaticoduodenectomy (Whipple), 307 distal, and 45 resection.
Multivariate Analysis of all Pancreatic Resections (n = 1061)
Any Complications
Variable
sCr 1.8
Age
HR (95% CI)
3.5 (1.3–9.3)
1.01 (1.001–1.02)
p–value
0.01
0.04
Major (Clavien III-V) Complications
Variable
HR (95% CI)
p–value
sCr 1.8
2.2 (1.04–4.8)
0.04
Age
1.01
0.10
(0.99–1.02)
HTN
1.3 (0.9–1.8)
0.17
Intra–op transfusion 1.8 (0.9–3.3
0.07
HTN
1.1 (0.9–1.5)
0.41
Intra-op transfusion
1.8 (0.9–3.4)
0.06
Male gender
1.4 (1.1–1.9)
0.01
Pre-op biliary stent
1.4 (1.1–1.9)
0.01
Intra-op drain placement 1.5 (1.1–1.9)
0.003
HR, hazard ratio; CI, confidence interval; sCr, serum creatinine (in mg/dL); HTN, hypertension.
92
Respiratory Failure
HR (95% CI)
4.7 (1.8–12.6)
1.02
(0.99–1.05)
HTN
1.4 (0.7–2.7)
Intra–op transfusion 2.2 (0.8–6.0)
COPD
2.3 (1.03–5.3)
Albumin <3
2.1 (1.2–3.9)
Variable
sCr 1.8
Age
p–value
0.002
0.17
0.35
0.12
0.04
0.02
Su1647
CONCLUSION: Clinical factors affecting survival were preoperative abdominal pain and hypertension. Intraoperative
factors affecting survival were EBL and the need for blood
transfusions. The only pathological factor affecting survival
was LNR. Finally, an uncomplicated postoperative course
was positively correlated with survival.
Clinicopathologic Features Influencing Survival in
Patients with Resected Pancreatic Adenocarcinoma
by Pancreaticoduodenectomy
Cynthia Weber1, Eileen Bock1, Michael G. Hurtuk1,
Gerard Abood1, Margo Shoup2, Jack Pickleman1,
Gerard V. Aranha1
1
Surgical Oncology, Loyola University Medical Center, Maywood, IL;
2
Surgery, Cadence Health, Winfield, IL
Su1648
A Comparison of the 2-Year Longitudinal Impact of
Surgical Versus Endoscopic Pancreatic Pseudocyst
OBJECTIVE: To determine clinicopathological features Drainage on Healthcare Utilization and Morbidity
that influence survival in patients with resected pancreatic
adenocarcinoma.
93
Sunday
Poster Abstracts
Jennifer M. Whittington, Scott D. Stevens, Daniel L.
Davenport, Austin Ward, Andrew C. Bernard, Shaun P. Mckenzie
METHODS: A retrospective review of a prospective data- University of Kentucky, Lexington, KY
base was conducted for patients undergoing pancreaticoINTRODUCTION: Previous reports have concluded that
duodenectomy for pancreatic adenocarcinoma at a single
endoscopic drainage (endo) of pancreatic pseudocysts has
institution from December 1993 to December 2010. Clinian advantage over surgical cystgastostomy (open) in terms
copathologic features and cancer related outcomes were
of both costs and morbidity. No study to date has looked
collected. The cohort was then analyzed for clinicopatholongitudinally at the overall benefit of these two strategies.
logical features influencing survival at 6 months, 1 year, 3
The purpose of our study was to compare 2-year resource
years, and 5 years.
utilization and morbidity between endo and open treatRESULTS: A total of 246 patients underwent pancreatico- ment of pancreatic pseudocyst.
duodenectomy for pancreatic adenocarcinoma. The cohort
METHODS: This study is a single center retrospective case
was comprised of 128 males (52%) and 118 females (48%),
review of patients treated between September 2004 and
with a median age of 68 years. Median operative time was
December 2011 for pancreatic pseudocyst. We extracted
6.25 hours with a median blood loss of 800 cc. Median hosclinical data from the initial procedure related admission
pital length of stay was 8 days. A total of 7 patients (2.8%)
along with post-procedure emergency department (ED)
required re-operation and 9% of patients were readmitted
visits and hospital readmissions for up to two years. We
within 30 days for postoperative issues. The 30-day mortalcalculated a composite morbidity scale ranging from 1) no
ity rate was 2.4% (n = 6).
intervention to 2) minor intervention (antibiotics), 3) readThere was a total of 101 associated complications in the mission, 4) repeat procedure or ICU care, to 5) death. Fishpostoperative period, with grade 3 or less accounting for er’s exact tests, t tests and Mann-Whitney U tests were used
79% of the observed complications, based on the Dindo/ to compare characteristics between the two groups where
Clavien complication scoring system. In regards to pan- appropriate.
creaticoduodenectomy specific complications, 29 (11.8%)
RESULTS: We identified 45 patients who had undergone
experienced delayed gastric emptying, 17 (6.9%) developed
drainage procedures, 17 endo and 28 open. Three endo
an anastomotic leak, with ISGPF grade A/B accounting for
patients who required conversion to open were classified as
the majority of leaks observed (6%). Overall survival of the
endo by intention to treat. Median follow up for the study
cohort was 85%, 63%, 25%, and 15% at 6 months, 1 year,
was 24 months. The two groups had similar etiologies, age,
3 years, and 5 years respectively, with a median survival of
gender and clinical risks (table). The open group had more
17 months.
multicysts and cysts with debris on imaging, but not sigUsing multivariate logistic regression, clinical factors that nificantly so. There was a trend toward more gastric varices
influenced survival were abdominal pain and preoperative in the endo group (29.4% vs. 7.1%, P = .09) but venous
HTN, where the presence of pain preoperatively negatively thromboses were similar in both groups (58.8% vs. 57.1%).
correlated with survival at 3 years (p = 0.021), and the pres- While initial morbidity was higher in the open group, readence of preoperative hypertension was negatively correlated mission occurred more than twice as often in endo patients
with survival at 6 months, 3 years, and 5 years (p = 0.012, (70.6% vs. 32.1%, P = .02) and total 2-year hospital days
p = 0.013, p = 0.019). Intraoperative estimated blood loss did not differ significantly in the two groups (p = 0.23).
(EBL) showed a negative correlation with survival at 3 years There was a trend towards increased procedural readmis(p = 0.02), and the need for intraoperative blood transfusions in the endo group (p = 0.07). In the open group, two
sion was negatively correlated with survival at 3 years and patients required subsequent repair of ventral hernias and
5 years (p = 0.012 and p = 0.019). The only pathologic fac- one patient required two surgeries for postoperative varitor to have a negative impact on survival was lymph node ceal bleeding. In the endo group three patients required
ratio (LNR), which correlated with decreased survival at repeat percutaneous drainage and one required repeat endo
6 months, 1 year, and 3 years (p = 0.033, p = 0.035, p = drainage in addition to the three conversions to open men0.01). Those who had no postoperative complications had tioned above.
higher odds of being alive at 6 months (p = 0.002)
insufficiency, representing fat absorptive disturbance was
defined as percent of cumulative 7-hour 13CO2 exhalation
(% dose 13C cum 7 h) <5%. Relationship with histological
degree of islet cells at cut margin and postoperative HbA1c
alteration were analyzed. In this study, diabetic patients
were identified as treatment with insulin or oral hypoglycemic medications or HbA1c level ≥ 6.9% (NGSP).
Patient Characteristics, Imaging and Outcomes
Variable
No. Patients
Male/Female
Mean age, y (S.D.)
Current Smoker, Diabetes, COPD
and/or Cardiac History
Etiology
Anatomic
EtOH
Other (HLD/Trauma)
Imaging
Venous Thrombosis
Gastric Varices
Multiple Cysts
Debris in Cysts
Outcomes
Readmitted
Procedural Readmission (s)
ED visit (s)
Total Hospital Days Overall,
mean (S.D.)
Median Morbidity Score
(Interquartile Range)
Endo
17
11/6
47.2 (11.3)
13 (76.5%)
Open
28
20/8
50.3 (13.7)
25 (89.3%)
P-value
8 (47.1%)
8 (47.1%)
1 (5.9%)
14 (50.0%)
11 (39.3%)
3 (10.7%)
10 (58.8%)
5 (29.4%)
2 (11.8%)
8 (47.1%)
16 (57.1%)
2 (7.1%)
9 (32.1%)
18 (64.3%)
1.00
0.09
0.29
0.35
12 (70.6%)
7 (41.2%)
5 (29.4%)
13.6 (18.0)
9 (32.1%)
4 (14.3%)
3 (10.7%)
19.7 (39.7)
0.02
0.07
0.23
0.49
4 (1.5–4)
2 (1–4)
0.24
0.74
0.42
0.40
RESULTS: Preoperatively, 14 patients (35%) were diabetes
and 26 patients (65%) were non-diabetes. In non-diabetes
26 patients, 12 patients (46%) developed impaired glucose
tolerance within one year after DP. 8 patients were administrated oral hypoglycemic medications, one patient needed
insulin treatment and other 3 patients were not administrated any medication. Differences in % dose 13C cum 7
h were not significantly between patients with DP (9.7 ±
3.2%) and healthy controls (13.3 ± 5.9%). No healthy controls had pancreatic exocrine insufficiency if the diagnosis was based on a % dose 13 C cum 7 h less than 5%. In
patients after DP operation, only one patient was 5% %
dose 13 C cum 7 h less than 5%. In the 26 pre-OP non-DM
patients the average percentage of islet cells at cut margin
was significantly lower in the post-OP DM group than in
the post-OP non-DM group (1.5 ± 0.7% vs 3.5 ± 1.5%, P =
0.01). The average area ratio of islet cells at cut margin was
correlated with postoperative HbA1c level (P = 0.025).
1.00
CONCLUSION: Differences of fat absorptive function were
not significant between patients with DP and healthy controls. Perioperative histological degree of islet cells at cut
margin is predictive of glucose metabolism insufficiency
after distal pancreatectomy (DP).
CONCLUSIONS: While endoscopic drainage of pancreatic pseudocysts may result in less initial procedure related
morbidity and length of stay, it is associated with increased
readmissions, increased procedure related admissions due
to treatment failure and does not provide significant benefit
in overall hospital days when compared to surgical drainage. Further studies are necessary to select which patients
are optimal candidates for each approach.
Su1650
Preoperative Prediction of the “High-Risk Pancreas”
by Artificial Neuronal Network Analysis of over 450
Pancreatoduodenectomies
Su1649
Hryhoriy Lapshyn1, Frank Makowiec1, Dirk Bausch1,2,
Ulrich T. Hopt1, Tobias Keck1,2, Ulrich Wellner1,2
1
Clinic for General and Visceral Surgery, University of Freiburg Medical
Center, Freiburg, Germany; 2Surgery, University Hospital of SchleswigHolstein Campus Lübeck, Lübeck, Germany
Histological Degree of Islet Cells at Cut Margin
Indicates Postoperative Glucose Metabolism
Insufficiency After Distal Pancreatectomy
Masahiko Morifuji1,2, Yoshiaki Murakami2, Kenichiro Uemura2,
Takeshi Sudo2, Yasushi Hashimoto2, Taijiro Sueda2, Akio Sakamoto1
1
Internal Medicine, Sanmu Medical Center, Chiba, Japan; 2Surgery,
Hiroshima University, Hiroshima, Japan
INTRODUCTION: Pancreatoduodenectomy (PD) has
become a standard operation with low mortality in highvolume centers, however perioperative morbidity remains
BACKGROUND: Pancreatogenic diabetes after pancre- substantial, mainly due to postoperative pancreatic fistula
atectomy is of growing importance due to the increasing (POPF). Development of preoperative protective measures
life expectancy of pancreatectomized patients. This study is hampered by a lack of strictly preoperative risk stratificaaimed to investigate whether perioperative histological tion. Predictive power of single parameters can be enhanced
degree of islet cells at cut margin are predictive of endocrine by optimally weighed combination of risk factors in an artipancreatic function after distal pancreatectomy (DP).
ficial neuronal network (ANN).
MATERIALS AND METHODS: This study included consecutive 40 patients who underwent distal pancreatectomy
(DP). The percent of islet cells of each pancreas was determined via histological examination of resected specimen at
pancreatic cut margin. Pre and postoperative HbA1c levels
were measured in blood samples to assess postoperative glucose metabolism insufficiency. For assessing post operative
fat absorptive function after DP, non-invasive 13C-mixed
triglyceride breath test (13C-MTG-T), labeled long chain
triglyceride mixture was performed. Pancreatic exocrine
94
METHODS: A panel of clinical and radiological parameters
were assessed retrospectively from patients with pancreatoduodenectomy in our institution and risk factors analysis
for the endpoint POPF (clinically relevant Grade B/C of
ISGPS definition) were identified. Preoperatively available
parameters were used for prediction of a high risk pancreas
in an ANN. Internal validation of the thereby identified risk
group was performed by testing for POPF and other relevant complications.
RESULTS: A total of 471 patients with PD operated from
2001 to 2012 were included. Out of twelve clinical and
radiological risk factors for POPF B/C, the most powerful
was a soft pancreas. When an ANN was trained to predict a
soft high-risk pancreas, correct prediction was achieved in
83% in the test group. Patients predicted to have a highrisk pancreas had a significantly higher rate of POPF and
severe complications compared to the low-risk group (POPF
B/C (38% vs 8%, p = 0.000), intraabdominal abscess (23%
vs 10%, p = 0.000), severe complications (26% vs 13%, p
= 0.003), severe postpancreatectomy hemorrhage (18% vs
6%, p = 0.012)), as well as a five-fold elevated mortality (5%
vs 1%, p = 0.034).
colonization in the surgical drain. In the patients without
bacteria in surgical drain, only 1% of the patients developed CR-POPFs, while 29% of the patients with bacteria in
surgical drain developed CR-POPFs (p < 0.01). Moreover, in
the patients without hyperamylasemia and no bacterial colonization in the surgical drain, no patients developed CRPOPF, while 60% of the patients with CR-POPF had both
hyperamylasemia and bacterial colonization in the surgical
drain (p < 0.01).
Su1651
Su1652
Activation of Pancreatic Enzyme Plus Bacterial
Infection Plays an Important Role in the Pathogenic
Mechanism of Clinically Relevant POPF After
Evolution of the Treatment of Gastroduodenal Artery
Pseudoaneurysms and Mesenteric Arterial Hemorrhage
Following Pancreaticoduodenectomy
CONCLUSION: Bacterial infection in addition to activation of pancreatic enzyme around the pancreatico-enteric
anastomosis might play an important role in the pathogenic mechanism of CR-POPF after PD. Prevention of postCONCLUSION: Clinical and radiological parameters com- operative pancreatitis of remnant pancreas with infection
bined in an ANN model can correctly predict a high-risk pan- control might be an area of focus for reducing the incidence
creas and severe complications already before the operation. of CR-POPF after PD.
Joseph Chen1, Laura Findeiss2, Aram N. Demirjian1,
David K. Imagawa1
1
Surgery, University of California-Irvine, Orange, CA; 2Radiology,
University of California-Irvine, Orange, CA
Kenichiro Uemura, Yoshiaki Murakami, Takeshi Sudo,
Yasushi Hashimoto, Naru Kondo, Naoya Nakagawa,
Hayato Sasaki, Kenjiro Okada, Hiroki Ohge, Taijiro Sueda
Surgery, Hiroshima University, Hiroshima, Japan
PATIENTS/METHODS: This is a retrospective analysis of
313 patients who underwent pancreaticoduodenectomy
from 2003–2012 at our institution, a high-volume, multidisciplinary hepato-pancreato-biliary center. The main outcome measure was mortality.
RESULTS: From 2003–2012, 10 out of 313 patients (3%)
presented with delayed major hemorrhage following pancreaticoduodenectomy, occurring between postoperative
OBJECTIVES: We retrospectively analyzed the possible days 6–18. Visceral arteries known to be affected were the
association of postoperative pancreatitis, bacterial coloni- gastroduodenal artery (GDA) (4), hepatic artery (3), and
zation in the surgical drain, and CR-POPF after PD using the pancreaticoduodenal artery (1). 5 patients presented
prospectively collected data base.
with gastrointestinal hemorrhage and 5 patients presented
METHODS: 250 consecutive patients undergoing PD were with hemoperitoneum. 1 patient underwent immediate
included. All patients were administered prophylactic anti- operative intervention, 2 patients underwent immediate
biotics, which were selected based on perioperative bile cul- operation followed by percutaneous intervention by intertures. POPFs were diagnosed by International Study Group ventional radiology (IR). Immediate IR intervention was
Pancreatic Fistula (ISGPF) criteria. Hyperamylasemia was performed in 7 patients. Mortality from GDA/visceral artedefined as serum amylase more than 3 times the upper limit rial hemorrhage occurred in 1 patient (10%).
of the reference value. Closed suction drains were inserted CONCLUSION: Delayed mesenteric arterial hemorrhage
along the pancreatico-enteric anastomosis, and surgical following pancreaticoduodenectomy requires early recognidrains were examined bacteriologically when they were tion and management. The mortality rate in our early experemoved.
rience with immediate operative intervention was 33%. A
RESULTS: Of 250 patients, 23% developed POPF; Grade modified operative technique led to preservation a long
A in 16%, Grade B in 6%, and Grade C in 1%. A total of GDA stump and use of a large metallic clip as a radiographic
32% of the patients had hyperamylasemia on postopera- marker/guide. This was found to aid in easier and quicker IR
tive day (POD) 1, and the presence of hyperamylasemia localization and coiling or stenting of the bleeding vessel.
on POD1 was closely associated with the development of The mortality rate has decreased to 0% in patients undergoPOPF (p < 0.01). A total of 43% of the patients had bacterial ing immediate IR intervention.
95
Sunday
Poster Abstracts
INTRODUCTION: Postoperative mortality in high volume centers for pancreaticoduodenectomy (Whipple) has
decreased to less than 4%. Late postoperative bleeding
occurs in 0.5–5% of cases, with reported mortality rates of
up to 60%.
BACKGROUND: Postoperative pancreatic fistula (POPF)
after pancreaticoduodenectomy (PD) is relatively common,
and remains a major cause of morbidity and surgical mortality. However, the underlying pathogenic mechanism of
POPF, with the exception of technical error, still remains
unclear. We previously reported that postoperative pancreatitis after PD plays an important role in the pathogenic
mechanism of POPF after PD. We hypothesized that the
bacterial infection in addition to the activation of pancreatic enzyme around the pancreatico-enteric anastomosis
could be associated with occurrence of clinically relevant
POPF (CR-POPF) after PD.
Su1653
Su1655
Trends in Pancreatic Surgery: Indications, Operative
Techniques and Postoperative Outcome of 1120
Pancreatic Resections
Is Frozen Section Histopathology of Any Value in
Patients Undergoing Resection of Intraductal Papillary
Mucinous Neoplasms?
Frank Makowiec, Tobias Keck, Ulrich ADAM, Hartwig Riediger,
Uwe A. Wittel, Ulrich F. Wellner, Ulrich T. Hopt
Department of Surgery, University of Freiburg, Freiburg, Germany
Daniel Joyce, Gavin A. Falk, Kevin M. El-Hayek, Sricharan
Chalikonda, Gareth Morris-Stiff, Matthew Walsh
Department of General Surgery, Section of Surgical Oncology/HPB,
Cleveland Clinic Foundation, Cleveland, OH
Low mortality rates after pancreatic resection (PaRes) have
been reported by many centers. Hospital volume, surgeon volume and adequate management of complications
are factors contributing to a better outcome. The aim of
our study was to evaluate trends in indications, operative
techniques and postoperative outcome in more than 1100
PaRes performed in our institution since 1994.
INTRODUCTION: Intraductal papillary mucinous neoplasms (IPMN) are cystic lesions of the pancreas that follow
a step-wise dysplastic sequence from adenoma to invasive
adenocarcinoma. Obtaining a frozen section (FS) at the time
of pancreatic resection could be important to determine
whether additional resection of the remnant is required.
The aim of this study is to report the correlation between FS
of the pancreatic neck and final histopathology for patients
with IPMN including those with IPMN carcinomas.
METHODS: 1120 PaRes were performed since 1994. The
vast majority of the operations was performed by three
surgeons. The perioperative data were documented in a
pancreatic database. For our analyses the study period was
subclassified into three periods (A 1994–2001/n = 363; B
2001–2006/n = 305; C since 2007/n = 452).
RESULTS: 81% of the PaRes were personally performed by
one of the 3 principal surgeons. The average annual number
of PaRes increased from 52 (period A) to 80 (C; n = 107 in
2011). The median age increased from 51 (A) to 65 years (C;
p < 0.001). In the entire group (n = 1120) indications for surgery were pancreatic/periampullary cancer (49%), chronic
pancreatitis (CP; 33%) and various other lesions (18%). The
percentage of PaRes for CP decreased from over 50% in period
A to 17% (C; p < 0.01). In contrast the frequency of IPMNs
increased from below 1% (A) to 8% (C; p < 0.05). About two
thirds of the operations were pancreaticoduodenectomies
(most PPPD). Due to the lower numbers of operations for CP
the rates of duodenum-preserving resections decreased from
18% (A) to 4% (C; p < 0.05). A more aggressive approach
in some patients with cancer and more resected IPMNs led
to an increase in total pancreatectomies during the study
period from 1% (A) to 6% (C). The frequency of mesentericoportal vein resections increased from 8% (A) to 20% (C; p <
0.01). Distal resections were performed in 17%. Laparoscopic
pancreatic head and distal resections were introduced by one
surgeon in period C and were performed in 4.7% of all cases
(12% of the cases in period C). Overall mortality was 2.4%
and comparable in the 3 periods (2.8%, 2.0%, 2.4%; p = 0.8).
The 3 principal surgeons in our series also had comparable
mortality rates (1.9–3.4%; p = 0.41). Overall complication
rates increased from 42% (A) to 56% (C; p < 0.01). The rate
of pancreatic leak grade B/C also increased from 5% (A) to
12% (C; p < 0.01) but the frequencies of relaparotomies were
comparable (10–14%; n.s.)
METHODS: The departmental pancreatic cyst database
was interrogated to identify all patients with a histopathological diagnosis of IPMN with or without pancreatic adenocarcinoma arising from within the IPMN. The degree
of dysplasia on the final pathology report was classified as
high (HGD), moderate (MGD), or low (LGD. Frozen section
results were reviewed with particular reference to identification of invasive carcinoma or high-grade dysplasia and
these findings were compared to final histopathological
findings, and related to patient outcome.
RESULTS: During the period January 2000 to December
2011, 121 patients underwent resection, consisting of 41
patients with an invasive carcinoma and 80 with IPMN
alone: HGD [n = 18]; MGD [n = 14]; and LGD [n = 48]
(on final pathology). There were 70 females and 51 males
with a median age of 68 years (IQR: 58–73). Of the patients
with IPMN carcinomas, 36 (88%) had a FS. Carcinoma or
HGD was seen at the transaction margin on FS in 4 patients
undergoing pancreatoduodenectomy leading to 4 extended
resections, 2 of which were total pancreatectomies. There
was 1 false-positive for invasive cancer that was found to
be non invasive on final pathology and 1 false-negative for
HGD/invasive carcinoma on frozen section that was found
to be an invasive cancer on final pathology. For those with
IPMN alone, 64 had frozen section analysis performed.
None had carcinoma/HGD at the transection margin on FS
or on subsequent histopathology. 3 patients in this group
died of IPMN-related carcinomas in their remnant pancreas. 2 had HGD on their initial resection and 1 had only
LGD, and all developed the subsequent cancers away from
the transaction margin.
CONCLUSIONS: Frozen section analysis allows identification of foci of carcinoma or HGD at the transection margin
during pancreatic resection for IPMN that should result in
further resection. However, the development of progressive
disease in the pancreatic remnants of patients without initial evidence of carcinoma means that radiological surveillance is required for this cohort.
CONCLUSIONS: Operative mortality in our high-volume
institutional series of more than 1100 pancreatic resections
was low throughout the study period. Mortality remained
low despite a more aggressive surgical approach to (malignant) pancreatic disease (more extended resections, more
vein resections, older patients). An increased overall morbidity may be explained by more clinically relevant pancreatic fistulas (more patients with soft pancreas) and better
documentation (many patients in randomized studies after
period A).
96
Su1656
Su1657
Endoscopic and Surgical Alternatives to
Pancreaticoduodenectomy and Distal Pancreatectomy
Central Pancreatic Resection
Vichin Puri, Vijay G. Menon, Alagappan Annamalai,
Nicholas N. Nissen
Hepatobiliary and Pancreatic Surgery, Cedars-Sinai Medical Center,
Los Angeles, CA
Jennifer K. Plichta, Eileen Bock, Michael G. Hurtuk,
Gerard Abood, Gerard V. Aranha
Surgery Department, Loyola University Medical Center, Maywood, IL
INTRODUCTION: Central pancreatectomy (CP) is an
uncommon technique used to treat select pancreatic
pathology. We evaluated the utility and safety of CP over a
10 year time span at a single institution.
PURPOSE: While standard resections such as pancreaticoduodenectomy and distal pancreatectomy are necessary
for malignant disease, low grade tumors and benign lesions
of the pancreas and duodenum present a unique surgical
dilemma. Select patients may benefit from non-standard
resections (NSR) which preserve parenchyma and function,
and thus may avoid the potential complications inherently
related to more traditional resections. Here, we describe our
experience with NSR of various pancreatic and duodenal
lesions.
METHODS: Review of prospective database (single surgeon) from 2003–2012. CP comprised 9% of all pancreatic
resections during this period (total of 310).
METHODS: A retrospective review of a prospectively collected database of 777 patients who underwent resections
of pancreatic and duodenal lesions between 1999 and
2012 was conducted. Of these, 45 patients underwent NSR,
defined as pancreatic or duodenal resections excluding standard pancreaticoduodenectomy or distal pancreatectomy.
Clinicopathologic features and outcomes were assessed.
RESULTS: In sum, 26 males and 19 females were evaluated;
median age 64 years (range 30–87) and median follow-up
4.4 years (range 0.3–13.3 years). Preoperatively, 32 patients
underwent EGD, 33 EUS, and 39 CT scans. The median
lesion size was 2.3 cm (range 0.7–9 cm). The various types
of NSR included: 16 pancreas-sparing duodenectomies, 9
central pancreatectomies, 9 enucleations, 6 ampullectomies,
4 transduodenal polypectomies, and 1 endoscopic polypectomy. The final pathologic diagnoses included: 12 villous
adenomas, 7 neuroendocrine tumors, 5 mucinous cystadenomas, 5 stromal tumors, 4 duodenal carcinomas, 3 serous
cystadenomas, 3 tubular adenomas, 2 lymphoepithelial
cysts, 2 IPMNs, and 2 other pathologies. EUS was 100%
accurate in predicting depth of mucosal invasion, while
EGD and CT were 100% accurate in identifying the lesion
location. Furthermore, the overall accuracy of pre-operative
imaging in selecting appropriate patients amenable to NSR
was 100%. Overall, five patients developed post-procedure
complications (10.9%). Of the central pancreatectomies (n
= 9), three developed pancreatic fistulas (33%), although no
patients developed diabetes or steatorrhea. One patient had
a subsequent episode of pancreatitis following ampullectomy, and one developed a pancreatic pseudocyst requiring
endoscopic drainage following enucleation. There were no
peri-operative mortalities. Of the four patients with duodenal carcinomas, all underwent pancreas-sparing duodenectomy, and the overall survival was 50% at the time of
analysis (deaths occurred at 1.7 and 4 years; follow-up for
two survivors was 4.1 and 11.7 years).
Central Pancreatectomy Managed with Dual Pancreatic-Enteric
Anastomosis.
CONCLUSION: Based on our findings, EGD, CT, and EUS
were 100% accurate in selecting appropriate patients for
NSR. Therefore, proper selection of patients using certain
imaging modalities may allow some patients to achieve
adequate resection, while avoiding more complicated and
morbid procedures, such as pancreaticoduodenectomy or
distal pancreatectomy.
CONCLUSION: Central pancreatectomy is a safe and valuable option for management of select proximal pancreatic
pathology and is associated with a low rate of long term
endocrine or exocrine insufficiency. Pancreatic fistula and
surgical complication rates are significant but not prohibitive. Novel reconstruction techniques such as those applied
on our series may allow greater application of this technique to more proximal pancreatic lesions.
97
Sunday
Poster Abstracts
RESULTS: Thirty patients underwent CP for diagnoses
including neuroendocrine tumor (n = 12), cystic neoplasm
(n = 9) and benign stricture (n = 9). Distal pancreatic continuity was established by pancreaticogastrostomy (n = 7),
pancreaticojejunostomy (n = 13), dual pancreaticoenterostomy (n = 9) or primary pancreatico-pancreatostomy (n =
1). Major complications were limited to 4 patients (13%)
who required re-laparotomy or percutaneous drainage. Five
patients (17%) developed postoperative pancreatic fistulae, of which 3 (10%) were ISGPF grade B/C. There was no
peri-operative mortality. At mean follow-up of 29 months,
no patients have developed recurrent tumor. Two patients
(7%) developed diabetes and no patient has exocrine insufficiency. The frequency of CP has remained constant over
the study time period, but patients operated in the more
recent 5-year period were more likely to have more proximal pathology (pancreatic head) and to undergo dual pancreatic anastomosis (Figure).
Su1658
Impact of Pancreatoduodenectomy Complications
on Adjuvant Therapy and Long-Term Outcomes for
Pancreatic Adenocarcinoma
Janak A. Parikh, Tarek Ajam, Attila Nakeeb, Nicholas J. Zyromski,
C. Max Schmidt, Eugene P. Ceppa, Henry A. Pitt, Michael G. House
Surgery, Indiana University Hospital, Indianapolis, IN
BACKGROUND: Postoperative morbidity is associated
with poor long-term outcomes for gastrointestinal cancers.
The purpose of this study is to determine the extent to
which postoperative complications after pancreatoduodenectomy for pancreatic adenocarcinoma impact adjuvant
therapy and overall survival.
METHODS: Over a five year period ending December 2009,
310 consecutive pancreatoduodenectomies for adenocarcinoma were performed at a single institution. Retrospective
review of a prospective patient database including data on
patient, operative, and tumor factors along with postoperative Clavien-Dindo (CD) classified complications, receipt of
adjuvant therapy, and survival was performed. Associations
with overall survival (OS), estimated by the Kaplan-Meier
method, were analyzed with log-rank testing.
RESULTS: Patients were predominantly male (57%) and
Caucasian (96%) with a median age at operation of 66
years (36–96 years). Median operative time was 325 minutes and median blood loss was 675 mL. Sixty-three percent
of patients had lymph node metastasis on final pathology.
Thirty-day mortality rate was 3.2%. Major postoperative
morbidity, defined as CD III-IV complications, were recorded
for 40 (13%) patients, while minor complications (CD I-II)
occurred in 155 (50%) of patients. Overall, 64% of patients
received adjuvant chemotherapy or chemoradiotherapy, of
which 5% received neoadjuvant chemoradiotherapy. Adjuvant therapy was administered to 76% of patients with no
postoperative morbidity versus 63% and 42% of patients
with minor or major complications, respectively (p =
0.02). Median OS for the cohort was 18.3 months (0–116
months). Improved median overall and 5-year survival (20
months and 21%, respectively) for patients with no postoperative morbidity was not significantly different to the
survival observed for patients with complications (18.8
months and 18% respectively), p = 0.36 (Figure 1). Median
OS and 5-year survival for patients who received adjuvant
therapy was 21 months and 18%, respectively, versus 15.5
months and 17% for patient who did not receive adjuvant
therapy, p = 0.27 (Figure 2).
98
CONCLUSIONS: Major complications after pancreatoduodenectomy alter plans for adjuvant therapy for pancreatic
adenocarcinoma. Unlike other gastrointestinal cancers,
postoperative morbidity is not associated with poor longterm outcomes for pancreatic adenocarcinoma.
Su1659
Su1660
Impact of Laparoscopic Approach on Postoperative Pain
and Opioid Consumption After Pancreatoduodenectomy
Pre-Operative Lovenox Does Not Increase Blood Loss
During Pancreaticoduodenectomy Compared to
Heparin
Naru Kondo, Michael B. Farnell, Florencia G. Que,
David M. Nagorney, Kaye M. Reid Lombardo, John H. Donohue,
Michael L. Kendrick
Shoichiro A. Tanaka, William C. Conway, Satvik Jhamb,
John S. Bolton
Surgical Oncology, Ochsner Medical Center, New Orleans, LA
BACKGROUND: Although laparoscopic approaches are
generally considered to result in reduced postoperative
pain compared to open approaches, objective evaluation of
amount of opioid consumption has not been evaluated for
pancreaticoduodenectomy.
CONCLUSION: Patients undergoing TLPD have lless opioid
consumption compared to those with the open approach.
Younger age, absence of diabetes, chronic pancreatitis indication and major postoperative complications are independent predictors of increased opioid consumption. These
findings warrant further evaluation as to the potential clinical impact of reduced pain and less opioid consumption
on patient-specific advantages including early recovery and
better quality of life after pancreaticoduodenectomy.
99
Sunday
Poster Abstracts
BACKGROUND: Pancreaticoduodenectomy (PD) is a
lengthy surgical procedure often done for malignancy,
both risk factors for DVT/PE, which also carries a significant
bleeding risk. We sought to determine if bleeding complications were increased with pre-operatively administered
AIM: The aim of this study was to investigate if total laparo- Lovenox, a drug given once daily and shown to have excelscopic pancreaticoduodenectomy (TLPD) results in reduced lent DVT/PE risk reduction, compared with pre-operative
opioid consumption over open pancreaticoduodenectomy Heparin.
(OPD).
METHODS: IRB approved retrospective chart review was
METHODS: A single-institutional retrospective cohort undertaken to collect data on all patients undergoing PD
study of all patients having undergone pancreaticoduode- from 1/1/08–12/31/11. Data points included demographic
nectomy between 2007 and 2010 was performed. Postoper- information, surgical details, and peri-operative outcomes,
ative pain was evaluated by calculating opioid consumption focusing on estimated blood loss (EBL) and blood usage.
from postoperative day (POD) 1 to POD 5. Five forms of DVT/PE prophylaxis consisted of either 5,000units subcunarcotic analgesics were used including: morphine, hydro- taneous Heparin or 40 mg subcutaneous Lovenox given
morphine, oxicodone, hydrocodone and fentanyl. To allow pre-operatively.
comparison, narcotic consumption was converted to mor- RESULTS: The 158 patients undergoing PD had a mean
phine equivalents using a standard conversion. Daily and age of 65 (range 40–85), 52% were men, and 11% received
total opioid consumption after PD was compared between neoadjuvant treatment. 21.5% of the cases included major
the LPD and (OPD) groups. Risk factors for increased total vascular resection, and average BMI was 27.5 (15.2–47). 52%
opioid consumption were evaluated using univariate and (82) of the patients had pancreatic adenocarcinoma, 5% (8)
multivariate analyses.
duodenal adenocarcinoma, and 7% (11) IPMN. There was
RESULTS: Five hundred and twelve consecutive patients no difference in mean EBL between the 92 patients receiv(LPD n = 123, OPD n = 390) were included in this study. ing pre-op Heparin (731 + 525 ml) and the 35 patients
Six patients (5%) with conversion to OPD were included in receiving pre-op Lovenox (794 + 634 ml, p = 0.58). Bleeding
LPD group based on intent-to-treat. Daily opioid consump- complications and overall blood usage were also not signifition of the LPD group was significantly less than that of cantly different between the 2 groups (p > 0.05).
OPD group from POD 2 through POD 5, and total opioid CONCLUSIONS: Pre-operatively administered Lovenox
consumption of LPD group was also significantly less (LPD: was not associated with an increase in EBL during PD
5.3 ± 6.4 mg/kg, OPD: 7.3 ± 9.4 mg/kg, P = 0.007). Multivar- compared with Heparin. Overall blood usage was also not
iate analysis revealed that younger age (<65 years old) (HR increased. This, along with once daily dosing and improved
1.89, 95% CI 1.29–2.79, P = 0.001), no preoperative diabe- efficacy make Lovenox and attractive option for DVT/PE
tes mellitus (HR 1.74, 95% CI 1.10–2.80, P = 0.01), PD for prophylaxis during PD.
chronic pancreatitis (HR 2.87, 95% CI 1.18–7.51, P = 0.02),
OPD (HR 2.01, 95% CI 1.26–3.27, P = 0.003) and postoperative major complication (Grade III-V) (HR 2.30, 95% CI
1.36–3.91, P = 0.001) were independently associated with
increased opioid consumption after PD (total opioid consumption >6 mg/kg).
Clinical: Small Bowel
CONCLUSION: In CD patients undergoing ileocecal resection, male gender, open surgery, a long course of disease,
and low postoperative hemoglobin levels are risk factors
to develop postoperative complications. Other potential
risk factors, such as age, body mass index, low preoperative
protein or albumin levels, the use of steroids or biologicals,
and NOD2 mutations had no effect on the development of
postoperative complications in the patient group analyzed.
Su1661
Risk Factors for Postoperative Complications After
Ileocecal Resection in Patients with Crohn’s Disease
Michael S. Kasparek1, Sophie Zehl1, Mario Mueller1,
Stephan Brand3, Martin E. Kreis2
1
Department of Surgery, Ludwig-Maximilians-University Munich,
Munich, Germany; 2Department of Surgery, Charité, Berlin, Germany;
3
Department of Internal Medicine II, Ludwig-Maximilinas-University
Munich, Munich, Germany
Su1662
The First Validated Nomogram to Predict 30-Day
Mortality Following Surgery for Small Bowel
Obstruction
BACKGROUND: After colorectal resections, patients with
Wissam J. Halabi1, Mehraneh D. Jafari1, Vinh Q. Nguyen2,
inflammatory bowel diseases may develop postoperative
1
, Steven Mills1, Alessio Pigazzi1,
complications. Our aim was to identify specific risk factors Joseph C. Carmichael
1
for postoperative complications in patients who underwent Michael J. Stamos
1
Surgery, University of California-Irvine, Orange, CA; 2Statistics,
ileocecal resection due to Crohn’s disease (CD).
University of California-Irvine, Irvine, CA
METHODS: We identified CD patients who underwent
ileocecal resection in the time period from 2001 to 2010 OBJECTIVE: Surgery for small bowel obstruction (SBO) is
in our hospital’s IBD patient register. Patients’ charts associated with significant mortality and surgeons are being
were reviewed for details regarding the type of surgical increasingly faced with complicated cases that have several
procedure performed, complications related to the sur- risk factors for fatal outcomes. To date, there have been no
gical procedure and the overall peri- and postoperative studies examining the interaction of several risk factors
course of the disease. In addition, all patients were geno- and their additive effect on mortality. Our aim was to contyped for the three main CD-associated NOD2 variants struct a comprehensive and validated model that takes into
p.Arg702Trp (rs2066844), p.Gly908Arg (rs2066847), and account all the factors that predict mortality in patients
undergoing surgery for SBO.
p.Leu1007fsX1008 (rs2066847).
RESULTS: 155 CD patients (54% female, age 35 [15–69]
years (median [range]) were identified who underwent
ileocecal resection. In 63 patients, laparoscopic ileocecal
resection was performed, while 92 patients underwent an
open ileocecal resection. 32 minor complications (wound
infection: n = 17 (11%); prolonged postoperative ileus: n =
10 (6%); urinary tract infection: n = 5 (3%)) and 34 major
complications (intraabdominal abscess formation: n = 15
(10%); anastomotic leak: n = 12 (8%); hemorrhage: n = 5
(3%), enterocutaneous fistula: n = 2 (1%)) occurred in 41
patients (26%), while 114 patients (74%) had an uneventful postoperative course. Open surgery (open surgery in
complicated group: 80% vs. open surgery in uncomplicated
group: 52%; p = 0.002) and male gender (male gender in
complicated group: 63% vs. male gender in uncomplicated
group: 40%; p = 0.018) were associated with postoperative complications. Patients with major complications had
a longer course of CD (8 [0-–31] vs. no complications: 4
[0–30] years; p = 0.024), a lower postoperative hemoglobin level (10.3 ± 0.4 vs. 11.5 ± 0.2 g/dl; mean ± SEM; p
= 0.038), and a trend towards a lower postoperative total
protein level (3.8 ± 0.3 vs. 5.2 ± 0.4; p = 0.051). Other factors such as preoperative laboratory results, age, body mass
index, nicotine consumption, use of steroids or biologicals,
as well as presence of CD-associated NOD2 mutations had
no effect on the incidence of postoperative complications
(all p = n.s.).
DESIGN: Using the ACS-NSQIP database from 2005 to
2010, we conducted a retrospective review of SBO cases
caused by adhesions or incarcerated hernias that underwent operative management. With 30-day mortality as the
primary endpoint, a predictive model was built using 52
presurgical, 8 surgical and 16 postsurgical variables. We
split the data into two sets: training set (75%) and a validation set (25%). The LASSO algorithm for logistic regression
was applied to the training set with 10-fold cross-validation
and the 1-SE rule used to select predictive variables. The
ROC curve and the AUC statistic were used to test our model’s predictive ability.
RESULTS: A total of 17,379 cases of surgical SBO cases were
identified. The cause of SBO was attributed to Adhesions
in 74% of cases whereas incarcerated hernia accounted for
the remaining 26%. The 30-day mortality was 5.7%. LASSO
identified several predictors of mortality listed in the table.
The following factors were not found to predict mortality:
gender, obesity, smoking, diabetes, emergency surgery, surgery day, disease type, and the use of laparoscopy. Thirtyday mortality can be predicted via the following equation:
ex/(1 + ex) where x in the sum of coefficients. The predictive model performed well with a high predictive power
and an AUC = 0.92.
100
Su1663
Predictors of Mortality Following Surgery for SBO: Coefficients and
Odds Ratios
Odds Ratios
0.03
0.02
0.02
0.51
1.03
1.02
1.02
1.66
0.15
0.07
1.64
1.05
0.90
0.71
0.64
0.17
0.11
0.05
1.16
1.07
5.18
2.87
2.47
2.03
1.89
1.18
1.12
1.06
Serum C-Reactive Protein As Predictor of Recurrence in
Patients Undergoing Ileo-Colonic Resection for Crohn’s
Disease: Results of a Longitudinal Prospective Study
5.27
2.27
2.24
2.18
2.12
1.50
1.46
1.32
1.27
1.23
1.19
1.09
1.04
Edoardo Iaculli, Cristina Fiorani, Sara Onali, Giorgia Tema,
Roberto Pezzuto, Livia Biancone, Rosa Scaramuzzo,
Khrystyna Porokhnavets, Achille Gaspari, Giuseppe S. Sica
BACKGROUND: Previous studies have evaluated the ability of biological markers to detect disease relapse in Crohn’s
disease (CD). Yet no studies have targeted a method to
anticipate recurrence after surgical resection. C-Reactive
Protein (CRP) is a valuable marker for predicting the outcome of several diseases including CD. The exact role of
CRP as a prognostic factor for future recurrence in CD is not
yet determined. Moreover no data are available investigating specific CRP modifications in these patients following
surgery.
OBJECTIVE: of present study was to determine the perioperative behaviour of the CRP in CD patients undergoing
elective ileo-cecal resection. Our hypothesis is that perioperative CRP changes are disease-specific and therefore
could detect subset of patient with more aggressive disease.
Secondary objective was to investigate the role of CRP as a
potential early prognostic marker for future recurrence.
METHODS: 52 patients undergoing IC resection for CD
were prospectively enrolled. Serial CRP levels were assessed
perioperatively: time 0, postoperative day (POD) 1 and POD
6. CD patients’ perioperative CRP findings were compared
against same interval assessments of two control groups
undergoing right colectomy and appendicectomy. Crohn’s
Disease Activity Index (CDAI) and Rutgeerts’ score (RS) were
evaluated for recurrence during 3 year follow-up protocol.
CONCLUSION: This is to date the most powerful and the
only validated nomogram to predict 30-day mortality following surgery for SBO. This model represents an easy-touse tool for surgeons to risk-stratify and counsel patients
and can be used as a quality outcome measure. Implementing strategies to modify certain risk factors may lower mortality in surgical SBO cases.
RESULTS: As expected, in all 3 groups CRP significantly
increased 24 hours after surgery vs baseline but the increase
was significantly higher in CD patients than in controls
(p < 0.001). Comparing to control groups CRP remained
remarkably high in CD (mean 32.2 mg/L) at POD 6. Difference between groups was statistical significant (p 0.03).
All CD patients evaluated at 3 year follow up were in clinical remission. Endoscopic recurrence (RS > 2) was found
in 51% at 1 year and in 42% at 3 years. Possible relation
between endoscopic recurrence rate or severity and perioperative CRP levels was investigated: multivariate ordinal
regression showed that postoperative increment of CRP is a
prognostic factor of recurrence at 3 years.
CONCLUSION: Present preliminary data show diseasespecific perioperative CRP levels for CD patients that reflect
immunomodulation impairment involved in disease etiology. The degree of such immunitary change and consequent severity of disease might be explored early after
surgery by determining CRP alterations. Data from larger
series can confirm that perioperative CRP levels might be
considered a novel prognostic factors of surgical recurrence.
101
Sunday
Poster Abstracts
Intercept
Preoperative Factors: ASA V
ASA IV
Disseminated cancer
Ventilator dependence
Septic shock
Dialysis dependence
Sepsis
Peripheral vascular disease
BUN > 40
Ascites
COPD
Weight loss > 10%
Age (absolute number
multiplied by coefficient)
Pneumonia
Creatinine > 1.2
Hematocrit > 38
Operative Factors: Bowel
Gangrene
Bowel Resection
Contaminated Case
Postoperative Factors: Shock
CVA
Acute Renal Failure
Re-Intubation
Myocardial Infarction
Bleeding
Return to OR
Failure to wean
Coefficients can be added together
Coefficient
–6.30
1.66
0.82
0.80
0.78
0.75
0.40
0.38
0.28
0.24
0.21
0.18
0.08
0.04
Su1664
Su1665
Predictors of Recurrence and Post Recurrence Survival
in Patients with Resected Ampullary Adenocarcinoma
Adenomas of the Ampulla of Vater: A Comparison of
Outcomes of Operative and Endoscopic Resections
Irene Epelboym1, Susan Hsiao2, James A. Lee1, Beth Schrope1,
John A. Chabot1, Helen Remotti2, John D. Allendorf1
1
Surgery, Columbia University Medical Center, New York, NY;
2
Pathology, Columbia University Medical Center, New York, NY
Edwin O. Onkendi1, Jordan Rosedahl2, William S. Harmsen2,
Florencia G. Que1
1
Surgery, Mayo Clinic, Rochester, MN, Rochester, MN; 2Biomedical
Statistics and Informatics, Mayo Clinic, Rochester, MN, Rochester, MN
BACKGROUND: Ampullary neoplasms are a rare subset of
intestinal cancers, the only treatment for which is complete
surgical resection. Controversy exists, however, with regard
to need for and type of adjuvant therapy. The management
approach is even less clear for those patients in whom the disease recurs. In this report, we aim to determine patient and
histological factors predictive of recurrence, and to describe
the survival experience of those with recurrent disease.
BACKGROUND: Data comparing operative and endoscopic resection of adenomas of the ampulla of Vater is
limited. We reviewed our experience in the treatment of
adenomas of the ampulla of Vater and compared the operative and endoscopic approaches.
Continuous variables were compared using Student’s t-test.
Categorical variables were compared using chi-square or
Fisher’s exact test. Predictors of recurrence were analyzed
using logistic regression. Survival was evaluated using
Kaplan-Meier method, and differences among groups were
assessed by log-rank test.
more common in the operative resection group (p < 0.01)).
Endoscopic resection was performed in 100 (73%) patients;
operative resection was performed in 37 (27%). Sixty seven
percent of patients required only 1 endoscopic resection
[piecemeal resection in 24 (36%)], while 33 (24%) required
2 or more resections (range 2–5). Patients who underwent
operative resection often had larger tumors >3.6 cm (p <
0.001) or intraductal extension (p = 0.04). Intraductal
extension and ulceration had no effect on recurrence (p
values = 0.62, 1.0) in both groups. Postoperative complications occurred in 48% of patients; post-endoscopic complications in 30% of patients (p = .09). Post endoscopic
resection complications included bleeding in 18 (7 required
transfusion or endoscopic or angiographic intervention);
pancreatitis (mild in 11; severe necrotizing in 1); ampullary obstruction from edema or blood clot in 2 and duodenal perforation in 1. Postoperative complications included
pancreatic leak (9), surgical site infection (4), anastomotic
leak (3), delayed gastric emptying (2), myocardial ischemia
or dysrhythmia (2), and renal failure (1). One patient died
of pancreatic leak with MOSF following operative resection
of a 6 cm sessile adenoma (mortality of 2%). Endoscopic
resection was associated with a 3-fold higher risk of recurrences than operative resection, 5% of which were invasive
cancers in both groups. Performing 2 or more endoscopic
resections for complete tumor removal relative to 1 complete initial resection was associated with 5 times higher
risk of recurrence (p < 0.001).
METHODS: Retrospective review of all patients in the gastrointestinal endoscopy and surgical databases treated for
adenomas of ampulla of Vater at our institution from 1992
METHODS: Patients who underwent surgical resection for to 2009. Clinicopathologic factors, morbidity, mortality,
ampullary adenocarcinoma at our institution were identi- recurrence and survival of patients treated by endoscopic
fied, and histological diagnosis was confirmed by inde- and surgical resection were comparatively analyzed.
pendent pathologist review. Presenting features, operative RESULTS: A total of 137 patients (mean age 59.3 yrs),
characteristics, postoperative outcomes, and overall and were treated for adenomas of the ampulla of Vater; 75
disease free survival were evaluated. Selected resection spec- (55%) males, follow up 91% (mean 4.6 years). The adenoimens were stained for presence of CK7, CK20, and CDX2 mas were tubular in 55 (40%) patients, tubulovillous in 62
using standard methods.
(45%) and villous in 20 (15%). Obstructive jaundice was
RESULTS: Between 1990 and 2011, 79 patients underwent
pancreaticoduodenectomy for ampullary adenocarcinoma.
Thirty patients received adjuvant chemotherapy, which was
gemcitabine based for 29 (96.6%). Among 74 R0 resections,
there were 24 cases of recurrence over 273 person-years
(median follow-up 28.7 months, median time to recurrence
8.7 months). Four (16.7%) were in the surgical bed and 20
(83.3%) distantly, predominantly in the liver. In univariable
analysis, no single demographic or clinical characteristic,
nor histologic staining pattern, was a statistically significant predictor of recurrence. Lymph node positivity was
significant in univariable but not in multivariable analysis,
and pathologic T stage was unassociated with recurrence.
Recurrent disease was managed by surgical resection in 2
cases, one local and one metastatic, after which the patients
survived 15.8 and 3.4 months, respectively. Fifteen patients
received chemotherapy (either 5FU or gemcitabine based)
only. Systemic therapy was not offered to 2 patients. Postrecurrence survival was not significantly different among
those who had surgery, chemotherapy, or no treatment (8.8
vs 8.0 vs 3.9 months, p = 0.39). Additionally, among those
who received chemotherapy, difference in median postrecurrence survival was not statistically significant in 5FU CONCLUSION: Endoscopic resection of adenomas of
compared with gemcitabine groups (16 vs 3.5 months, p = ampulla of Vater is associated with a 3-fold higher recur0.107).
rence rate than operative resection; recurrences may be
CONCLUSIONS: Optimal treatment approach for recur- invasive. There is a 5-fold higher risk of recurrence if 2 or
rent ampullary adenocarcinoma remains unclear. Survival more endoscopic resections are needed for complete tumor
is equivalent whether surgical resection or systemic chemo- removal as compared to one complete initial resection.
therapy is employed, and no single cytotoxic protocol is Operative resection is associated with lower recurrence rates
for larger tumors and tumors with intraductal extension.
associated with improved outcome.
102
Su1666
Clinical Outcomes for Neuroendocrine Tumors of the
Duodenum and Ampulla of Vater: A Population-Based
Study
Reese W. Randle, Shuja Ahmed, Naeem A. Newman,
Clancy J. Clark
General Surgery, Wake Forest Baptist Health, Winston Salem, NC
BACKGROUND: Neuroendocrine tumors (NETs) of the
duodenum are quite rare representing only 4% of all carcinoid tumors. Limited single-institution case series indicated that ampullary NETs have worse survival than NETs
located in the duodenum. The aim of the current study was
to evaluate the overall survival (OS) of patients with ampullary NETs compared to patients with duodenal NETs using a
population based registry.
METHODS: We conducted a retrospective comparative
cohort study using the Surveillance, Epidemiology, and End
Results (SEER) registry from 1988 to 2009. Patients with
pathology confirmed NETs of the duodenum and ampulla
of Vater were identified, and overall survival was evaluated
using Kaplan-Meier estimates and Cox proportional hazard
regression. Multi-variable survival analyses included covariates with p < 0.1 and less than 10% of data missing.
CONCLUSIONS: NETs of the ampulla of Vater are more
advanced at presentation and have worse OS than duodenal NETs. After controlling for significant predictors of OS,
tumor location remained an independent predictor of OS
in resected patients.
Laparoscopic vs. Open Bilateral Inguinal Hernia Repair:
A NSQIP Analysis
Karen E. Gibbs
OBJECTIVES: Laparoscopic inguinal herniorrhaphy was
introduced into surgical practice in 1990. It has shown a
great deal of promise and was shown to allow quicker and
more thorough assessment and repair of bilateral groin
hernias. However the evolution of tension-free open repair
with mesh allows use of local or regional anesthesia and is
associated with rapid recovery and a low recurrence rate. We
sought to compare a large number of patients and compare
national trends and outcomes between these approaches.
METHODS: The NSQIP database was queried for laparoscopic or open bilateral inguinal hernia repair. Age, gender
and comorbidities were quantified and outcomes data collected. Specifically, morbidity, mortality, length of stay and
operative times were examined. Statistical analysis was then
performed. A p-value of <0.05 was considered significant.
RESULTS: A total of 4985 patients were identified, of
which 2025 patients underwent open repair of bilateral
inguinal hernia and 2960 patients underwent laparoscopic
repair.
CONCLUSIONS: Nationally, 59.4% of bilateral hernias
were repaired laparoscopically. More patients with diabetes,
HTN and history of CABG underwent open repair. Laparoscopic and open approaches have a similar complication
profile. Operative time was shorter in the laparoscopic
group (75.9 ± 35 vs. 85.2 ± 38.3 min, p < 0.001) as was
length of stay (0.18 ± 1.1 vs. 0.409 ± 3.0 days, p < 0.001).
103
Sunday
Poster Abstracts
RESULTS: The study cohort included 1360 (92%) patients
with duodenal NETs and 120 (8%) with ampullary NETs.
Ampullary NETs were larger (median tumor size 18 vs. 10
mm, p < 0.001), higher grade (poorly and undifferentiated
tumor 42% vs. 12%, p < 0.001), and higher SEER historic
stage (distant metastasis 18% vs. 9%, p < 0.001) than duodenal NETs. Ampullary NETs were also more likely to be
resected (78% vs. 60%, p < 0.001). OS was significantly
worse for patients with ampullary NETs than for patients
with duodenal NETs (median OS 98 vs. 143 months; HR
1.38, 95% CI 1.02–1.86, p = 0.037). For resected patients
(n = 878), OS was similar between ampullary and duodenal NETs (median OS 182 vs. 164 months; HR 1.42, 95%
CI 0.96–2.09, p = 0.078). Using univariate survival analyses, significant predictors for worse OS in resected patients
included older age (p < 0.001), larger tumor size (p = 0.035),
higher grade (p < 0.001), higher SEER historic stage (p <
0.001), and radiation treatment (p = 0.003). After adjusting for significant predictors of OS, ampullary NETs had significantly worse OS than duodenal NETs (HR 1.63, 95% CI
1.05–2.53, p = 0.031).
Su1667
neoadjuvant therapeutic concepts (QCGC’07/09) and compared to former data obtained in a study with similar design
(EGGCS’02) but no neoadjuvant treatment arm.
Table 1: Patient Comorbidites
Male gender
Diabetes on oral
Diabetes on Insulin
HTN
CHF in 30 days
History of MI in 6 months
Prior PCI
Prior CABG
PAD
ESRD
Smoker
Bleeding disorder
ASA III or above
Open Repair
N = 2025
1877 (92.7%)
96 (4.7%)
23 (1.1%)
742 (36.6)
2 (0.1%)
1 (0%)
117 (5.8%)
123 (6.1%)
13 (0.6%)
10 (0.5%)
409 (20.2%)
46 (2.3%)
25 (1.2%)
Laparoscopic
Repair N = 2960
2825 (95.4%)
101 (3.4%)
20 (0.7%)
834 (28.2%)
2 (0.1%)
2 (0.1%)
109 (3.7%)
105 (3.5%)
12 (0.4%)
9 (0.3%)
566 (19.1%)
34 (1.1%)
14 (0.5%)
P-Value
<.001
0.013
0.013
<0.001
1
1
.001
<.001
0.308
0.350
0.363
.003
.005
RESULTS: From 01/01/2007–12/31/2009, 2,897 patients
from 141 hospitals were enrolled in the study with the
following rates (QCGC’07/09 [EGGCS’02: n = 1,139
patients]): Resection (91.2 [87.1]%), gastrectomy (74.5
[79.8]%), R0-resection (82.8 [82.3]%) explorative laparotomy (4.9 [6.3]%), UICC-III/IV (45.2 [41.8]%), hospital
lethality (6.0 [8.3]%) & esophagojejunal anastomotic insufficiency (6.0 [5.8]%).
• After inauguration of multimodal procedures (n = 498;
18%)
— the proportion of patients with no or only palliative surgical intervention decreased considerably—
palliative rate (no R0-resection, i.e., palliative or no
operation: In 2002 [40%] vs. 2007–2009 [24.5%]);
— hospital lethality (overall, 6%/with neoadjuvant
chemotherapy, 3.4%) and peri- & postoperative
morbidity did not increase;
Table 2: Patient Outcome and Complications
Superficial SSI
Deep incisional SSI
Pneumonia
PE
Return to OR
ARF
UTI
MI
DVT
Operative time (min)
Length of stay (days)
Mortality
Open Repair
N = 2025
8 (0.4%)
1 (0%)
4 (0.2%)
1 (0%)
1 (0%)
19 (0.9%)
0 (0%)
6 (0.3%)
0
3 (0.1%)
85.2 ± 38.3
0.409 ± 3.0
2 (0.1%)
Laparoscopic
Repair
N = 2960
8 (0.4%)
0
3 (0.1%)
2 (0.1%)
2 (0.1%)
24 (0.8%)
2 (0.1%)
9 (0.3%)
1
3 (0.1%)
75.9 ± 35
0.18 ± 1.1
0 (0%)
—
P-Value
1
0.406
0.452
1
1
0.643
0.517
1
1
0.135
<0.001
<0.001
0.165
4.4% (n = 23/521) of patients with neoadjuvant
treatment could not be resected.
• There were no changes of the distribution of tumor sites
and stages (according to UICC classification), in particular, no reduction of advanced tumor stages.
• Gastrectomy rate decreased from 79.8 to 74.5%—the
supposed reduction of radicality at the primary tumor
lesion was associated with an extension of lymphadenectomy compared with 2002–D1: 11.9% (n = 245/2,052
resected patients with curative intention); D2: 79.5%;
D3/4: 5.7/2.8%.
• Two trends continued: Predominating esophagojejunal
stapler anastomosis, 96% (pouch: Approx. 20%).
• A hospital-volume effect could not be observed.
• A postoperative adjuvant chemotherapy (only patients
without neoadjuvant treatment) received 15.8% of the
patients (n = 327).
Clinical: Stomach
• The 5-year survival rate of the whole patient group
(including curative & palliative intention) increased
from 40.0% up to 48.5% but, in particular, in stage II–in
stage IV: Increase from 3.5 to 11.3%).
8Su1668
Outcome of the Surgical Treatment of Gastric Cancer
After Inauguration of the Neoadjuvant Concept
Using a Systematic Multicenter Prospective Clinical
Observational Study
CONCLUSION: After inauguration of multimodal concepts, there was an effective improval of the overall survival
without increased perioperative risk in the daily clinical care
of gastric cancer; however, patients undergoing endoscopic
tumor ablation & exclusively palliative chemotherapy were
not included.
Frank Meyer1, Karsten Ridwelski2, Lutz Meyer3, Henry Ptok4,
Ingo Gastinger4, Hans Lippert1
1
Department of Surgery, University Hospital, Magdeburg, Germany;
2
Department of Surgery, Municipal Hospital, Magdeburg, Germany;
3
Department of Surgery, Municipal Hospital, Plauen, Germany;
4
Department of Surgery, Municipal Hospital, Cottbus, Germany
AIM & Methods: By means of a systematic multicenter
prospective observational study, quality of surgical care for
a representative group of patients with gastric cancer in
daily clinical practice was investigated after inauguration of
104
8Su1669
10, 15, 20, 30, 40, 50, 60, 75, 90, 105, 120, 135, 150, 165,
180 minutes after meal. 13CO2 content was measured by
The Tolerance to Volume Load, But Not the Reservoir or infrared spectrophotometry. Wagner-Nelson analysis was
performed on measured data. The reservoir and emptying
Emptying Capacity, Reflects the Patients’ Living States
capacity of the remnant stomach were calculated as retenAfter Gastrectomy
tion rate at 5 minutes after meal (RR5) and half emptying
Koji Nakada, Masahiko Kawamura, Hideo Konishi, Taizo Iwasaki,
time (T1/2), respectively. For drink test, mineral water (10
Keishiro Murakami, Fumiaki Yano, Kazuto Tsuboi,
ml/kg) was ingested for 5 min at equal rate. The severity
Yoshio Ishibashi, Norio Mitsumori, Nobuyoshi N. Hanyu,
and the duration of abdominal symptoms caused by DT
Hideyuki Kashiwagi, Noburo Omura, Katsuhiko Yanaga
was scored 0 (none) to 3 (severe) and 0 (none) to 4 (more
Surgery, The Jikei University School of Medicine, Tokyo, Japan
than 30 minutes), respectively. The tolerance to volume
Upper gastrointestinal tract has various physiological roles, load was assessed by DT total score (the sum of both seversuch as, the capacity to store or empty the ingested food by ity and duration scores). The questionnaire was performed
the stomach, and the tolerance to volume load to receive a to examine the ingested amount of food per meal, the frecertain amount of food by the upper gastrointestinal tract quency of daily meals, the change in body weight and the
as a whole. The gastric surgery may alter these physiologi- restriction to daily life.
cal properties, and then, could impair the patient’s living The multivariable analysis was performed to explore the
states. However, the information about this concern is effect of physiological properties on patients’ living states
limited.
after gastrectomy.
AIM: To study the effect of physiological properties of the RESULTS: (Table 1) The reservoir and emptying capacupper gastrointestinal tract on patients’ living states after ity of the remnant stomach had no effect on patients’
gastrectomy.
living states. The impairment in the tolerance to volume
METHODS: 13C-acetate breath test (13-BT), drink test load (higher scores) resulted in reduced meal amount and
(DT) and the questionnaire had performed in the patients restricted daily life. The frequency of daily meal was higher
[n = 53] who received conventional gastrectomy (total in the patients with total gastrectomy.
with Roux-en-Y [TG; n = 17], distal with Billroth-I [n = CONCLUSION: The tolerance to volume load by DT, but
17], distal with Roux-en-Y [n = 19]). For 13-BT, liquid meal not the reservoir or emptying capacity by 13C-BT, reflected
(200kcal/200 ml) mixed with 100 mg of 13C-acetate sodium the patients’ living states after gastrectomy.
salt was given. Breath samples were collected before and 5,
Table 1: The Effect of Physiological Properties on Patients’ Living States After Gastrectomy
T1/2 (min)
DT tolal score
Type of gastrectomy [TG]
R2
* p < 0.05
Frequency of Daily Meals
p-Value
—
NS
Change in Body Weight
p-Value
—
NS
Restriction to Daily Life
OR (95% CI)
p-Value
—
NS
—
NS
—
NS
—
NS
—
NS
–0.436
0.0012*
–
NS
–0.269
0.0561
1.48 (1.09–2.01)
0.0128*
NS
0.395
0.0062*
–0.274
0.0671
—
NS
—
0.294
0.260
105
0.168
0.144
Sunday
Poster Abstracts
RR5 (%)
Ingested Amount of Food
p-Value
—
NS
8Su1670
Su1671
Predictors of Cardiopulmonary Complications
Following Bariatric Surgery
Long Term Recurrence and Survival Rates in
Gastrointestinal Stromal Tumours (GISTs) Treated
by Minimally Invasive Surgery
Chris S. Crowe, Trit Garg, Natalia Leva, Homero Rivas,
John M. Morton
Surgery, Stanford University, Stanford, CA
Evangelos S. Photi1, Helen Stubbings2, Laszlo Igali3,
Edward Cheong3, Allan Clark1, Michael P. Lewis3
1
INTRODUCTION: Bariatric surgery provides effective and Medicine, Norwich Medical School, Norwich, United Kingdom;
2
enduring weight loss as well as resolution of comorbid dis- Oncology Department, Norfolk and Norwich University Hospital,
ease. Many bariatric patients suffer from cardiopulmonary Norwich, United Kingdom; 3Oesophagogastric Cancer Centre, Norfolk
conditions prior to surgery and receive relief from these and Norwich University Hospital, Norwich, United Kingdom
comorbidities following surgery. However; little is known INTRODUCTION: Gastrointestinal Stromal Tumours
about what predicts cardiopulmonary complications in (GISTs) are the most frequently occurring sarcoma of the GI
these already at risk patients. This study analyzes risk fac- tract. Current treatment usually involves resection of the
tors for cardiopulmonary complication for bariatric surgery. tumour with consideration of adjuvant imatinib, dependMETHODS: Over a 10-year period at a single academic institution, 1634 patients underwent one of three procedures:
Roux-en-Y gastric bypass, sleeve gastrectomy, or adjustable
gastric banding. Complications were analyzed during a
90-day post-operative window. Cardiopulmonary complications included DVT/PE, myocardial infarction, arrhythmia, and cerebrovascular accident. Non-cardiopulmonary
complications included anastomotic leak/intra-abdominal
abscess, bowel obstruction, pneumonia, bleeding, and
ulcer/stricture. Pre-op biochemical cardiac risk values,
demographics, and anthropometric features were collected
prospectively Pre-op biochemical risk factors were matched
to post-operative values to calculate percent change. Continuous variables were analyzed by student t-test. P-values
≤ 0.05 were considered significant. All analyses were performed using Stata/SE statistica software, release 12.
ing on the risk of recurrence. Complete R0 resection is an
important aspect of surgery though the surgical or pathological margin required is unclear. Laparoscopic resection is
used increasingly for these tumours. We aimed to examine
the risk of recurrence, both local and metastatic, after laparoscopic resection with a macroscopic 10 mm margin. Risk
of relapse can be estimated based on Miettinen and Lasota
criteria and this can also be used to guide frequency of clinical follow-up and imaging.
METHODS: From the upper GI tumour database we identified primary non-metastatic GISTs of the upper GI tract
treated by laparoscopic local resection. Cases were then
graded for risk of progression based on histopathological
findings using criteria such as tumour size, location within
the GI tract and number of mitoses. This produced 5 risk
groups: high, moderate, low, very low and no risk of proRESULTS: Of 12 preoperative characteristics included in gressive disease. Time to event was then calculated for each
the regression model, HDL ≤ 40 (OR 2.40, 95% CI (1.11– patient, the event being either death due to GIST, GIST
5.19)), high-sensitivity C-reactive protein ≥ 11 (OR 2.22, recurrence (as evidenced on follow up CT abdomen/pelvis),
95% CI (1.05–4.67)), Age ≥ 50 (OR 2.72, 95% CI (1.31– or being recurrence free up to the end of the study.
5.63)), and BMI ≥ 50 (OR 2.31, 95% CI (1.12–4.76)) were RESULTS: A total of 90 patients with primary upper gastrofound to be significant predictors of cardiopulmonary intestinal GISTs were identified from March 2000 to October
complication. Furthermore, these features were not found 2012. The site of occurrence was gastric in 77 cases, small
to be significant predictors of non-cardiopulmonary com- bowel in 11 cases, duodenal in 1 case and oesophageal in 1
plication. At 12 months after surgery, those experiencing a case. Patients underwent surgical resection via a laparoscopic
cardiopulmonary complication had a 9% improvement in approach where possible with a standard local resection marHDL compared to 23% improvements in those experienc- gin of 10 mm (R0). Follow up was for a mean of 4.5 years.
ing a non-cardiopulmonary complication or no complication at all. Individual t-tests comparing cardiopulmonary Three patients in the high risk group who died of disease
complication to non-cardiopulmonary complication and developed distant metastases (two patients with liver and
no complication were all significant. A logistic regression one with peritoneal disease). Two other patients in the
was used to show that incidence of a cardiopulmonary same group developed recurrence (one patient with liver
complication, baseline HDL ≤40, age ≥ 50, and BMI ≥ 50 are and one with ileum/bladder metastases) but remain alive.
all individual predictors for a negative percent change in One patient in the moderate risk group died of omental
metastases. Two other patients developed liver metastases,
HDL at 12 months.
one of whom died of thyroid cancer whilst on imatinib
CONCLUSION: HDL, hs-C-reactive protein, age, and BMI therapy and the other remains alive on imatinib therapy
were all found to be significant predictors of cardiopulmonary complication. HDL, which is cardio-protective, The low and very low risk groups had a 10 year progression
showed reduced post-op improvement in patients with car- free survival of 100% with no incidences of GIST related
diopulmonary complications at 1 year. This study clearly death.
identifies factors that influence a patient’s risk of cardiopulmonary complication after bariatric surgery.
106
predictors of LN metastasis. Tumor size, site, degree of differentiation, and perineural invasion status did not predict
LN metastasis. The presence of LVI was the only factor that
significantly predicted LN metastasis on multivariate analysis, as well as a significantly worse 5-year disease-specific
survival. T1a tumors without LVI had a 4.3% rate of positive LN, whereas T1b tumors with LVI had a 64.3% rate of
positive LN.
GIST Related Deaths and Recurrences for Each Risk Group
Risk Group
High
Moderate
Low
Very low
No risk
Number
11
11
31
32
5
Number of GIST
Related Deaths
3
1
0
0
0
Number of GIST
Recurrences
2
2
0
0
0
CONCLUSIONS: T1 gastric cancers limited to the mucosa,
without evidence of LVI, and N0 on EUS can be safely
considered for limited resection. However, given an unacceptably high incidence of LN metastasis, any T1 gastric
cancer with submucosal invasion, LVI, or N + by EUS should
undergo radical resection with lymphadenectomy.
Su1674
Laparoscopic Sleeve Gastrectomy as a Revision from
Laparoscopic Adjustable Gastric Band: One Year Results
Melissa Bagloo, Beth Schrope
Surgery, Columbia University, New York, NY
CONCLUSION: A 10 mm surgical margin results in no
local recurrence at up to 10 years. The low distant recurrence rate suggests that these tumours can safely be treated
laparoscopically with an R0 resection using a surgical margin of 10 mm. Distant recurrence is relatively low even in
the high risk group for such tumours.
Su1672
Rima Ahmad1, Benjamin H. Schmidt1, Nicole J. Look Hong1,
Jonathan D. Schoenfeld2, Jennifer Y. Wo2, Eunice L. Kwak3,
Lawrence S. Blaszkowsky3, David P. Ryan3, Ted Hong2,
David W. Rattner1, John T. Mullen1
1
Surgery, Massachusetts General Hospital, Boston, MA; 2Radiation
Oncology, Massachusetts General Hospital, Boston, MA; 3Medical
Oncology, Massachusetts General Hospital, Boston, MA
METHODS: A prospectively maintained clinical database
was reviewed retrospectively. Data were reviewed for the
period August 2010 to August 2012. Data collected included
indication for revision, and degree of weight reduction.
Indications for revision included slipped LAGB, epigastric
pain, dysphagia, GERD, emesis, and weight loss failure or
weight regain. All candidates met NIH criteria for bariatric surgery. Patients underwent laparoscopic gastric band
removal and conversion to sleeve gastrectomy either in one
or two stages. Operative technique was similar in all cases.
BACKGROUND: The application of endoscopic and local
resections for early gastric cancers is limited by the presence of regional lymph node (LN) metastases. We sought to RESULTS: Twenty patients (17 female, 3 male) underwent
determine the incidence and predictors of LN metastases in revision from LAGB to LSG between August 2010 to August
2012 by two surgeons (MB and BS). A one-stage procedure
patients with early gastric cancer.
was done in 14 patients (70%), while two-stage procedure
METHODS: A total of 71 patients with pT1 gastric adewas done in 6 patients (30%). Mean preoperative weight
nocarcinoma underwent radical surgery without neoadjuand BMI before the original LAGB placement were 281.7
vant therapy at our institution between 1995 and 2011.
(220–373) lb and 46.70 (39.01–56.57) kg/m2, respectively.
Preoperative endoscopic ultrasound (EUS) staging was perMean weight, BMI and % excess weight loss (% EWL) at
formed on 17 patients. Clinicopathologic factors predicting
the nadir of the LAGB were 220.77 (156–322) lb, 37.33
regional LN metastases were analyzed.
(30.63–51.75) kg/m2, and 43.55% (13.95–66.60) respecRESULTS: LN metastases were present in 2 of 28 (7.1%) tively. The average interval between LAGB placement and
T1a tumors and 14 of 43 (32.6%) T1b tumors, for an over- LSG was 4.79 (1.74–7.71) years. Mean preoperative weight
all rate of nodal positivity of 23%. The median number of and BMI before conversion to LSG were 261.3 (197–360) lb
examined LN for the entire cohort was 15, including 20 for and 42.62 (35.07–54.96) kg/m2, respectively. Mean % EWL
LN-positive patients and 15 for LN-negative patients. On was 21.41%, 31.82%, and 39.02% at 3, 6, and 12 months,
univariate analysis, the presence of submucosal tumor inva- respectively. Data was available for 9, 14, and 15 patients
sion (p = 0.012), lymphovascular invasion (LVI) (p < 0.001), at the 3, 6, and 12 month time points, respectively. There
and positive nodal status by EUS (p < 0.001) were significant were no mortalities.
107
Sunday
Poster Abstracts
Predictors of Lymph Node Involvement in T1 Gastric
Carcinoma
BACKGROUND: Laparoscopic adjustable gastric banding
(LAGB) is known to have a considerable revisional surgery
rate, reported from 10% to 40 + %. Mechanical complications such as band slip, esophageal dilation or development
of a hiatal hernia can lead to symptoms of GERD, dysphagia, and epigastric pain; weight loss failure/regain are also
prevalent factors that lead patients to seek surgical revision.
Weight loss data for conversion to sleeve gastrectomy is
sparse. We present our initial series of patients who have
undergone revision from LAGB to laparoscopic sleeve gastrectomy (LSG).
DISCUSSION: Our data indicates that revisional surgery
from LAGB to LSG at one year averages 39.02% EWL (range
0% to 70.92%). Published data for primary LSG have shown
results of approximately 60% EWL (ranges reported approximately 30% to 80%) at one year. Our preliminary data suggests that weight loss after conversion from LAGB to LSG
may not result in weight loss equivalent to primary LSG.
This relatively small number of patients does not allow
comment as to the etiology of the relatively poor weight
loss seen here, although factors such as nadir weight loss
achieved with the band, interval between banding and
sleeve (one or two stage), preoperative LSG weight, or others, may provide insight as more data becomes available.
Translational Science: Colon-Rectal
> C: TT = 44.3%; TC = 43.9%; CC = 11.7%, –765G > C: GG
= 58.3%; GC = 31.7%; CC = 1.3%). A high frequency of
the wild genotype Cox-2 –765GG and polymorphic genotype Cox-2 –1195GG and VEGF-A –634CC was found in
an Asiatic (mostly Japanese) population. VEGF-A –2578C
> A, and –460T > C were associated to familial history of
cancer. There were associations between wild homozygous
VEGF-A (–2578CC; –460TT; –634GG; + 936 CC), and wild
homozygous Cox-2 (–1195AA; 8437TT; 765GG) SNPs with
pre-operative CEA, histological type, peritumoral deposits, perineural and angiolymphatics invasion, lymph node
metastases or pN, and stage IV disease, p < 0.04. Wild homozygous genotype of VEGF-A and Cox-2 were significantly
correlated with a worst progression-free survival and overall
survival when compared to the combined heterozygous or
recessive genotypes in a multivariate analysis.
CONCLUSIONS: 1. Wild homozygous VEGF-A and Cox-2
SNPs were associated to disease progression and survival in
patients with advanced colorectal cancer; 2. VEGF-A and
Cox-2 SNPs may be useful markers of aggressiveness in
these patients; 3. Molecular data may orientate the appropriate target therapy in novel clinical trials.
Su2127
Wild Homozygous VEGF-A and Cox-2 Gene
Polymorphisms Are Associated to Worst Prognosis in
Patients with Colorectal Cancer (CRC)
Michele T. TomitãO1, Guilherme C. Cotti1, Marcia S. Kubrusly1,
Evelise Pelegrinelli- Zaidan1, Adriana V. Safatle-Ribeiro1,
Rosely A. Patzina2, José Eluf-Neto3, Ivan Cecconello1,
Sergio C. Nahas1, Ulysses Ribeiro1
1
Gastroenterology, University of São Paulo, São Paulo, SP, Brazil;
2
Pathology, University of São Paulo, São Paulo, Brazil; 3Preventive
Medicine, University of São Paulo, São Paulo, Brazil
BACKGROUND: The vascular endothelial growth factorA (VEGF-A) and Cyclooxygenase-2 (Cox-2) polymorphisms
have been implicated in colorectal cancer (CRC). VEGF-A
and Cox-2 polymorphisms might modify the levels of protein expression and may have a considerable influence on
disease phenotype, which may have important clinical/
genomic implications.
AIMS: To evaluate single nucleotide polymorphisms (SNPs)
in the VEGF-A, and Cox-2 genes and their prognostic values for patients operated on for CRC; and to investigate
possible interactions between these genetic variations and
clinicopathologic characteristics in CRC.
METHODS: VEGF-A and Cox-2 SNPs have been analyzed
in 230 prospective patients who underwent surgical resection, and had a minimum of 5 years follow-up. DNA was
isolated from leukocyte using extraction and purification
kit, followed by amplification by polymerase chain reaction
(PCR). Real-time analysis was used for genotyping VEGF-A
and Cox-2 SNPs through the TaqMan ® SNP Genotyping
Assay.
RESULTS: We determined frequencies of four VEGF-A
biallelic SNPs with twelve haplotypes: (–2578 C > A: CC =
36.1%; CA = 46.1%; AA = 17.8%; –460T > C: TT = 34.3%;
TC = 45.7%; CC = 20%; –634G > C: GG = 48.7%; GC =
40.4%; CC = 10.9%; + 936 C > T: CC = 74.3%; CT = 23.5%;
TT = 2.2%), and three COX-2 SNPs with nine haplotypes
(–1195A > G: AA = 63.5%; AG = 31.3%; GG = 5.2%; 8437T
Su2128
Age, Gender, and Folate Metabolism Polymorphisms
Influence on Gene Promoter Methylation in CRC
Patients
Francesca Migheli1, Andrea Stoccoro1, Fabio Coppedè1,
Lucia Migliore1, Roberto Spisni2, Marco Biricotti2,
Alessandra Failli3, Annalisa Legitimo3, Rita Consolini3
1
Translational Research and New Technologies in Medicine and
Surgery, Division of Medical Genetics, University of Pisa, Italy,
Pisa, Italy; 2Surgical Pathology, University of Pisa, Italy, Pisa,
Italy; 3Clinical and Experimental Medicine, Division of Pediatrics
(Laboratory of Immunology), University of Pisa, Italy, Pisa, Italy
Colorectal cancer (CRC) is the third most common cancer in men and the second in women worldwide. Almost
60% of the cases occur in developed regions. CRC arises
from a multistep process that involves an accumulation
of mutations/epimutations in tumor suppressor genes
and protooncogenes. DNA methylation is an important
control program that modulates gene expression in the
organism. Genome-wide hypomethylation and promoterspecific hypermethylation are thought to contribute to agerelated pathologies. Moreover female sex hormones have
been implicated in the etiology of several women’s cancers
and may participate in different pathways associated with
distinct DNA methylation signatures. Folates are essential
nutrients whose metabolism is required for the production of S-adenosylmethionine (SAM), the major intracellular methylating agent, and for the synthesis of DNA and
RNA precursors. Impairments in folate metabolism might
result in increased frequency of point mutations as well
as altered methylation of tumor suppressor genes, thereby
contributing to cancer initiation and progression. Reduced
folate levels have been associated with increased CRC risk
108
in healthy people, whilst increased folate availability is
believed to enhance CRC progression in individuals harbouring preneoplastic lesions. There is increasing interest in
understanding the correlation among folate availability, its
metabolism, and the methylation levels of tumor suppressor genes in CRC tissues. For this purpose we collected 104
CRC patients and searched for correlation among clinicopathological characteristics, common polymorphisms of
genes participating in folate metabolism (MTHFR 677 C > T,
MTHFR 1298A > C, MTR 2756A > G, MTRR 66A > G, TYMS
28 bp repeats, TYMS 1494 6 bp del, RFC1 80A > G, DNMT3B
–149 C > T, and DNMT –579 G > T) and promoter methylation of APC, MGMT, hMLH1, RASSF1A, CDKN2A, tumor
suppressor genes. Genotyping was performed by means of
PCR/RFLP technique and DNA methylation analyses by
means of methylation-sensitive high resolution melting
(MS-HRM). A precise value of gene promoter methylation
was obtained by means of an algorithm recently developed
by us. MGMT and hMLH1 methylation levels showed a
significant positive correlation with aging and female gender. Moreover, some interesting correlation among folate
metabolism polymorphisms and promoter methylation
levels were found. No significant association among promoter methylation and CRC location, stage and tumor size
was found. Only a borderline association between TNM
stage IV and increased hMLH1 methylation and TNM stage
III and a higher RASSF1A methylation (with respect to the
other stages) have been observed. The study of epigenetic
marks to better understand colorectal carcinogenesis and
to identify new tools for diagnosis and prognosis as well as
for therapeutic interventions is then extremely promising.
Whole exome analysis was performed on 16 DNA samples from histological characterised esophageal cancer (n
= 8) and the corresponding non-tumor biopsies (n = 8).
Extracted DNA was applied to NimbleGen capture exon
hybridisation, adapter ligation and subsequent deep
sequencing on an Illumina HiSeq platform. After tumor
macrodissection, DNA from additional 147 formalin-fixed
and paraffin-embedded (FFPE) EAC and SEC biopsies was
extracted using the Qiagen M48 robotic system. After
DNA quality control, multiplex PCR libraries, representing
tumor-relevant genetic loci, were prepared from 50 quality
controlled EAC and SCC DNA samples. Multiplex libraries
were analyzed for more than 2000 putative driver mutations by next generation sequencing on the MiSeq Illumina
platform.
745 putative driver mutations in 657 genetic loci were
found in a first whole exome screening step. p53 hot spot
mutations occurred in two third of the esophageal cancers.
In addition to the p53 mutations, whole exome analysis
identified more than two mutation hits in genes for the
regulatory phosphatase unit, an adhesion P-cadherin and
cycline kinase 12. These mutations were also addressed by
conventional Sanger sequencing. Subsequently, DNA samples from 147 SCC and EAC were studied. Analyses of a hot
spot cancer panel in 50 samples, that had passed the quality control, confirmed high frequency of p53 mutations,
but a lack of K-Ras mutations. In addition, a set of further
mutations such as in PIC3CA, PP2R1B, and PPP1R1B were
shown, whose clinical relevance has to be addressed in
future studies.
NGS is a sensitive method in evaluation of the mutation
status of esophageal cancer, providing the opportunity to
detect a wide range of genetic alterations, which have to
be linked to cancer progression, therapeutic outcome and
personalized treatment options in future studies.
Su2129
Whole Exome Sequencing Revealed Putative Driver
Mutations in Esophageal Cancer
Peter P. Grimminger1, Martin Peifer2,4, Roman Thomas4,
Martin K. Maus1, Jan Brabender3, Arnulf H. HöLscher1,
Reinhard BüTtner5, Margarete Odenthal5
1
Department of General-, Visceral- and Tumor Surgery, University
Clinic Cologne, Cologne, Germany; 2Department of Translational
Genomics, University of Cologne, Cologne, Germany; 3General- and
Visceral Surgery, St. Antonius Hospital, Cologne, Germany; 4Cologne
Center for Genomics, University of Cologne, Cologne, Germany;
5
Pathology, University of Cologne, Cologne, Germany
Esophageal cancer is one of the most common malignancies
in the Western world with increasing incidence of esophageal adenocarcinoma (EAC). Despite improvements in staging, surgical procedures, and post-operative treatments, the
overall survival of patients with esophageal cancer remains
low. In order to evaluate the mutation status of EAC and
109
Sunday
Poster Abstracts
Translational Science: Esophageal
squamous cell cancer of the esophagus (SCC) we performed
next generation sequencing (NGS) approaches on a wide set
of tumor-derived DNA from histological classified EAC and
SCC biopsies.
Translational Science: Other
Su2130
Outcomes of Lung Transplant Patients with Severe GI
Complications
Loretta Erhunmwunsee1, Jennifer M. Hanna2,
Anthony Castleberry2, Matthew Hartwig1, Christopher R. Mantyh2
1
Cardiothoracic Surgery, Duke University Medical Center, Durham,
NC; 2General Surgery, Duke University Medical Center, Durham, NC
PURPOSE: The incidence of gastrointestinal (GI) complications after Lung Transplantation (LTx) is not well
described. This study attempts to identify the incidence of
GI complications after LTx, characterize the risk factors that
lead to GI complications, and then determine the impact of
GI complications on post-transplant outcomes.
CONCLUSIONS: There is a high incidence of GI complications in patients who undergo LTx. Recipients who suffer a
GI complication after LTx have diminished overall survival.
Total ICU days was an independent factor associated with
having a GI complication.
METHODS: A prospective database of patients who underwent LTx between 2005 and 2011 was queried. Generalized linear regression was used to determine risk factors
for developing GI complications. A multivariable Cox
regression model was developed to predict the impact of
GI complications and other factors on the survival of these
patients.
Su2131
RESULTS: During the study period 543 patients underwent LTx. 137 GI complications (Table 1) occurred in 124 of
these patients. 62 of these patients subsequently underwent
operative management of their GI complication. Patients
who had a GI complication had a statistically significant
worse 5 year survival (51% vs 65%) when compared to
those who did not have a GI complication (p = 0.006) ( Figure 1). On univariable analysis, having a diagnosis of cystic
fibrosis (p = 0.03), ischemic time (p = .05), total length of
stay (LOS) (p = 0.0008), total ICU days (p = 0.0004) and an
elevated FK level (p = .005) were associated with having
a GI complication after transplantation. On multivariable
analysis, total ICU days (OR = 1.005, 95% CI 1.003–1.007)
was an independent factor associated with having a GI
complication.
GI Complication Incidence
N = 124 patients
C diff colitis
Biliary
Perforation/Leak
Diverticulitis
GI Bleed
Gastroduodenal ulcer
Esophageal candidiasis
Slipped Nissen
SBO
Bleed -Non-GI
Ischemic Colitis
Retroperitoneal abscess
Eneterocutaneous Fistula
Miscellaneous
Total
Total Number
26 (19%)
22 (16%)
13 (9.5%)
11 (8%)
10 (7.3%)
9 (6.6%)
9 (6.6%)
6 (4.4%)
5 (3.6%)
5 (3.6%)
4 (3%)
2 (1.5%)
2 (1.5%)
13 (9.5%)
137
Number that Went to OR
0
20 (91%)
10 (76.9%)
9 (81.8%)
0
0
0
6 (100%)
4 (80%)
3 (50%)
2 (50%)
2 (100%)
1 (50%)
5 (38.5%)
62 (46%)
Per-Umbilical Laparoscopic Access
Roger H. Pozzo, Rodrigo Arrangoiz, Fernando Cordera,
Enrique Luque-De-LEóN, Eduardo Moreno, Manuel Munoz Juarez
Surgery, American British Cowdray Medical Center, D.F., Mexico
INTRODUCTION: The advent of laparoscopic surgery is
one of the most important advances in modern surgical
technique. In order to perform laparoscopic procedures it
is necessary to access the peritoneal cavity and establish a
pneumoperitoneum. Placement of the first port remains
a critical and unavoidable step in laparoscopic surgery. In
order to minimize complications associated with placement
of the first trocar, several techniques have been reported.
Herein we describe the per-umbilical technique (PUT)
approach developed by our surgical group that takes advantage of the anatomical defect left by the umbilical vessels
at the umbilicus after birth. PUT provides a quick, safe, and
reliable initial surgical access to the peritoneal cavity that
has produced excellent functional and cosmetic results.
METHODS: Retrospective cohort of patients who underwent various laparoscopic procedures by our surgical group
using PUT for access to the peritoneum from January 2000
to September 2012 at the ABC Medical Center, in Mexico
City. Patients with prior midline laparotomy involving
the umbilicus were excluded, but not those with previous
transverse umbilical herniorraphies.
RESULTS: Within that timeframe there were 963 patients
(M = 419; F = 544) with an average age of 40 years (range:
15–83). With a median follow up time of 6-years In our
cohort no complications occurred during the insertion of
the first trocar. A small abdominal wall defect, were the
obliterated umbilical vessels cross the musculoaponeurotic
layer, was identified in all patients except those with a previous surgical procedure at this site. Postoperative complications occurred in 39 patients (1.5%) of which the main
one was postoperative seroma (N = 24 patients). Superficial
surgical site infection occurred in eight patients (0.84%),
hematoma in two patients (0.21%), and incisional hernia
at the umbilical port site occurred in five patients (0.51%).
The average time to place the first trocar using PUT was 1.5
minutes (range: 1–7 minutes).
110
CONCLUSION: We describe a modified open technique
that has not been previously reported in the literature for
placement of the first trocar taking advantage of a constant
anatomical defect left by the obliterated umbilical vessels
which is almost universally present. The PUT is quick, safe,
reliable, simple, and easy to learn. It is associated with minimal morbidity and has excellent cosmetic results. Based
on our experience, we believe that this method provides
surgeons with an effective and safe way to insert the first
trocar and we recommend it as a routine procedure for the
accessing the peritoneal cavity for abdominal laparoscopic
surgery.
liver resulting in a robust reduction of the expression of
genes involved in liver bile acids synthesis (CYP7A1) and
uptake and secretion (NTCP, MRP2, MRP3, OSTD/E) ultimately leading to reduced bile acid concentrations in the
blood. In addition, IT repressed the liver expression of neoglucogenetic (PECK) and lipogenetic (FAS, SREBP1c) genes.
IT enhanced FGF-15 mRNA expression in the intestine and
this effect was further enhanced by CDCA (Figure). Activation of intestinal FXR associates with an improvement of
OGTT and with a reduction of glucose plasma levels.
Translational Science: Small Bowel
Su2132
Dissociation of Activity of Ileal and Liver FXR Mediates
Metabolic Effects in a Rodent Model of Bariatric
Surgery
Andrea Mencarelli1, Chiara Santorelli2, Luigina Graziosi2,
laudio D’Amore1, Barbara Renga1, Sabrina Cipriani1,
Eleonora Distrutti3, Annibale Donini2, Stefano Fiorucci1
1
Medicina Clinica e Sperimentale, University of Perugia, Perugia, Italy;
2
Dipartimento di Scienze Chirurgiche, University of Perugia, Perugia,
Italy; 3Azienda ospedaliera di Perugia, Perugia, Italy
Sunday
Poster Abstracts
BACKGROUND: The global growing burden of obesity
and type 2 diabetes mellitus is widely recognized as one
of the most challenging threats to public health. Bariatric
surgery represents a potentially useful strategy for management of diabetes and obesity. FXR is a bile acid activated
receptors expressed in entero-hepatic tissues.
AIMS: Here we have investigated whether bariatric surgery
activates liver and intestinal bile acids activated receptors
and how these receptor regulate metabolic adaptation to
surgery.
METHODS: Wistar rats were followed for 7 months after
Ileal interposition (IT) or sham operation. In the last week
animals were challenged with CDCA, 10 mg/kg, a FXR
ligand.
RESULTS: IT selectively increases intestinal expression/
activity of FXR and liver X receptor (LXR), as demonstrated
by increasing expression of theirs target genes in the intestine including FGF-15 and ABCG5/8, respectively. In contrast, IT selectively repressed FXR and LXR activity in the
CONCLUSIONS: These findings provide a mechanistic
explanation to the metabolic effects exerted by bariatric
surgery and provide a model for investigating the effect of
selective activation of intestinal FXR.
111
Monday, May 20, 2013
12:00 PM – 2:00 PM
West Hall A
POSTER SESSION I
(NON-CME)
373.2) was significantly higher than the BCD group result
(295.6, CI: 276.0, 306.6; p < 0.0001). Similarly, for IL8, the
median PreOp CRC level (pg/ml) (17.3, CI 17.8, 22.8) was
higher than the BCD groups outcome (14.2, CI: 12.8, 16.8;
p < 0.001). Of note no correlation was found between ANG
or IL8 plasma levels and cancer stage.
Basic: Colon-Rectal
Mo1834
Plasma Levels of the Proangiogenic Proteins
Angiogenin and Interleukin-8 Are Significantly
Increased in Patients with Colorectal Cancer
M.C. Shantha Kumara H1, Hiromichi Miyagaki1,2,
Xiaohong Yan1, Elizabeth Myers1, Sonali A. Herath1,
Sahani De Silva1, Linda Njoh1, Vesna Cekic1, Richard L. Whelan1
1
Surgery, St Luke Roosevelt Hospital, New york, NY;
2
Gastroenterological Surgery, Oska University, Suita, Japan
INTRODUCTION: It has been shown that the proangiogenic proteins angiogenin (ANG) and interleukin-8 (IL8)
are produced by endothelial cells (EC), fibroblasts and
peripheral blood cells. Also, some colon, breast, and prostate cancers have been shown to over express ANG and IL8.
EC surface actins are receptors for ANG; the binding of ANG
to actin on EC’s promotes degradation of the basement
membrane which facilitates EC migration, an essential
early step in angiogenesis. EC’s also express the IL-8 receptors CXCR1 and CXCR2; tumor derived IL8, via binding to
these receptors, in an autocrine fashion, enhances tumor
cell proliferation and survival and also promotes pathologic angiogenesis. IL8’s pro-angiogenic effects are independent of VEGF. Plasma ANG and IL8 levels in patients
with colorectal cancer (CRC) have not been well studied.
This study’s purpose was to compare preoperative (PreOp)
plasma ANG and IL8 levels in patients with CRC and benign
colonic diseases (BCD).
METHOD: Patients undergoing colorectal resection for
CRC or BCD prospectively enrolled in an IRB approved tissue/data bank, for whom PreOp plasma was available, were
studied. Clinical, operative and pathologic data were collected. Plasma ANG (ng/ml) and IL8 (pg/ml) levels were
determined via ELISA in duplicate and reported as median
95% CI. Levels between groups were compared by the
Mann-Whitney test (significance p < 0.05).
RESULTS: A total of 122 CRC (66% colon, 34% rectal)
and 96 BCD (adenoma 50%, diverticulitis 47%, other 3%)
patients were included. Plasma stores (PreOp samples) did
not permit both assays to be done for all patients. In regards
to ANG, 86 CRC and 80 BCD patients were studied while
the IL8 assay included 73 CRC and 62 BCD patients. The
median PreOp CRC ANG level (ng/ml) (339.9, CI: 339.6,
CONCLUSION: The median PreOp plasma ANG and
IL8 levels in the CRC group were modestly increased
(21–25%) vs. the BCD patients. ANG and IL8 shed from
tumors expressing these proteins may be responsible for
the increase. Alternate sources may be neovascularization
and inflammation at the tumor site. Further study of larger
groups with concomitant tumor analysis would help determine the clinical relevance, if any, of these changes, the
source of the added protein and would better define the
relationship between cancer stage and blood levels.
Mo1835
Intestinal Permeability Is Increased During
Postoperative Ileus in Mice
Xue Zhao2, Till M. Macheroux2, Michael S. Kasparek2,
Mario Mueller2,3, Martin E. Kreis1
1
Surgery (CBF), Charité University Medicine, Berlin, Germany;
2
Surgery, University of Munich, Munich, Germany; 3Gastroenterology,
University of Zuerich, Zuerich, Switzerland
INTRODUCTION: Pathophysiology of postoperative ileus
(POI) involves an intestinal inflammatory response. One
potential mechanism is translocation of macromolecules
from the gut lumen. We aimed to investigate whether the
time course of translocation is dependent on molecular
weight.
METHODS: C57Bl6 mice were deeply anesthetized by
isoflurane inhalation and gavaged with flourescein isothiocyanate conjugated dextrane (FITC-dextrane, 4.4 kDa)
and horseradish peroxidase (HRP, 40 kDa). One hour later,
a mini-laparotomy was performed and the small intestine manipulated in standardized fashion to induce POI,
while control animals received sham laparotomy without
manipulation. Intestinal permeability was assessed in POI
animals or sham controls 1, 3 and 9 hours later in different
subgroups (each n = 6). For this purpose blood was taken
by right ventricular puncture and serum concentrations of
FITC-dextrane and HRP determined by spectrophotometry.
Data are mean ± SEM.
112
RESULTS: Serum levels of FITC-dextrane (4.4 kDa) in ng/ml;
*p < 0.05; **p < 0.001 POI vs. sham
Sham 72 ± 5 83 ± 2 56 ± 6 (1 h/3 h/9 h)
Basic: Hepatic
Mo1837
POI 120 ± 8* 183 ± 22** 65 ± 5 (1 h/3 h/9 h)
Beneficial Effects of Diazoxide on Hepatic Ischemia/
Serum levels of horse radish peroxidase (40 kDa) in ng/ml;
*p < 0.05 POI vs. sham. Sham 198 ± 18 240 ± 29 226 ± 24 (1 Reperfusion Injury
h/3 h/9 h) POI 350 ± 38* 388 ± 38* 300 ± 28 (1 h/3 h/9 h). Mateus A. Nogueira, ANA Maria M. Coelho, Sandra N. Sampietre,
Nilza A. Molan, Rosely A. Patzina, Luiz C. D’Albuquerque,
CONCLUSIONS: Intestinal permeability for macromolecules was already increased a few hours after induction Marcel C. Machado
of postoperative ileus. This appeared to be independent of Gastroenterology, University of São Paulo, São Paulo, Brazil
their molecular weight. Translocation of macromolcules BACKGROUND/AIM: Pretreatment with diazoxide, an
into the intestinal wall early after induction of postop- opening mitoKATP, increases tissue tolerance against ischeraitve ileus is a potential trigger of subsequet intestinal emia/reperfusion (I/R) injury, however, there are no prior
inflammatory responses.
studies of the role of diazoxide on hepatic I/R injury. In the
Supported by the Else Kröner-Fresenius Stiftung 2011_A214. present study, we evaluated the effect of diazoxide on local
and systemic liver I/R process.
METHODS: Wistar male rats underwent partial liver ischemia performed by clamping the pedicle from medium and
left anterior lateral segments during an hour under mechanical ventilation. They were divided into 2 groups: Control
Group (n = 26): rats received saline and Diazoxide Group
(n = 26): rats received IV diazoxide (3.5 mg/kg) 15 minutes
before liver reperfusion. Four and 24 hours after reperfusion, blood were collected for determinations of AST, ALT,
TNF-D, IL-6, IL-10, and TGFE1. Liver tissues were assembled
for mitochondrial oxidation and phosphorylation, malondialdehyde (MDA) content, and histologic analysis. Pulmonary vascular permeability and myeloperoxidade (MPO)
were also determined.
Basic: Esophageal
Mo1836
Bile Acid at Low pH Can Cause Dilatation of
Inter-Cellular Spaces in In Vitro Stratified Primary
Esophageal Cells, Possibly by Modulating WNT and
BMP Signaling
Sayak Ghatak1, Marie Reveiller4, Liana Toia2, Andrei Ivanov3,
Tony Godfrey2, Jeffrey H. Peters2
1
Biology, University of Rochester, Rochester, NY; 2Surgery, University of
Rochester, Rochester, NY; 3Human and Molecular Genetics, Virginia
Commonwealth University Medical Center, Richmond, VA; 4Medicine
and Pathology, NYU Langone Medical Center, New York, NY
CONCLUSION: Diazoxide maintains liver mitochondrial
function, increases liver tolerance to I/R injury, and reduces
systemic inflammatory response. These effects require further evaluations for using in a clinical setting.
Grants from FAPESP2010/19078-1
113
Monday
Poster Abstracts
The pathognomonic feature of reflux esophagitis secondary to gastro-esophageal reflux disease is the presence of
dilated intercellular spaces in the stratified squamous lining
of the esophagus. Bile acid is a major constituent of gastroesophageal refluxate. In our present study, we developed a
novel in vitro transwell culture model for stratified esophageal squamous epithelium. We grew h-TERT transformed
primary esophageal cell line EPC1 on polyester transwell
surfaces, apically and basally supplemented with calcium
enriched media, and observed that the EPC1 cells gradually
stratify into a 11-layered squamous epithelium in 7 days.
This epithelium also demonstrated well-formed cell junctions, essential for formation of the stratified epithelium.
When the EPC1 cells on transwells were treated with a combination of bile acid and pH5, there was loss of epithelial
barrier function. Electron microscopy and confocal imaging of the cell junctions showed disruption of adherens
junction, tight junction and desmosomes, thus leading to
dilated intercellular spaces. At the cellular level, the combination of bile acid and pH5 induced E-catenin phosphorylation and reduced SMAD-1/5/8 phosphorylation, both of
which can lead to loss of cell junction proteins. In conclusion, combination of bile acid at low pH in our trasnwell
culture model mimicked the effects of gastro-esophageal
reflux in vivo, possibly by modulating WNT and BMP signaling pathways.
RESULTS: Four hours after reperfusion Diazoxide Group
presented elevation of AST, ALT, TNF-D, IL-6, IL-10 and
TGFE1 serum levels significantly lower than Control Group
(p < 0.05). A significant reduction on liver MDA content and
on mitochondrial dysfunction were observed in Diazoxide
Group compared to Control Group (p < 0.05). No differences in pulmonary vascular permeability and MPO activity were observed between groups. Twenty four hours after
reperfusion Diazoxide Group showed a reduction of AST,
ALT, and TGFE1 serum levels when compared to Control
group (p < 0.05).
Basic: Pancreas
8Mo1839
8Mo1838
Osteopontin (OPN) Isoforms, Diabetes, Obesity, and
Cancer: What’s One Got to Do with the Other? A New
Role for OPN
PTK6 Regulates Migration and Invasion of Pancreatic
Cancer Cells with ERK1/2 Dependent Pathway
Hiroaki Ono, Hiromichi Ito, Marc D. Basson
Surgery, Michigan State University, East Lansing, MI
BACKGROUND: Protein Tyrosine Kinase 6 (PTK6) is a nonreceptor type tyrosine kinase, known to be overexpressed in
various cancers including pancreatic cancer. The biological
role of PTK6 in cancer remains unclear. We hypothesized
that PTK6 is a key regulator of pancreatic cancer invasion.
Konrad Sarosiek, Elizabeth Jones, Galina Chipitsyna,
Mazhar AL-Zoubi, Shivam Saxena, Christopher Y. Kang,
Ankit V. Gandhi, David Tichansky, Charles J. Yeo, Hwyda A. Arafat
BACKGROUND: Alternative splicing of osteopontin (OPN)
produces three splice variants: OPNa, OPNb, and OPNc. We
have previously demonstrated a role for OPNc in pancreatic
ductal adenocarcinoma (PDA) inflammation and proposed
its potential as a novel therapeutic target to reduce PDAMETHODS: We used 3 cell lines derived from human pan- associated inflammation. The aims of this study were to
creatic cancers, BxPC3, Panc1, and MIAPaCa2. PTK6 expres- examine the expression pattern of OPN splice variants in
sion and activation were evaluated using western blotting. sera from patients with pancreatic lesions and to determine
PTK6 expression was manipulated using siRNA gene silenc- their correlation with the presence of systemic inflammaing or transfection of expression vector. Cellular migratory conditions, such as obesity and diabetes. In addition,
tion and invasion were evaluated using a Boyden chamber the functional significance of the individual isoforms was
transmigration assay without or with Matrigel, respectively. evaluated.
Downstream signals associated with the effect of PTK6 on
METHODS: Serum samples were obtained from 90 patients
cellular migration and invasion were assayed using western
undergoing pancreatic surgery at a single institution.
blotting and a specific small molecule inhibitor.
Patients were grouped into 8 subgroups based on the disease
RESULTS: Pancreatic cancer cell lines expressed PTK6 at process and presence of obesity and/or diabetes. Sera from
various levels; BXPC3 expressed PTK6 robustly, while Panc1 age-matched healthy volunteers were analyzed (n = 29).
and MIAPaCa2 expressed much lower levels of PTK6. In Real-time polymerase chain reaction and ultraviolet light
all 3 cell lines, suppression of PTK6 expression by siRNA illumination of ethidium-bromide gel staining were used
significantly reducted both cellular motility and invasion to examine the OPN mRNA and its individual isoforms. In
through matrigel (0.59/0.49 fold for BXPC3, 0.61/0.62 vitro, wound healing, cell proliferation and soft-agar colony
for Panc1, 0.42/0.39 for MIAPaCa2, respectively, p < 0.05 formation assays evaluated the functional impact of each
for each). In contrast, forced over-expression of PTK6 by isoform in PDA cells transfected with isoform-specific cDNA.
transfection of a PTK6 expression vector in Panc1 and A panel of inflammation-related genes was also analyzed.
MIAPaCa2 cells significantly increased cellular migration
RESULTS: Sera were obtained from PDA patients (mean age
and invasion (1.57/1.67 fold for Panc1, and 1.44/1.57 for
66 ± 1.12 (SE) years; 40 male). Histopathology confirmed
MIAPaCa2, respectively, p < 0.05). Gene silencing of PTK6
PDA in 58 patients, IPMN in 32. Diabetes (type 2) alone was
reduced the activation of ERK1/2, but not AKT and STAT3,
detected in 13 PDA and 4 IPMN patients and in combinawhile overexpression of PTK6 increased ERK1/2 activation.
tion with obesity in 5 PDA and 1 IPMN patients. In PDA
When the cells were treated with U0126, a specific inhibionly, the presence of OPNb was seen in 33% of the patients’
tor of ERK1/2, the effect of PTK6 overexpression on cellular
sera, OPNc in 48%, with both being present in 15%. The
migration/invasion was completely abolished.
presence of diabetes and/or obesity was associated with
CONCLUSION: PTK6 regulates cellular migration and complete disappearance of OPNb and only expression of
invasion in pancreatic cancer, via the MAPK/ERK signaling OPNc (82% of PDA diabetics, 100% of obese PDA patients,
pathway. Our findings suggest that PTK6 may be a novel and 100% of obese diabetic patients with PDA). No OPNb
therapeutic target for pancreatic cancer.
or c was detected in the normal sera. OPNc had a significant
association with presence of systemic inflammation (OR =
6.8 [1.7–65, 95% CI]; p < 0.05). In vitro studies show that
overexpression of OPNb and c isoforms significantly (P <
0.05) and (P < 0.02), respectively, increased the activity of
PDA cells in soft-agar colony formation and wound healing
assays compared with controls.
CONCLUSIONS: Our data show for the first time the significant association between OPN splice variant c (OPNc)
and the presence of systemic inflammation in patients with
obesity and/or diabetes. In vitro data suggest that increased
OPNc expression in PDA cells is associated with increased
migration capacity. Unraveling the functional role of OPNc
in systemic inflammation is essential to understanding its
significance as a marker and a therapeutic target during
metastasis development in PDA.
114
Mo1840
Clinical: Biliary
Local and Systemic Effects of Aging on Acute
Pancreatitis
8Mo1687
ANA Maria M. Coelho1, Marcel C. Machado1,
Sandra N. Sampietre1, Nilza A. Molan1, Inneke M. Van Der
Heijden2, José Eduardo M. Cunha1, Luiz C. D’Albuquerque1
1
Gastroenterology, University of São Paulo, São Paulo, Brazil;
2
Infectious Diseases, University of São Paulo, São Paulo, Brazil
Introperative Cholangiogram Reduces Risk of Bile
Duct Injury During Cholecystectomy: Results from a
National Quality Registry
BjöRn TöRnqvist, Cecilia STRöMberg, Lars Enochsson,
Magnus Nilsson
BACKGROUND/AIM: Acute pancreatitis (AP) is associDepartment of Clinical Science, Intervention and Technology,
ated with high morbidity and mortality rates. Aging process
has been found to influence the course and outcome of AP. Karolinska Institutet, Stockholm, Sweden
The aim of this study was to evaluate the local and systemic BACKGROUND: Bile duct injury during cholecystectomy
effects of aging on severity of AP in an experimental model. is a dreaded complication. Regarding prevention, the idenMETHODS: AP was induced in male Wistar rats by intra- tification of patient and procedure-related risk factors are
ductal 2.5% taurocholate injection and divided into 2 essential. The protective effect of intraoperative cholangioexperimental groups: GI (n = 20): Young (3 month old gam has been controversial and widely debated due to lack
rats), and GII (n = 20): Older (18 month old rats). Two of conclusive studies. The aim of this study is to identify
and 24 hours after AP blood were collected for determina- risk factors for bile duct injury at cholecystectomy using the
tions of amylase, AST, ALT, urea, creatinine, glucose, and highly valid Swedish national registry for gallstone surgery,
of plasma ileal fatty acid binding protein (I-FABP). TNF-D GallRiks, where more than 90% of the Swedish cholecystecand IL-6 levels were determined in serum and ascitic fluid. tomies are registered.
Liver mitochondrial oxidation and phosphorylation and
malondialdehyde (MDA) contents, and pulmonar myeloperoxidade (MPO) activity were also performed. Bacterial
translocation was evaluated by bacterial cultures of pancreas expressed in colony-forming units (CFU) per gram.
CONCLUSIONS: In this study, using the highly valid
Swedish national registry for gallstone surgery, risk factors
for iatrogenic bile duct injury during cholecystectomy were
analysed. Patients with acute cholecystitis were at higher
risk for bile duct injury. Intention to use intraoperative
cholangiogram reduced bile duct injury rates in general and
severe injuries in particular. The most noticeable protective
effect of intraoperative cholangiogram was seen among
patients with acute cholecystitis. The main contribution
of this study is the intention-to-do data on intraoperative
cholangiogram, and the results suggest that routine use of
intraoperative cholangiogram at cholecystectomy may be
beneficial.
115
Monday
Poster Abstracts
METHODS: All cholecystectomies in GallRiks, from the
start of the registry on May 1 2005 until December 31 2010
were included. Patient, institutional and procedure related
risk factors for iatrogenic bile duct injury were analysed
using multivariate logistic regression. The intention to use
RESULTS: A significant increase in serum amylase, AST, intraoperative cholangiogram was defined as performed or
ALT, urea, creatinine, glucose, I-FABP, and IL-6 levels, and attempted cholangiogram, thus using the intention-to-do
a reduction in serum and ascitic fluid TNF-D levels were approach.
observed in the elder group compared to the young group RESULTS: Among 51 041 cholecystectomies, 747 (1.46%)
(p < 0.05). Liver mitochondrial dysfunction, MDA con- bile duct injuries ranging from minor to major lesions were
tents, and pulmonary MPO activity were increased in the identified. Patients with acute cholecystitis had a 25%
older group compared to the young group (p < 0.05). Also, increased risk of bile duct injury compared to patients witha significant increase in positive bacterial cultures obtained out cholecystitis (OR 1.25 (95% CI 1.04 to 1.49)) Additionfrom pancreas tissue in older group was significantly ally, the risk of severe bile duct injuries (transections of major
increased compared to young rats (p < 0.05).
ducts with loss of ductal tissue or lesions above the hepatic
CONCLUSION: This study demonstrated that aging confluence) were doubled among patients with acute choinfluences the course of acute pancreatitis evidenced by lecystitis (OR 2.13 (95% CI 0.96 to 4.75)). The intention to
increased local and systemic lesions and the increased in use intraoperative cholangiogram reduced the overall risk
bacterial translocation. These findings may have significant of bile duct injury by 25% (OR 0.75 (95% CI 0.62 to 0.92))
and the risk of severe bile duct injuries by 66% (OR 0.44
therapeutic implication in the clinical setting.
(95% CI 0.30 to 0.63)). The association between intended
intraoperative cholangiogram and the reduction in risk of
bile duct injury were most prominent among patients with
ongoing acute cholecystitis. This group had a risk reduction
of 56% (OR 0.44 (95% CI 0.30 to 0.63)).
Mo1689
Outcome in the Partial and Complete Injury Groups
Post-Cholecystectomy Acute Bile Duct Injuries
Partial Injury
Complete Injury
n = 121
n = 44
n = 77
P Value
Fistula closure
37 (84%)
43 (57%)
p = 0.001
Stricture formation
20 (45%)
70 (92%)
p = 0.000
* 5 out of the 126 patients whose injury could be classified as partial or complete
died and are excluded.
Vinay K. Kapoor, Anand Prakash, Rajneesh K. Singh,
Anu Behari, Ashok Kumar, Rajan Saxena
Surgical Gastroenterology, Sanjay Gandhi Post-Graduate Institute of
Medical Sciences (SGPGIMS), Lucknow, India
INTRODUCTION: Gall stone disease is common in north
India and cholecystectomy is one of the commonest opera- Outcome Based on Adverse Factors
tions performed. Bile duct injury (BDI) is a not uncommon
but dangerous complication of cholecystectomy, more so of No. of Adverse Factors
Fistula Closure
laparoscopic cholecystectomy (LC). We have reviewed our 0 (n = 9)
9 (100%)
experience with management of acute BDI.
1 (n = 18)
17 (94%)
Stricture Formation
1 (11%)
9 (50%)
2 or 3 (n = 77)
54 (70%)
64 (84%)
>3 (n = 34)
15 (44%)
30 (91%)
Total (n = 138*)
95 (69%)
104 (75%)
* 8 Patients died due to complications of acute BDI and are excluded.
PATIENTS: Retrospective analysis of 146 patients with
post-cholecystectomy acute BDI referred to and managed
at a tertiary level healthcare facility over 18 years and in
whom follow up information was available. Patients who
presented with BDI due to non-cholecystectomy procedures and those with established benign biliary strictures
Mo1690
(BBS) were excluded from this analysis.
RESULTS: There were 47 males and 99 female patients with
a mean age of 40 (range 12–71) years. The index surgery was
open cholecystectomy in 103, open cholecystectomy with
common bile duct (CBD) exploration in 9 and laparoscopic
cholecystectomy in 34 patients. Patients were referred to us
at a median of 20 (range 0–730) days after cholecystectomy.
51 out of 146 (35%) patients had one or more pre-referral
interventions (surgical 26, percutaneous 17, endoscopic 2
and combinations 6). Based on isotope scintigraphy (58),
cholangiography (52) or both (24), BDI could be classified
as partial (n = 46, 37%) or complete (80, 63%) in 126/146
patients. Based on their clinical presentation, the patients
with BDI were classified into external biliary fistula EBF (n
= 69), biloma (n = 49), bile peritonitis (n = 21) and bile
ascites (n = 7). 52 patients were managed conservatively, 41
had percutaneous intervention, 7 had endoscopic intervention, 26 were operated and 20 had combination of these
procedures. 8 (6%) patients (6 with bile peritonitis) died
due to the complications of BDI. Fistula closed in 95/ 138
(69%) surviving patients and 104/ 138 (75%) formed a biliary stricture (37/44 88% and 20/44 45% in partial injury
vs. 43/77 57% and 70/77 92% in complete injury). Open
cholecystectomy as the index procedure, jaundice at presentation, complete injury, delayed (>20 days) referral and
high (>350 ml) fistula output were predictors for persistence
of fistula and development of biliary stricture. If more than
3 adverse factors were present, the biliary fistula persisted in
more than 70% of the cases and biliary stricture developed
in more than 90% of cases.
CONCLUSION: Post-cholecystectomy BDI is associated
with significant morbidity and even mortality. Management and outcome of post-cholecystectomy BDI depends
on the clinical presentation and whether the injury is partial or complete. The short term and long term outcome of
the acute BDI in terms of fistula closure and development
of biliary stricture could be predicted based on presence of
adverse factors.
Hepatolithiasis: Transhepatic Team Management
Janak A. Parikh1, Henry A. Pitt1, Joal D. Beane1,
Matthew S. Johnson2
1
Surgery, IN University School of Medicine, Indianapolis, IN;
2
Radiology, Indiana University School of Medicne, Indianapolis, IA
BACKGROUND: Intrahepatic stones are very uncommon
in Western societies. In comparison, hepatolithiasis occurs
more frequently in Southeast Asia because of the high prevalence of congenital biliary cysts and hepatobiliary parasites. Many Asian patients present with advanced disease
which is usually managed with left hepatectomy. In North
America both the underlying biliary pathology and the timing of presentation differ, but management has not been
standardized, in part, because of the rarity of the disease.
This analysis documents the etiology, presentation and outcomes of a transhepatic team approach for management of
hepatolithiasis at a Western referral center.
METHODS: The records of patients with hepatolithiasis
managed by interventional radiologists (IR) and surgeons
from 2002 through 2012 were reviewed. Surgery was undertaken when required to repair the biliary pathology and/or
when the stone burden was extensive. All but one patient
were managed with 20F transhepatic stent (s) placed either
percutaneously or during surgery. Choledochoscopy was
performed in almost all patients either percutaneously or
intraoperatively to assist with stone removal. Laser lithotripsy and balloon dilation were undertaken for difficult
stones and strictures. Transhepatic stents were removed
when patients were stone and stricture free. A successful
outcome was defined as stent removal without symptoms
requiring more procedures.
RESULTS: Seventy-four patients were managed by IR alone
(66%) or by IR and surgery (34%). The mean age was 55.6
years, and 51.4% were women. The majority of patients were
Caucasian (80%), and only five (7%) were Asian. Underlying biliary pathology included benign strictures (55%),
choledocholithiasis (22%), sclerosing cholangitis (12%),
choledochal cysts (10%), and biliary parasites (1%). Twenty
116
patients (27%) had biliary cirrhosis, and 17 of these patients
developed hepatolithiasis after undergoing orthotopic liver
transplantation. Fifteen additional patients (20%) had a
prior biliary-enteric anastomosis. Upper abdominal pain
(65%), cholangitis (47%) and jaundice (34%) were the most
common presenting symptoms. The median number of IR
procedures was 11, and choledochoscopy (88%) laser lithotripsy (68%) and balloon dilation (47%) were performed
frequently. Surgical management included cholangio- or
hepatico-jejunostomy in 22 patients (88%) and hepatectomy in one (4%). Recurrent stone and stricture rates were
both 26% and were managed with further biliary stenting.
None of the patients have developed a cholangiocarcinoma
with a median follow-up of 29 months.
patients and the common hepatic artery in 1, and perineural invasion was mostly recognized. The median operation
time and blood loss were 554 min. (range, 438 to 1025) and
1392 ml (610 to 2900), respectively. Median graft length
and reconstruction time were 3 cm (2 to 4) and 24 min.
(19 to 30), respectively, and the hepatic artery reconstruction spent 28 min. (14 to 60). Morbidity occurred in 50%
and 2 patients (1 HLPD and 1 HL) died in hospital for liver
abscess and MRSA septemia. Median and 5-year survivals of
all patients were 24 months and 33.3% (2 patients survived
over 5 years).
CONCLUSION: Despite the small number of the subjects,
en bloc resection of HDL actually brought the favorable
results for intractable diseases. This strategy can be justified
CONCLUSIONS: A combined interventional radiologic for the rigorously selected patients.
and surgical approach employing large bore transhepatic
stents is a safe, but labor intensive, method for managing Mo1692
hepatolithiasis. This approach preserves hepatic parenExtended Hepatectomy with Portal and Hepatic Artery
chyma and prevents malignant degeneration.
Resection for Advanced Perihilar Cholangiocarcinoma
Mo1691
En Bloc Resection of Hepatoduodenal Ligament for
Advanced Biliary Malignancy
Yuji Kaneoka, Atsuyuki Maeda, Masatoshi Isogai
Surgery, Ogaki Municipal Hospital, Ogaki, Japan
Minoru Esaki, Kazuaki Shimada, Shutaro Hori, Yoji Kishi,
Satoshi Nara, Tomoo Kosuge
Hepato-Biliary pancreatic Surgery, National Cancer Center Hospital,
Tokyo, Japan
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Monday
Poster Abstracts
OBJECTIVES: The aim of this study was to clarify shortand long-term outcome of extended hepatectomy with porFrom 1996, en bloc resection of the hepatoduodenal liga- tal vein resection (PVR) or hepatic artery resection (HAR)
ment (HDL) concomitant with the neighboring organs had for perihilar cholangiocarcinoma.
been adapted for advanced biliary malignancy to achieve
R0 (histological curative) resection. Preoperative indication METHODS: Patients with perihilar cholangiocarcinoma
for this drastic surgery is a locally advanced disease involv- who underwent resection between January 2000 and
ing the portal trunk and bilateral hepatic arteries without December 2011 for perihilar cholangiocarcinoma were
the distant metastases. The portal vein was reconstructed analyzed retrospectively. Operative variables, mortality,
by the autologous vein graft and the hepatic artery was morbidity, and survival were compared among standard
reconstructed by the gastroduodenal or middle colic artery resection with no PVR and no HAR (S group), with PVR
because the long segmental resections of the vessels were without HAR (PV group) and with HAR (HA group).
mandatory.
RESULTS: A total 230 patients underwent surgical resecPATIENTS: This study comprised of 12 patients with 5 tion for perihilar cholangiocarcinoma, 172 (75%) in S
gallbladder carcinomas (GBC) and 7 cholangiocarcinomas group, 37 (16%) in PV group, and 21 (9.1%) in HA group
(CCC). Mean age of the patients was 62 years (range, 43 were enrolled. Operative time and blood loss were 633 minto 71); 7 females and 5 males. HLPD (hepato-ligamento- utes and 1415 ml in S group, 665 and 2028 in PV group,
pancreatoduodenectomy) was applied for 5 GBC and 2 775 and 2076 ml in HA group, respectively. Those with PV
CCC, and HL (hepato-ligamentectomy) for 5 CCC. PD was and HA group were significantly more than in those with S
added when massive HDL invasion was apparent. About group (both P = 0.04). Mortality and more than grade IIIa
the extent of hepatic resection, 1 right trisectionectomy, complications occurred in 4 (2.3%) and 17 (9.9%) patients
4 right hepatectomies, and 2 left hepatectomies in HLPD; with S group, in 0 and 5 (14%) with PV group and 0 and
1 right hepatectomy and 4 left hepatectomies in HL, and 3 (14%) with HA group. The rates of more than Grade IIIa
total caudate lobectomy was routinely performed. Surgical complications were comparable among 3 groups. Overall
technique and outcome of the patients were investigated 5-year survival rate and median survival time were 49% and
47.5 months in S group, 22 and 25.0 in PV group, 21 and
retrospectively.
21.4 in HA group. There was significant difference in surTiming of vascular reconstruction: The portal vein resection vival in patients between S and PV, S and HA group, respecand reconstruction was performed before the extirpation of tively. Especially, patients in HA group with R1 (surgical
the specimen, namely, just after the division of the hepatic margin positive) or with severe perineural infiltration were
ducts, and then the residual hepatic transection was fol- associated with unsatisfactory prognosis, which were not
lowed. The right external iliac vein was always used for the survived for more than 3 years.
graft. Contrary, the hepatic artery reconstruction was folCONCLUSIONS: PVR and HAR for advanced perihilar
lowed after the extirpation of the specimen.
cholangiocarcinoma were feasible. It can provide a favorRESULTS: R0 resection was achieved in 9 out of 12 patients able prognosis in selected patients of advanced perihilar
(75%). Positive margin was found in the hepatic duct in 2 cholangiocarcinoma.
Mo1693
Mo1694
Percutaneous Transhepatic Gallbladder Drainage
Without Cholecystectomy Is Optimum Procedure in
High-Risk Patients
Major Bile Duct Injury Requiring Operative
Reconstruction After Laparoscopic Cholecystectomy: A
National Perspective, 2001–2009
Masanori Akada1,2, Michinaga Takahashi1, Tatsuya Ueno1,
Shun Sato1, Shinji Goto1, Kyohei Ariake1, Shinpei Maeda1,
Hiroo Naito1
1
Surgery, South Miyagi Medical Center, Miyagi, Japan; 2Surgery,
Tohoku University, Sendai, Japan
Taranjeet Kaur, Brian S. Diggs, Brett C. Sheppard,
John G. Hunter, James P. Dolan
General Surgery, Oregon Health & Science University, Portland, OR
OBJECTIVE: Major bile duct injury (BDI) after laparoscopic cholecystectomy (LC) remains a serious concern.
According to Tokyo Guidelines 2007 for the magagemant of This study was done to determine the national incidence
acute cholecystitis, early cholecystectomy has been recom- and mortality for major BDI requiring operative reconstrucmended as first option. However percutaneous transhepatic tion after LC in the United States during the years 2001–
gallbladder drainage (PTGBD) is available for patients with 2009. Our results were compared to previously publish
moderate or severe acute cholecystitis. After PTGBD, while major BDI rates after LC reported between 1991 and 2000.
most patients undergo cholecystectomy, some patients DESIGN: Using the Nationwide Inpatient Sample of more
are treated by drainage alone, especially in very elder or than 4 million patients who underwent cholecystectomy
high-risk patients. The indication of cholecystectomy after for the years 2001–2009, we used procedure-specific codes
PTGBD remains unclear.
to measure national estimates for LC. We then calculated
MATERIALS AND METHODS: Medical records of 340 biliary reconstruction procedures that occurred after LC.
patients who were admitted to our hospital with acute cho- Biliary reconstruction performed as part of another primary
lecystitis between November 2006 and October 2011 were procedure was excluded. Finally, we analyzed incidence and
mortality rates associated with biliary reconstruction.
reviewed.
RESULTS: Sixty-six patients underwent PTGBD under RESULTS: The percentage of cholecystectomies performed
ultrasonographic guidance. Thirty-two patients underwent laparoscopically has increased over time from 71% in
cholecystectomy after PTGBD (Group A), and 34 patients 2001 to 78% in 2009. The associated mortality rate for LC
were treated by drainage alone (Group B). Because all the was 0.56% in 2001 and 0.42% in 2009 (p = 0.002). The
patients of Group B suffered from severe medical problems incidence of BDI requiring reconstruction after LC was
such as cardiovascular disease, neurologic disease, and 0.11% compared to 0.15% during 1991–2000 (p < 0.001).
dementia, they were not considered as indications for sur- The average mortality rate for patients undergoing biliary
reconstruction was 4.3% vs. 4.5% (p = 0.576) as reported
gery under general anesthesia.
previously.
All patients were categorized as moderate or severe cholecystitis. Average age of Group A and Group B were 74 CONCLUSIONS: The incidence of major BDI requiring
and 83. One patient of each group died (3.1% and 2.9%) reconstruction after LC has decreased slightly compared to
without discharge from the hospital. Rate of acalculous that seen between 1991 and 2000. In addition, associated
cholecystitis was 25% and 38%, respectively. Cholecystitis mortality rates are similar. This suggests that BDI requiring
recurred in four patients of Group B (12%) and all of them reconstruction after LC has attained a consistently low rate
were calculous. No significant difference was noted in the between 2001 and 2009.
prognosis of the two groups.
CONCLUSION: Though the recurrence rate of Group B was
not negligible, total prognosis of each group was not significant. Therefore, PTGBD without cholecystectomy is likely
to be acceptable for high-risk patients with acute cholecystitis, and cholecystectomy should be reserved for a salvage
procedure after recurrence.
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Mo1695
CONCLUSION: Percutaneous cholecystostomy remains
a valuable tool to treat cholecystitis in high risk populations. This study illustrates that cholecystostomy tube
placement can be the definitive treatment for acute cholecystitis in high risk populations. Further studies will be
needed to delineate which patients will eventually need a
cholecystectomy.
Percutaneous Cholecystostomy Placement in a
High Risk Population with Acute Cholecystitis
Ariana M. Winder, Joseph A. Blansfield, Valerie Erath,
Todd Ellison, Nicole Woll, Marie A. Hunsinger, Mohsen M.
Shabahang, John A. Semian, Mohanbabu B. Alaparthi
Surgical Oncology, Geisinger Medical Center, Danville, PA
BACKGROUND: The standard of care for cholecystitis is
cholecystectomy, however in high risk surgical patients the
mortality rate from cholecystectomy can be as high as 18
to 30%. An alternative for this population is placement of
a percutaneous transhepatic cholecystostomy which allows
for cholecystectomy electively, under more stable conditions. The goal of this study was to evaluate cholecystostomy use at our institution, study predictors of success
with this treatment in high risk patients, and study which
patients were treated definitively with cholecystomy tube
placement.
METHODS: All patients who underwent cholecystostomy
tube placement between 2007 and 2012 were included in
this study. Electronic health records were retrospectively
reviewed to delineate factors related to cholecystostomy
failure based on two criteria: the need for cholecystectomy
within 14 days of cholecystostomy placement or death
within 30 days following cholecystostomy.
Mo1696
Congenital Pouch Colon: A Clinical Study
Kewal K. Maudar
1
G.I. Surgery, Bhopal Memorial Hospital & Research Centre, Bhopal,
India; 2Paediatric Surgery, Gandhi Medical College, Bhopal, India
INTRODUCTION: Congenital pouch colon (CPC) is a
rare supralevator anorectal anomaly in which the whole of
colon or part of the colon is replaced by a pouch like dilatation. The pouch ends blindly with urogenital tract communication. The present study highlights the incidence,
classification and management of CPC
METHODS: 104 cases of congenital pouch colon managed
from Jan, 2000 to Oct, 2012 were reviewed. 83 male and 21
female neonates were operated for CPC.
RESULTS: CPC accounts for 12.55% of all anorectal malformations (ARM) and 23.33% of high ARM. The average
age of presentation was 2.16 days; 28.5% with poor general
condition. Preoperative diagnosis of CPC was possible in
71% of cases in our study. Sixty-four percent (n = 36) of
cases had incomplete pouch colon while 35% (n = 20) had
complete pouch colon. As initial procedures for incomplete
CPC included right transverse colostomy done in 40%, and
colostomy at descending colon just proximal to pouch in
10%. Ileostomy in 20% & window colostomy in 30% was
done for complete CPC. As definitive procedures; pouch
excision and abdomino-perineal pull-through of colon was
done in 53, coloplasty & abdomino-perineal pull-through
of coloplasty colon was done in 15, & pouch excision &
abdomino-perineal pull-through of terminal ileum was
done in 20 cases.
CONCLUSION(S): Staged Surgical procedures were safe
with overall mortality of 17%.
119
Monday
Poster Abstracts
RESULTS: Seventy-six patients (32 women, 42%) with a
mean age of 67 years old (range: 24–94) underwent cholecystostomy during the study period. The patients had an
average of three comorbid conditions. Overall, 53 (70%)
patients treated with cholecystostomy experienced clinical success as defined above. Twenty-three patients (30%)
underwent cholecystostomy tube placement that was
a clinical failure. Of these, 6 patients (8% of the entire
cohort) needed cholecystectomy within 14 days of cholecystostomy. Twenty patients (29% of the entire cohort)
died within 30 days of the procedure (3 patients failed both
criteria). A uni-variate analysis was performed to determine
if there were certain patient characteristics that would predict cholecystostomy treatment failure but the only statistically significant indicators for risk of death within 30 days
were intensive care unit (ICU) admission (p = 0.001) and
patients who had shock or sepsis (p = 0.02). Other clinical
factors did not prove to be predictive of success including
comorbidities, method of presentation, imaging characteristics, antibiotic usage, bile cultures, and American Society
of Anesthesiologists (ASA) physical status classification. Of
the 76 total patients, 24 (31.6%) had a cholecystectomy
an average of 66 days following cholecystostomy placement (Interquartile range: 19, 71). Of the 53 patients who
experienced initial clinical success, 35 patients (66% of
these patients) were definitively treated and did not need
a cholecystectomy.
Clinical: Colon-Rectal
Mo1697
Colonic Disasters Approached by Emergent Total
Colectomy: Lessons Learned from 120 Consecutive
Cases
Michael Schweigert1, Attila Dubecz1, Norbert Solymosi2,
Hubert J. Stein3, Dietmar Ofner1
1
Department of General and Thoracic Surgery, Klinikum Nuremberg
Nord, Nuremberg, Germany; 2Szent István University, Budapest,
Hungary; 3Department of Surgery, Paracelsus Medical University,
Salzburg, Austria
OBJECTIVE: Diverse abdominal emergencies result in
irreversible devitalization of the colon. Mainly the very
elderly are affected. Morbidity and mortality are significant
while adequate surgical strategies are still controversially
discussed. Aim of this study is to investigate the outcome
of emergent complete colectomy with special respect to
results in the very elderly.
MATERIAL AND METHODS: Records of 120 consecutive
patients who underwent emergent subtotal or total colectomy at a German tertiary referral hospital were reviewed
in a retrospective study. Indication groups as well as age
groups were formed for statistical analysis.
RESULTS: There were 73 male and 47 female patients with
a mean age of 70 years. Altogether 81 total and 39 subtotal colectomies were performed for mainly ischemia related
large intestine infarction (62), obstructing carcinoma (17),
fulminant diverticulitis (10), ulcerative colitis (9) and pseudomembranous colitis (7).
Mean ASA score was 3.47. Severe sepsis or even septic shock
was present in 82 cases. In-hospital-mortality was 42. Colectomy for ischemic bowel infarction showed significant
higher mortality than for pseudomembranous colitis (p =
0.018) whereas there were no further significant differences
amidst the indication groups. Between the age groups
there was neither significant difference in mortality nor
in prevalence of sepsis. However, sepsis (OR: 16.81; 95%
CI 3.89–153.32; p < 0.001), ASA score ≥4 (OR: 5.84; 95%
CI: 2.33–16.00; p < 0.001) and total colectomy (OR: 4.40;
95% CI: 1.57–14.12; p = 0.02) were associated with higher
mortality.
CONCLUSIONS: Emergent colectomy provides a practical solution for a wide range of heterogeneous abdominal
emergencies resulting in colonic disintegration and necrosis. Outcome depends on the underlying disease, ASA score,
extent of colonic resection and presence of sepsis whereas
age shows no significant influence. Therefore, we conclude
that advanced age itself should not be regarded as contraindication for emergent colectomy.
Figure 1: Ischemic colitis with transmural infarction Fig 1a shows
complete gangrene of the colon in an 82-year-old man. The specimen
is ischemic and necrotic from cecum to sigmoid colon. Fig 1b shows
a colectomy specimen from a 78-year-old woman. Easily visible are
multiple black colored sections resembling transmural gangrene.
120
Mo1698
A Comparison of Tumour and Host Determinants
of Outcome in Screen Detected Versus Non-Screen
Detected Colorectal Cancer: A Contemporaneous Study
David Mansouri1, Donald C. Mcmillan1, Campbell S.
Roxburgh1, Emilia Crighton2, Paul G. Horgan1
1
United Kingdom; 2Public Health Directorate, NHS Greater Glasgow &
Clyde, Glasgow, United Kingdom
BACKGROUND: Screening for colorectal cancer using the
faecal occult blood test (FOBt) has been shown to reduce
cancer specific mortality through the detection of early
stage disease. However, it is recognised that there are additional tumour factors, such as the presence of venous invasion, and host factors, including the systemic inflammatory
response, that are key determinants of outcome independent of stage. To date, the prevalence of such factors has
not been examined in screen-detected colorectal cancer (1).
AIM: The aim of this study was to compare the prevalence
of tumour and host determinants of outcome in patients
with screen detected (SD) and non-screen detected (NSD)
colorectal cancer in a contemporaneous group.
METHODS: All patients who underwent potentially curative surgery for colorectal cancer either via the national
FOBt screening programme (SD) or presented symptomatically in a single institution (NSD) between May 2009 and
April 2011 were identified from prospectively maintained
databases.
Figure 2: Acutely obstructing carcinoma of the left colon Due to acute
large bowel obstruction the abdomen is monstrously distended. Fig 2a
shows the female patient already placed in supine position ready for
surgery. The large intestine is bulging out immediately after laparotomy
(Fig 2b). Serosal rupture and bursting of the tenia (arrows) are clearly
visible. Some parts of the distended colon show ischemic lesions. Fig 2c
shows the specimen following total colectomy. An acutely obstructing
carcinoma of the sigmoid colon (arrow) was causative for the ileus. Again
serosal tears and bursting is obvious.
When node negative patients were examined independently (n = 242;177 SD, 65 NSD), the differences in both the
tumour and host determinants of outcome remained. SD
patients had less evidence of vascular invasion (p = 0.034),
margin involvement (p = 0.039) and tumour perforation
(p = 0.059), in addition to having a lower systemic inflammatory response (NLR > 5 in 7% vs 23%, p < 0.001) and less
anaemia (18% vs 54%, p < 0.001) than NSD patients.
CONCLUSIONS: The results from this study suggest that,
compared with NSD tumours, SD tumours, in addition to
being of an earlier stage, have more favourable tumour
pathological features. Furthermore, adverse host prognostic
factors such as the presence of anaemia and an elevated
systemic inflammatory response are also less likely to be
present in patients with SD tumours.
121
Monday
Poster Abstracts
RESULTS: A total of 394 (288 SD, 106 NSD) patients were
identified. Compared with the NSD patients, SD patients
were more likely to be younger (p < 0.001) and have
tumours that were colonic (p = 0.001), left sided (p < 0.001)
and of an earlier stage (50% Dukes A vs 17% Dukes A, p <
0.001). When high risk tumour features were examined,
vascular invasion (p = 0.023), margin involvement (p =
0.009), poor differentiation (p = 0.009) and tumour perforation (p = 0.093) were all less likely to be present in SD
tumours. The systemic inflammatory response, as measured
by the Neutrophil to Lymphocyte Ratio (NLR), was elevated
in significantly less SD patients than NSD patients (NLR > 5
in 7% vs 24%, p < 0.001). In addition, less SD patients were
anaemic (22% vs 50%, p < 0.001).
REFERENCES:
1. Mansouri D, et al. Screening for colorectal cancer: What
is the impact on the determinants of outcome? Crit Rev
Oncol Hematol. 2012. Epub September 2012.
Comparison of Tumour and Host Determinants of Outcome in
Screen Detected vs. Non-Screen Detected Colorectal Cancer
Screen
Detected
n (%)
288 (100)
Tumour stage
A
144 (50)
B
67 (23)
C
70 (24)
D
7 (2)
Vascular invasion (a)
Y/N
121 (42)/160 (56)
Peritoneal involvement
Y/N
11 (4)/277 (96)
Margin involvement
Y/N
6 (2)/282 (98)
Tumour perforation
Y/N
2 (1)/286 (99)
Poorly differentiated
Y/N
6 (2)/282 (98)
Neutrophil:Lymphocyte
Ratio (b)
16 (7)/230 (93)
≥5/<5
Non-Screen
Detected
n (%)
METHODS: Patients undergoing elective resection for
colorectal cancer were included in the study (n = 310). The
patients were admitted to one of two independent colorectal units. One unit employed enhanced recovery procedures
(n = 150), the other used conventional care (n = 160). From
a prospectively maintained database, data on postoperative
infective complications and C-reactive protein concentrations on postoperative days 1 to 5 was extracted.
p-Value
106 (100)
17 (17)
50 (47)
31 (29)
8 (8)
<0.001
61 (58)/43 (41)
0.023
22 (21)/85 (79)
<0.001
8 (8)/98 (92)
0.009
3 (3)/103 (97)
0.093
8 (8)/98 (92)
0.009
25 (24)/79 (76)
<0.001
52 (50)/52 (50)
<0.001
RESULTS: A total of 310 patients were included. Age and
sex were similar in both groups. Co-morbidity, as demonstrated by ASA scores, was significantly less in the enhanced
recovery group, and there were also fewer rectal cancers as
well as earlier tumour stage (p = 0.005, p = 0.030, and p =
0.008 respectively). In the enhanced recovery group length
of stay was significantly shorter and laparoscopic surgery
was used in approximately 30% of cases (both p < 0.001).
The method of perioperative care was not significantly associated with a difference in the rate of postoperative infective complications, or C-reactive protein on postoperative
days 1 to 5.
When patients with rectal cancers were excluded from further analysis (n = 211), age, sex and tumour stage were similar in both groups. Co-morbidity remained significantly
less in the enhanced recovery group (p = 0.024), length of
stay was significantly shorter and laparoscopic surgery was
used in 30% of cases (both p < 0.001). Enhanced recovery
was significantly associated with a reduction in the development of pneumonia following elective surgery for colon
cancer (p = 0.028), but was not associated with a significant
difference in the systemic inflammatory response following
on postoperative days 1 to 5.
Anaemia (b)
Y/N
53 (22)/193 (78)
However, data on their effect on infective complications
and the systemic inflammatory response remains limited.
Recent studies have shown that the magnitude of the systemic inflammatory response following surgery predicts
the development of infective complications. The aim of the
present study was to assess the impact of enhanced recovery on the rate of infective complications, and the systemic inflammatory response, following colorectal cancer
resection.
[a. n = 385 (98%): b. n = 350 (89%)]
Mo1699
Infective Complications Following Colorectal Cancer
Resection: Enhanced Recovery Confers No Advantage
over Conventional Care
Michelle L. Ramanathan1, Graham Mackay2,
Jonathan J. Platt1, Paul G. Horgan1, Donald C. Mcmillan1
1
Department of Surgery, University of Glasgow, Glasgow, United
Kingdom; 2Department of Surgery, Glasgow Royal Infirmary, Glasgow,
United Kingdom
AIM: Enhanced recovery after surgery programmes aim to
attenuate the stress response to surgery and are said to be
associated with reduced hospital morbidity and mortality.
CONCLUSION: Enhanced recovery was associated with
a significant reduction in length of hospital stay. In contrast, the post-operative systemic inflammatory response
was similar in the conventional care and enhanced recovery groups. Overall complication rates, both infective and
non-infective, were also similar. Enhanced recovery does
not appear to be associated with a reduction in the postoperative systemic inflammatory response or overall infective
complications.
122
Mo1700
ability to tolerate a diet or resolution of obstructive symptoms (successful treatment), rates of re-obstruction, hospital
length of stay, and quality of life. We excluded case studies
with fewer than 5 patients, studies of operations with curative rather than palliative intent, studies of percutaneous
procedures, and studies where outcomes of benign obstruction could not be separated from malignant.
Palliative Surgery for Malignant Bowel Obstruction:
A Systematic Review
Terrah J. Paul Olson1, Carolyn Pinkerton2, Karen J. Brasel2,
Margaret L. Schwarze3
1
General Surgery, University of Wisconsin Hospital and Clinics,
Madison, WI; 2Surgery, Medical College of Wisconsin, Milwaukee,
WI; 3Division of Vascular Surgery, University of Wisconsin School of
Medicine and Public Health, Madison, WI
RESULTS: We screened 2347 titles and selected 109 articles
for review. Fifteen studies fit our inclusion and exclusion
criteria. Survival and post-operative outcomes are summarized in the table. Median postoperative survival was low
OBJECTIVES: Malignant bowel obstruction (MBO) from (range 36 days-7.9 months) while postoperative mortality
peritoneal metastasis has a grim prognosis regardless of the was high (range 6–32%). Complications included wound
primary cancer. Patients presenting with MBO have a life dehiscence, enterocutaneous fistulae, sepsis, pulmonary
expectancy of weeks to months. When conservative treat- emboli, and cardiopulmonary complications. Median
ments such as medications and gastric drainage are inad- lengths of stay ranged from 13–25 days. Rates of re-obstrucequate, palliative surgery may provide symptomatic relief. tion varied widely (range 6–47%). No studies reported qualMorbidity and mortality after surgery for MBO is high, and ity of life postoperatively.
effects of palliative surgery on patients’ quality of life are
not well characterized. We performed a systematic review to DISCUSSION: This review highlights postoperative outbetter characterize palliative surgery outcomes for patients comes that can be used preoperatively to inform surgical
with MBO to guide decision making about the value of sur- decision making for MBO. Given the high mortality and
gery and associated postoperative interventions in the set- substantial length of stay relative to overall survival, a thorough discussion of the patient’s values and goals is advisting of incurable cancer.
able. Patients should be apprised of the modest chance of
MATERIALS AND METHODS: We searched PubMed, resuming a diet or relieving symptoms. Because 30–40% of
EMBASE, CINAHL Plus, Cochrane Library, Web of Knowl- these terminally ill patients will experience serious compliedge, and Google Scholar from inception through August cations, patients should discuss whether aggressive man2012 for all available literature in all languages. We included agement of postoperative complications is in line with their
studies reporting outcomes after open or laparoscopic sur- goals. Additionally, this study highlights a profound lack of
gery for bowel obstruction from peritoneal metastases from attention to patient-centered outcomes for palliative surgiany primary malignancy. Outcomes of interest included sur- cal therapy.
vival, postoperative mortality, postoperative complications,
Table: Outcomes After Palliative Surgery for Malignant Bowel Obstruction
N
79
63
30
85
Malignancy
CRC*, GYN†, other
CRC, non-GYN other
CRC
CRC, GYN, other
123
Post-Operative
Complications
35% (28/79)
44% (28/63)
27% (8/30)
42% (36/85)
Successful Treatment
Not reported
45% (29/63)
Not reported
55% (47/85)
44% (39/89)
74% (66/89)
5% (1/20)
Not reported
Not reported
32% (6/19)
85% (23/27)
68% (13/19)
13% (3/23)
27% (24/90)
48% (11/23)
66% (59/90)
32% (8/25)
20% (5/25)
33% (9/27)
31% (19/60)
59% (16/27)
Not reported
23% (15/64)
15% (8/52)
58% (37/64)
65% (34/52)
Monday
Poster Abstracts
Post-Operative
Survival
Mortality
Median 5 months
10% (8/79)
Median 3 months
21% (13/63)
Not reported
17% (5/30)
Median 3 months
22% (19/85)
(range 0–144 months)
Turnbull 1989
89
CRC, non-GYN other
Median 98 days
13% (12/89)
(range 1 day–2.5 years)
Van Ooijen 1993
20
GYN, CRC, other
Median 36 days
Not reported
(range 3–151 days
Wong 2009
27
CRC, GYN, other
Not reported
15% (4/27)
Bais 1995
19
Ovarian
Median 109 days
11% (2/19)
(range 15–775 days)
Kim 2009
23
Ovarian
Not reported
Not reported
Kolomainen 2012
90
Ovarian
Median 90.5 days
18% (16/90)
(range <1 day–6 years)
Lund 1989
25
Ovarian
Median 68 days
32% (8/25)
(range 7–919 days)
Mangili 2005
27
Ovarian
Not reported
22% (6/27)
Piver 1982
60
Ovarian
Median 2.5 months
17% (10/60)
(range <1–27 months)
Pothuri 2003
64
Ovarian
Median 7.9 months
6% (4/64)
Rubin 1989
52
Ovarian
Median 5.8 months
17% (9/52)
(range 0.02–37 months)
*Colorectal cancer †Gynecologic malignancies including ovarian, cervical, uterine, and endometrial cancers
Study
Abbas 2006, 2007
Blair 2001
Lau 1993
Mäkelä 1991
Mo1701
Surgical Stricturoplasty in the Treatment of Pouch
Strictures
Xian-Rui Wu1, Saurabh Mukewar2, Pokala R. Kiran1,
Feza H. Remzi1, Bo Shen2
1
Departments of Colorectal Surgery, Cleveland Clinic, Cleveland, OH;
2
Department of Gastroenterology/Hepatology, Cleveland Clinic,
Cleveland, OH
OBJECTIVE: To evaluate the efficacy of stricturoplasty in
the treatment of pouch strictures in comparison with endoscopic balloon dilation.
CONCLUSIONS: Patients with pouch strictures had a
SUMMARY BACKGROUND DATA: There was only one similar overall pouch survival after being treated with striccase report on surgical stricturosplasty in treating pouch turoplasty and endoscopic balloon dilation. Surgical stricturoplasty tended to have a better stricture-free survival
strictures.
benefit.
METHODS: Consecutive inflammatory bowel disease
(IBD) patients with ileal pouch strictures seen in our Pouchitis Clinic from 2002–2012 were studied. Efficacy and Mo1702
safety were evaluated with both univariate and multivari- Outpatient Anal Exploration and Fistula Treatment in
ate analysis.
RESULTS: A total of 167 patients met the inclusion criteria,
including 16 (9.6%) who had surgical stricturoplasty and
151 (90.4%) had at least one endoscopic stricture dilation
therapy. Ninety-four patients (56.3%) were male, with a
mean age at the diagnosis of pouch strictures of 41.6 ± 13.2
years. Fifty-one patients (30.5%) had multiple pouch strictures, and pouch inlet strictures occurred in 100 (59.9%).
The mean length of pouch strictures was 1.2 ± 0.6 cm. No
difference was identified between the stricturoplasty and
dilation groups in clinicopathological variables, except for
degree of strictures (P = 0.019). After a mean follow-up of 4.1
± 2.6 years, pouch stricture recurred in 92 patients (55.1%)
and 21 (12.6%) developed pouch failure. The time interval
between the procedure and pouch stricture recurrence or
pouch failure was longer in the stricturoplasty group than
in the dilation group (P < 0.001). Although patients in the
two groups had a similar overall pouch survival (5-year
overall-pouch-survival: 83.1% vs. 82.0%), patients treated
with stricturoplasty seemed to bear a better pouch stricturefree survival than those with endoscopic balloon dilation
(5-year pouch-stricture-free-survival: 39.8% vs. 33.1%).
There was no difference in complication rates between the
two groups.
Table: Multivariate Analysis of the Risk Factors Associated with Overall
Pouch Survival and Pouch Stricture-Free Survival
Characteristic
Hazard Ratio
Overall Pouch Survival
Postop use of biologics (yes vs no)
6.249
Degree of stricture (3 vs 1 or 2)
4.125
Post-IPAA complications (yes vs no)
5.528
Treatment modality (stricturoplasty vs
0.974
endoscopic balloon dilation)
Pouch Stricture-free Survival
Number of stricture (2 vs 1)
4.827
Degree of stricture (3 vs 1 or 2)
2.005
Treatment modality (stricturoplasty vs
0.548
endoscopic balloon dilation)
95% CI
P Value
2.296–17.012
1.707–9.970
2.038–14.995
0.205–4.632
<0.001
0.002
0.001
0.973
3.167–7.356
1.239–3.245
0.279–1.075
<0.001
0.005
0.080
Patients with Symptomatic Peri-Anal Crohn’s Disease:
Preliminary Report
Rosa Scaramuzzo, Edoardo Iaculli, Cristina Fiorani,
Livia Biancone, Giovanna Del Vecchio Blanco, Sara Di Carlo,
Giuseppe S. Sica
BACKGROUND: One third of Crohn’s disease (CD)
patients presents fistula in ano. Peri-anal disease (PAD) in
CD patients can be clinically asymptomatic or extremely
severe. Gold standard in the diagnosis and treatment of
symptomatic PAD in CD is the exploration of the anal canal
and distal rectum under anesthesia (EUA). This procedure is
generally offered as a day case surgery. Giving the shortage
of resources, it is not always possible to proceed as planned,
and an incorrect timing may well represent a relevant issue
in the clinical management of these patients.
In a prospective longitudinal study we aimed to assess the
feasibility of an outpatient assessment and treatment of
symptomatic PAD in CD patients.
METHODS: All CD patients under regular follow-up at
our Inflammatory Bowel Disease referral center, presenting
with symptomatic PAD, were offered surgical consultation.
Data of patients seen between February 2010 until April
2011 were collected for the purpose of the study. All clinical
information, including previous EUA and\or records from
Magnetic Resonance Imaging and endoscopic ultrasound
were reviewed. Outpatient anal canal exploration (OE)
and treatment was undertaken during the specialist surgical consultation. Fistula were classified according to Park’s
classification; type of outpatient treatment and compliance
were recorded and pain was assessed by VAS scale at the
time of the procedure. Patients were followed up in the surgical clinic for 12 months.
RESULTS: During the study period, 26 CD patients with
symptomatic PAD were referred to the surgical outpatient
clinic. All the 26 non selected patients were offered surgical exploration. Compliance was excellent as none refused
the proposed treatment. It was possible to perform a full
124
OE in 23 (88%) patients. In Table 1 are reported details of
procedure and findings. In 23 patients (88%) it was possible
to complete OE of the anal canal and distal rectum. Out
of these 23 patients in 20 (87%) a surgical procedure was
undertaken (77% of the grand total).
CONCLUSIONS. From this preliminary experience, OE
and fistula treatment because of symptomatic PAD in CD
seems to be feasible in referral centers, with results comparable with most EUA series.
Results of the Study According to Park’s Classification
Imaging
Outpatents Treatment
VAS
Relapse After # of Exams
Type of Fistula
#
%
Setonage
Drainage # of Treatment (Median 0–10) Procedure # (%) MRI
US
Suprasphinteric
7 (6) *, (1) **
30
2 (28%)
4 (57%)
1 (14%)
1.57 (0–3)
1 (14%)
2
1
Intersphinteric
4 (3) *
17
3 (75%)
1 (25%)
0
2.25 (1–4)
0
1
0
Extrasphinteric
6 (2) *,
26
5 (83%)
0
1 (17%)
1.7 (1–3)
3 (50%)
4
0
Trans-sphinteric
3 (1) *
12
2 (66%)
0
1 (33%)
1.7 (0–4)
0
2
1
Rectovaginal
2 (1) *, (2) **
9
2 (100%)
0
0
2.5 (2–3)
0
1
1
Unclassified
2 (1) *
9
0
2 (100%)
0
1 (1–1)
0
1
0
() * fistula relapsed after previous treatment () ** fistula with more than one tract
Concordance
with Imaging
MRI
US
1/2
1/1
1/1
-–
3/1
-–
1/2
1/1
1/1
1/1
0/1
–
observed a subclinical myopathy characterized by an abnormal distribution of myonuclei relocated from the periphery
Clinical Profile and Skeletal Muscle Histopathology
inside the myofiber, and by the presence of regenerating
muscle fibers. The percentage of myofibers with abnormally
of Patients Affected with Early Diagnosed Colorectal
Cancer: Diagnostic and Prognostic Markers of Disease? located myonuclei was significantly higher in patients
(median = 9%) compared to controls (median = 2.7%) (p =
Mario Gruppo1, Nicoletta Adami2, Sandra Zampieri2,
0.0002). Moreover, the percentage of regenerating myofiRoberto Rizzato1, Mario Bernardo3, Benedetto Mungo1,
ber expressing the MHC-emb and N-CAM biomarkers was
Renato Salvador1, Lino Polese1, Stefano Merigliano1
higher in patients compared to controls (MHC-emb posi1
Department of Surgical, Oncological and Gastroenterological
tive 14,6% vs 5,9% p = n.s; N-CAM positive 31,7% vs 5,9%,
Sciences, University Hospital of Padua, Padova, Italy; 2Department
p = 0.04) (Table 1). No correlations were found between
of Biomedical Sciences, University Hospital of Padua, Padova, Italy;
the histopathological findings of the skeletal muscle and
3
Department of Emergency, Anaesthesiology and Intensive care,
clinico-serological characteristics of the patients. We found
an inverse correlation between the number of abnormally
University of Tor Vergata, Rome, Italy
BACKGROUND: Skeletal muscle in patients with cancer nucleated myofibers and the presence of lymph node
undergoes many morphological changes due to immuno- metastasis (N + ) (ñ) = -0.64 (p = 0.002). Myofibers atrophy
inflammatory factors of tumor origin and/or to the phar- wasn’t observed. The ATPase analyses of skeletal muscle
macologic treatment of the disease. The latest event of biopsies from patients and controls showed a higher percentage of fast type fibers in skeletal muscle biopsies from
these changes is cancer cachexia.
cancer patients compared to controls (56% vs 46%, p =
The aim of our study was to investigate the clinical charac- 0.06) (Table 1). Interestingly, the internally nucleated myoteristics and the histopathologic features of skeletal muscle fibers were predominantly of fast type (Figure 1).
and excised tumor from patients affected with colorectal
cancer at diagnosis in order to possibly identify clinical fac- Table 1: Histopathological Features of Rectus Abdominis Muscle Biopsies
tors associated to myopathic features that could be used as
Patients
Controls
p
predictive biomarkers of disease progression.
Mo1703
Mean myofiber diameter (m)
51.1
50.3
n.s.
Abnormally nucleated myofibers (%)
9
2.7
0.0002
Type II fibers (%)
56
46
0.06
MHC-emb positive myofibers (%, no.)
14.6 (6)
5,9 (1)
n.s
N-CAM positive myofibers (%, no.)
31.7 (3)
5,9 (1)
0.04
MHC-emb embryonic myosin heavy chain; N-CAM neural cell adhesion molecule;
n.s. not significant.
RESULTS: 44 patients and 17 controls affected with noninflammatory benign diseases, were recruited for the study.
In the skeletal muscle biopsies from cancer patients, we
125
Monday
Poster Abstracts
PATIENTS AND METHODS: Morphometric studies and
immunohistochemical analyses were performed on intraoperative rectus abdominis muscle biopsies from weight stable
patients with an early diagnosis of colorectal cancer, before
systemic or radiant therapies, with no signs of muscle weakness or myopathies. The correlation between histopathologic findings of skeletal muscle biopsies, resected tumor,
and clinico-serological characteristics was investigated.
analyze categorical variables and a Mann-Whitney test used
for continuous variables. A forward logistic regression was
utilized to identify factors independently associated with
the need for reoperation using all available covariates, with
a p-value <0.05 considered to be statistically significant.
RESULTS: 61 patients met study inclusion criteria. Median
age of the study cohort was 45 (range, 14–92) years, and
included 32 males (53%). Indications for surgery were
inflammatory bowel disease (n = 25), cancer (n = 15),
small bowel obstruction (n = 9), and other conditions (n
= 12). Anastomotic types included enterocolic (n = 17),
enteroenteric (n = 16), enteroanal (n = 14), colorectal (n
= 8), colocolonic (n = 4) and coloanal (n = 2). TwentyFigure 1: A and B: ATPase staining after preincubation at pH 4.35, of
two patients (36%) had an infraperitoneal anastomosis. 50
cross sections from control (A) and patient (B) muscle biopsies. Fastpatients (82%) successfully underwent therapeutic PD of a
type fibers are visualized as light, while slow-twitch fibers are dark.
perianastomotic fluid collection, with median follow-up of
Fast fibers are predominant in cancer patients muscle biopsies and
16 months. 11 patients (18%), at a median interval of 16
preferentially show internal nuclei (arrowhead). Calibration bar = 100 m. days, required reoperation following PD. A forward logistic regression showed cardiopulmonary disease (p = 0.03)
CONCLUSIONS: Patients affected with colorectal cancer and cancer surgery (p = 0.01) to be factors independently
display early signs of a subclinical myopathy, character- associated with the need for reoperation. Level of the anasized by abnormally nucleated and regenerating myofibers, tomosis, initial fecal diversion/stoma, fluid collection size
that is inversely associated with the presence of lymph and microbiology of aspirate did not predict failure of PD.
node metastasis. Additional follow-up studies are needed to CONCLUSION: Cardiopulmonary disease and cancer surclarify this association, but our observation could provide gery appear to be independent predictors for failure of PD
new diagnostic biomarker of disease progression in specific and the need for reoperation following symptomatic GI
subgroup of patients.
anastomotic leak. For patients without these risk factors,
PD is a valuable tool for managing anastomotic leaks conservatively with a high degree of success.
Mo1704
Risk Factors for Failure of Percutaneous Drainage
and Need for Re-Operation Following Symptomatic
Gastrointestinal Anastomotic Leak
Mo1706
The Impact of Laparoscopic Versus Open Approach on
Re-Operation Rate After Segmental Colectomy
Seth Felder, Galinos Barmparas, Zuri A. Murrell, Phillip Fleshner
Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
BACKGROUND: Anastomotic leak is a devastating complication following gastrointestinal (GI) surgery. Few studies have evaluated the role of CT-guided percutaneous
drainage (PD) in the management of these leaks. The aim
of this study was to define predictive clinical, laboratory,
radiographic, or operative factors for CT-guided PD failure
of symptomatic anastomotic leaks after GI surgery.
Paul Speicher, Betty Jiang, John Migaly
Surgery, Duke University Medical Center, Durham, NC
BACKGROUND: Unplanned return to the operating room
has recently gained favor as a reliable indicator of surgeryspecific complications. Despite this, reoperation rate has
not been well studied as a primary outcome when comparing laparoscopic with open approaches for colorectal resection. The goal of this study was to determine the impact of
METHODS: A 10-year retrospective review of an interven- a laparoscopic approach on rate of reoperation after elective
tional radiology database was conducted to identify patients segmental colectomy.
with symptomatic anastomotic leak after undergoing GI METHODS: The NSQIP Participant Use Data File for 2005–
surgery. Inclusion criteria were patients having small bowel 2011 was used to retrospectively identify all patients who
or colorectal surgery, the operating surgeon documenting underwent either open or laparoscopic segmental colon
clinical concern for postoperative anastomotic leak, a sup- resection for neoplasms, diverticular disease, and polyp
porting CT demonstrating a fluid collection adjacent to an disease. To capture only elective cases, the following were
anastomosis, and the use of PD as initial therapy. Exclusion excluded: emergency cases, ASA class 5 (moribund patient
criteria included patients undergoing foregut surgery, con- who is not expected to survive without the operation), and
comitantly undergoing hepatobiliary or pancreatic anasto- preoperative sepsis. The primary outcome measure was rate
moses, and/or solid organ resection. Patient characteristics of early return to the operating room, defined in NSQIP
(clinical, laboratory, radiographic, operative) following as returns to the operating room within the 30-day posta technically successful PD who then failed and required operative period. A multiple logistic regression model was
reoperation for anastomotic leak were compared to those constructed to determine the independent effect of surgical
successfully treated with PD. Fisher’s exact test was used to approach on rates of unplanned reoperation.
126
RESULTS: Between 2005 and 2011, a total of 39,897
patients were identified who met the study inclusion criteria. Preoperative characteristics between open and laparoscopic groups were similar, despite being statistically
significant due to very large sample sizes (Table 1). A total
of 1,726 reoperations (4.3%) were identified. In the open
approach group, 852 of 16,644 patients (5.1%) required
reoperation, compared to 874 of 23,253 patients (3.8%) in
the laparoscopic group. After adjusting for potential confounders, laparoscopic colorectal resection was found to
have an adjusted odds ratio of 0.82 (95% CI 0.74 to 0.92, p
= 0.001) as compared to the traditional open approach for
risk of return to the operating room.
with inconclusive results. Using a large administrative dataset, we found that for segmental colectomy, laparoscopic
approach was associated with a small but statistically significant decrease in odds of return to the operating room.
Reoperation is a relatively rare but costly complication after
elective segmental colectomy, and remains a potential area
for significant quality improvement.
Adjusted for the following pre-operative variables: age,
gender, smoking status, body mass index, alcohol use,
functional independence level, do-not-resuscitate status,
medical comorbidities (bleeding disorders, COPD, CAD,
CHF, dyspnea, renal failure), case contamination, operative
time, disseminated malignancy, pre-operative weight loss,
DISCUSSION: Numerous studies have included reoperation chemotherapy, radiation therapy, ASA class 3 or greater,
rate as a univariate secondary endpoint when comparing resident assistance in OR.
laparoscopic versus open approach to colorectal procedures,
Preoperative and Intra-Operative Characteristics
Characteristic
p-value
<0.001
0.181
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.17
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.002
0.71
<0.001
<0.001
<0.001
Multivariable Logistic Regression for Postoperative Outcomes Following Laparoscopic Approach
Complication
Return to the operating room within 30 days
Superficial surgical site infection
Deep incisional surgical site infection
Organ space surgical site infection
Post-operative sepsis
All-cause 30-day mortality
95% Confidence Interval
Lower
Upper
0.74
0.92
0.59
0.70
0.40
0.63
0.66
0.88
0.53
0.69
0.47
0.73
Odds Ratio
0.82
0.64
0.50
0.76
0.61
0.58
127
p-Value
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
Monday
Poster Abstracts
Age (median) in years
Female gender
Smoking status
Preoperative dyspnea
Do-not-resuscitate order
Diabetes mellitus
Chronic steroid use
Non-independent functional status
Alcohol > 2 drinks/day
History of COPD
History of CAD
History of CHF
Dialysis-dependent preoperatively
Disseminated malignancy
>10% weight loss in last 6 months
Bleeding disorder
Preoperative transfusion
Chemotherapy in 30 days preop
Radiation therapy in 90 days preop
Preoperative ventilator dependence
Resident participation in OR
Contaminated or dirty case
ASA class 3 or greater
Operative time (median)
Surgical Approach
Laparoscopic (n = 23,253)
65 (55,74)
12045 (52.0%)
3367 (14.5%)
2209 (9.5%)
79 (0.4%)
3403 (14.6%)
481 (2.1%)
553 (2.4%)
704 (3.5%)
1015 (4.4%)
1953 (9.8%)
138 (0.6%)
82 (0.4%)
450 (1.9%)
545 (2.3%)
622 (2.7%)
152 (0.7%)
75 (0.4%)
25 (0.1%)
2 (<0.1%)
11680 (60.1%)
1884 (8.1%)
9395 (40.4%)
141 (107,184)
Open (n = 16,644)
67 (56,77)
8752 (52.7%)
2967 (17.8%)
2134 (12.8%)
169 (1.1%)
2885 (17.3%)
509 (3.1%)
996 (6.0%)
569 (3.8%)
1106 (6.6%)
1865 (12.5%)
199 (1.2%)
122 (0.7%)
965 (5.8%)
1008 (6.1%)
767 (4.6%)
240 (1.4%)
155 (1.0%)
51 (0.3%)
11 (0.1%)
8774 (60.3%)
2715 (16.3%)
9117 (54.8%)
131 (95,181)
Mo1707
Mo1708
Insurance Affects Readmission After GI Surgery: A
Longitudinal Analysis
Local Excision of T1 and T2 Rectal Cancer: Proceed
with Caution
Zeling Chau1,2, Elan R. Witkowski1, Sing Chau NG2,
Elizaveta Ragulin-Coyne1, Heena P. Santry1, Tara S. Kent3,
A. James Moser2, Mark P. Callery3, Jennifer F. Tseng1,2
1
Department of General Surgery, University of Massachusetts,
Worcester, MA; 2Division of Surgical Oncology, Beth Israel Medical
Center – Harvard Medical School, Boston, MA; 3Department of
Surgery, Beth Israel Medical Center – Harvard Medical School,
Boston, MA
Mohamed M. Elmessiry, Antonio Maya, Giovanna Da Silva,
Steven Wexner, Mariana Berho
Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
PURPOSE: The purpose of this study was to compare the
results of local excision (LE) with total mesorectal excision
(TME) of early rectal cancer
BACKGROUND: Hospital readmission rates are increasingly used to measure quality of care. The impact of
insurance on postoperative readmission rates is not well
characterized. We aimed to determine the impact of insurance on short-term readmissions for GI surgery.
METHODS: Florida State Inpatient Database queried to
identify all esophageal, gastric, pancreas, liver and colon
resections performed for cancer during 2007–2009. Patients
<18, ≥65 or with Medicare excluded to reduce the effect of
Medicare confounding. Annual surgical volume calculated
by tertiles. Readmission defined as inpatient admission ≤30
days from index discharge. Univariate and multivariate
analyses performed by chi-square and logistic regression.
For all, p-values <0.05 considered significant.
METHODS: After IRB approval, medical records of patients
with T1, T2 N0M0 rectal adenocarcinoma treated by curative LE or TME without preoperative radiotherapy from
2004 to 2012 were reviewed. Chi-square and ANOVA tests
were used to compare categorical and continuous variables,
respectively. Survival rates were compared using KaplanMayer test
RESULTS: 153 patients were included in the study, 79
underwent TME and 74 LE. The two groups were similar
in regards to age, gender, BMI, ASA score, co-morbidities,
tumor location, size, grade and stage. In TME, the mean
operative time was prolonged (196 vs. 77 min, P < 0.00),
the mean estimated blood loss was significantly more (214
vs. 26 ml, P < 0.00) and hospital stay was significantly
increased (7.4 vs. 2.5 days, P < 0.001). No patient had stoma
after LE compared to 48.7% after TME (P = 0.00). Postoperative infection was more common after TME (21.6 vs. 0%,
P = 0.00). Margins were involved by tumor in 13.5% after
LE compared to 0% after TME (P = 0.00). 13.5% of patients
treated initially by LE were re-operated for unfavorable histological findings and 4.1% had residual tumor. The mean
follow up period was 35 months). In 56 patients with pT1,
there was no mortality and although not statistically significant an increase in local recurrence after LE vs TME of
16.1 vs. 5.3%; P 0.20 and an increase in the estimated disease-free survival (DFS) after TME 76.6 vs. 62.8% (P = 0.18).
In 68 patients with pT2, local recurrence was significantly
higher after LE (42.8 vs 6.3%, P 0.00), the estimated DFS
was higher after TME 81.5 vs. 44.5% (P = 0.003). However,
there was no difference in the estimated overall survival,
82.8% vs. 79.4% ( P = 0.93)
RESULTS: 7585 patients underwent esophageal, gastric,
pancreas, liver and colon resections 2007–2009. Of those
137 (1.8%) were esophagectomies, 516 (6.8%) gastrectomies, 458 (6.0%) pancreatectomies, 444 (5.9%) hepatectomies and 6137 (80.9%) colectomies. Mean patient age was
53.8 years. In all, 5549 patients (73%) had private insurance, 894 (11.8%) Medicaid, and 1142 (15.1%) uninsured.
Medicaid patients had worse overall outcomes, including
mortality, LOS, complications and readmission rates (Table).
Overall 30-day readmission rate was 11.2% and increased
over the study period from 10.5 to 11.9%. Medicaid had the
highest readmission rates at 13.9% followed by uninsured
11.9% and private 10.6%. In multivariable analysis, Medicaid insurance (OR 1.3 95% CI 1.1–1.7), increased patient
comorbidities (OR 1.3 95% CI 1.0–1.5), and high volume
hospitals (OR 1.4 95% CI 1.2–1.7) demonstrated associa- CONCLUSIONS: LE of early rectal cancer is associated with
a higher rate of local recurrence rates and decreased DFS.
tions with readmission.
These disadvantages are especially significant for T2 lesions.
Table: Outcomes by Insurance
Caution must be exercised when contemplating LE.
Medicaid
Uninsured
Private
Mortality
(%)
7.2
4.4
3.7
Mean LOS
(Days)
13.0
10.5
8.5
Complications
(%)
35.1
28
23.7
Readmission
Rates (%)
13.9
11.9
10.6
CONCLUSION: Early readmissions after GI surgery remain
high. Multiple factors, potentially including case complexity and patient population, may make high-volume hospitals such as academic hospitals particularly vulnerable.
With the rise of global payments and Accountable Care
Organizations, understanding and preventing readmission,
including reducing insurance-related disparities, will be of
paramount importance.
128
Mo1709
μ-receptor antagonist, has been demonstrated to accelerate
GI recovery and reduce LOS after open bowel surgery in five
Outcomes of Survival in Converted Laparoscopic
multicenter prospective, randomized controlled trials when
Resections for Colorectal Malignancy over a 10-Year
utilized in the setting of enhanced recovery pathways.
Despite the relatively high cost of the drug, large case conPeriod
trol studies have estimated reductions in total hospital costs
Arthur Yushuva, Andres X. Samayoa, Iswanto Sucandy,
in patients receiving Alvimopan but based upon regional
Soo Kim, Mark Zebley, Steven A. Fassler
cost data. The purpose of this study was to evaluate clinical
Colorectal Surgery, Abington Memorial Hospital, Abington, PA
and economic outcomes (direct costs) for Alvimopan use in
BACKGROUND: Laparoscopic colorectal surgery has com- laparoscopic surgery at a single institution.
parable oncologic outcomes compared to open resections
METHODS: The medical records at Huntington Hospital
for cancer. The outcomes in patients undergoing laparowere queried retrospectively between January 2010 and
scopic conversions have been questioned by conflicting
June 2012 for all patients ≥18 years of age who underwent
reports. In a previous report published in 2008 we found no
elective, laparoscopic small bowel, colon and/or rectal resecchange in overall survival in patients undergoing convertions with anastomoses (with/without diverting stomas).
sion of a laparoscopic procedure for colorectal carcinoma.
Patient who required TPN or end ostomies were excluded.
However, the long-term outcomes are still uncertain due
Patients were collected from a cohort of two surgeons who
to limited number of publications. The present study is a
frequently use Alvimopan. Characteristics of patients who
10-year follow-up of prospectively collected database to
received Alvimopan were compared with historical controls
evaluate the effect of conversion on long-term survival.
of patients who did not receive Alvimopan. Outcome meaMETHODS: A retrospective review of prospectively col- sures including LOS, complications, readmission rates, and
lected database of patients undergoing laparoscopic resec- direct hospital costs were compared.
tion for colorectal cancer between January 1998 and June
RESULTS: In this 27-month period, 94 patients under2009 in a single institution. The cohort was divided into
went laparoscopic resections. Surgical indications included
two groups: patients with successfully completed laparocancer (n = 46, 49%) and diverticulitis (n = 31, 33%) with
scopic colectomy (LAP) and those whose colectomy was
the remaining 17 (18%) consisting of inflammatory bowel
converted to open (CON). Only patients with stages 1–3
disease, colostomy reversal, and rectal prolapse. The mean
were included. Patients with metastatic diseases where
age of all patients was 62.5 ± 12.6 years, and 54 (57%) were
excluded from the study. The overall survival was compared
female. The laparoscopic procedures included 31 (33%)
using Kaplan-Meier analysis.
right colon resections, 56 (60%) left, sigmoid or low anteRESULTS: A total of 425 patients were divided into 388 rior colon resections, 3 (3%) reversal of colostomies, and
in the LAP group and 37 in CON group. There was no dif- 4 (4%) small bowel resections. There were no differences
ference in age, gender, stage, number of harvested nodes between the groups for these parameters. For these cohorts
and length of follow up between two groups (p > 0.288). of patients, use of this drug was associated with shorter LOS
There was a significant increase in median blood loss for and reduced total direct hospital costs (net of drug costs,
CON group (350 ml vs. 100 ml; p < 0.001), increased length see Table 1). There were no differences between the groups
of procedure (135 vs. 109.5 min; p < 0.001) and increased in mortality, GI morbidity, superficial or deep surgical site
length of hospital stay in CON group (6 vs. 3 days; p < infections, or rates of reoperation or readmission.
0.001). Survival at 2, 3 and 5 years was: 84%, 79%, and
72%, respectively for the LAP group and 70%, 68%, and Laparoscopic Resections
62% in the CON group (Long-rank test: 0.016).
Control
Alvimopan
n = 55 (mean)
5 ± 2.2
10091 ± 4038
n = 39 (mean)
3.9 ± 1.5
8558 ± 2038
Difference
–1.1 days
–$1533
p-Value
0.007
0.032
Cost ($,SD)
Mo1710
CONCLUSIONS: Consistent with the tightly controlled
RCTs in open bowel resections showing a reduction in postoperative ileus and LOS, broadened use of Alvimopan in
laparoscopic surgery was associated with a reduction in LOS
and direct hospital costs without increasing complication
rates.
Alvimopan Use Is Associated with Reduced Length of
Stay and Direct Hospital Costs in Laparoscopic Bowel
Resections
Aaron G. Lewis, Troy M. Maynor, Lisa Arnot, John Goeders,
Ken Wong, Verenice Palestina, Gabriel Akopian, David Lourie,
Howard S. Kaufman
Huntington Memorial Hospital, Pasadena, CA
INTRODUCTION: Time to recovery of GI function is
a major determinant of length of stay (LOS) in patients
undergoing intestinal resection. Alvimopan, a selective gut
129
Monday
Poster Abstracts
CONCLUSION: The results of this study propose that there
may be a survival disadvantage in patients requiring a con- LOS (days,SD)
version for laparoscopic resection for colorectal malignancy. Direct Hospital
Mo1711
Mo1712
Lymph-Nodes Harvest Might Be Ameliorated by
Ex-Vivo Intra-Arterial Methylene Blue Dye Injection
After Colorectal Cancer Surgery
The Effects of Advanced Age on Post-Operative
Morbidity and Mortality Following Cytoreductive
Surgery with Hyperthermic Intraperitoneal
Chemotherapy
Pierpaolo Sileri, Luana Franceschilli, Ilaria C. Ciangola,
Federico Perrone, Nicola Di Lorenzo, Claudio Arcudi,
Achille Gaspari
Surgery, University of Rome Tor Vergata, Rome, Italy
Sarah J. Mcpartland, Martin D. Goodman
Surgery, Tufts Medical Center, Shrewsbury, MA
INTRODUCTION: Lymph node (LN) assessment has a critical role in staging colorectal cancer thus influence 5-year
survival rates. Despite this, several studies have shown that
the nodal harvest is highly variable and often inadequate.
In this study we retrospectively evaluated the adequacy of
LN assessment in our institution and, prospectively, we
evaluated if ex-vivo intra-arterial methylene blue dye injection results in a better and more accurate lymph-nodes harvest at standard pathology dissection. We also correlated
these with oncologic staging and outcome.
METHODS: Inclusion criteria were: elective CRC surgery (R-colectomy, L-colectomy, rectal anterior resection,
abdominal perineal excision); no prior colorectal surgery;
no preoperative evidence of distant metastatic disease; no
previously undetected liver metastasis, advanced disease
or carcinosis at surgery. We retrospectively analyzed 146
patients who underwent colorectal cancer resection from
5/2005 to 8/2009 to assess LNs counts (expressed in percentages; <8 or 12 LNs). Prospectively, a total of 204 consecutive patients with primary resectable were studied: after
surgery, retrieved specimens were ex-vivo injected (98) or
not (106) with methylene blue die and sent for standard
pathology. Lymph-nodes were grouped into four categories
according to the size: <1 mm,1–2 mm, 2–4 mm and greater
than 4 mm. Mann-Whitney and Student t-test were used
for statistical analysis.
INTRODUCTION: Cytoreductive surgery with heated
intraperitoneal chemotherapy (CRS-HIPEC) can prolong survival in patients with advanced gastrointestinal
neoplasms confined to the peritoneal cavity. To date, no
prospective studies have addressed the feasibility of this
procedure in patients of advanced age. As a population,
patients of advanced age are at higher risk for perioperative
complications following any major abdominal surgery. It
has been suggested in the literature that advanced age may
be a contraindication to this potentially life-saving procedure. We sought to better quantify the effects of advanced
age on outcomes following CRS-HIPEC.
METHODS: All patients who underwent pre-operative
evaluation for CRS-HIPEC from 2007 to 2012 were reviewed
for inclusion in the study. Patients for whom adequate
cytoreduction could not be achieved (and therefore intraperitoneal chemotherapy was not provided) were excluded
from the study. The patients for whom CRS-HIPEC was performed were subsequently grouped and analyzed according to age at time of surgery. Demographic, operative, and
post-operative data was prospectively collected. Informed
consent was obtained and the study received institutional
review board approval.
RESULTS: Complete follow-up information was available
for 99 patients. There were no statistically significant differences in 30-day mortality. Table 1 summarizes measured
outcomes. Older patients had longer lengths of stay. DifferRESULTS: In our retrospective cohort of patients mean ences in cardiac and pulmonary function were most affected
number of retrieved LNs was 17 ± 7 being <8 LNs in 19% of by age. Patients over age 70 were less likely to be extubated
cases and <12 LNs in 40% with similar percentages among in the first 24 hours following surgery. Cardiac arrhythmia
(i.e. atrial fibrillation) and post-operative delirium were
different type of resections.
After blue injection, the average lymph-node harvest was seen more often in patients over age 70. There were no sta18 ± 6 (range 9–33) in the stained group and 13 ± 7 (range tistically significant differences among age groups regard4–34) in the unstained. Despite this trend, the difference ing infection, post-operative transfusion requirement, renal
was significant only after anterior resection and abdomi- dysfunction, or thrombotic/thromboembolic events.
noperineal excision. Methylene blue injection significantly CONCLUSIONS: Patients of advanced age are more likely
reduced the risk of inadequate LNs harvest (LNs <8: 17% to develop pulmonary complications, cardiac dysrhythto 0; LNs <12:30% to 12%). Gender, age (> or < 80 years mias, and delirium following CRS-HIPEC, as compared to
old), BMI (< or > 28 kgs/m2) and open or laparoscopic sur- younger patients. This may contribute to overall longer
gery did not influence the count. Lower LN counts were lengths of stay for patients of advanced age following this
procedure. However, in our analysis, differences in morobserved in both groups after neo-adjuvant radiotherapy.
The largest difference was found in size groups between 1 bidity between age groups had no effect on post-operative
and 4 mm causing a shift in size distribution toward smaller mortality. We conclude that CRS-HIPEC can be safely performed in patients of advanced age.
lymph-nodes retrieval.
CONCLUSIONS: Ex-vivo intra-arterial methylene blue dye
injection augments lymph-nodes retrieval thus allowing a
more accurate colorectal cancer staging and possibly the
oncologic outcome.
130
Total LOS (days)
Total ICU LOS (days)
Extubated within 24 hrs of surgery
Mechanical ventilation >48 hrs
Wound infection
Intra-abdominal infection
Post-operative pRBC transfusion
Deep vein thrombosis
Pulmonary embolism
Acute kidney injury (creatinine
>2.0)
Cardiac arrhythmia
Acute myocardial infarction
Post-operative delirium
LOS = length of stay
Group I – <50
Years
9.77
4.03
38.5%
7.7%
5.1%
15.4%
33.3%
5.1%
0
5.1%
p value
[Group I vs.
Group IV]
0.035
0.81
0.19
0.32
0.45
0.67
0.47
0.63
-–
0.45
Group II –
50–59.9 Years
9.5
4.03
25.9%
11.1%
0
3.7%
48.1%
0
0
7.4%
p Value
[Group II vs.
Group IV]
0.098
0.54
0.029
0.57
–
0.46
0.88
0.12
-–
0.37
Group III –
60–69.9 Years
12.59
2.42
45.4%
4.5%
9.1%
13.6%
50%
9.1%
4.5%
0
p Value
[Group III vs.
Group IV]
0.42
0.18
0.63
0.21
0.32
0.78
0.81
1.00
0.32
–
Group IV – >70
Years
16.91
3.27
18.2%
18.2%
0
9.1%
45.4%
9.1%
0
0
2.6%
0
2.6%
0.007
-–
0.056
3.7%
0
3.7%
0.032
–
0.079
4.5%
0
0
0.063
–
0.061
27.3%
0
9.1%
RESULTS: Twenty-four (34%) patients had an AEG I, 43
(61%) an AEG II and 4 (5%) patients an AEG III. A primary
tumor resection was performed in 59 (83%) patients while
12 (17%) patients initially received a neoadjuvant therapy.
There was a significant correlation between cN + -category
and neoadjuvant therapy (10/23 with cN + versus 2/48
with cN0-Kategorie; p < 0.001). Primary resected patients
showed the following pT-/pN-categories: pT1 22%, pT2
59%, pT3 19%, pN0 39% and pN + 56%, whereas clinical
and histopathological pN-category consisted in 55% of the
patients. Neoadjuvant treated patients showed the following pT-/pN-categories:
Mo1714
Gastroesophageal Junction Tumors Clinically Staged
cT2: Accuracy of Staging Results and Therapeutic
Consequences at Two Academic Centers
Daniel Vallbohmer1, Susanne Blank2, Leila Sisic2,
Sebastian Kraus1, Andreas Krieg1, Wolfram T. Knoefel1,
Markus W. Buchler2, Katja Ott2
1
Department of Surgery, University of Dusseldorf, Dusseldorf,
Germany; 2Department of Surgery, University of Heidelberg,
Heidelberg, Germany
PATIENTS AND METHODS: Between 2001 and 2011 71
patients with AEG were clinically staged cT2 (cN0 = 48; cN
+ = 23) based on endoscopy, endosonography and computed tomography. All study patients underwent surgical
resection (R0 resection rate: 96%). Statistical analyses were
performed using an established database.
131
Monday
Poster Abstracts
ypT0 25%, ypT1 25%, ypT2 50%, ypN0 50% and ypN +
42%. The overall survival of primary resected patients compared patients undergoing neoadjuvant therapy was not
BACKGROUND: Multimodality treatment options in significantly different. In addition, no significant survival
locally advanced (cT3/4) tumors of the gastroesophageal benefit was detected in patients with cN + -status receiving
junction (AEG) have been established over the last years. neoadjuvant therapy.
However, the therapeutic approach in patients with cliniCONCLUSIONS: The accuracy of clinical staging in
cally staged cT2 tumors remains highly controversial. At
patients with cT2 tumors of the gastroesophageal junction
this, the most important determinant is the accuracy of
is poor. As in primary resected patients over- and understagclinical staging and final histopathological report. Thereing balance each other, pre-therapeutic over-staging occurs
fore, we aimed to evaluate the association of clinical and
in about 50% of the patients. A neoadjuvant therapy can
histopathological staging in patients with cT2 tumors in
not generally recommended in this patient group.
respect of possible therapeutic consequences.
Mo1715
Outcomes of Esophagectomy for Esophageal Achalasia
in the United States
Daniela Molena, Miloslawa Stem, Anne O. Lidor
Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
BACKGROUND: While the outcomes after Heller myotomy have been extensively reported, little is known about
patients with esophageal achalasia who are treated with
esophagectomy.
METHODS: This was a retrospective analysis using the
Nationwide Inpatient Sample over an 11-year period
(2000–2010). Patients admitted with a primary diagnosis
of achalasia who underwent esophagectomy (Group 1)
were compared to patients with esophageal cancer who
underwent esophagectomy (Group 2) during the same time
period. Primary outcome was in-hospital mortality. Secondary outcomes included length of stay (LOS), post-operative
Mo1716
complications and total hospital charges. A propensitymatched analysis was conducted comparing these same Comparison of Long Term Survival After Endoscopic
outcomes between Group 1 and well-matched controls in Resection vs. Ablation in Early Esophageal Cancer: An
Group 2 during the same era.
RESULTS: Among 43,668 patients admitted with a primary diagnosis of achalasia, 963 (2.2%) underwent esophagectomy. The overall in-hospital mortality in Group 1
was 2.7%. The most common post-operative complications in this group were pneumonia (17%) and pulmonary
compromise (29%). During the same time period, 18,003
patients with esophageal cancer underwent esophagectomy. Patients in Group 1 were younger, healthier, and had
a lower mortality when compared to Group 2. Post operative LOS and complications were similar in both groups,
although hospital charges were significantly higher in
Group 1. (Table 1). The most common surgical procedure
was a partial esophagectomy in both groups. The number
of colon interpositions was higher in Group 1 (1% versus
4%, p = 0.0001). The propensity matched analysis showed
a trend toward a higher mortality in Group 2 (7.8% versus
2.9%, p = 0.08). Among patients who died in both groups
the most common associated diagnosis codes were respiratory complications and sepsis. Older male patients had the
highest mortality among patients with achalasia.
CONCLUSION: This is the largest study to date examining
outcomes after esophagectomy in patients with achalasia.
In these patients, unadjusted mortality is statistically lower
than in patients with esophageal cancer, while operative
morbidity appears comparable. In a propensity matched
analysis, there remains a trend toward lower mortality in
Group 1. Based on these data, esophagectomy can be considered a safe option, and surgeons should not be hindered
by a perceived notion of prohibitive operative risk in this
patient population.
Analysis of Surveillance Epidemiology and End Results
Data
Attila Dubecz1, Norbert Solymosi2, Rudolf J. Stadlhuber1,
Michael Schweigert1, Jeffrey H. Peters3, Hubert J. Stein1
1
Surgery, Klinikum Nurnberg, Nurnberg, Germany; 2Faculty of
Veterinary Science, Szent Istvan University, Budapest, Hungary;
3
Division of Thoracic and Foregut Surgery, Department of Surgery,
University of Rochester School of Medicine and Dentistry, Rochester, NY
BACKGROUND: Safety and efficacy of endoscopic therapy
for early esophageal cancer is well established but long-term
outcomes are not available. Our objective was to assess and
compare long-term survival in patients with early esophageal cancer managed with either endoscopic mucosal resection (EMR) or ablative treatments (AT).
METHODS: We identified 495 patients with endoscopically treated early adenocarcinoma of the esophagus and
the gastric cardia diagnosed between 1998 and 2009 from
the Surveillance, Epidemiology, and End Results (SEER)
database. Demographic variables and cancer-related survival were assessed.
RESULTS: Almost 80% of all patients were male. Average
age was 66.5y. Forty-percent of the patients had T1a cancer.
More than 88% of the patients were treated with EMR. Average follow-up was 33.6 months. Although five-year cancer
related survival was slightly superior after AT (81% vs.78%;
p < 0.001), ten-year survival rates were significantly better
in patients undergoing EMR (78% vs. 61%; p < 0.001).
CONCLUSION: Patients with early esophageal cancer managed with EMR have superior long-term survival compared
to those treated with ablative therapies.
132
Mo1717
Mo1718
Diagnosis and Surgical Treatment of Esophageal
Carcinoma with Coexistent Intrathoracic Great Vessel
Anomalies
Esophagectomy for Cancer Can Be Performed
Safely and with Good Perioperative Outcomes in
Octagenerians
Long-Qi Chen, Zhongxi Niu
Thoracic Surgery, West China Hospital, Sichuan University,
Chengdu, China
Vadim P. Koshenkov1, Tulay Koru-Sengul2, Angela T. Prescott1,
Carlo Maria Rosati1, Monika E. Freiser1, Danny Yakoub1,
Alan S. Livingstone1
1
Surgery, University of Miami, Miami, FL; 2Epidemiology, University of
Miami, Miami, FL
OBJECTIVE: Intrathoracic great vessels accompany the
full course of the esophagus in chest. The anomalies of
these vessels can not only result in dysphagia symptom by
direct compression, but also make the resection of esophageal cancer more difficult due to the malformation or even
direct invasion of these vessels. The aim of this study is to
summarize our experience in diagnosis and surgical treatment on 7 patients with esophageal cancer and coexistent
intrathoracic great vessel anomalies.
METHODS: From January 2007 through November 2012,
1032 patients with esophageal carcinoma underwent cure
intent esophagectomy. Among them there were 7 patients
with coexistent intrathoracic great vessel anomalies
(0.68%), including aberrant right subclavian artery (ARSA)
in 3 patients, abnormal left brachiocephalic vein drainage
in 2, right aortic arch (RAA) in 1 and aortic isthmus pseudoaneurysm in 1. They were 6 males and 1 female, with an
average age of 58.42 years. Their examination findings and
surgical treatment result were retrospectively analyzed.
CONCLUSION: The intrathoracic great vessel anomalies that coexisted with esophageal carcinoma are easily
neglected on esophageal barium study or endoscopy. Therefore, enhanced chest CT should be a preoperative routine
examination, with additional angiogram or 3D reconstruction. The vessel anomaly might interfere the mobilization
of the esophagus and need be clarified before the operation. Some need pretreatment like ductus arteriusus ligation or endovascular stent implantation to facilitate the
esophageal mobilization. A careful lymphadenectomy and
prophylactic ligation of thoracic duct are recommended to
avoid associated complications. If necessary, the abnormal
vessel can be dissected to prevent uncontrolled bleeding.
METHODS: A retrospective review was performed for
patients that had undergone esophagectomy for cancer at a
tertiary care referral center from 1/2000 to 6/2012. Clinicopathologic factors and survival data for octogenarians were
analyzed and compared to patients who were 79 years old
or younger.
RESULTS: Among the 34 patients who met the inclusion
criteria, 21 (61.8%) had comorbidities. Of these, pre-existing cardiac disease was identified in 16 (47.1%), pulmonary
in 6 (17.6%) and diabetes mellitus in 3 (8.8%). Median age
was 82, 76.5% were male, 76.5% had adenocarcinoma that
was distal (88.3%), and 50.0% of tumors were poorly differentiated. Stages 0 through III were observed in 2 (5.9%),
6 (17.6%), 9 (26.5%) and 17 (50.0%) patients, respectively. Neoadjuvant chemotherapy or chemoradiotherapy
was administered to 25 (73.5%) patients, with 12 (48.0%)
undergoing downstaging. Transhiatal esophagectomy was
performed in 28 (82.4%) patients, with an r0 resection in 31
(91.2%). Median length of stay (LOS) was 10 days. Mortality and morbidity rates were 5.9% and 44.1%. These were
not significantly different from 10 days, 4.4% and 46.1%,
respectively, for a group of 293 patients that were 79 years
old or younger. Cardiac, pulmonary, and infectious complications were encountered in 17.6%, 14.7%, and 2.9%,
respectively. Anastomotic leak occurred in 5 (14.7%)
patients, and reoperation rate was 2.9%. Median, 3-year,
and 5-year survival were 21 months, 55.9%, and 37.1%
respectively. Overall survival was worse for octogenarians
when compared to younger patients (p < 0.0001) (Figure 1).
CONCLUSION: Mortality, morbidity and length of stay in
octogenarians were comparable to patients who were 79
years old or younger, while the overall survival was worse.
With appropriate patient selection, good perioperative outcomes can be accomplished in octogenarians undergoing
esophagectomy for cancer.
133
Monday
Poster Abstracts
RESULTS: The vessel anomalies were all missed on preoperative routine esophageal barium study and endoscopy.
They were mostly identified by enhanced chest CT, some
with the help of 3D vessel reconstruction or angiogram.
During operation, the aortic malformation needed additional management: patient with RAA had ductus arteriusus ligation and dissection to facilitate the mobilization of
the esophagus via left thoracotomy, while the aortic pseudoaneurysm underwent endovascular stent implantation
before esophagectomy via right thoracotomy. All the other
anomalies did not need special treatment, while caution
was needed when performed lymphadenectomy due to
the varied right recurrent laryngeal nerve or abnormal vein
drainage. Besides, the thoracic duct was routinely ligated.
All patients were recovered and discharged unevenly.
INTRODUCTION: The number of elderly patients that are
being diagnosed with cancer in the United States has risen,
as lifespan has increased. Consequently, octogenarians are
now considered more frequently for operations with high
rates of mortality and morbidity, such as esophagectomy.
Inconsistent data exists regarding the outcomes of esophagectomy in this population group.
Figure 1
Mo1719
RESULTS: Of the 1105 patients studied, 237 (21%) had an
elevated IRP. Sixty four percent were female with a mean
age of 56.8 ± 15.4 years. Mechanical causes of obstruction
were most common (100/237, 42%) including postoperative in 50, large hiatal hernia in 48 and esophageal cancer in 2. Achalasia was present in 75 patients (32%). The
remaining 62 (26%) had an elevated IRP without evidence
of mechanical obstruction. Dysphagia was the primary
presenting symptom in 85% of patients in the achalasia
group, 31% of the mechanical group and 13% of the functional group (p < 0.009). Interestingly, upper respiratory
symptoms were significantly more common in patients
with functional outflow obstruction (26% vs. 1% achalasia
and 4% mechanical, p < 0.001). The mean IRP also varied amongst the clinical groups, highest in achalasia 31.0 ±
11.7 mmHg, intermediate in mechanical obstruction (23.5
± 8.6 mmHg) and lowest in the functional group (18.7 ± 3.8
mmHg) p < 0.001. A similar pattern was seen in the mean
intra-bolus pressures 28.6 ± 15.0 mmHg, 20.1 ± 7.4 mmHg
and 14.9 ± 4.0 mmHg, respectively. Nearly 40% (22/57) of
the patents with functional outflow obstruction parameters
were pH positive suggesting GE barrier failure despite the
manometric findings. Fundoplication was performed in 9
of these 22 patients (41%) with good response. Five of the
remaining functional patients underwent treatment; myotomy in one and Botox in 4.
The Clinical Spectrum of Esophagogastric Junction
Outflow Obstruction Identified via High Resolution
Manometry
Poochong Timratana, Michal J. Lada, Dylan R. Nieman,
Michelle S. Han, Christian G. Peyre, Carolyn E. Jones,
Thomas J. Watson, Jeffrey H. Peters
Department of Surgery, University of Rochester Medical Center,
Rochester, NY
INTRODUCTION: The identification of esophagogastric junction (EGJ) outflow obstruction via high resolution manometry (HRM) is increasingly common and of
unclear clinical significance. The objective of this study was
to review the HRM characteristics of EGJ outflow obstruction and to assess how this diagnosis translates into clinical
practice.
CONCLUSIONS: The predominant etiologies of EGJ outMETHODS: A retrospective review was conducted of flow obstruction are mechanical obstruction and achalasia.
1105 symptomatic patients who underwent HRM between Mechanical causes should be excluded before functional
9/09 and 8/12. EGJ outflow obstruction was defined as an outflow obstruction is diagnosed and treated. HRM paramelevated 4 second lower esophageal sphincter integrated eters of functional outflow obstruction may be present in a
relaxation pressure (IRP). Patients with elevated IRP were subset of patients with pH positive GERD. The ideal mandivided into 3 groups: achalasia, mechanical obstruction agement of patients with symptomatic functional obstruc(large hiatal hernia, postoperative and neoplasia) and function remains unclear.
tional obstruction (no obvious underlying cause). Clinical
and demographic data, presenting symptoms, upper endoscopic findings, treatment and post-treatment outcomes
were compared among the groups.
134
Mo1720
operative (mean OR duration 4.6 (SD 1.5) hours, 42% IvorLewis, 22% minimally-invasive) characteristics between
Economic Impact of an Enhanced Recovery Pathway
pre- and post-pathway groups. Median LOS was lower in
for Esophagectomy
the post-pathway group (pre 10 [IQR 9–17] vs. post 8 [IQR
7–17] days, p = 0.011). There was no difference in 30-day
Lawrence Lee1, Chao LI1, Lorenzo E. Ferri1, Nicolas Robert1,
Franco Carli2, David S. Mulder1, Gerald M. Fried1, Liane S. Feldman1 complications between the two groups (pre 62% vs. post
1
59%, p = 0.803), and overall mortality was low (1%, 1/106).
Surgery, McGill University Health Centre, Montreal, QC, Canada;
2
Anaesthesia, McGill University Health Centre, Montreal, QC, Canada The median costs of the on-course and minor deviation
groups were significantly lower after implementation of the
PURPOSE: Surgical care pathways can improve quality ERP (Table 2). The overall cost savings per patient (WAMand efficiency of care but require significant resources to C -WAMC ) was $1472.
pre
post
implement and maintain. Payers require information about
Table
1:
Defi
nition
of Deviation-Based Cost Modeling Groups
cost when deciding whether to adopt new quality initiatives. Data have been lacking to support the cost-effectiveDeviation
Hospital Course
Clinical Impact
ness of enhanced recovery pathways (ERP) for complex
On-course
LOS 50th percentile
None or minor severity (Clavien I-II)
procedures, such as esophagectomy. The objective of this
LOS = 50th to 75th percentile None or minor severity (Clavien I-II)
study was to investigate the impact of ERP on medical costs Minor
None or minor severity (Clavien I-II)
Moderate
LOS >75th percentile Any
for esophagectomy.
METHODS: All patients undergoing elective esophagectomy for malignancy or high-grade dysplasia from 2009
to 2011 at a single high-volume university hospital were
identified from a prospective database. From June 2010,
all patients were enrolled in a 7-day multidisciplinary ERP
incorporating printed patient education material and structured daily care plans with indications for intensive care
admission, early structured mobilization, diet and drain
management. Thirty-day morbidity and mortality were
graded using the Clavien classification. Total medical costs
(derived by micro-costing and including overhead, but
excluding physician fees) were calculated from an institutional perspective, and expressed in 2011 Canadian dollars ($CAD). Deviation-based cost modeling, a validated
method to compare the clinical and economic impact
of clinical pathways, was used to compare costs between
the pre- and post-pathway groups. Patients were classified
into four deviation groups based on length of stay (LOS)
and postoperative morbidity (Table 1). Median costs and
interquartile range (IQR) were calculated for each deviation group, and weighted according to relative proportion
of each deviation to provide the weighted-average median
cost (WAMC) per patient.
hospital duration
Major
Any hospital duration
LOS = length of stay
Moderate severity (Clavien IIIa)
Major severity (Clavien IIIb-V)
Table 2: Economic Impact of ERP Using Deviation-Based
Cost Modeling
Pre-Pathway
(n = 47)
Deviation mix, % (n)
On-course
47% (22)
Minor
19% (9)
Moderate
15% (7)
Major
19% (9)
Median costs, $CAD
[IQR]
On-course
$12 195 [11 303, 13 364]
Minor deviation
$16 698 [15 094, 21 937]
Moderate deviation $21 459 [18 022, 22 627]
Major deviation
$33 190 [24 378, 73 888]
Weighted-average
$18 457
median cost, $CAD
ERP = enhanced recovery pathway
Post-Pathway
(n = 59)
p-Value
0.559
56% (33)
13% (8)
12% (7)
19% (11)
$11 225 [9 964, 12 260]
$13 120 [12 222, 15 672]
$25 432 [22 837, 31 709]
$31 709 [24 330, 44 588]
$16 985
0.024
0.021
0.035
0.732
135
Monday
Poster Abstracts
RESULTS: A total of 106 patients were included for
CONCLUSIONS: A multidisciplinary ERP for esophagecanalysis (47 pre-pathway, 59 post-pathway). There were
tomy was associated with significant cost-savings without
no differences in patient (mean age 64 (SD 10) years, 80%
increase in morbidity or mortality.
male), pathologic (81% adenocarcinoma, 75% received
neoadjuvant therapy, 38% stage I-II, 55% stage III-IV), and
Mo1721
Mo1722
Can an Effective Nissen Fundoplication Improve the
Weak Motility of Barrett’s Esophagus?
Laparoscopic Nissen – Hill Hybrid: A Promising
Solution for Type III Para-Esophageal Hernia
Angela FalcãO, Sergio Szachnowicz, Rubens A. Sallum,
Francisco C. Seguro, Ary Nasi, Julio R. Rocha, Ivan Cecconello
Department of Gastroenterology, Esophageal Surgical Division –
University of São Paulo Medical School – Brazil, São Paulo, Brazil
Ralph W. Aye, Aditya Gupta, Jorge A. Huaco-Cateriano,
Alexander S. Farivar, Eric VallièRes, Brian E. Louie
Division of Thoracic Surgery, Swedish Medical Center and Cancer
Institute, Seattle, WA
BACKGROUND: Abnormal esophageal motility is frequent
in Barrett’s esophagus (BE); isn’t yet clear if is a primary
abnormality or a consequence of injury. Non-propagated
contractions, simultaneous or low amplitude contractions
compromise esophageal clearance. That suggests extension
of the inflammatory process to the muscle layer, affecting
esophageal motility. Surgical treatment would decrease the
inflammation of the esophageal mucosa improving the
change in esophageal motor function.
BACKGROUND: High rates of recurrence have been
reported in patients after traditional repair of Type III paraesophageal hernia (PEH), ranging from 10% at 6 months to
60% radiographic recurrence at 5 years. This study evaluates a new Hybrid antireflux operation that combines the
components of Nissen fundoplication and the Hill repair,
in managing these challenging hernias.
METHODS: We performed a prospective study on the
1st 50 consecutive patients undergoing Hybrid repair for
OBJECTIVE: Access the effect of antireflux surgery on symptomatic Type III PEH, from July 2006 to Oct 2009. IRB
esophageal motility in patients with Barrett’s esophagus approval was obtained. Demographic, operative, clinical
with esophageal motility disorder.
and quality of life data were collected. Manometry, EGD,
METHODS: We evaluated 20 consecutive Barrett’s patients UGI, and 48-hour pH testing were obtained pre-operaoperated with esophageal dismotility. Inclusion criteria tively and at midterm (MT: 6–12 months post-operative)
were: 12 months of minimum follow-up, asymptomatic follow-up. Quality of life was measured with QOLRAD and
patients out of PPIs, with endoscopy study without esopha- Dysphagia Severity Scores (DSS) pre-operatively, and postoperatively at short term (ST: 1–3 months) as well as MT
gitis and topic fundoplication.
follow-up.
RESULTS: Thirteen patients were male (65%), the mean
age was 54.95 ( ± 3.53) years, the lenght of Barrett esopha- RESULTS: Fifty patients (age 42–85 years, mean 66) with
gus was 3.7 ( ± 0.56). Follow-up was 76.2 ( ± 9.27) months symptomatic PEH (mean hernia size = 7 cm) underwent the
in average. The 24-hour pH monitoring after antireflux Hybrid repair and were followed for an average of 19.8 ± 15
surgery showed a significant reduction or absence acid months (range 3–62 months). There was no 30-day or inreflux (p < 0.01). Before surgery the manometric evaluation hospital mortality. There were 5 major morbidities: 1 intrashowed 17 patients (85%) with LES hypotonia, 12 patients operative bougie perforation repaired laparoscopically, 1
(60%) had esophageal body hypocontractility, two patients limited intra-op bleed, 1 early reoperation for esophageal
(10%) had nutcracker esophagus and four patients (20%) obstruction, 1 re-admission with myocardial infarction,
had abnormal esophageal peristalsis (IEM). There was an and 1 gastrotomy repaired laparoscopically. There were 2
increase in the LESRP compared with preoperative values deaths noted in MT follow-up, both unrelated to the priin 70% of the patients, the mean LESRP was 10.99 ( ± 1.92) mary procedure. Follow up data were available for 40/50
before and 14.93 ( ± 1.33) after ARS (p 0.024). After ARS (80%) patients. On MT follow up, 33/38 (87%) patients had
40% of patients with hypocontractility showed an increase resolution of dysphagia, and 35/38 (92%) had resolution of
in amplitude of the peristaltic contractions in distal esoph- heartburn. There was 1 clinical recurrence (2.5%) requiring
agus and thease, 30% returned to normal values; both reoperation at 3 years, and 3 (7.5%) asymptomatic radiopatients with nutcracker esophagus have normalised con- graphic fundic herniations. All recurrences had an intact,
intra-abdominal gastro-esophageal junction (GEJ) and no
traction amplitude (p = 0.021).
objective evidence of reflux. Five patients (12.5%) had
Five patients (25%) showed worsening of contraction dysphagia on MT follow-up; 3 (7.5%) underwent dilation
amplitude and 15% remained with severe hypocontractil- with symptom resolution. Two patients (5%) had resumed
ity. Four patients (20%) who had normal esophageal peri- anti-secretory medications, without objective evidence of
stalsis before ARS evoluated with aperistalsis or IEM after reflux. Mean DeMeester scores improved from 56.6 to 6.7
ARS. Three patients (15%) with abnormal esophageal peri- (p = 0.008). Lower esophageal sphincter pressure showed
stalsis showed improvement and normalized the esoopha- no change (22.1 to 20.9, p = 0.98). QOLRAD improved both
geal peristalsis (p = 0.201).
in ST (3.1 to 5.7, p < 0.001) and MT (3.1 to 6.6, p < 0.001)
CONCLUSION: At least 50% of patients with BE with follow up, as did the DSS (27.2 to 41.7, p < 0.001).
impaired esophageal motility who underwent surgery had
improvement of the esophageal motility disoderes, 40%
reached normal values and patients with nutcracker esophagus showed normalization of contractility.
136
CONCLUSIONS: Laparoscopic Nissen-Hill hybrid is an
effective repair for patients with PEH. It anchors the GEJ
securely in the abdomen, combining the axial integrity of
the Hill repair with the radial strength of the Nissen. Early
clinical as well as radiologic recurrence rates are lower than
those reported for Nissen fundoplication, with symptom
control equal to or exceeding the traditional anti reflux
procedures. Long-term follow-up and direct comparisons to
other repairs are needed.
Hybrid Repair for PEH: Results
Parameter
LESP
QOLRAD (Pre op to ST)
QOLRAD (Pre op to MT)
DSS
DeMeester Score
Pre-Op
22.13 ± 14.63
3.13 ± 1.85
3.13 ± 1.85
27.19 ± 16.58
56.6 ± 41.63
Post-Op
20.9 ± 9.77
5.74 ± 1.16
6.6 ± 0.68
41.67 ± 7.18
6.67 ± 7.14
p-Value
0.98
<0.0001
<0.0001
<0.0001
0.008
METHODS: From our prospectively maintained database,
we retrospectively reviewed all patients who underwent
Neoadjuvant chemoradiotherapy for resectable esophageal
cancer between November 1999 and December 2010 at
Division of surgical gastroenterology, Dept of General surgery, PGIMER, Chandigarh. Out of total 188 patients with
carcinoma esophagus, 117 patients underwent Neoadjuvant
chemoradiotherapy (NACRT).104 patients had squamous
cell carcinoma (SCC) and 13 patients had adenocarcinoma
(ADC). Mean interval between NACRT and surgery rest of
the patients was 44.36days .Patients were divided into 3
groups on the basis of timing to surgery: group I, ≤30 days
(n = 52); group II, 31to 60 days (n = 56); and group III, 61
to 90 days (n = 11). The Cox regression model and KaplanMeier plots were used to analyze the data.
RESULTS: Groups were comparable in terms of patient
and tumor characteristics. Difference in Overall survival
and disease free survival in three groups of patient was not
statistically significant. The Mean (±SD) and median (95%
CI) overall survival in these three groups of patient was 34.9
(6.9) months & 16 (7–24) months, 42.2 (8.24) months &
23 (12–33) months and 14.2 (1.96) months & 12 (9.3–14.6)
months respectively (P = 0.6). The Mean ( ± SE) and median
(95% CI) disease free survival in these three groups of
patient was 31 (6.73) months & 12 (4–19) months,43 (9,4)
months&17 (6–27) months and 18 (2) months &10 months
respectively (P = 0.2). Patients in group III had better relief
in dysphagia, better weight gain and higher rates of pathological complete response without any significant increase
in post operative complication and recurrence.
Mo1723
Does Delayed Surgery Have an Impact on Outcome
After Neoadjuvant Chemoradiotherapy (NACRT) in
Patients with Carcinoma Esophagus?
Rajesh Gupta1, Sunil D. Shenvi1, Yalakanti R. Babu1,
Saurabh Kalia1, Rajinder Singh1, Rakesh Kapoor2,
Surinder S. Rana3, Deepak K. Bhasin3
1
Surgical Gastroenterology Division, Postgraduate Institute of
Medical Education and Research, Chandigarh, India; 2Radiation
Oncology, Postgraduate Institute of Medical Education and Research,
Chandigarh, India; 3Gastroenterology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
CONCLUSION: Delayed surgery after NACRT does not
compromise the outcomes of patients with locally advanced
carcinoma esophagus.
OBJECTIVE: Esophagectomy is usually recommended
within 4 to 6 weeks after completion of Neoadjuvant
chemoradiotherapy (NACRT). However, because of various logistic factors, the surgery can get delayed. Aim of this
study was to evaluate whether delayed surgery after NACRT
affects postoperative outcomes in patients with locally
advanced carcinoma esophagus.
Monday
Poster Abstracts
137
Mo1724
Prospective Study of Quality of Life After Laparoscopic
Paraesophageal Hernia Repair with Bio-Prosthetic Mesh
Kashif A. Zuberi1, Qingwen Kawaji2, Michael R. Marohn1,
Miloslawa Stem1, Richard M. Fleming1, Michael Schweitzer1,
Kimberley E. Steele1, Anne O. Lidor1
1
Surgery, Johns Hopkins University School of Medicine, Baltimore, MD;
2
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
INTRODUCTION: Laparoscopic repair of paraesophageal
hernia (PEH) with bio-prosthetic mesh (BP) has been shown
to result in excellent relief of symptoms and improved quality of life (QOL) despite a relatively high recurrence rate. We
evaluated our patient population to determine if change in
quality of life is related to recurrence as well as specific risk
factors that may increase the probability of recurrence after
repair of PEH.
CONCLUSION: Our analysis of difference in symptom
METHODS AND PROCEDURES: This is an analysis of scores after laparoscopic PEH repair suggests that significant
data derived from an ongoing prospective study. From worsening occurs with radiologically recurrent hernias >2
4/2009 to 10/2012, we enrolled 99 patients who underwent cm with respect to early satiety and dysphagia. We were
elective laparoscopic PEH (type III) repair with BP (Veri- unable to demonstrate at one year follow up if any specific
tas® collagen matrix, Synovis®, St. Paul MN) buttressed risk factors increase the incidence of recurrence. Overall,
over a primary cruroplasty. All patients underwent Nissen patients with recurrent PEHs continue to experience excelfundoplication. A validated GERD-specific QOL tool was lent QOL and rarely require re-operation.
administered to patients before, and at 2 and 12 months
post-operatively. UGI was performed at one year and recur- Mo1725
rence was defined as a PEH greater than 2 cm. A single
radiologist blinded to patient information read all stud- Long Term Outcomes of Re-Do Fundoplication in
ies. Demographic factors, comorbidities, and preoperative Elderly (>65 Years) Patients: A Single Center Experience
esophago-gastric testing were analyzed as possible indica- Parth K. Shah, Tommy H. Lee, Se Ryung Yamamoto,
tors for recurrence. Approriate statistical analysis was used Pradeep K. Pallati, Kalyana C. Nandipati, Sumeet K. Mittal
to compare variables. Univariate logistic regression was Creighton University, Omaha, NE
used to examine risk factors.
BACKGROUND: Re-do fundoplication (RF) is reported to
RESULTS: Overall 99 patients were analyzed. Median age improve quality of life and patient satisfaction in more than
was 61.3 years (range 24–89) with 64.65% women. Of 99 80% of patients with failed fundoplication. However, the
patients, 10 were not available for follow up and 50 reached role of re-do fundoplication in elderly (>65 years) patients
their one year milestone and also underwent interval UGI. is not well reported in the literature. The aim of this study
Four patients required reoperation, of which only one was was to assess long term outcomes of RF in elderly patients.
for symptomatic recurrent PEH. The overall preoperative, 2
month, and 1 year QOL scores were 28.49, 9.99, and 10.78 METHODS: A retrospective review of patients ≥65 years
respectively (p = 0.00). Our recurrence rate was 30% (n = of age who underwent RF at a single institution by a single
15) at a mean follow up of 425 days (range 234–802). The surgeon for recurrent GERD (2004–2008) was performed.
compared mean QOL scores between the preoperative, two Patients were contacted at 1, 3, 5, 7 and 10 year intervals
month, and one year follow-up were all statistically signifi- after surgery and administered a standard symptom quescant. The symptoms of early satiety and dysphagia did not tionnaire. Symptom assessment was done using a 0–3 scale,
improve in the patients in whom a recurrence was detected, and grade 2–3 symptoms considered to be significant.
otherwise there was significant improvement in all other Patients were also asked to grade their satisfaction with surindividual symptoms assessed in the QOL tool. There was gery on a scale of 1–10.
no association between diabetes, smoking history, the use
of gastropexy, or previous abdominal surgery and PEH
recurrence. Preoperative testing with manometry and gastric emptying studies were statistically unable to identify
patients at risk of recurrence.
138
RESULTS: Of 114 patients undergoing RF during the
period, 31 elderly patients (27%) were included in the study
group. The mean age was 72 years (65–85 years) with 22
(70%) women. Heartburn and dysphagia were the most
common indications for a re-operative procedure with 15
patients (48%) and 14 patients (45%) patients, respectively.
Recurrent hiatal hernia was noted in 17 (55%) patients.
Laparoscopic Nissen fundoplication was the original surgery in 23 (75%) patients. Toupet fundoplication was the
most common re-operative procedure (17 patients–55%).
The majority (65%) of RF were completed laparoscopically.
Additionally, there were 4 laparoscopic to open surgery
conversions and 4 thoracic procedures. Intra-operative viscus perforation and solid organ injury were identified in
26% (8 patients) and 10% (3 patients), respectively. Major
post-operative complications were noted in 10 patients (2
arrhythmia, 3 post-operative leaks, 1 post-operative bleeding and 4 pulmonary). One patient required return to the
operating room on POD#3 for a leak. Median ICU and
total hospital stay were 6 (range 1–45) days and 6 (range
2–55) days, respectively. There was no 30 day or in-hospital
mortality. Greater than five year follow-up was available
for 17 patients (mean of 72 months). Four patients died
in the interim from unrelated causes. Moderate to severe
symptoms were reported by a total of 5 patients (29%) (3
heartburn, 2 regurgitation, 1 dysphagia and chest pain in
none). Seven patients were on acid suppressive medications. Excellent satisfaction (grade 8-10) was reported by 13
(77%) patients and good (grade 6–7) by 3 (18%) patients.
The majority (88%) of patients stated that they would recommend the procedure to a friend if needed.
and more advanced technology resulting in a more costly
procedure. The purpose of this study was to determine the
cost difference between MIE and OE.
METHOD: One hundred and forty one consecutive cases
of esophagectomies were reviewed at a single institution
between May 2005 and Jan 2012. We excluded in hospital
mortalities and MIEs which were converted to OE. The MIE
category consisted of laparoscopic Ivor-Lewis esophagectomies and laparoscopic 3-hole esophagectomies. The OE
category consisted of transhiatal esophagectomies. A propensity score and quantile regression was used to estimate
adjusted median costs associated with all esophagectomies.
Propensity scores for MIE vs OE were modeled by logistic
regression and adjusted for BMI, smoking status, American
Society of Anesthesiology score, coronary artery disease,
hyperlipidemia, hypertension, chronic obstructive pulmonary disease, gastroesophageal reflux disease, diabetes and
neoadjuvant therapy. Data considered for the comparison
analysis were: general surgeon’s time, thoracic surgeon’s
time, anesthesiologist’s time, medications administered,
surgical equipment, Intensive Care Unit [ICU] cost, intermediate ICU cost and general floor cost.
Minimally invasive esophagectomy (MIE) is reported to
result in decreased length of hospital stay, blood loss and pulmonary complications compared to open esophagectomy
(OE). However, MIE requires a longer operative duration
139
Monday
Poster Abstracts
RESULTS: One hundred and eleven esophagectomies (laparoscopic = 78, open = 33) were included in the study. Of the
78 MIE patients, two patients underwent laparoscopic Ivor
Lewis Esophagectomy and 76 patients underwent thorascopic 3-hole esophagectomy which made up the majority of MIE cases. All 33 OE patients underwent transhiatal
esophagectomies. Ten patients were converted from MIE to
OE and were excluded from the study. Fourteen patients
underwent a hybrid esophagectomy and were excluded
CONCLUSION: RF can be safely performed laparoscopically from the study. Six hospital mortalities were excluded from
in the majority of patients ≥65 years of age for recurrent the study. The median operative time was 488 (range, 299–
GERD after initial fundoplication. The long-term post-oper- 651) minutes for MIE vs 266 (range, 146–542) minutes for
ative outcomes in this subset of patients are satisfactory OE. Median ICU stay for both groups was 3 days. Median
though associated with high peri-operative morbidity.
Hospital stay was 9 (range, 5–62) days for MIE vs 10 (range,
7–56) days for OE. Perioperative morbidity was 32.6% for
Mo1726
MIE vs 48.5% for OE. The estimated median total cost associated with an MIE procedure was $20,898.97 vs $22,577.66
Laparoscopic Versus Open Esophagectomy: A Clinical
for OE. The difference was substantial $1,678.69 (95% CI
and Cost Analysis
$-788.14-$6938.10); however, there was insufficient data to
1
1
2
Wei Phin Tan , Zhi Ven Fong , Scott W. Cowan ,
suggest statistical significance.
Nathaniel R. Evans2, ADAM Berger1, Scott W. Keith3,
CONCLUSIONS: A systematic, prospective study analyzing
Karen A. Chojnacki1, Francesco Palazzo1, Laura Pizzi4,
cost differences between MIE and OE is required to better
Ernest L. Rosato1
delineate true economic differences.
1
Department of General Surgery, Thomas Jefferson University,
Philadelphia, PA; 2Division of Thoracic Surgery, Thomas Jefferson
University, Philadelphia, PA; 3Division of Biostatistics, Thomas
Jefferson University, Philadelphia, PA; 4Division of Pharmacy and
Outcomes Research, Thomas Jefferson University, Philadelphia, PA
Mo1727
flux repair and also has potential for staple line dehiscence.
An alternative is to use a Hill gastropexy to lengthen the
esophagus and combine it with a Nissen fundoplication,
thus maintaining the intraabdominal position, preventing
acid reflux, preserving motility and avoiding a staple line.
We compared these two repairs to determine if a combined
Nissen Hill (NH) was equivalent to a Collis Nissen (CN).
Comparing the Post-Operative Manometric
Characteristics of the Laparoscopic Nissen
Fundoplication and the Laparoscopic Hill Repair
Richard C. Wiseman1, Ralph W. Aye1, Lee L. Swanstrom2,
Alexander S. Farivar1, Brian E. Louie1
1
Institute, Seattle, WA; 2The Oregon Clinic, Portland, OR
METHODS: We performed a retrospective review of consecutive patients with short esophagus undergoing either
primary laparoscopic CN or NH repairs between 2007 and
BACKGROUND: The Laparoscopic Nissen Fundoplication 2012 from a prospectively collected database. Short esopha(LNF) and the Laparoscopic Hill Repair (LHR), in which the gus was defined as less than 2 cm of intraabdominal length
gastroesophageal junction is fixed to the preaortic fascia, after mobilization above the inferior pulmonary veins and
were shown in a recent randomized trial to be equivalent prior to crural closure. CN was performed via wedge funin controlling uncomplicated GERD at 12 months. Mano- dectomy to lengthen the esophagus whereas NH used 2
metrically, the LNF achieved a statistically significant Hill gastropexy sutures to provide intraabdominal length.
increase in LES pressure; whereas, LHR did not. This study A standard Nissen fundoplication was added to both.
aims to further evaluate the post-operative high resolution All patients underwent physiologic testing before and 6
manometry studies from this trial to determine if differ- months post op with quality of life (QOL) assessment at
ences between the two repairs can explain the resultant each visit.
GERD control.
RESULTS: A short esophagus was identified in 38 patients.
METHODS: Of 46 LNF patients and 56 LHR patients who Three were excluded: transthoracic CN (1) and revision Niswere randomized, there were 16 LNF patients and 20 LHR sen to NH (2). Thus, 14 underwent CN and 21 NH. The
patients with available post-op manometric testing. High groups had similar demographics, GERD history, size of
Resolution Manometry (HRM) was performed using the hiatal hernia and prior stricture. There was no mortality
Manoscan system and analyzed using ManoView (V2.0) or major morbidity. No staple leaks occurred with CN. At
Software. Manometries were interpreted by a single clini- mean follow up of 6 months, % time pH <4 was 4.6 for
cian, blinded to the procedure performed using the Chi- CN vs. 1.5 for NH; Mean DeMeester scores were 20.4 vs.
cago classification.
6.8 respectively. There were two abnormal DMS in the CN
RESULTS: The overall LES length among LNF and LHR group and one in the NH group. One CN patient reported
groups was similar. (2.7 vs 2.3, p = 0.15). However, the mean persistent symptoms and was placed back on PPI therapy
intra-abdominal LES length after LNF was longer (1.8 vs 1.2, while none required PPI therapy in the NH group. Endop = 0.047) than after LHR. The integrated relaxation pres- scopic esophagitis was seen only in the CN group (3/14).
sures were also similar (11.7 vs 10.7, p = 0.54). The percent One radiographic hernia recurrence was seen in each group;
peristalsis was similar with 91% achieving 100% peristalsis both were small and asymptomatic with normal DeMeester
with distal amplitudes of 91 and 89 mm Hg respectively. scores and did not require PPIs. Dysphagia scores improved
The distal contractile integral was 2299 compared to 2087 from pre- to postop in the NH group (31 to 42) but not in
(p = 0.66).
the CN group (38 to 36). QOL improved from pre op and
DISCUSSION: Post-operative manometric analysis using was similar post op across the groups: QOLRAD (6 vs. 7),
high resolution manometry was unable to detect measurable GERD-HRQL (10.3 vs. 5.8) in the CN and NH.
differences between the LNF and LHR to explain how each
repair results in GERD control. The difference in intraabdominal LES length likely reflects the difference in the anatomy
of the gastroesophageal junction after reconstruction.
Mo1728
CONCLUSIONS: The CN and NH repairs achieved excellent
early results in the surgical management of short esophagus. Radiographic recurrences were similar, but the CN had
more frequent abnormal distal esophageal acid exposure,
more endoscopic evidence of esophagitis and some persistent dysphagia. The NH is an acceptable alternative to CN.
A Combined Nissen Fundoplication with Hill Gastroplasty Mo1729
Is an Alternative to Collis-Nissen Repair in the
Safety and Symptom Control Efficacy of ePTFE-mesh
Treatment of Short Esophagus
in Hiatal Hernia Repair with Nissen Fundoplication for
Zeljka Jutric, Brian E. Louie, Alexander S. Farivar,
Gastroesophageal Reflux
Eric VallièRes, Ralph W. Aye
Institute, Seattle, WA
Johannes Miholic, Emanuel Sporn, Alexander Di Monte
Medical University of Vienna, Vienna, Austria
OBJECTIVES: The short esophagus is a challenging problem resulting from long standing reflux, stricture, and/or
hiatal hernia. Standard treatment lengthens the esophagus with a Collis gastroplasty added to an antireflux repair.
This however places acid secreting mucosa in an aperistaltic segment of tubularized stomach at or above the antire-
BACKGROUND: Preoperative hiatal hernia ≥3 cm is associated with a threefold relative risk for reflux symptom
recurrence after fundoplication without mesh. This report
assesses the short-term safety and efficacy of ePTFE mesh
used for repair of herniae ≥3 cm in length in Nissen fundoplication for samptomatic reflux.
140
PATIENTS AND METHODS: 22 Patients with gastroesophageal reflux disease and typical symptoms responding at least in part to PPI therapy were entered into a pilot
study. Inclusion criteria comprised also endoscopic evidence
of erosions and/or abnormal esophageal acid exposure,
and a hiatal hernia of ≥3 cm in length. Study endpoints
were the time to recurrence of reflux symptoms and the
postoperative incidence of dysphagia with ensuing intervention. A cohort of 45 patients having undergone fundoplication without mesh for reflux with hiatal hernia from
1996–2007, who have been carefully audited for symptom
recurrence served as a comparison group. The study population underwent Nissen fundoplication with tension free
repair of the hiatus using a Goretex® dual mesh in inlay
technique secured by single non-absorbable sutures. The
patients were contacted at 1, 3, and 6 months postop, and
6 monthly therafter. A symptom recurrence was defined by
heartburn and/or regurgitation more frequently than once
a week and/or the need for PPI treatment to control reflux
symptoms. A significant dysphagia was defined as swallowing difficulites severe enough that the patient accepted an
offered intervention: endoscopy or endoscopic dilatation.
The patient characteristics are shown in Table 1.
Patients and Results
Variable
Age
Gender (M:F ratio)
Hiatal hernia (cm)
Sympt recurrences
Overall follow-up
Time to recurrence
Mesh (n = 22)
54 (34–70)
1.1
5 (3–8)
0/22
15 mo (2–44)
..
No mesh
PTFE
Rate Of
36 mo
12%
..
Incomplete Lower Esophageal Sphincter Relaxation
on High-Resolution Manometry Is an Independent
Predictor of Solid Diet Failure in Post-Roux-en-Y Gastric
Bypass Patients
Shikha Mangla1, ANA C. Tuyama1, Robert Burakoff1,
David B. Lautz2, Christopher C. Thompson1, Walter W. Chan1
1
Gastroenterology, Brigham and Women’s Hospital, Boston, MA;
2
Bariatric Surgery, Emerson Hospital, Concord, MA
BACKGROUND: Roux-en-Y gastric bypass (RYGB) is an
effective surgery for weight loss in obese patients. Current
guidelines recommend advancement to regular diet in 1–2
months post-RYGB. Failure to advance or dietary intolerance may have clinical and nutritional implications. A prior
study suggested that up to 30% of post-RYGB patients may
develop dysphagia. RYGB may affect the Vagal innervation
to the esophagus, and the resultant esophageal dysmotility
may play a role in post-RYGB dietary complications. Understanding esophageal motor functions by high-resolution
manometry (HRM) and their association with dietary outcome post-RYGB may allow more effective, targeted therapy for symptoms and dietary complications.
AIM: To investigate the association between esophageal
motor dysfunctions on HRM and intolerance to solid diet
among post-RYGB patients.
Controls (n = 45)
57 (27–74)
2.5
5 (3–10)
13/45 (29%)
115 mo (12–183)
32 mo (10–115)
METHODS: This was a retrospective cohort study of postRYGB patients who underwent HRM at a tertiary care center in 6/2007–5/2012. Patients with underlying esophageal
dysmotility pre-RYGB, HRM performed less than 2 months
after RYGB, or need for parenteral or tube feeding were
excluded. The primary outcome was diet at the time of HRM
(liquid [LD] vs solid [SD]). Esophageal motor characteristics
were extracted from HRM. Fisher-exact or chi-squared test
for binary variables and student’s t-test for continuous variables were used to assess for differences between LD and SD
groups. Multivariate analysis was performed using forward
stepwise logistic regression.
Symptom Recurrence Rates
Estimated
12 mo
5%
0
Mo1731
Recurrence
120 mo
30%
..
141
Monday
Poster Abstracts
RESULTS: 63 patients met inclusion criteria (age 51 ± 10.3
yrs, 91% F), and 21 subjects (33.3%) could only tolerate LD.
Patients on LD were more likely to have at least one abnormal parameter on HRM than those on SD (61.9% vs 28.6%,
p = 0.01). Univariate analyses showed that elevated basal
lower esophageal sphincter (LES) pressure (9.52% vs 0%, p
= 0.04), incomplete LES relaxation (22% vs 0%, p = 0.04),
increased esophageal body contraction amplitude (119 ± 56
vs 93 ± 41 mmHg, p = 0.05), and dysphagia (52% vs 16%,
p = 0.003) were significantly associated with LD. On multivariate analysis, incomplete LES relaxation remained an
COMMENT: ePTFE mesh for narrowing the hiatus in hiatal indepedent predictor for LD (OR 11.73, p = 0.02).
hernia repair with Nissen Fundoplication seems safe and
effective. The difference in recurrence rates as compared to
a historical control group with otherwise identical operative technique is not (yet?) significant. If the promising
results should sustain, inlay application in hiatal hernia
should be proficient to further improve the performance of
fundoplication.
RESULTS: No conversions, revisions, or reoperations were
suffered in the study group. Following a mean follow-up of
18 r 12 months no symptom recurrences were encountered
in the study group. Two patients reported dysphagia, in
one resolved after endoscopy, the other requiring two dilatations. The Weibull parametric analysis of symptom free
survival revealed a borderline significant (p = 0.09) influence in favor of of mesh and the recurrence rate estimates
in the control group as follows: 1 year: 5%, 3 years 12%,
and 5 years: 30%.
CONCLUSIONS: Post-RYGB patients unable to tolerate SD
are more likely to have abnormal findings on HRM. Incomplete LES relaxation is independently associated with LD
use, while other hypermotility patterns (hypertensive LES
and increased esophageal body contraction) are also more
prevalent. In addition to pouch or anastomotic abnormalities, esophageal motor dysfunction should be considered in
assessing post-RYGB patients’ failure to tolerate SD. HRM
should play a role in evaluating post-RYGB dietary complications. Future studies should examine the potential causes
of this dysfunction and explore the effect of therapies targeting LES relaxation on clinical and dietary outcome.
Clinical: Hepatic
8Mo1732
Transplantation for HCC Improves Progression Free
Survival But Not Overall Survival When Compared to
Resection
Rafael Pieretti-Vanmarcke1,2, Hui Zheng3,2, Nahel Elias1,2,
David L. Berger1,2, Kenneth Tanabe1,2, Keith D. Lillemoe1,2,
Cristina R. Ferrone1,2
1
Department of Surgery, Massachusetts General Hospital, Boston, MA;
2
Harvard Medical School, Boston, MA; 3Biostatistics, Massachusetts
General Hospital, Boston, MA
CONCLUSIONS: For HCC patients within Milan criteria,
transplantation is associated with a lower recurrence rate,
but not a significantly improved overall survival. Patients
outside of Milan criteria had a significantly poorer OS
when compared to patients within Milan criteria who were
resected or transplanted, reflecting a more aggressive disease biology.
Mo1733
Influence of Preoperative Laboratory Values on
Perioperative Mortality Following Hepatic Resection for
Malignancy
Mashaal Dhir1, Lynette M. Smith1, George Dittrick2,
Quan P. Ly1, Aaron R. Sasson1, Chandrakanth Are1
1
University of Nebraska Medical Center, Omaha, NE; 2Surgery,
Nebraska Methodist Hospital, Omaha, NE
BACKGROUND: Abnormal preoperative laboratory values
have been associated with increased mortality in patients
undergoing hepatic resection for malignancy. However,
cutoff values for these preoperative labs have been defined
arbitrarily. The aim of the current study was to identify
cut off values for these preoperative laboratory denominators which can help identify patients at increased risk of
mortality.
METHODS: Patient undergoing liver resection for malignancy (primary and secondary) were extracted from 2005–
OBJECTIVE: To compare the outcomes of patients with 2010 National Surgical Quality Improvement Database. We
hepatocellular carcinoma (HCC) undergoing either liver determined the optimal cutoffs for each laboratory denominator using the classification and regression tree analysis
transplantation (LT) or resection (LR).
METHODS: A single institution retrospective analysis of (CART), and the “party” package for conditional inference
trees in R. Patients were classified according to the cutoffs
327 HCC patients treated between 8/1991–12/2011.
determined from CART analysis and logistic regression
RESULTS: A total of 327 patients with HCC underwent sur- analysis was used to fit a multivariate model, with backward
gical treatment of whom 79% were male, 19% had hepatitis variable selection.
B and 44% hepatitis C. Patients underwent transplantation
(n = 138) or surgical resection (n = 189). Of the resected RESULTS: A total of 4812 patients who underwent liver
patients 126 did not meet the Milan Criteria (MC) while resections for malignancy were included. Statistically signif63 patients were within MC. When comparing resected icant association was seen between increased 30 day morpatients within MC to transplanted patients the median tality and preoperative laboratory values including serum
tumor diameter was 3.2 cm and 3.0 cm, respectively. Recur- Na d 135 meq/L, BUN >19 mg/dl, serum creatinine >1.68
rence rates were 57% for resected patients within MC and mg/dl, serum albumin d 2.6 g/dl, bilirubin >1.8 mg/dl,
13% for LT patients (P < 0.0001). The model end-stage liver SGOT >50 IU/L, alkaline phosphatase of >149 IU/L, WBC
disease (MELD) score median was 7 for resected patients >10,790/ul, Hct d 28, and INR >1.1. In a multivariate logiswithin MC and 10 for LT patients. The median overall sur- tic regression model, albumin d 2.6, SGOT > 50, INR > 1.1,
vival (OS) was 40 months for both resected and transplanted BUN > 19, and alkaline phosphatase > 149 are independent
patients. The OS at 1, 3, and 5 years was 47%, 40%, and 23% predictors of 30 day mortality with an area under the curve
for resected patients within MC and 59%, 49%, and 33% for of 0.77.
transplanted patients. (p = ns). Significant clinicopathologic CONCLUSIONS: Cutoff laboratory values defined in the
factors predicting survival were age, size of lesion, lympho- current study may help identify patients who are at higher
vascular invasion, Patients outside of MC who were resected risk of mortality from hepatic resections.
had a significantly decreased survival compared to patients
within MC and those who were transplanted.
142
Mo1734
heterogeneity or growth over time (120, 81%), a cancer history (113, 76%), and/or symptoms (39, 26%). The majority
Resected Splenic Masses Discovered on Imaging Are
of patients underwent a preoperative CT (138), although
Frequently Malignant: A Review of 148 Cases
PET (25), MRI (23), and ultrasound (8), were also included
in patient evaluations. Among the resected spleens, the
Ciaran T. Bradley, Amudhan Pugalenthi, Vivian E. Strong,
majority had a malignant mass (93, 63%). 90% were parenWilliam R. Jarnagin, Daniel G. Coit, T.P. Kingham
chymal metastases, including ovarian cancer (39, 42%),
Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
followed by melanoma (14, 15%) and colorectal cancer (9,
BACKGROUND: Solid and cystic splenic masses discov- 10%). While the majority of the patients with malignant
ered on imaging studies often pose diagnostic and man- splenic lesions had a previous history of cancer (85 of 93;
agement dilemmas. This study analyses a large series of 91%), among those patients without a previous history of
splenectomies to identify preoperative factors associated cancer (n = 35), most had benign lesions (77%). On multiwith malignant splenic masses.
variate analysis of several clinicopathologic factors, a previMETHODS: Pathology records at a single institution ous history of cancer was the only independent predictor
were reviewed for all splenectomies. Those performed as of malignancy in the splenic lesion (odds ratio 6.3; 95%
a component of a larger resection, for lymphoma stag- CI, 2.32–16.97; p = 0.00). Imaging described as “suspicious
ing, or debulking for a surface malignancy were excluded. for malignancy” by the radiologist (e.g. by virtue of heteroDemographic and clinicopathologic factors were obtained. geneity) or lesions that enlarged on interval scans did not
Univariate and multivariate analyses identified factors asso- correlate with malignancy in the spleen.
ciated with an increased risk of malignancy.
CONCLUSION: While the spleen is an uncommon site of
RESULTS: Between 1986 and 2012, 2,745 patients under- malignant disease, resected splenic masses are frequently
went splenectomy. 148 were performed for splenic lesions malignant, especially in patients with a previous history of
identified on abdominal scans. The indication for resec- cancer.
tion included suspicious imaging characteristics such as
Factors Associate with Malignancy in Resected Splenic Masses
Variable
Sex (M v. F)
Age
Symptomatic
Previous history of cancer
Imaging \”suspicious for malignancy\”
Increasing size
Odds Ratio
0.424
1.018
0.593
10.2
1.24
0.745
Univariate
95% CI
0.20.8
0.99–1.04
0.24–1.45
4.17–25.1
0.54–2.85
0.32–1.71
P-value
0.018
0.098
0.253
0.000
0.601
0.489
Odds Ratio
0.472
6.28
Multivariate
95% CI
0.21-1.06
2.32-16.97
P-value
0.70
0.000
features of patients who survived more than 5 years were
compared with those died within 5 years.
Mo1735
Analysis of Clinicopathological Factors Contributing
an Actual 5 Year Survival After Hepatectomy for
Intrahepatic Cholangiocarcinoma
RESULTS: Of all 113 patients underwent surgical resection, 33 patients (29.2%) survived more than 5 years.
BACKGROUND: Hepatectomy is the only chance of cure
for patient with intrahepatic cholangiocarcinoma (ICC),
because there is a lack of other effective treatments for
achieving an actual 5 year survival. However clinicopathological feature predicting 5-year survival after hepatectomy
has not been well clarified.
METHODS: 113 consecutive ICC patients with mass-forming (MF) macroscopic tumor type and MF plus periductal
infiltrating (PI) type, who underwent surgical resection at
a single institution between January 1990 and December
2006, were retrospectively analyzed. Patients who died of
unknown causes, and who was lost to follow up within 5
year were excluded from the study. The clinicopathologic
In univariate analysis, MF type (p = 0.015), preservation
of extra bile duct resection (p = 0.014), operation without blood transfusion (p = 0.001), absence of intrahepatic
metastasis (p = 0.006), absence of vascular invasion (p =
0.022), negative lymph node involvement (p < 0.001), and
microscopic curative resection (p = 0.001) were significantly related to 5 year survival.
Multivariate analysis showed that operation without blood
transfusion, absence of intrahepatic metastasis and negative lymph node involvement were independent factors
associated with survival for more than 5 years, with odds
ratios (95% confidence interval) of 6.743 (1.784–25.491; p
= 0.005), 4.302 (1.391–13.306; p = 0.011), 3.886 (1.401–
10.664; p = 0.009), respectively.
CONCLUSION: In MF and MF + PI type of ICC, hepatectomy without blood transfusion, absence of intrahepatic
metastasis and negative lymph node involvement significantly contribute an actual 5 year survival.
143
Monday
Poster Abstracts
Shutaro Hori1, Kazuaki Shimada1, Satoshi Nara1, Minoru Esaki1,
Yoji Kishi1, Tomoo Kosuge1, Hidenori Ojima2
1
Hepatobiliary and Pancreatic Surgery Division, National Cancer
Center Hospital, Tokyo, Japan; 2Pathology Division, National Cancer
Center Hospital, Tokyo, Japan
Mo1736
Hepatic Metastasectomy Offers Improves Local Tumor
Control Among Patients with Recurrent Colorectal
Metastases
Victor M. Zaydfudim1, Jeffrey S. Scow1, Grant D. Schmit2,
Guido M. Sclabas1, Benzon Dy1, David M. Nagorney1
1
Division of Gastroenterologic and General Surgery, Mayo Clinic,
Rochester, MN; 2Department of Radiology, Mayo Clinic, Rochester, MN
INTRODUCTION: Hepatic metastasectomy is an accepted
treatment strategy for patients with colorectal metastases to
the liver with demonstrated improvement in survival. Ablative strategies have been proposed for patients with recurrent liver metastases to avoid pitfalls of re-operative liver
resection. The aim of this study was to evaluate the survival
benefit of repeat metastasectomy and to compare hepatic
resection to radiofrequency ablation (RFA) among patients
CONCLUSIONS: Metastasectomy offers improved local
with recurrent hepatic metastases.
tumor control among patients with recurrent hepatic
METHODS: Patients continuously followed for primary colorectal metastases and should remain the preferred treatcolorectal malignancy, as well as, treatment of initial and ment strategy for these patients. Majority of the patients
recurrent colorectal metastases to the liver between 1992 with recurrent hepatic metastases are candidates for suband 2008 were included in this retrospective cohort study. segmental metastasectomy.
Clinical variables were compared between patients treated
with hepatic resection, hepatic ablation, or both treatment
modalities for recurrent hepatic colorectal metastases. Inde- Clinical: Pancreas
pendent radiologist, blinded to other covariates, categorized hepatic disease recurrence as local recurrence adjacent
8Mo1737
to the site of resection/ablation or new metastases.
RESULTS: Ninety-three patients (median age 60 years
(range 33–89), 57% male) were treated for recurrent hepatic
metastases: 46 underwent recurrent hepatic resection, 38
underwent RFA, and 9 underwent both treatment modalities. Initial colorectal tumor stage, hepatic burden of initial liver metastases, anatomic resections of initial liver
metastases, and disease free interval between primary resection and treatment of recurrent metastases did not differ
between recurrent treatment groups (all p ≥ 0.259). There
was no difference in use of systemic therapy for treatment of initial and recurrent hepatic metastases (all p ≥
0.105). Only 19% of patients treated with RFA had more
than one hepatic metastasis, compared to 33% of resected
patients, and 100% of patients treated with both modalities
(p < 0.001). Among patients treated with hepatic metastasectomy, 15% underwent anatomic resection of ≥2 segments, while 85% underwent sub-segmental resections.
32 patients (34%) developed local re-recurrence at hepatic
treatment site during a median of 12 months (range 1–142
months) follow-up with cross-sectional imaging after treatment of recurrent metastases. At 1- and 5- year follow-up,
local recurrence rates were lowest among patients treated
with hepatic metastasectomy compared to RFA and both
treatment modalities: 17% vs. 41% vs. 75% at 1 year and
36% vs. 52% vs. 100% at 5 years, respectively (p < 0.001,
Figure). Overall survival did not differ between treatment
groups (p = 0.730).
The Effect of Splenectomy on Complication Rates After
Distal Pancreatectomy: A Meta-Analysis
Noah Rozich, Angel Matos, Alison Gegios, Emily Winslow
Department of Surgery, University of Wisconsin, Madison, WI
BACKGROUND: Distal pancreatectomy is being performed more commonly for patients with benign findings,
and minimally invasive techniques are frequently applied
in this population. As a result, the role of spleen preservation during distal pancreatectomy has been debated. Many
conflicting and under-powered case series have been published but no randomized trial comparing these techniques
has been initiated. As a result, there is significant controversy about the impact of splenectomy on distal pancreatectomy complication rates. We therefore undertook a
systematic review and subsequent meta-analysis in order to
provide objective evidence to this debate.
METHODS: A comprehensive search for published Englishliterature studies of left pancreatectomy from 1980–2012
was undertaken. All studies were screened for our inclusion criteria: > than 10 pts, non-traumatic indication, treatment of spleen detailed, and postoperative complications
described in relation to treatment of spleen. Two generations of ancestral searching was used. When multiple series
from a single institution were encountered, the largest and
highest quality series was selected for inclusion. Continuous variables were calculated as a variable weighted by the
proportion of patients in each study.
144
RESULTS: More than 1000 articles were found using the
initial search criteria, and after detailed review, 52 studies with 3355 patients were included. Of these, 15 studies
including 1482 patients both compared distal pancreaticosplenectomy (DPS) to spleen-preserving distal pancreatectomy (SPDP) and detailed postoperative complications.
This group is the focus of this report. The mean age was
52.8 years, and 41% were male. A wide variety of pathologic diagnoses were included with 37.4% being for cystic
disease, 21.2% pancreatitis, 16.8% neuroendocrine tumors,
and only 9.4% pancreatic cancer. When the groups were
compared, there were more with pancreatitis in the SPDP
group, and more with pancreatic cancer in the DPS group
(Table 1). Weighted values for length of surgery and length
of stay were similar, but there was a trend towards higher
blood loss in the DPS group. When postoperative complications were analyzed, there was no significant difference
between groups (see Table). Importantly, there was no difference in rates of infectious complications, pancreatic fistulae, or thrombotic complications. Notably, spleen related
complications (infarcts or delayed splenectomy) occurred
in 8.8% of patients with splenic preservation.
Number
Mean age (yrs)
Gender (% male)
Diagnosis (n,%)
Pancreatitis
Pancreatic cancer
Cystic disease
Operative Variables
Length of surgery (min)
Estimated Blood Loss
(mL)
Length of hospital stay
(days)
0.044
0.0001
NS
198.8
499.9
181.7
303.7
NA
NA
10.4
8.9
NA
(n, %)
113 (21.2%)
26 (4.9% )
3 (0.56%)
NS
NS
NS
5 (0.94%)
NS
16 (3.0%)
2 (0.4%)
47 (8.8%)
NS
NS
NA
Postoperative Complication
Pancreatic leak
208 (21.9%)
Infectiouscomplications
64 (6.8%)
Thrombotic
9 (0.95%)
complications
Hemorrhagic
13 (1.4%)
complications
Reoperation
28 (2.95%)
Mortality
6 (0.6%)
Spleen-related
NA
complication
Pablo E. Serrano, Peter T. Kim, Gulav Naman, Hassan AL-Ali,
Sean Cleary, Paul D. Greig, Ian D. Mcgilvray,
Carol-Anne Moulton, Steven Gallinger, Alice C. Wei
Surgery, Princes Margaret Cancer Centre, Toronto General Hospital,
University of Toronto, Toronto, ON, Canada
BACKGROUND: Prophylactic intraperitoneal closed-suction drains after pancreaticoduodenectomy (PD) are widely
used even though its value is not well determined due to
the limited number of studies available to date. The main
objective of this study is to analyze the risk-benefit association of prophylactic drainage after PD.
METHODS: This is a retrospective cohort study of 635
patients who underwent a PD from January 1, 2000 to
December 31, 2010. Analyses of the clinical, pathological
and surgical outcomes of patients who had a closed-suction
drain placed during PD were compared to those patients
without drain.
CONCLUSION: Although DPS is performed more often
in patients with malignancy and may have slightly higher
blood loss, this meta-analysis does not demonstrate any
increase in complication rates when compared SPDP. In
fact, the 9% complication rate related to spleen preservation raises the question of if organ preservation offers any
substantive advantage.
CONCLUSION: The use of prophylactic intraperitoneal
closed-suction drains does not alter the postoperative complication or mortality rate after PD. The similar pancreatic
leak and intra-abdominal abscess rate along with the comparable risk of postoperative interventional radiology drainage
or surgical exploration between groups suggests that there
is no increased benefit from the use of prophylactic closedsuction drainage after PD, therefore its role warrants further
discussion.
145
Monday
Poster Abstracts
111 (25.3%)
10 (2.3%)
186 (42.5%)
Risk-Benefit Assessment of the Use of Intraperitoneal
Drainage After Pancreaticoduodenectomy
RESULTS: Median age was 63 years (17 to 84). The majority
of PD were performed for periampullary cancer (547/635,
86%) with 258/635, 40.7% pancreatic adenocarcinomas.
There were 368/635, 58% patients in the drain group and
267/635, 42% without drain. During the first 6 years of the
cohort, 160/190, 84% patients had a drain placed during PD
vs. 253/445, 57% in the last 6 years, odds ratio (OR) 3.9, 95%
confidence interval (CI): 2.5 to 6.3; p < 0.01. Demographic,
surgical and pathologic characteristics were similar between
groups. There was no difference in the overall complication
rate (278/635, 43.8%; 45.7 vs. 42.2; p = 0.4), major complication rate/Clavien-Dindo Class ≥3 (110/635, 17.3%; 18.2 vs.
14.7; p = 0.3), 90-day/in-hospital mortality rate (8/635, 1.3%;
1.1 vs. 1.4; p = 0.7) and pancreatic leak rate (50/368, 12.1%;
13.6% vs. 10.1%; p = 0.18. Patients with a diagnosis of pancreatic cancer had a much lower pancreatic leak rate compared to patients without pancreatic cancer, 5.6% vs. 16.4%,
OR 3.3, 95% CI: 1.8 to 6.6; p < 0.01; without any difference
in the percentage of patients that had a drain placed in this
group (65% vs. 59%; p = 0.1). Median length of hospital stay
was longer for the drain group, (10 vs. 9 days, p = 0.04); also,
patients with drain that developed a complication had a significantly longer hospital stay than those without drain who
also developed a complication (20 vs. 16 days, p = 0.04).
Intraperitoneal drainage did not alter the risk of wound infection (67/635, 10.8%, 11.3 vs. 9.2; p = 0.4), intra-abdominal
abscess (79/635, 14.3%, 15.3 vs. 11.2; p = 0.1), re-intervention (69/635, 12.2%, 12.7 vs. 10.6; p = 0.4) or reoperation
(16/635, 3.4%, 3.3 vs. 1.8; p = 0.2) after PD.
DP with
DP with Spleen
Splenectomy (DPS) Preservation (SPDP) p Value
Demographics
948
534
54.3
51.7
NA
44.4%
32.8%
0.0003
140 (19.7%)
82 (11.5%)
269 (37.8%)
Mo1738
Mo1739
Efficacy of Wrapping the Pancreatic Stump with a
Bioabsorbable Sheet and Fibrin Glue After Distal
Pancreatectomy
Daisuke Ban, Kota Sato, Satoshi Matsumura, Takumi Irie,
Takanori Ochiai, Atsushi Kudo, Noriaki Nakamura, Shinji Tanaka
Department of Hepato-Biliary-Pancreatic Surgery, Tokyo Medical and
Dental University, Tokyo, Japan
BACKGROUND: Distal pancreatectomy (DP) is a simple
operative procedure. However, morbidity associated with
pancreatic fistula has remained unresolved. In 25 of 70 DPs,
we wrapped the pancreatic stump in a bioabsorbable sheet
with fibrin glue. The aim of this study was to evaluate the
efficacy of our wrapping method.
METHOD: Between January 2006 and October 2012, 70
laparoscopic and open patients underwent DP. Pancreatic
stump closure was achieved with a stapler or by conventional hand-sewn closure. In the wrapping group, the pancreatic stumps were wrapped with a polyglycolic acid felt
bioabsorbable sheet (0.15 mm thick), and fibrin glue was
sprayed onto the wrapped stump. Pancreatic fistulas were
classified according to the grading system of ISGPF. The primary endpoint was the occurrence of a clinical pancreatic
fistula, including Grade B and C.
Mo1740
Predictors of Same Hospital Readmission Versus
Readmission to Another Hospital After Surgery for
Pancreatic Cancer: A SEER-Medicare Study
Marquita R. Decker1,2, David Y. Greenblatt2, Chee P. Lin1,
Jeffrey A. Havlena1,2, R Scott Saunders1, Sara Fernandes-Taylor1,2,
RESULT: Of the patients, 25 (36%) underwent pancreatic Noelle K. Loconte3,2, Heather B. Neuman1, Sharon M. Weber1,
stump wrapping, and 45 (64%) had no additional treat- Maureen A. Smith2, Amy Kind3,2, Caprice C. Greenberg1,2,
ment after pancreatic stump closure (non-wrapped-). In Emily Winslow1
the wrapped group, Grade A, B, and C pancreatic fistulas 1Department of Surgery, University of Wisconsin, Madison, WI;
occurred in 7 (28%), 2 (8%), and 0 patients, respectively. In 2
Health Innovation Program, University of Wisconsin, Madison, WI;
the non-wrapped group, Grade A, B, and C pancreatic fis- 3
tulas occurred in 6 (13%), 17 (38%), and 1 (2%) of subjects, Department of Medicine, University of Wisconsin, Madison, WI
respectively. The incidence of clinical pancreatic fistula OBJECTIVE: Patients who undergo pancreatic surgery are
in wrapped patients was significantly lower than that in among those at the highest risk for readmission. Evidence
unwrapped patients (p = 0.004). The average of the amylase suggests that same hospital readmission is less costly than
value in pancreatic drains in the unwrapped and wrapped readmission to another hospital. The objective of this study
group was 3893 IU/L and 15562 IU/L on postoperative day was to identify modifiable and non-modifiable predictors
(POD) 1, 1401 IU/L and 1736 IU/L on POD 3, respectively. of same versus other hospital readmission among patients
On POD 1, the drain amylase value in wrapped patients who undergo surgery for pancreatic cancer.
was significantly lower than that in unwrapped patients (p METHODS: Medicare beneficiaries who underwent major
= 0.004). Other clinical features and treatments including pancreatic resection from 2000 to 2008 were identified
age, sex, body mass index, primary disease, American Soci- from the Surveillance, Epidemiology, and End Resultsety of Anesthesiologists classification, previous laparotomy, Medicare database. Demographics, co-morbidities, cancerintraoperative bleeding, operation time, laparoscopic sur- related and treatment-related variables as well as hospital
gery, stump closure method, and blood transfusion were characteristics were examined. Using multivariable logistic
not significantly related to pancreatic fistula.
regression, predictors of readmission were identified and
CONCLUSION: The present study suggests that a bioabsorbable sheet with fibrin glue wrapping has advantages
after distal pancreatectomy and may reduce the incidence
of pancreatic fistula.
then compared to predictors of same versus other hospital
readmission.
RESULTS: Of 2,486 patients, 512 (21%) were readmitted
within 30days of discharge. One thousand six hundred
eighty five (68%) had their surgery at an academic medical center and 607 (24%) at a National Cancer Institutes
(NCI) -designated cancer center. One thousand six hundred
forty two (66%) had an initial length of stay greater than
10 days and 471 (19%) were discharged to a skilled nursing
facility (SNF). Predictors of readmission included severity of
co-morbidities (Charlson Comorbiditiy Score ≥3: OR 1.54
[95% CI 1.08–2.2] p = 0.017), initial length of stay greater
than 10 days (OR 1.66 [95% CI 1.32–2.17] p < 0.001), and
146
discharge to a SNF (OR 1.50 [1.15–1.95] p = 0.003). Of the
readmitted patients, 387 (76%) returned to the same hospital while 125 (24%) were readmitted to another hospital.
After controlling for co-morbidities, neoadjuvant radiation
and chemotherapy, and other treatment-related variables,
readmission to another hospital was more likely for patients
if time from diagnosis to surgery was greater than 60 days
(OR 3.80 [95% CI 1.67 –8.68] p = 0.005). Readmission to
another hospital was also more likely if the hospital where
the pancreatic surgery occurred was an NCI-designated cancer center (OR 1.91 [95% CI 1.11 –3.28], p = 0.019) or if
it was affiliated with a medical school (OR 2.31 [95% CI
1.10–4.83] p = 0.027).
CONCLUSIONS: Readmission is common in patients who
undergo surgery for pancreatic cancer, and almost 1 in 4
readmitted patients go to another hospital. Risk factors for
30-day readmission include comorbidities and a complicated post-operative course resulting in prolonged length
of stay and discharge to a skilled nursing facility. Predictors of readmission to another hospital relate to prolonged
time from diagnosis to surgery and pancreatic surgery at
a tertiary care hospital. This study identifies the group of
patients who are likely referred for resection from their
local setting to a tertiary care center as a target for interventions to prevent or redirect readmissions.
Multivariable Analysis Identifying Predictors of Readmission to
Another Hospital After Pancreatic Surgery
Bridging the Gap in Hospital Accounting: Acute
Pancreatitis 2001–2009
Kenneth W. Bueltmann, Kenneth Laube, Marek Rudnicki
Surgery, Advocate Illinois Masonic Medical Center, Chicago, IL
INTRODUCTION: Acute pancreatitis (AP) was found in
the discharge records of 461,302 patients in 2010 according to the National Inpatient Sample (NIS). This illness was
concurrently present in 288,597 discharges as the primary
diagnosis. The financial ramifications of the disease have
increased dramatically over the last decade, exceeding $9
billion in total aggregate charges. This reflects the “national
bill” for AP treatments. $3 billion in costs were directly
related to discharges coded for primary AP in 2010. This
study will explore the financial aspects of inpatient AP diagnosis over time and characterize these observations at the
National level.
METHODS: The NIS database and cost-charge ratio (CCR)
files were utilized in conjunction with SAS 9.3 for all analyses. The weighted group averages (GAPIIC) include both
operating and capital-related costs and were used to calculate charges and costs from the total charge records. Independent means and standard errors were generated from
the costs and charges columns for each discharge in the
years 2001 and 2009. Results were tabulated and relative
changes over the time period and their associated statistical
significances were calculated using the NIS Z-test calculator.
RESULTS: The number of discharges for all diagnoses of AP
(ICD-9 Code 5770) increased 34% from 330,664 to 441,455
from the year 2001 to 2009 (p < .001). Primary diagnosis of
AP represented 221,664 and 274,119, respectively, a 24%
increase thereof (p < .001). Lengths of stay for primary AP
diagnoses in this same time period decreased from 6.1 to
5.1 days (–16%, p < .001). Gender distribution was found
to be equivocal. GAPIIC average fell 5.2 percent from 2001
to 2009 (p < .001). Total average charges for all adult AP
diagnoses increased 73%, $25,073 to $43,410 (p < .001),
while average costs increased 31% from $11,257 to $14,769
(p < .001). The difference between hospital charges and service costs increased 107%, from $13,815 to $28,641 (p <
.001). Aggregate charges for primary AP diagnosis increased
from $4,279,659,980 to $8,581,512,698, a 101% change
(p < .001).
CONCLUSION: This study finds an increasing gap between
hospital costs and charges for treatment of AP. Although
costs appear to be managed, charges are dramatically
inflated. The inherent power of the NIS has provided evidence that healthcare providers have controlled the treatment costs of AP in the last decade. Increased transparency
and movement towards accountability in medical care
demands further clarification. Continued investigations
may reveal that the fiscal cliff which confronts the healthcare industry is not a matter of care generated cost, but may
reflect an intrinsic lack of efficiency in insurance premiums,
administration, and overhead.
147
Monday
Poster Abstracts
Explanatory Variables
Adjusted OR
95% CI
P Value
Age
0.314
66–69
Reference
70–74
1.26
(0.64 –2.49)
75–79
1.30
(0.66 – 2.59)
80 +
2.02
(0.95 – 4.29)
Time From Diagnosis To Surgery
0.005
<30 days
Reference
30 to 60days
1.58
(0.85 – 2.91)
>60 days
3.80
(1.67 – 8.68)
Hospitalizations In Previous Year
0.767
0
Reference
1
0.85
(0.48 – 1.50)
2
0.71
(0.35 – 1.44)
3+
1.01
(0.50 – 2.03)
Initial Length of Stay
0.113
<10days
Reference
10 + days
1.54
(0.88 – 2.71)
Index Hospital Med School
2.31
(1.10 – 4.83)
0.027
Affiliation
Index Hospital Number of Beds
0.687
<300
0.75
(0.32 – 1.75)
300–600
0.82
(0.49 – 1.36)
>600
Reference
Index Hospital NCI Designation
1.91
(1.11 – 3.28)
0.019
Index Hospital Available Hospice
0.70
(0.43–1.14)
0.148
Neoadjuvant Chemo or
0.72
(0.25 – 2.07)
0.734
Radiation
DischargeTo Skilled Nursing
0.60
(0.33 – 1.06)
0.077
Facility
*Controlled for stage at diagnosis and diabetes mellitus in addition to above listed
variables
Mo1741
Mo1742
Mo1743
Clinico-Pathological Features of Solid Pseudopapillary
Neoplasms of the Pancreas
Risk Factors and Management of Postpancreatectomy
Hemorrhage in over 1000 Pancreatic Resections
Pablo E. Serrano1, Hassan AL-Ali1, Steven Gallinger1,
Ian D. Mcgilvray1, Carol-Anne Moulton1, Alice C. Wei1,
Stefano Serra2, Sean Cleary1
1
Surgery, Princes Margaret Cancer Centre, Toronto General Hospital,
University of Toronto, Toronto, ON, Canada; 2Pathology, Toronto
General Hospital, University of Toronto, Toronto, ON, Canada
Ulrich Wellner1,2, Frank Makowiec1, Hryhoriy Lapshyn1,
Dirk Bausch1,2, Ulrich T. Hopt1, Tobias Keck1,2
1
Clinic for General and Visceral Surgery, University of Freiburg
Medical Center, Freiburg, Germany; 2Department of Surgery, University
Hospital of Schleswig-Holstein Campus Lübeck, Lübeck, Germany
INTRODUCTION: Postpancreatectomy Hemorrhage (PPH)
BACKGROUND: Solid pseudopapillary neoplasms (SPN) is a rare but relevant complication after pancreatic resections. The aim of this study was to analyze risk factors and
are rare pancreatic tumors with low malignant potential.
management of PPH in a large patient collective.
METHODS: This is a retrospective analysis of 24 patients
with a diagnosis of SPN who underwent resection. The METHODS: The study was carried out retrospectively on
main objective of this study was to describe the clinico- the basis of a prospectively maintained database. Patients
with major pancreatic resections were included. PPH was
pathological features and surgical management of SPN.
defined according to the ISGPS. For statistical analysis, SPSS
RESULTS: Median age at diagnosis was 35.5 years (13 to
Software Version 20 was used.
64). Most patients were female, 20/24, 83%. Most patients,
14/24, 58% were symptomatic at diagnosis, (11/24, RESULTS: From 1994 to 2012, n = 1082 Patienten aged 9
79% had abdominal pain). Median tumor size was 4.7 bis 89 years were included (729 pancreatoduodenektomies
cm (2.1 to 12) with 15/24, 62.5% occurring in the body (PD), 188 distal pancreatic resections, 123 duodenum-preor tail and 9/24, 37.5% in the head or neck of the pan- serving procedures and 42 pankreatectomies). Incidence of
creas. Most tumors were solid and cystic in nature (18/24, PPH was 7% and 3% for severe (Grade C) PPH, 90% were
75%), without calcifications (6/24, 25%) and encapsulated late (>24 h postOP) PPH and about half of PPH had an intra(16/24, 70%). There were 8/24, 33% pancreaticoduodenec- luminal origin.
tomies, 4/24, 17% spleen-preserving distal pancreatecto- With Grade C PPH, mortality rose significantly to over 30%
mies, 10/24, 42% distal pancreatectomy-splenectomy and (overall 1.3%). Primary management consisted in endo2/24, 8% central pancreatectomies. Major complications scopic, angiographic and operative intervention. For severe
occurred in 3/24, 12.5% patients, with 6/24, 25% pancreatic PPH, success rate of non-operative therapy was around
leak rate (5/6, 83% ISGPF-type A leak). All cases displayed 50%. Risk factors for PPH were higher age and BMI and
strong E-catenin, CD56, progesterone receptor, alpha-1 pancreatic fistula (POPF). Pancreatogastrostomy (PG) in PD
antitrypsin and neuron-specific-enolase staining with loss had a significantly higher incidence of PPH than pancreatoof E-cadherin. Most cases stained positive for vimentin jejunostomy (PJ) mostly due to intraluminal PPH from the
(11/12, 92%) and CD10 (14/15, 93%). Three SPN were con- PG site. However, mortality after occurrence of PPH was sigsidered malignant, 3 developed liver metastases, 2 of which nificantly lower with PG (8% vs 28%, p < 0.05) compared to
were initially found at presentation and 2 had local recur- PJ, and PG was independently associated with lower overall
rence in the retroperitoneum. Two patients had evidence mortality survival in multivariate analysis, while age, POPF
of lymphovascular invasion; one of them had lymph node and PPH were the relevant risk factors for death.
involvement and eventually developed liver metastases.
Curative resection of metastases was offered to 2 of the 3 CONCLUSIONS: PPH is a major determinant of mortality
patients, the other patient died of disseminated metastatic risk in pancreatic surgery. Non-operative management is
disease 5 years after diagnosis of recurrence, 10 years after successful in about half of cases of severe PPH. Intraluminal
initial pancreatic resection. Chemotherapy (gemcitabine PPH is more frequent with PG, however mortality after PPH
and erlotinib) was given to only one patient with unre- and overall mortality were significantly reduced with PG.
sectable metastatic disease. Median follow-up period was
30 months (4 to 129), 21/24, 87.5% patients did not have Mo1744
recurrence and all patients except one were alive at the end
Mortality of Severe Acute Pancreatitis (SAP) Patients
of the study period.
CONCLUSIONS: SPN are tumors with a low but real malignant potential. Metastases and lymphovascular invasion
are the only features that can predict an aggressive behavior. Resection of liver metastases can offer cure to some of
these patients with aggressive SPN.
with Infected Necrosis or Persistent Organ Failure
Is High But May Be Reduced by Specialist Care and
Innovative Therapeutic Modalities
Omer Jalil, Rami Radwan, Aamer F. Iqbal, Chirag Patel,
Ashraf M. Rasheed
Dempartment of Surgery, Royal Gwent Hospital, Newport, United Kingdom
INTRODUCTION: Severe acute pancreatitis (SAP) is best
supported in high dependency or intensive therapy units
(HDU or ITU) setting and associated with high mortality
and morbidity despite best efforts at attaining early diagnosis and timely intervention.
148
AIM: To study management and disease-related mortality
of patients admitted to ITU with SAP with specific emphasis
on the group that succumbed to the disease in an attempt
to understand the circumstances that lead to this event and
identify interventions that may have abrogated this eventuality and indicators that may have predicted the fate of
these patients.
Mo1745
II (SN or Transient OF)
III (IN or Persistent OF)
IV (IN & Persistent OF)
RESULTS: Of the 163 patients reviewed, 14 (9%) were in
group A and 149 (91%) were in group B. Endpoints were
similar between the two groups, however 22 patients (15%)
in group B had their epidural discontinued early due to
either severe hypotension or epidural malfunction. Within
this group, patients older than 72 and with a BMI less than
or equal to 20 had their epidural discontinued in 80% of
cases compared with 12% of patients not meeting this
criteria. There was no significant difference in endpoints
between the 22 patients that had their epidural discontinued prematurely and the other 127 patients in group B who
did not require premature epidural discontinuation.
Peri-Operative Epidural May Not Be the Preferred
Form of Analgesia in Select Patients Undergoing
Trevor Axelrod1, Bernardino M. Mendez2, Gerard Abood2,
James Sinacore1, Gerard V. Aranha2, Margo Shoup3
METHODS: Retrospective case per case detailed analy- 1Loyola University Chicago Stritch School of Medicine, Maywood, IL;
sis of management and outcome of consecutive patients 2Surgery, Loyola University Medical Center, Maywood, IL; 3Surgery,
admitted to ITU with SAP during the period of 2007–2010. Cadence Healthcare, Warrenville, IL
Medical records were reviewed by a single abstractor (OJ)
for patient characteristics and disease severity scoring. The INTRODUCTION: Over the past decade, epidural analgedevelopment of necrosis, infected necrosis (IN) or organ sia and anesthesia (EAA) has become the preferred method
failure (OF) was recorded. Patients were classified into of pain management for major abdominal surgery. With
group I (No necrosis, No OF), group II (sterile necrosis or regards to pancreaticoduodenectomy (PD), the superior
transient OF), group III (IN or persistent OF) and group IV form of analgesia, as evidenced by their respective non(infected necrosis and persistent OF). The hospital course analgesic outcomes, has been debated. In this study, we
of the four groups were studied in relation to fluid resus- compare postoperative morbidity and mortality with EAA
citation, use and type of prophylactic or therapeutic, use and IV analgesia in patients who underwent PD. We also
of prophylactic anti-fungal, early introduction of enteral examine preoperative factors that lead to epidural disconfeeding, radiological/surgical intervention and any post- tinuation and the consequence of premature epidural discontinuation on morbidity and mortality.
intervention complications.
RESULTS: 51 patients admitted to ITU with SAP (APACHE METHODS: A retrospective review of a prospective dataII > 8, modified Glasgow score > 3) during the period of base of PDs performed at a single institution was conducted
2007–2010. All cases fulfilled the Atlanta criteria of SAP. for the time period between January 2007 and July 2011.
Median age: 66 ± 17.5. SAP was alcohol induced in 12% Patients receiving IV analgesia (group A) were compared
and due to gallstones in 59% of patients. No cause was with patients receiving EAA alone or in conjunction with
identified in 25% of patients. Median hospital stay and ITU IV analgesia (group B). Endpoints included mortality, major
stay were 14 and 3.23 days respectively. Forty one patients postoperative complications, postoperative hypotension,
(80%) received antibiotics and thirty five patients (69%) postoperative fluid requirements, length of stay, and hospihad nutrition support but neither of them seems to have tal readmission within 30 days. Multivariate logistic regresa significant impact on survival (p = 0.6 and 0.06 respec- sion was performed to measure the predictive success of
tively). The overall mortality rate during the study period epidural analgesia in comparison to IV analgesia for each
(3 years) was 38% (n–19) above national average of 30%. endpoint, as well as to measure the predictive success of
All 7 patients in group IV died; 5 had necrosectomy and 1 preoperative parameters including age, gender, BMI, surgical indication, and comorbidity. Using these same preoperhad CT guided drainage of infected acute fluid collection.
ative parameters, Classification and regression tree (CART)
Outcome (death) was statistically correlated with organ analysis for predictive modeling was used to determine
dysfunction criteria (Atlanta criteria and APACHE II score). predictors of epidural failure. Chi-Squared analysis was also
performed to compare patients who had epidural failure
Group
Total Number
Mortality
% Mortality
with the rest of group B using the previously assessed morI (No N & No OF)
12
0/12
0%
bidity and mortality endpoints.
0/2
12/30
7/7
0%
40%
100%
CONCLUSION: While the presence of ‘IN or persistent
OF’ in SAP (group III) is associated with high mortality,
the combination of ‘IN and persistent OF’ (group IV) is
uniformly fatal. Further research is necessary to confirm
findings in our study and to explore ways of optimising
patients in group III to improve survival.
CONCLUSION: EAA may be contraindicated in elderly,
underweight patients undergoing PD given their increased
risk of epidural-induced hypotension or malfunction. However, premature epidural discontinuation was not associated with increased morbidity and mortality. Prospective
randomized trials are warranted to further determine if EAA
should be avoided in this specific population.
149
Monday
Poster Abstracts
2
30
7
Mo1746
Mo1747
Postoperative Serum Amylase Predicts Pancreatic
Fistula Following Pancreaticoduodenectomy
Significance of Radiographic Splenic Vessel
Involvement in Pancreatic Ductal Adenocarcinoma
(PDAC) of the Body and Tail
Jordan M. Cloyd, Brendan Visser, George A. Poultsides,
Zachary Kastenberg, Jeffrey A. Norton
Nathaniel B. Paull1, Geraldine Chen2, Adnan Alseidi1,
Thomas R. Biehl1, Ravi Moonka1, Scott Helton1, David Coy2,
1
BACKGROUND: Pancreatic fistula (PF) is the most com- Flavio G. Rocha
1
mon complication following pancreaticoduodenectomy Surgery, Virginia Mason Medical Center, Seattle, WA; 2Radiology,
(PD) and is associated with high morbidity. Despite this, Virginia Mason Medical Center, Seattle, WA
few preoperative or perioperative risk factors have been OBJECTIVES: Major abodminal vessel invasion by PDAC
identified. In this study, we measured the postoperative in the head of the gland typically represents more advanced
serum amylase level and studied its ability to predict the disease not amenable to surgical resection. During distal
development of PF.
pancreatectomy for PDAC of the body or tail, the splenic
METHODS: A retrospective review of 176 consecutive PD
performed by one surgeon between 2006 and 2011 was
conducted. Preoperative demographic, perioperative data
and clinical outcomes were recorded. Comparison statistics
and logistic regression were used to analyze the association
between the serum amylase on postoperative day one and
the development of PF. PF was defined and scored based on
the International Study Group on Pancreatic Fistula.
vessels are routinely removed for tumor clearance and
lymphadenectomy. However, little is known about the biologic significance of splenic artery and vein involvement in
PDAC of the body or tail and we hypothesize that it may be
an adverse prognostic factor.
CONCLUSIONS: An abnormally elevated serum amylase
on postoperative day one following PD is associated with a
five-fold higher risk of developing a pancreatic fistula. This
readily available and inexpensive test may assist in the earlier detection of pancreatic fistula.
significantly worse overall survival (OS) when compared to
abutment or no involvement (median OS 15 months vs 31
months, p < 0.04).
METHODS: All cases of distal pancreatectomy for PDAC
at a single institution between 2000–2010 were retrospectively reviewed from an IRB-approved database. PreoperaRESULTS: 146 of 176 consecutive PD cases (83.0%) had tive computed tomography (CT) imaging was re-reviewed
serum amylase on postoperative day one recorded. 27 of by a single radiologist and splenic artery and vein involvethe 146 developed a PF (18.5%): 6 type A, 19 type B and 2 ment was graded as none, abutment, encasement or occlutype C. Patients with a PF had a mean serum amylase on sion. Demographic, laboratory, operative, pathological, and
postoperative day one of 659 ± 581 compared to 246 ± 368 outcome data were collected and correlated to the degree
in control patients (p < 0.001). Patients with leaks were also of splenic vessel involvement. Statistical analysis was peryounger (60.3 ± 11.3 vs 65.5 ± 11.1, p < 0.05), less likely formed using a Chi-Square with Fisher’s exact test and surto have pancreatic adenocarcinoma (40.7% vs 68.9%, p < vival compared by the method of Kaplan-Meier with log
0.05) and less likely to have a duct-to-mucosa anastomo- rank test.
sis (63.0% vs 88.2%, p < 0.01). A serum amylase of 140 RESULTS: 46 patients were identified, of which 44 had
U/L, the laboratory’s upper limit of normal, was empirically preoperative cross-sectional imaging available for evaluachosen as the cutoff value in order to maximize sensitivity tion to make up the study cohort. 39 (89%) patients had
while maintaining specificity. On logistic regression analy- radiographic tumor involvement of the splenic vein (23
sis, a serum amylase > 140 U/L on postoperative day one abutment, 6 encasement, 10 occlusion) while 32 (73%)
was strongly associated with developing a PF (OR 5.48, 95% patients had tumor involvement of the splenic artery
CI 1.94–15.44) as was receiving an intussuscepting anasto- (20 abutment, 12 encasement, none with occlusion). 28
mosis (OR 4.41, 95% CI 1.69–11.52). Greater age (OR 0.96, patients had both arterial and splenic involvement while
95% CI 0.93–1.00) and a diagnosis of adenocarcinoma (OR three patients had neither. There was no significant differ0.31, 95% CI 0.13–0.71) were associated with not develop- ence in margin positivity, perineural or lymphovascular
ing PF. Sensitivity and specificity of a postoperative serum invasion between patients with or without splenic vessel
amylase > 140 U/L was 81.5% and 55.5%, respectively. Posi- involvement. However, splenic artery encasement corretive and negative predictive values were 29.3% and 93.0%, lated with lymph node positivity (p < 0.02). Splenic artery
respectively.
but not vein encasement or occlusion was associated with a
CONCLUSIONS: Patients with PDAC of the body or tail
presenting with radiographic encasement of the splenic
artery but not the vein have a worse prognosis and should
be considered for additional treatment such as neoadjuvant
therapy prior to an attempt at resection.
150
Mo1748
Mo1749
Outcomes of Surgery for Chronic Pancreatitis
Patients with Familial Pancreatitis Have a Better
Quality of Life After Total Pancreatectomy with Islet
Autotransplantation
Rajesh Gupta1, Sunil D. Shenvi1, Rajinder Singh1,
Surinder S. Rana1,2, Deepak K. Bhasin2
1
Surgical Gastroenterology Division, Postgraduate Institute of Medical
Education and Research, Chandigarh, India; 2Gastroenterology,
Postgraduate Institute of Medical Education and Research,
Chandigarh, India
Stefanie M. Owczarski1, Katherine A. Morgan1, David B. Adams1,
Hongjun Wang1, Jeffrey J. Borckardt2, Alok Madan2
1
Surgery, MUSC, Charleston, SC; 2Psychiatry and Behavioral Sciences,
MUSC, Charleston, SC
INTRODUCTION: Debilitating abdominal pain remains
the most common presentation of chronic pancreatitis and
the treatment remains challenging. This study analyzed the
outcome of surgery in patients with chronic pancreatitis.
CONCLUSIONS: Tailored surgery for chronic pancreatitis has excellent benefit in pain relief without significant
increase in functional abnormalities. Frey’s procedure was
the commonest surgery performed in the present study.
151
Monday
Poster Abstracts
INTRODUCTION: Familial pancreatitis (FP) patients
live with debilitating pain from a young age and have an
increased risk of developing pancreas cancer. Quality of life
(QOL) following total pancreatectomy with islet autotransPATIENTS AND METHODS: We retrospective reviewed plantation (TPIAT) in this patient population is not well
details of patients undergoing surgery for chronic pancre- understood.
atitis between January 2002 and June 2013 at Division of METHODS: A prospectively collected database of patients
Surgical Gastroeneterology, PGIMER, Chandigarh. A total undergoing TPIAT for FP was reviewed over a 1 year period.
of 60 patients were admitted for surgery, however, surgery Data pertaining to insulin requirements and diabetes conwas not performed in five due to medical reasons.Indica- trol, pain scores, and SF-12 physical quality of life (pQOL)
tions for surgery was pain in 51 patients, gastric outlet and mental health QOL (mhQOL) (normal population 50,
obstruction in 2 and bleeding in 2 patients.
SD 10) in the perioperative period were reviewed. QOL is
RESULTS: 38/60 were males and mean age was 37 (SD ± improved if the result increases by at least 3 points or is > or
12.94). 22 patients were alcoholics and 17 were smokers. = to 35. Approval from the IRB was obtained.
47 patients were on oral and 10 patients were on intrave- RESULTS: Thirteen patients (6 males, median age 21, range
nous analgesics while 3 did not require regular analgesics. 12–50) underwent TPIAT for FP. Average time from diagno10 patients had diabetes mellitus and 11 had steatorrhea sis to surgery was 10 years. Physical QOL (pQOL) changed
preoperatively. 39 patients underwent Frey’s procedure from 35 pre-op to 39 at 6 months and 49 at 1 year. Mental
while Whipple’s procedure was done in 6 and Izbicki’s pro- health QOL (mh QOL) changed from 46 pre-op to 45 at
cedure was done in two. LPJ was done in two while bipolar 6 months and 41 at 1 year. Average pain score decreased
ligation and distal pancreatectomy with splenectomy (for from 3 pre-op to 2 at 6 months and at 1 year after surgery.
splenic artery pseudo aneurysm) was done in another two. 4/13 (30%) of patients were diabetics prior to surgery, 2
Roux-en-y cystojejunostomy performed in 2. Three patients were insulin diabetics and took 10 and 40 units of insulin
underwent reoperation for poor pain control; 2 patient daily (u/D), and 2 were non-insulin diabetics. Number of
with LPJ done previously underwent Frey’s procedure after islets transplanted averaged 186,297 (3,667–580,224). All
2 years while one patient who had undergone Frey’s proce- patients required insulin post-op and averaged 26 u/D at
dure underwent Whipple’s procedure after 4 years.
6 months and 32 u/D at 1 year following surgery. Average
There were no in hospital mortalities. 4 patients died dur- HbA1C was 5.7 pre-op, 8 at 6 months, and 8.2 at 1 year.
ing follow up; cause being alcoholic cirrhosis in 2, suicide CONCLUSION: TPIAT effectively improves physical QOL
in 1 and diabetic ketoacidosis with sepsis in another. Two in patients with FP despite all patients requiring daily insupatients had postoperative intraluminal bleed and one lin after surgery. Mental Health QOL remains normal after
needed re-exploration. After a mean follow up of 23.9 surgery. More experience is needed to better understand
months ± SE 23.6 months (median: 13 months; range 1 to optimal timing of surgery but earlier referral may improve
84 months); 54% of patients reported excellent pain relief, endocrine outcomes.
20% patients reported good pain relief and 11.4% patients
had fair pain relief (on regular oral pain killers). Two
patients developed new onset diabetes controlled by diet
and medications, while in 4 patients diabetes worsened.5
patients had new onset stetorrhea which was transient in
all and settled with dietarymodification in two and enzyme
supplementation in another three.
Mo1750
Lesion with Vascular Invasion: Distribution, Characteristics and
Complications
Irreversible Electroporation of Unresectable Soft Tissue
Tumors with Vascular Invasion
Prejesh Philips1, Susan Ellis1, David A. Hays2,
Govindarajan Narayanan3, Erik M. Dunki-Jacobs1,
Robert C. Martin1
1
Surgical Oncology, University of Louisville, Louisville, KY;
2
Department of Radiology, Baptist Little rock, Little Rock, AR;
3
Radiology, University of Miami, Miami, FL
INTRODUCTION: IRE is a novel technique, which delivers
localized electric current using peri-tumoral probes causing
irreversible cell membrane damage and cell death. Due to
its non-thermal action, it is ideally suited for tumors with
vascular invasion. This study was designed to evaluate the
safety and efficacy of IRE in peri-vascular tumors.
METHODS: Analysis of 107 consecutive patients over 7
institutions with tumoral vascular invasion (defined as <5
mm from major vessel) was done from a prospective multiinstitutional registry. Safety parameters, complications and
efficacy were evaluated. Patients without follow-up or those
unfit for general anesthesia were excluded.
RESULTS: A total of 117 procedures were performed for 84
pancreatic and 17 liver lesions among others. Majority had
prior chemotherapy (82,76.7%) or local treatment such as
radiation 47 (44%), other ablations (11,10.2%) or embolization therapy (10,9.3%). Percutaneous access for IRE was
used in 32 (27%) patients while laparotomy access was
used in 81 (69%). Concurrent major abdominal procedures
were performed in 56 (61%). Vascular invasion was either
to the portal vein (n = 82), hepatic vein (n = 6), SMA/SMV
(n = 24) or celiac axis (n = 6). Procedure time (Median 170
mins) was significantly higher in patients with concurrent
major surgery (195 vs. 114 minutes, p < 0.000). Per patient,
median 2 lesions of 3.5 cm target size and tumor size of 3 ×
2 × 2.75 cm were ablated. Overall Morbidity rate was 36.7%,
attributable complication rate was 16.2% and high-grade (>
Grade 3) complication rate was 5.1%. Three vascular complications (SMV, portal vein and Hepatic artery thrombus)
and 2 peri-procedure deaths (one unrelated) were seen. Diabetes (p = 0.05), pancreatic lesions (p < 0.001), prior radiation (p = 0.01) and concurrent major procedures (p = 0.02)
were associated risk factors. Incomplete ablation was seen
in 7 (6%) patients. Median follow up was 12 months with
LRFS was 9.2 months.
Complications
Liver (17)
3 (17.6%)
Pancreas (84)
37 (44%)
CRHM* (11)
0
Pancreatic adenocarcinoma
38 (50%)
(76)
Laparotomy Access (81)
39 (48.1%)
Percutaneous access (33)
3 (9%)
High-Grade
Complications
2 (11.7%)
17 (20.2%)
0
16 (21%)
20 (24.7%)
1 (3%)
P Value#
0.2/0.3
0.007/0.2
0.01/0.02
<0.000/ 0.1
<0.000/0.002
<0.000/0.005
(lower CR) *
0.02/0.07
Concurrent major
27 (48%)
13 (23%)
abdominal procedure (56)
Target Size (yes vs. no, cm) 3.8 vs. 3.5
3.65 vs. 3.6
0.1
Length of stay (yes vs. no,
10.6 vs. 4.7
15 vs. 5.4
<0.000/<0.000
Days)
PMH Diabetes (20)
13 (65%)
7 (35%)
0.009/0.05
Radiation (47)
24 (51%)
12 (25.5%)
0.01/0.1
Prior Ablation/resection (17)
1 (5.2%)
0
0.01/ 0.002
# p value significant <0.05 CR Complication rate CRHM Colorectal Hepatic
metastasis
Mo1751
Clinical Significance of Portomesenteric Vein
Abutment Among Patients with Pancreatic Ductal
Adenocarcinoma
Victor M. Zaydfudim1, Kengo Asai1, Clancy J. Clark1,
Christina M. Wood-Wentz2, Heather J. Wiste2,
David M. Nagorney1, Michael B. Farnell1, Michael L. Kendrick1
1
Division of Gastroenterologic and General Surgery, Mayo Clinic,
Rochester, MN; 2Division of Biomedical Statistics and Informatics,
INTRODUCTION: The definition of borderline resectable
pancreatic head ductal adenocarcinoma has been scrutinized in recent investigations and alterations to practice
guidelines have been proposed. Current controversy questions the ability to achieve a margin-negative resection and
equivalent survival among patients with portomesenteric
vein involvement. The aim of this study was to evaluate
operative resectability of patients with portomesenteric
vein involvement and to correlate the extent of venous
involvement with survival.
CONCLUSION This is the largest study of any interstitial
ablation in tumors with vascular invasion. The low vascular and IRE-related complication rates high ablation rate
demonstrates IRE’s safety efficacy in these locally advanced
tumors with vascular invasion.
152
METHODS: All consecutive patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma at a
single institution from 2000 to 2007 were included in this
retrospective study. Patients who received neoadjuvant
treatment prior to resection and patients with arterial abutment were excluded. Venous involvement was categorized
using pre-operative cross-sectional imaging as 1) none, 2)
portomesenteric vein (PMV) abutment <180°, 3) PMV abutment ≥180°, and 4) PMV impingement/occlusion. Univariate logistic regression and Cox proportional hazards models
were constructed. All four levels of venous involvement
were compared to each other; Benjamini-Hochberg method
was used to adjust for multiple comparisons.
Mo1752
Does Weight Affect Outcomes Following Total
Pancreatectomy with Islet Autotransplantation?
Stefanie M. Owczarski1, Katherine A. Morgan1, David B. Adams1,
Hongjun Wang1, Joseph Romagnuolo3, Kelley Martin3,
Jeffrey J. Borckardt2, Alok Madan2
1
Surgery, MUSC, Charleston, SC; 2Psychiatry and Behavioral Sciences,
MUSC, Charleston, SC; 3Gastroenterology and Hepatology, MUSC,
Charleston, SC
INTRODUCTION: The incidence of weight loss following total pancreatectomy with islet autotransplantation
RESULTS: 290 patients (median age 68 years (range for chronic pancreatitis and its effect on insulin require38–90), 58% male) underwent pancreaticoduodenectomy. ments and Quality of life (QOL) post-operatively is poorly
30- and 90- day mortality was 0.7% and 1.7%, respectively. understood.
117 patients (40%) had venous involvement: 73 abutment METHOD: A prospectively collected, IRB approved data<180°, 21 abutment ≥180°, and 23 PMV impingement/ base at a single institution was reviewed. Patients with a
occlusion. Margin negative resection was achieved in 83% BMI greater than or equal to 25 were compared to those
of patients without venous involvement compared to 73% with a BMI less than 25 prior to surgery. Data pertaining
patients with abutment <180° (p = 0.09), 29% of patients islet yield, insulin requirements, laboratory results, and
with abutment ≥180° (p < 0.01), and 52% of patients with quality of life (QOL) were reviewed at 6 months and 1 year
PMV impingement/occlusion (p < 0.01). Patients with following surgery. The SF12 survey was used to asses QOL
abutment <180° were more likely to have margin negative (normal population 50, SD 10). QOL is improved if the
resection than patients with abutment ≥180° (p < 0.01). result increases by at least 3 points or is > or = to 35.
Retroperitoneal margin was positive in 15%, 16%, 48%, RESULTS: 100 consecutive patients were reviewed (78
and 30% among the patient groups. Patients with abutment females, average age 42) from March 2009 to present. 19
≥180° had more frequent positive retroperitoneal margins patients were omitted due to lack of at least 6 month postthan patients without venous involvement or abutment op data and 12 patients were omitted who were insulin
<180° (both p≤0.01). 58 patients (20%) required PMV resec- diabetics pre-op. 42/69 patients (60%) were overweight
tion and reconstruction: 7% of patients without venous or obese prior to surgery (BMI > 25), with an average BMI
involvement compared to 36% with abutment <180°, 43% pre-op of 30, prealbumin 23, A1C 5.5, pQOL 25, mhQOL
with abutment ≥180°, and 48% with PMV impingement/ 36, and took no insulin prior to surgery. Their median islet
occlusion (all p < 0.01). There were no significant group yield was 244,781 IEQ and 3,316 IEQ/kG (range 14,312–
differences in recurrence-free and overall survival (all p ≥ 1,168,725 IEQ, 234–16,009 IEQ/Kg). At 1 year post-op,
0.09).
their BMI decreased to 25, and prealbumin was 17, A1C
7.6, pQOL 34, mhQOL 41, mean daily insulin 21 u. 34/42
(80%) of these overweight patients had a sustained postoperative weight loss of at least 10% of their pre-op weight.
Comparatively, the patients who had a BMI < 25 prior to
surgery (n = 27) were found to have an average BMI 20
pre-op, prealbumin 21, A1C 5.6, pQOL 26, mhQOL 36, and
took no insulin prior to surgery. Their median islet yield
was 150,168 IEQ and 2,370 IEQ/Kg (range 16,266–816,425
IEQ, 312–15404 IEQ/Kg). At 1 year post-op, their BMI was
19, Pre-albumin 15, A1C 7.1, pQOL 35, mhQOL 41, and
they averaged 10 u/D insulin. The difference in insulin
requirements between the two groups is statistically significant (p = 0.042).
CONCLUSION: Patients who are overweight or obese
prior to TPIAT require more insulin following surgery even
though they have higher islet yield and experience significant weight loss compared to those who are not overweight
prior to surgery. Both groups experienced an improved
physical and mental health QOL following TPIAT.
153
Monday
Poster Abstracts
CONCLUSIONS: Portomesenteric vein abutment ≥180°
is associated with significantly higher risk of margin positive resection. While patients without venous involvement
and patients with vein abutment <180° can be explored for
curative resection, patients with PMV abutment ≥180° and
impingement/occlusion might benefit from neoadjuvant
therapy.
Mo1753
Taken together, these results suggest that PHH3 may provide a more accurate assessment of mitotic rate in PNET.
Additional studies are currently underway to expand this
cohort to assess mitotic rate determined by PHH3 stain
compared to Ki-67 with several different observers.
Improving the Detection of Mitoses in Pancreatic
Neuroendocrine Tumors Using Phosphohistone H3
Stephanie L. Goff1, Matteo Ligorio3, Jennifer A. Wargo1,
Zachary Cooper1, Dennie T. Frederick1, Francesco Sabbatino3,
Vikram Deshpande2, Cristina R. Ferrone3
1
Surgical Oncology, Massachusetts General Hospital, Boston, MA;
2
Pathology, Massachusetts General Hospital, Boston, MA; 3General
Surgery, Massachusetts General Hospital, Boston, MA
Pancreatic neuroendocrine tumors (PNET) are being diagnosed with greater frequency and have a widely variable
natural history. Recent advances in staging for PNET incorporate the mitotic rate for tumors identified on hematoxylin and eosin stains (H&E), dividing lesions into low grade,
intermediate grade, and high grade based on mitotic rate.
This staging system can help with prognostic information,
and may also guide adjuvant treatment, but is reliant on an
accurate assessment of mitotic count. By H&E, mitotic figures can be difficult to identify and require an experienced
histopathologist for accurate enumeration. Proliferative
index, as measured by Ki-67, is also used in PNET but may
over-represent actual mitotic figures since this also captures Pancreatic neuroendocrine tumor stained with anti-phosphohistone3
the G1 phase. More recently, staining with phosphohistone
(PHH3) antibody highlighting mitotic figures.
H3 (PHH3) has been described for use in identifying mitotic
figures in malignancies such as melanoma and glioblastoma. PHH3 is exclusively expressed in the mitotic phase of
the cell cycle thus yields a much more accurate representation of mitotic rate in tumors. Our hypothesis was that an
anti-PHH3 antibody can more accurately identify mitotic
rates in pancreatic neuroendocrine tumors (PNET) than
traditional H&E staining. This will result in more accurate
staging and will improve patient management.
Histologic sections from 77 patients with PNET were
stained with both H&E and anti-PHH3 antibodies and
were reviewed by a blinded histopathologist to assess total
mitotic count. Tumors were graded by number of mitoses
and correlated with clinical outcome.
Correlation with clinical outcome with mitotic rate as determined by H&E
and PHH3.
The results demonstrate a significantly higher number of
mitoses identified using the PHH3 stain compared to H&E
(p < 0.05). In this patient population, traditional H&E
staining did not correlate with survival, but PHH3 staining
for <2 mitoses was highly sensitive for clinical outcome.
(p < 0.05, mean follow-up >36 months).
154
Mo1754
The Role of Adjuvant Chemoradiotherapy in
Pancreatobiliary Versus Intestinal Subtypes of
Ampullary Cancers
Sanjay S. Reddy, Harry S. Cooper, Karen Ruth, Yun Shin Chun,
James C. Watson, John P. Hoffman
Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA
BACKGROUND: Ampullary cancers traditionally have had
more favorable outcomes than tumors in the pancreatic
head. Current literature suggests the use of adjuvant therapies may be of benefit in populations with certain high risk
features. Whether adjuvant therapies in specific histological subtypes influence outcomes has remained unanswered.
METHODS: We retrospectively analyzed 44 patients from
1996–2010 at a dedicated cancer center. Pathological stage,
histological subtypes (pancreatobiliary (PB) versus intestinal (INT)), margin status, lymphovascular invasion (LVI),
perineural invasion (PNI), overall survival (OS) and disease
free survival (DFS) were analyzed. Kaplan-Meier methods were used to estimate survival, and differences were
assessed using the log rank and Wilcoxon tests. We looked
at differences in survival by histological subtype within the
adjuvant chemoradiotherapy (ACRT) and surgery only subgroups, accounting for stage.
CONCLUSIONS: The use of ACRT in patients with ampullary tumors may be more important for survival than histologic type. Larger studies will be needed to distinguish the
effects of adjuvant therapy from those on histologic type.
155
Monday
Poster Abstracts
RESULTS: Of 44 patients, 15 were male and 29 female;
average age was 64. Twenty patients underwent a classic
pancreatoduodenectomy (PD), and 24 a pylorus preserving PD. Nine percent of patients were pathologic stage IA,
18% IB, 23% IIA, 36% IIB, and 14% III. Upon review by
a senior pathologist, 25 patients were found to have a PB
histology, 18 INT, and 1 mixed. LVI and PNI were found in
32% and 25%. Neoadjuvant chemoradiation was given to 3
patients. ACRT was given to 15 patients, adjuvant chemotherapy to 5, and adjuvant radiation to 2. Nineteen patients
underwent surgical resection with no other modality. OS
at 2 years was 75% for PB compared to 70% for INT; at 5
years, 63% and 46%, respectively (p = 0.11). Within the
ACRT group, the PB patients had improved OS than INT
(p = 0.027). DFS at 2 years was 63% for PB compared to
59% for INT; at 5 years, 58% and 28% (p = 0.05). Within the
ACRT group, the PB patients had improved DFS than INT
(p = 0.01). The choice between gemcitabine versus 5 fluorouracil (5FU) based regimens did not reach statistical significance when comparing survival. Comparing stage, IIBs
showed improved OS and DFS than IIAs (p = 0.05,0.006).
Within IIBs, ACRT improved OS irrespective of histology
(p = 0.010). Stratifying PB patients within the IIB group, OS
and DFS were improved compared to its intestinal variant
when ACRT was given (p = 0.03,0.02).
Mo1755
Does Time Interval Between Chemoradiation and
Surgery Affect Outcomes in Pancreatic Cancer?
Mo1756
Kathryn T. Chen1, Karthik Devarajan2, John P. Hoffman1
1
Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA;
2
Biostatistics, Fox Chase Cancer Center, Philadelphia, PA
Gastrointestinal Stromal Tumors of Extraintestinal
Origin: Prognosis Based on Location
INTRODUCTION: Neoadjuvant chemoradiation given for
locally advanced pancreatic cancer is recognized to improve
respectability rates, and response to therapy has also been
shown to be a prognostic factor. There is no data in the
literature regarding time interval between chemoradiation
and surgery, and response rates. We sought to evaluate the
relationship between time interval from radiation therapy
and pathologic response.
METHODS: We retrospectively analyzed the records of 55
patients who underwent neoadjuvant chemoradiation for
borderline resectable pancreatic cancers prior to definitive
resection. Patients either proceeded directly to resection
following chemoradiation or continued on chemotherapy
depending on CA19-9 and pathologic response. We divided
patients into three groups with respect to time interval
between completion of chemoradiation and resection: A
(0–10 weeks), B (10–20 weeks), and C (>20 weeks). Pathologic response was defined as major (>95% fibrosis), partial
(50–94% fibrosis), or minor (<50% fibrosis).
Joyce Wong, Ciara E. Calitri, Gang Han, Anthony P. Conley,
Ricardo J. Gonzalez
Surgery, Moffitt Cancer Center, Tampa, FL
BACKGROUND: While gastrointestinal stromal tumors
(GIST) commonly arise from a gastric or intestinal (INT)
location, extraintestinal GIST (E-INT) have been described.
This study addresses the clinical and prognostic differences
in GIST arising from the stomach or intestinal tract as well
as extraintestinal or unknown (UNK) locations.
METHODS: A prospectively maintained single-institution
database of patients with the diagnosis of GIST was
reviewed. Demographics, pathologic factors and survival
were analyzed using Pearson’s chi-square test, Fishers exact
test, or Kaplan Meier curves where applicable.
RESULTS: From 1990–2011, 282 patients with pathologic confirmation of GIST were referred to our center. The
majority were male (56%) and Caucasian (83%). Tumors
were commonly of gastric (N = 148, 52%) or INT (100, 35%)
origin. Less commonly, GIST arose from an E-INT (22, 8%)
or unknown (UNK, 12, 4%) location. Multivariate analyRESULTS: There were 32 patients in group A, 9 patients sis stratified by tumor origin showed that age varied across
in group B, and 14 patients in groups C. There was no sig- groups, with E-INT GIST found in older patients (median
nificant difference between the groups with respect to age age 69 vs. 65 years for gastric, 60 for INT, and 64 for UNK,
or CA19-9 at diagnosis. The median post-chemoradiation p = 0.03). Tumor size was also greater in the E-INT group:
CA19-9 was significantly higher for group C compared to median size 13 cm vs. 6.4 cm in gastric, 7.6 cm in INT, and
group A, but there was no subsequent difference in the 8.6 cm in UNK, p = 0.05. Gender, ethnicity, and tumor
median pre-operative CA19-9. There was no difference with mitotic rate were similar across groups. Additionally, use of
regards to R0 resection between all three groups. Patients neoadjuvant or adjuvant therapy was similar across groups.
in groups B and C were significantly more likely to have a Ultimately, 84% of gastric GIST underwent surgical explomajor response than in group A (p < 0.026).
ration vs. 93% INT, 82% E-INT, and 50% of UNK-primary
CONCLUSION: There is no detriment in prolonged time
interval between neoadjuvant chemoradiation and definitive resection provided there is ongoing chemotherapy.
In our series, patients with a time interval greater than 20
weeks were more likely to have a major response to neoadjuvant therapy prior to surgery.
GIST. Nearly 10% of gastric and INT GIST were unresectable
at surgery, vs. 44% E-INT. GIST of E-INT location also had
higher rates of margin-positive resections, versus those of
gastric or INT origin (56% vs. 12% and 24%, respectively, P <
0.0001). The median follow-up was 77 months. Unknown
primary and E-INT GIST exhibited a worse median OS (42
and 38 months, respectively), while INT or gastric GIST
had better median OS (86 and 79 months, respectively, P <
0.05). Smaller tumor size, negative surgical margins, lower
mitotic rate, and use of tyrosine kinase inhibitors all positively impacted OS. 35% of gastric GIST developed recurrent
disease vs. 61% INT and E-INT, and 100% of UNK primary
GIST. Only mitotic rate and mutational status affected DFS;
univariate analysis demonstrated mitotic rate > 10/50 high
power fields and PDGFRA mutations were associated with
worse DFS (P < 0.05). However, disease free survival (DFS)
did not differ according to tumor origin.
CONCLUSION: Although GISTs are considered to have
variable malignant potential, E-INT and UNK GIST are more
likely to be unresectable at presentation and to develop
disease recurrence. Extraintestinal and unknown primary
GIST have a worse OS. This may be due to a significantly
larger tumor size and advanced stage at presentation that
may prohibit effective surgical resection.
156
Mo1757
Mo1758
Diagnostic Strategy for Acute Abdomen Caused
by Perforation of the Gastrointestinal Tract: Can
Computed Tomography Detect Perforated Site Even
in the Small and Large Bowel?
Ileo-Cecal Resection in Crohn’s Disease Patients:
Clinical Impact on Quality of Life and Nutrition
Giuseppe S. Sica, Silvia Di Pardo, Edoardo Iaculli,
Cristina Fiorani, Andrea Divizia, Emanuele Picone,
Achille Gaspari, Livia Biancone
Tatsuya Ueno1, Michinaga Takahashi1, Shinji Goto1,
Shun Sato1, Masanori Akada1, Kyohei Ariake1, Shinpei Maeda1,
Takashi Hirosawa1, Masato Katahira1, Chikashi Shibata2,
Hiroo Naito1
1
Surgery, Southmiyagi Medical Center, Shibata-gun, Japan; 2Surgery,
Tohoku University Hospital, Sendai, Japan
BACKGROUND: Relationship between surgery, quality of
life (QoL) and nutrition in Crohn’s Disease (CD) patients is
unclear. Aim of the study was to evaluate the consequences
of surgical resection on the QoL with particular regard to
nutritional aspects, of a consecutive group of CD patients
Due to advanced technology, computed tomography (CT) under regular follow up.
scan can make more precise diagnosis than ever even in the
field of gastrointestinal (GI) tract. We previously reported METHODS: Eighty consecutive patients undergoing ileoaccuracy rate of CT in diagnosing perforated gastro and cecal resection were randomly selected from database.
duodenal ulcer, was more than 90%, which means that GI Patients were divided into 2 groups: A laparoscopic and B
endoscopy and/or upper GI series are not required to con- open resection. Body Mass Index (BMI), biochemical levfirm the perforated sites of upper GI tract in most cases. It’s els of albumin, creatinine, urea, cholesterol, triglycerides,
still uncertain, however, whether or not CT scan can accu- serum iron, ferritin and complete blood count (Hb hemorately detect perforated site in patients (Pts) with small and globin and Ht hematocrit) were recorded before surgery
and 6 and 12 months after the operation. The Student t
large bowel perforation (SLBP).
test was performed in order to find differences before and
AIM: To clarify how precisely CT scan can detect perforated after surgery. Patients were also asked to fill out the spesite in SLBP, and if CT scan can differentiate gastroduodenal cific IBDQ-QoL questionnaire and a second multiple choice
perforation (GDP) from SLBP.
questionnaire designed to specifically evaluate nutritional
METHOD: Since 2002 to 2010, Medical records of Pts with aspects.
GDP and SLBP who underwent laparotomy or laparoscopic RESULTS: Data from 68 patients (31group A and 37 group
operation, were retrospectively reviewed.
B) were completed in order to make comparisons. The two
groups were homogeneous in term of gender, age and duration of disease. BMI significantly increase after surgery in
the short and long term in group A (p 0.002 and 0.0001)
and at 12 moths in group B (p 0.003). Albumin levels also
showed a significant increase in both groups 6 months after
surgery (A:p = 0.0001 and B:p = 0.015), whilst a further
increase at 12 months is seen only in group A (p = 0.04).
Serum iron level is increased 12 months after I-C resection
(group A p = 0.003; group B p = 0.02), and so is the Hb level
(group A p = 0.02; group B p = 0.05). Significant differences
in Ht were visible at 12 month only in group A (p = 0.02).
Thirty-five patients (68.5%) filled the IBDQ-QoL questionnaire. Mean score was 163/224 with no differences between
the two groups. All patients filled the nutritional based
questionnaire: 52% before surgery but only 9.5% after after
ileo-cecal resection were forced on a specific diet. 71.5% of
patients believe its QoL improved after ileo-cecal resection,
whilst 20% sees no differences and 8.5% a worsening. No
CONCLUSION: When compared to GDP, accuracy rate to significant differences were noted between groups.
detect perforated site in SLBP, was decreased, especially in CONCLUSION: QoL, with particular regard to nutritional
small bowel and trauma-related perforation. This decrease aspects seems ameliorate after ileo-cecal resection in CD
might be associated with little inflammatory change such as patients. Laparoscopic surgery may play a role in the midedema at perforated site soon after trauma and little intra- dle and long term outcome probably thanks to the shortluminal gas in the small bowel. When SLBP is suspected est recovery time and the favorable acceptation among
on CT scan, early exploratory laparotomy or laparoscopic patients.
examination should be considered. Once GDP is detected
on CT scan, surgical or conservative therapy should be
started as soon as possible. Gastrointestinal endoscopy and/
or upper GI series were considered unnecessary in GDP.
157
Monday
Poster Abstracts
RESULTS: one hundred and fifty-eight Pts (92 for GDP and
66 for SLBP) were operated for GDP and SLBP. Gastric cancer, gastric ulcer, and duodenal ulcer induced the perforation in all GDP Pts. Causes of SLBP were idiopathic (20 Pts),
cancer-related perforation (15), diverticulum (8), trauma
(7), foreign body (6), and others (10). Accuracy rate of CT
scan in diagnosing site for GDP was 93.3%. On the other
hand, the accuracy rate in SLBP was 84.6% (70.4% for small
bowel and 89.7% for large bowel), and the rate decreased
to 57.1% when limited to trauma. Two Pts who underwent
laparotomy after diagnosed as SLBP on CT scan, had no
perforation. One of them had trauma, and the other was
finally diagnosed as pneumatosis intestinalis. There were
no Pts who were at first diagnosed as GDP, but had actually
SLBP. Mortality rate of GDP was 7.6%, while that of total
SLBP, idiopathic, cancer-related, diverticulum, and traumarelated perforation, were 18.2%, 15.0%, 40.0%, 25.0%, and
0.0% respectively.
Mo1759
Mo1760
Role of Gastrografin Challenge in Early Postoperative
Small Bowel Obstruction
Assessment of Postoperative Complications in
Patients with IBD: A Single Academic Medical Center
Experience
Mohammad A. Khasawneh1, Maria L. Martinez Ugarte2,
Eric J. Dozois2, Michael P. Bannon1, Martin D. Zielinski1
1
Trauma, Critical Care and General Surgery, Mayo Clinic, Rochester,
MN; 2Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
Samantha J. Quade, Joshua Mourot, Anita Afzali,
Mika N. Sinanan, Scott D. Lee, Jie Kate Hu, Christopher J. Park
General Surgery, University of Washington, Seattle, WA
INTRODUCTION: Early small bowel obstruction (ESBO)
following abdominal surgery presents a diagnostic and therapeutic challenge. Abdominal imaging using Gastrografin
(GG), has been shown to have diagnostic and therapeutic
properties when used in the setting of small bowel obstruction outside the early postoperative period (>6 weeks). We
hypothesize that a GG challenge will reduce need for reexploration in patients with ESBO.
BACKGROUND: In Chrons Disease approximately 70%
of all patients will ultimately require surgical intervention.
Previous literature indicates that 30% of patients have postoperative complications. Pre operative nutrition with TPN
has also been controversial.
Our retrospective review demographics and patient characteristics were documented and both preoperative and surgical characteristics were identified to ascertain if the results
METHODS: Patients with ESBO (<6 weeks following from a single institution were congruent with the previous
abdominal surgery) who underwent a GG challenge published literature.
between 2010–2012 were case controlled, based on age ± 5
PURPOSE: Assessment of post operative complications,
and sex, to an equal number of patients that did not receive
pre operative predictive factors and need for reoperation
a GG challenge. Groups were compared to assess differences
and reinstitution of medical therapy in IBD.
in rates of reoperation for obstruction.
METHODS: Retrospective review of 57 patients charts who
RESULTS: 105 patients with ESBO who received a GG
underwent surgical intervention for IBD. Patients undergochallenge. There were 76 males in each group (72%) with
ing surgical resection were included in the initial analysis.
an average age of 64 years (range, 59–68). An open or laparoscopic approach in the index operation was done equally Pre operative surgical characteristics, nutrition and surgical
between groups (67% vs 70% and 33% vs 30%, respectively indication for intervention were analyzed.
p = 0.44). The mean time from surgery to GG challenge The need for reoperation and reinstitution of medical therwas (11.3, range = 9.8–12.9) days. There was no difference apy was based on patient symptoms and an endoscopic
between groups in the rate of re-operation (12% vs 9%, p = evaluation, which included a Rutgeerts score.
0.48), days from surgery to re-operation (9.1 [range 4.2–14]
vs 13.5 [range 7.9–19.2], p = 0.23), morbidity (35% vs 42%, RESULTS: 57 patients [current analysis] 51% female, mean
p = 0.23), and mortality (8% vs 7%, p = 0.78). Hospital age 45 years, 30% of patients had undergone prior reseclength of stay was greater in patients who received GG tion. 77% Chrons Disease.
(18.2 vs 11.5, p = 0.0001) days. There were no GG aspi- Patient characteristics included 46% smoking, anatomiration events. . There were more patients that received cal site of disease 44% TI disease, small bowel in 17% and
abdominal computed tomography in the GG group (74% colonic in 30%. Medical Therapy included Biologics in
vs 45%, p = 0.0001), of these patients, the GG group were 53%, IM 38% and steroids in 43%.
more likely to have a transition point (55% vs 33%, p =
Albumin mean 3.5g/dL [postoperative early complications:
0.01).The GG challenge had a positive predictive value of
mean 3.3 g/dL, no complications 3.6 g/dL].
91%, negative predictive value of 50%, sensitivity of 96%
and specificity of 30% to predict ESBO resolution without Preoperative TPN 84% with an associated overall complication rate 31%.
operative intervention.
CONCLUSION: Use of the GG challenge in the immedi- SURGICAL INDICATION: Stricture/Obstruction 39%, Fistula
ate postoperative period appeared to be safe. There was no 19%, Refractory to medications 21%, Abscess 5%, Perforadifference, however, in the rate of re-exploration between tion 2%.
groups. Further study in a prospective, randomized fashion
is needed to elucidate the effects of GG in ESBO.
158
Surgical Operation: Ileocolectomy 35%, TI resection 5%,
stricturoplasty 4% and the remaining small bowel resection.
Type of anastomosis Hand Sewn end-to-end 58% patients
[41% complication rate], side to end 18% [57% complication rate] and stapled end to end 24% [complication rate
67%].
Perioperative blood transfusion was required in 5% patients,
100% patients had complications.
Operative Blood Loss no complication 82 cc and complication 232 cc mean.
Perioperative length of stay mean 8 days [5.6 vs. 12.2 with
post operative complication].
Overall Complication rate was 39%. Anastomotic leak rate
4%, Bowel obstruction 5%, prolonged ileus defined as >5
days 18%, Abscess formation 5%, Superficial wound infection 7% [no deep wound infections], UTI 5%, DVT 2%, PE
0%, Hernia 2%.
Reoperation required in 20% of patients.
CONCLUSIONS: Surgical Intervention for IBD can be associated with high morbidity and high rates of further medical and surgical intervention. Initial data analysis it appears
that factors associated with a higher post operative complication rate are Albumin < 3.3, Perioperative Blood transfusion and stapled anastomosis.
Monday
Poster Abstracts
159
Mo1761
Table 2: Postoperative Outcome and Complications
Laparoscopic vs. Open Unilateral Inguinal Hernia
Repairs: A NSQIP Analysis
Karen E. Gibbs
OBJECTIVES: Open inguinal hernia repair has been the
mainstay in both elective and emergent hernias for most of
surgical history. The advancement of laparoscopic hernia
repair has challenged this notion; however few trials have
compared the laparoscopic approach to open. We sought
to query the NSQIP database to amass a large number of
patients to better characterize patent comorbidities and
outcomes of both approaches.
METHODS: The NSQIP database was queried for laparoscopic or open inguinal hernia repair for unilateral hernias from 2007 to 2009. Age, gender and comorbidities
were quantified and outcomes data collected. Specifically,
morbidity, mortality, length of stay and operative times
were examined. Statistical analysis was then performed. A
p-value of <0.05 was considered significant.
Superficial SSI
Deep incisional SSI
Organ space SSI
Wound disruption
Pneumonia
PE
Failure to extubate
Return to OR
ARF
Cardiac arrest
MI
DVT
Sepsis
Neuro complication
Overall morbidity
Operative time (mins
Hospital stay (days)
Mortality
Open Repair
N = 25192
87 (0.3%)
18 (0.1%)
11 (0.0%)
10 (0.0%)
27 (0.1%)
16 (0.1%)
14 (0.1%)
7 (0.0%)
177 (0.7%)
5 (0%)
59 (0.2%)
14 (0.1%)
19 (0.1%)
26 (0.1%)
16 (0.1%)
141 (0.5%)
58.6 ± 26.9
0.27 ± 3.9
18 (0.1%)
Laparoscopic Repair
N = 4563
13 (0.3%)
2 (0.0%)
0
1 (0.0%)
1 (0.0%)
1 (0.0%)
2 (0%)
1 (0%)
24 (0.5%)
0
0
2 (0%)
1 (0.0%)
2 (0%)
2 (0%)
12 (0%)
59.2 ± 31.3
0.16 ± 1.2
1 (0%)
P-Value
0.572
0.757
0.392
1
0.112
0.498
1
1
0.204
1
0.600
1.0
0.246
0.3
1
.012
0.183
<0.001
0.342
RESULTS: A total of 29,755 patients were identified, out
of which 25,192 underwent open hernia repair, while 4,563 CONCLUSIONS: Our study revealed that only 15% of uniunderwent laparoscopic repair.
lateral hernias were repaired laparoscopically. The more
CONCLUSIONS: Our study revealed that only 15% of uni- diverse anesthetic choices available for open repair allowed
lateral hernias were repaired laparoscopically. The more patients with significant comorbidities to undergo hernia
diverse anesthetic choices available for open repair allowed repair. Despite this there was an increased overall rate of
patients with significant comorbidities to undergo hernia morbidity (0.5% vs. 0.2%, p = 0.012). Other outcomes mearepair. Despite this there was an increased overall rate of sures were not different except for length of stay, which was
morbidity (0.5% vs. 0.2%, p = 0.012). Other outcomes mea- longer for the open group.
sures were not different except for length of stay, which was
longer for the open group.
Mo1762
Table 1: Patient Comorbdities
Age
Male gender
Diabetes on oral
Diabetes on Insulin
HTN
COPD
CHF in 30 days
History of MI in 6
months
Prior PCI
Prior CABG
PAD
ESRD
BMI
Anesthesia type
General Local MAC
Spinal
ASA III or above
Bleeding disorder
Partially Dependent
Steroid use
Smoker
Open Repair
N = 25192
55.9 ± 17.3
22668 (90%)
1190 (4.7%)
383 (1.5%)
8987 (35.7%)
727 (2.9%)
41 (0.2%)
35 (0.1%)
Laproscopic Repair
N = 4563
52.3 ± 16.1
4155 (91.1%)
143 (3.1%)
36 (0.8%)
1314 (28.8%)
59 (1.3%)
4 (0.1%)
1 (0.0%)
1334 (5.3%)
167 (3.7%)
1414 (5.6%)
168 (3.7%)
189 (0.8%)
189 (0.8%)
133 (0.5%)
13 (0.3%)
26.3 ± 4.3
26.5 ± 4.3
16776 (66.6%) 534 4473 (98.0%) 5 (0.1%)
(2.1%) 6414 (25.5%) 73 (1.6%) 8 (0.2%)
979 (3.9%)
378 (1.5%)
23 (0.1%)
567 (2.3%)
63 (1.4%)
200 (0.8%)
16 (0.4%)
345 (1.4%)
36 (0.8%)
5054 (20.1%)
772 (16.9%)
P-Value
<.001
0.026
<.001
<.001
<.001
<.001
0.301
0.035
<.001
<.001
.005
0.033
0.006
<0.001
<.001
<.001
0.001
.001
<.001
Long-Term Outcomes Following Endoscopic vs.
Transduodenal Ampullectomies for Ampullary
Adenomas
Abhishek Mathur2, Sharona B. Ross1, Carrie E. Ryan1,
Kenneth Luberice1, Franka Co1, Paul Toomey1, Arthi Sanjeevi2,
Patrick Brady2, Alexander Rosemurgy1
1
General Surgery, Florida Hospital Tampa, Tampa, FL; 2Morsani
College of Medicine, Tampa, FL
INTRODUCTION: The increased application of screening and diagnostic upper endoscopy has increased the
frequency of identifying premalignant ampullary lesions.
These premalignant lesions need extirpation to derail the
adenoma➝carcinoma sequence. Extirpative ampullectomy,
whether endoscopic or operative, should be definitive treatment. However, the recurrence rates after polypectomy and
the number of interventions to rid the polyp are not established. We undertook this study to determine the utility
of and long-term outcomes after endoscopic vs. operative
ampullectomy.
METHODS: From 2002 to 2011, 35 patients underwent
operative transduodenal ampullectomy and 38 patients
underwent endoscopic ampullectomy per American Society
for Gastrointestinal Endoscopy (ASGE) guidelines. Median
data are presented.
160
RESULTS: Patients undergoing operative vs. endoscopic
therapy were similar in gender, age, BMI, and pretreatment
evaluation. Transduodenal ampullectomy was undertaken
for larger polyps than endoscopic polypectomy (2.1 cm
vs. 1.5 cm respectively, p < 0.001). 97% of transduodenal
ampullectomies had microscopically negative (R0) margins whereas 50% of endoscopic ampullectomies had R0
margins. 16/38 (42%) patients treated endoscopically were
without disease at last follow-up, though 5 patients were
lost to follow-up, 1 patient underwent a pancreaticoduodenectomy for cancer, and one patient died; 15/38 (39%)
had residual or recurrent disease despite numerous endoscopic reinterventions. 29/35 (82%) of patients treated with
transduodenal ampullectomy were without disease at last
follow-up, though despite R0 margins at resection, 5/35
(14%) patients had recurrent or persistent disease; 1 patient
underwent a pancreaticoduodenectomy for cancer and 1
patient died.
CONCLUSIONS: After endoscopic ampullectomy, residual
disease is common and recurrence is frequent and much
higher than after transduodenal ampullectomy. The endoscopic approach is further encumbered by patients lost to
follow-up. Despite vigilant endoscopic follow-up, whatever
the approach for the ampullectomy, cancer will be encountered. This is not an “apples to oranges” comparison, but
rather a “big apples to small apples” comparison that does
not justify endoscopic ampullectomy rather than transduodenal ampullectomy, except under circumstances more
stringent than proposed by the ASGE (e.g., smaller tumors
more amenable to complete extirpation). Further data is
needed to justify application of endoscopic ampullectomy
using ASGE guidelines.
Clinical: Stomach
Mo1763
Hemi-Double Stapling Technique Versus Hand-Suture
for Billroth-I Gastroduodenostomy: An Analysis of
84 Consecutive Patients
CONCLUSIONS: HDS reduced operative time and blood
loss, but increased postoperative anastomotic bleeding. It
is important that we confirm the hemostasis of bleeding
from the staple line during surgery and perform endoscopic
hemostasis immediately if bleeding is unresponsive to conservative management.
Mo1764
Preoperative Chemotherapy Results in Unpredictable
Response in Gastric Cancer: No Magic Bullet
Houssam Osman, Mandy L. Rice, Tanyss L. Winston,
Ashley Thomas, Dhiresh R. Jeyarajah
Surgery, Methodist Dallas Medical Center, Dallas, TX
INTRODUCTION: Neoadjuvant chemotherapy for locally
advanced gastric cancer was proposed as treatment modality to improve survival. The chemotherapy treatment effect
is evaluated in the surgical specimen and divided based on
the degree of dead tumor cells into 4 categories; no effect,
mild effect, moderate effect, and significant effect. We present our experience with neoadjuvant chemotherapy in
patients with gastric carcinoma.
METHOD: 25 patients with distal esophageal, gastroesophageal junction (GEJ), and gastric carcinoma who
underwent neoadjuvant chemotherapy between January
2011 and August 2012 have been identified retrospectively
in our cancer registry. Chemotherapy regimens and number of cycles were reviewed and the histological treatment
effects were then compared.
RESULTS: No histological treatment effect was identified
in one patient (4%) with GEJ tumor who received 3 cycles
of Epirubicin, Cisplatin, and 5-Fluorouracil. Mild treatment
BACKGROUND AND AIMS: Hemi-double stapling (HDS) effect was noted in 9 patients (36%); 7 patients received
for Billroth-I gastroduodenostomy is a simple technique 2 preoperative cycles and 2 patients received 3 cycles. 9
and it has many advantages including reduced operative patients (36%) were found to have moderate treatment
time and equalization of surgical technique, while poten- effect; 4 of them received 2 cycles, 3 patients received 3
tial complications including anastomotic bleeding and cycles, one received 4 cycles, and one received 5 cycles. Sigstricture. The aim of this study was to retrospectively evalu- nificant treatment effect was identified in 6 patients (24%);
ate the surgical outcome and complications of HDS com- half of them received 2 cycles while 2 patients received 3
pared to hand-suture (HS).
cycles, and one patient received 6 cycles of Oxaliplatin and
METHODS: We analyzed 84 patients divided into 2 groups, Xeloda.
HDS group with 31 patients and HS group with 53 patients, CONCLUSION: The response of gastric cancer to preopwho underwent B-I reconstruction in open distal gastrec- erative chemotherapy cannot be predicted based on chetomy between October 2002 and September 2012 in our motherapy regimen or number of cycles received. 40% of
hospital.
patients experienced no or minimal effect. Further studies
are needed to evaluate the correlation between the treatment effect grade and survival benefit.
161
Monday
Poster Abstracts
Akira Ouchi, Masahiko Asano, Keiya Aono, Tetsuya Watanabe,
Yudai Kato
Department of Surgery, Chita City Hospital, Aichi, Japan
RESULTS: There was no difference between the 2 groups
with regard to background factors. In the HDS group, operative time was shorter (113 ± 20 min. v.s. 153 ± 37 min.,
p < 0.01) and blood loss was less (97 ± 90 ml v.s. 161 ± 121
ml, p < 0.01) than in the HS group. Postoperative anastomotic bleeding occurred in 4 cases of the HDS group and
significantly more than in the HS group (12.9% v.s. 0%,
p < 0.01).All 4 cases needed blood transfusion and 1 case
that was unresponsive to conservative management needed
endoscopic hemostasis the day after surgery. Anastomotic
leakage occurred in 1 case of the HDS group. There were no
differences in hospital stay and mortality rate.
Mo1765
RESULTS: The study population consisted of 25 (37.9%)
Asians, 24 (36.4%) Caucasians, 11 (16.7%) Hispanics, 7
The Development of Ulcer Disease After Roux-en-Y
(10.6%) African-Americans. The incidence of lymph node
Gastric Bypass
metastasis was 3.1% in Asians and 17.1% in non-Asians,
respectively. Nine patients underwent EMR and 58 patients
Usha K. Coblijn, Sjoerd D. Kuiken, Sjoerd M. Lagarde,
underwent gastrectomy with LN dissection. Among the
Bart A. Van Wagensveld
latter group, eight (13.8%) patients had LN metastasis.
Sint Lucas Andreas Ziekenhuis, Amsterdam, Netherlands
Subgroup analysis comparing the histopathologic characBACKGROUND/AIMS: With the growing performance teristics of T1b with T1a EGC was performed; nine (36.0%)
of bariatric surgery a subsequent increase in complications patients with T1a and 11 (40.7%) patients with T1b had
associated with this surgical procedure takes place. This diffuse type histology (p = 0.26). The incidence of lymph
research focuses at marginal ulceration (MU) after (laparo- node metastasis was 4.0% with T1a in comparison to 25.9%
scopic) Roux-en Y Gastric Bypass surgery (LRYGB). Aim of with T1b (p = 0.03). The survival rate for the T1b group
this study was to asses the incidence, symptoms, mecha- (92.6%) did not differ significantly from that of the T1a
nism and treatment of MU after LRYGB surgery.
group (93.5%) during the follow-up period.
METHODS: All files of patients who underwent a LRYGB CONCLUSIONS: EGC in Asian Americans is less likely
were searched for signs of abdominal pain, epigastric burn, to be associated with LN metastases than non-Asian EGC
nausea or other symptoms of ulcer disease. Also symptoms regardless of depth or histotype. In our small series with
of (perforated) MU as acute abdominal pain, vomiting, ethnic diversity, patients with T1b EGC had significantly
melaena and haematemesis were scored. Possible contrib- higher LN metastasis rate but did not have a significantly
uting factors were identified. Results of medical and surgical different survival rate from those with T1a, indicating that
treatment were evaluated.
gastrectomy with LN dissection should remain the standard
RESULTS: 419 patients underwent LRYGB. 26 (6.2%) of strategy for T1b EGC.
them developed MU of which five (1.2%) presented with
perforation. The use of non-steroidal inflammatory drugs Mo1767
(NSAIDs), smoking and prednisolon- inhalation corticosteroids significantly contributed to the development of MU. Development and Validation of PGSAS-45, an
Five patients needed reoperation. All other patients could Integrated Questionnaire to Assess Postgastrectomy
be treated conservative with proton pump inhibitors occa- Syndrome
sionally together with Ulcogant®.
Koji Nakada1,12, Masami Ikeda2,12, Masazumi Takahashi3,12,
CONCLUSION: Marginal ulceration after LRYGB is more Shinichi Kinami4,12, Masashi Yoshida5,12, Yoshikazu Uenosono6,12,
frequently being recognized as a major problem due to the Yoshiyuki Kawashima7,12, Atsushi Oshio8, Yoshimi Suzukamo9,
increase in bariatric procedures. The use of nicotine and Masanori Terashima10,12, Yasuhiro Kodera11,12
NSAIDs must be stopped and inhalation corticosteroids 1Surgery, The Jikei University School of Medicine, Tokyo, Japan;
should be minimized.
2
Asama General Hospital, Saku, Japan; 3Yokohama Municipal
Citizen`s Hospital, Yokohama, Japan; 4Kanazawa Medical School,
Mo1766
Kanazawa, Japan; 5International University of Health and Welfare,
Mita Hospital, Tokyo, Japan; 6Kagoshima University Graduate School
Current Treatment Strategy for Early Gastric Cancer at
of Medicine, Kagoshima, Japan; 7Saitama Cancer Center, Saitama,
a New York Urban Medical Center
8
Japan;
Waseda University, Tokyo, Japan; 9Tohoku University
Shinichi Fukuhara, Marissa M. Montgomery,
Graduate School of Medicine, Sendai, Japan; 10Shizuoka Cancer
Steven T. Brower, Martin S. Karpeh
Center, Shizuoka, Japan; 11Nagoya University Graduate School of
Department of Surgery, Beth Israel Medical Center, New York, NY
Medicine, Nagoya, Japan; 12Japan Postgastrectomy Syndrome Working
BACKGROUND: Gastrectomy with lymph node (LN) disParty, Tokyo, Japan
section was considered as the gold standard for early gastric
cancer (EGC) in the past. However, expansion of the criteria BACKGROUND: Postgastrectomy syndrome (PGS) is
for endoscopic treatment has been currently proposed. This common after gastrectomy. Information regarding actual
study aims to investigate the histopathologic determinants details of the PGS and their relation to surgical procedures,
and outcomes of EGC in order to redefine the current treat- however, is limited possibly due to the fact that optimal
instrument to assess PGS is lacking. A questionnaire, Postment strategy.
gastrectomy Syndrome Assessment Scale (PGSAS) -45, was
METHODS: The gastric cancer tumor registry at our institherefore developed by a voluntary group, Japan Postgastution was reviewed. Sixty-seven patients were identified
trectomy Syndrome Working Party. PGSAS-45 was designed
who underwent either endoscopic mucosal resection (EMR)
to assess severity of the PGS, the status of oral food intake
or gastrectomy for EGC or high grade dysplasia between
and degree of recovery in terms of social roles, and impact
2006 and 2011. A retrospective analysis was performed
of these factors on patients’ well-being.
on the medical records of these patients. Mean follow-up
period was 21 ± 18 (1–73) months.
162
METHODS: PGSAS-45 is an integrated questionnaire consisting of 45 items including items selectively taken with
permission from the standardized generic QOL questionnaire SF-8 (8 items) and the symptom-specific QOL questionnaire gastrointestinal symptom rating scale (GSRS; 15
items). Items selected from an item pool as being clinical
relevant by 47 gastric surgeons were added to these to constitute the PGSAS-45. In the current study, 52 institutions
were involved in “Postgastrectomy Syndrome Assessment
Study (PGSAS)”, a nation-wide study to validate PGSAS-45,
in which a total of 2520 PGSAS-45 questionnaires (86% of
those that were originally sent out) were retrieved from
the patients who received either of the six different types
of gastrectomy procedures. Of these, 1516 questionnaires
retrieved from the patients who received conventional
gastrectomy (total with Roux-en-Y [n = 393], distal with
Billroth-I [n = 909], distal with Roux-en-Y [n = 475]) were
statistically analyzed.
Mo1770
Depression, Anxiety, and Stress Reduction After
Bariatric Surgery
Natalia Leva, Chris S. Crowe, Nayna A. Lodhia, John M. Morton
INTRODUCTION: Bariatric surgery is an effective and
enduring therapy for weight loss and comorbidity remission. This study assesses patients’ depression, anxiety, and
stress before and after bariatric surgery utilizing the DASS
questionnaire.
BMI, weight, and excess weight loss were found to have no
correlation to reduction of DASS scores. Waist circumference reduction, however, was correlated with reduction
in depression specific (p = 0.096) and anxiety specific (p =
0.011) scores.
CONCLUSION: Weight loss surgery provides promising reductions in DASS scores, even at the 3-month time
point. Those with depression scored higher at baseline,
but fortunately had greater improvement of those scores at
3-months. Waist circumference was also found to be associated with change in DASS scores.
163
Monday
Poster Abstracts
METHODS: Demographic, preoperative, and three-month
postop data were prospectively collected for 135 consecutive surgeries at a single academic institution. Before surgery and at a 3 months post op, the DASS questionnaire was
administered. Weight, anthropometric features, and demographic data were collected. DASS scores were compared to
RESULTS: The 23 symptom items of PGSAS-45 was com- demographic, preop, and postop data by student T-test and
posed of seven symptom subscales (SS), ‘esophageal reflux chi-squared analysis for continuous and dichotomous variSS’, ‘abdominal pain SS’, ‘meal-related distress SS’, ‘indiges- ables respectively using GraphPad Prisim 6.
tion SS’, ‘diarrhea SS’, ‘constipation SS’ and ‘dumping SS’ RESULTS: All 135 patients completed preoperative DASS
by factor analysis. The seven symptom subscales and other questionnaires. Of these, 93 patients were at or beyond the
two domains, ‘quality of ingestion SS’ and ‘dissatisfaction 3-month postoperative time point. 55% of these patients
for daily life SS’, had good internal consistency in terms of completed their 3-month questionnaires. Patient demographics included an average BMI 45, age 47, 51% white,
Cronbach’s alpha (.65–.88).
Multiple regression analysis demonstrated that the sum of and 4 total preoperative comorbidities. Depression, anxinewly added 8 symptoms had larger impact [Beta] com- ety, stress, and total DASS scores reduced significantly at
pared to the sum of 15 symptoms of GSRS, in ingestion 3 months when all patients were analyzed. When divided
(.32, .02), ability for working (.35, .09), loss in body weight by surgery type, those undergoing gastric bypass showed
(.24, .07), physical component summary (PCS) (.35, .17) significant reduction in all measures. Patients undergoing
sleeve gastrectomy only improved their stress scores (p =
and dissatisfaction for daily life SS (.60, .11).
0.031) while patients undergoing gastric banding improved
The associations between patient’s condition (symptoms, their stress (p = 0.016) and total DASS (p = 0.05) scores.
ingestion, ability for working) and HRQOL (PCS and men- Depression was self-reported in 49% of patients. Those that
tal component summary [MCS] of SF-8, dissatisfaction for reported depression pre-operatively had significantly higher
daily life SS) was evident. The effect size [Beta, R2] was depression specific scores than those without self-reported
medium to large for all domains (.32 to .60, all p < 0.0001). depression (p = 0.045). Anxiety and stress specific scores,
CONCLUSIONS: The results indicated that the PGSAS-45 as well as total DASS scores, were not significantly different
provides a valid and reliable integrated measurement of between those with and without self-reported depression
(all p values >0.252). Three months after surgery, those with
QOL in gastrectomized patients.
pre-operative self-reported depression had greater percent
reduction in all scores, although none of these differences
were significant.
Mo2130
Minimally Invasive Full Thickness Colonic Resection: A
Novel Localised Excision Procedure
Adela Brigic1, Paul D. Sibbons2, Chris H. Fraser1,
Susan K. Clark1, Robin H. Kennedy1
1
Department of Surgery, St. Mark’s Hospital and Academic Institute,
Harrow, United Kingdom; 2Northwick Park Institute for Medical
Research, Northwest London Hospitals NHS Trust, Harrow, United
Kingdom
AIMS: Worldwide introduction of the bowel cancer screening programmes has lead to an increase in the number of
patients diagnosed with complex, benign colonic polyps
unsuitable for endoscopic resection. A significant proportion is referred for hemicolectomy, which is associated with
significant risk of morbidity and mortality. To address this
and improve clinical outcomes, we modified a previously
reported full thickness laparo-endoscopic excision (FLEX)
technique developed in our institution.
METHODS: Following a series of ex-vivo experiments to
standardise procedural steps, surgery was performed in
five 70-kg pigs. A simulated colonic polyp was created by
Figure 1: Full-thickness colonic specimen with APC marks delineating
endoscopic injection of Spot® and the clearance margin
was delineated by circumferential placement of mucosal clearance margin.
argon plasma coagulator (APC) marks. Full thickness eversion of the colonic wall that contains the simulated lesion
was achieved by endoscopic placement of prototype BraceBars (BBs). The everted segment was excised using a linear
laparoscopic stapler placed below the BBs. The first pig was
terminated immediately and others 8 days after surgery.
RESULTS: Procedure duration was defined from placement
of mucosal APC marks to specimen excision with a median
time of 26 min (range 20–31 min). All excised specimens
contained three pairs of BBs delineating clearance margin
with a median diameter of 5.1 cm (range 4.5–6.3 cm).
Postoperative recovery in survival animals was uneventful
and post-mortem examination demonstrated well-healed
resection sites with no evidence of intra-abdominal infection or inadvertent organ damage. Endoscopic evaluation
of anastomoses at post-mortem examination excluded stenosis. Histological assessment of the partial circumferential
anastomosis showed primary closure by mucosal abuttal
and regeneration together with restoration of continuity of
submucosa.
CONCLUSIONS: This proof-of-concept survival study has
demonstrated the feasibility of safely achieving full thickness colonic specimens exceeding 5 cm in diameter. Accurate placement of endoscopic BBs ensures completeness of
excision, reducing the risk of recurrence or residual disease
while laparoscopic overview avoids collateral damage.
Figure 2: Endoscopic examination of the excision site 8 days post
procedure.
This is the first localized excision technique described to
date suitable for translational study in humans as an alternative to hemicolectomy. The ability to preserve mesenteric
vasculature and colonic length is likely to result in less morbidity and mortality, reduced treatment costs and better
functional outcomes.
164
Mo2131
Risk Factors for Postoperative Ileus in Patients
Undergoing Laparoscopic Colorectal Surgery
Mo2132
Udo Kronberg1, Vivian Parada1, Alejandro J. Zarate1,
Magdalena Castro2, Valentina Salvador1, Claudio Wainstein1,
Francisco LóPez-KöStner1
1
Colorectal Unit, Clinica Las Condes, Santiago, Chile; 2Academic
Research Unit, Clinica Las Condes, Santiago, Chile
Accurate Haemodynamic and Image Based Assessment
of Blunt Traumatic Splenic Injury May Identify Those
Who Will Benefit from a Conservative Approach
CONCLUSIONS: CT grading of splenic injury is underreported and splenectomy is over-represented in this
cohort. Protocol-based management and CT grading of all
splenic injuries is recommended and will aid in identifying
those who may benefit from a safe conservative approach.
165
Monday
Poster Abstracts
Chris Brown, Rami Radwan, Karen Litton, David Fleming,
Ashraf M. Rasheed
INTRODUCTION: Postoperative ileus (POI) after lapa- General/Upper GI Surgery, Gwent Institute for Minimal Access Surgery,
roscopic colorectal surgery leads to increased anxiety for Newport, United Kingdom
patients and caregivers, and is associated with prolonged
hospital stay and increased costs. The aim of this study is to INTRODUCTION: Recognition of overwhelming postinvestigate pre-, intra- and postoperative risk factors associ- splenectomy infection in splenectomized patients led to
ated with the development of POI in patients undergoing greater efforts to conserve splenic tissue following blunt
trauma. Nonoperative management (NOM) of splenic
laparoscopic colorectal surgery.
trauma has emerged as a means to enhance splenic salvage.
PATIENTS AND METHODS: Patients undergoing lapa- Accurate assessment of haemodynamic stability and injury
roscopic colectomy between January 2008 and January severity are prerequisites to safety of such approach. Identi2012 were identified from a prospectively maintained lapa- fication of splenic injuries that require early surgical repair
roscopic database. Clinical, metabolic and pharmacologic or removal is vital.
data were obtained retrospectively by reviewing the clinical charts. Patients with rectal resection were excluded. POI AIM: To study the management of traumatic splenic injury
was defined as absence of bowel function for 5 or more at our institution and compare it against published guidedays, or the need for reinsertion of a nasogastric tube after lines from SSAT (Society for Surgery of the Alimentary Tract)
starting oral diet in the absence of mechanical obstruction. and AAST (American Association for Surgery in Trauma) in
Factors associated with POI were analyzed using Chi-square relation to assessment, indications for splenectomy and
or Fisher’s exact test for categorical variables, Mann-Whit- role of NOM in absence of associated injuries.
ney U test for continuous variables. A multivariate analysis METHODS: A retrospective database was constructed to
was carried out by logistic regression. P-values <0.05 were include splenic injuries admitted over a 10 year period.
considered statistically significant, and Odds Ratios were Cases were captured by searching the electronic CT scan
calculated with a 95% confidence interval.
reports database for those containing the words “splenic
RESULTS: Complete data were obtained from a total of injury/rupture/haematoma/laceration” and the surgical
167 patients, with a median age of 50 years (i: 15–90), and database for operations coded as “Splenectomy/Splenora slight male predominance (55%). POI was observed in rhaphy”. Cases were cross-checked against splenic pathol24/167 patients (14,3%). On univariate analysis, some pre- ogy specimens’ reports. Cases not associated with traumatic
operative factors were significantly related to POI, such as injury were excluded. A range of parameters were assessed
higher age (p = 0,0007), higher ASA status (p = 0,003), pre- and compared against published guidance from both
operative diagnose (cancer vs. no cancer; p = 0,002), and SSAT and AAST. All index and follow up CT images were
history of previous abdominal surgery (p = 0,019). BMI re-reviewed and re-graded by a radiologist blinded to the
was not related to POI, neither as continuous variable nor outcome. The neo-CT reports with haemodynamic and
as categorized factor (<30 vs. ≥ 30). Among the intra- and haematologic status was compared with actual managepostoperative factors, a longer OR time (p = 0,003) as well ment and final outcome.
as a lower postoperative potassium level (p = 0,0004) were RESULTS: 48 cases of blunt traumatic splenic injury were
observed in patients suffering from POI. Neither the amount identified; RTA was the most frequent mechanism of injury.
of intraoperative opioids nor the use of postoperative mor- 38 underwent splenectomy while 10 were managed conphin-based PCA was related to POI. On multivariate analy- servatively. CT assessment was performed in all cases bar 4
sis, previous abdominal surgery (OR 2,83, CI 1,067–7,832), who were taken straight for resuscitative laparotomy. AAST
OR time (OR 1,007; CI 1,0011–1,0142) and postoperative grading of the severity of splenic injury was reported in
potassium levels (OR 0,0199; CI 0,064–0,6219) showed to 8.3% of cases. Repeat imaging was sought in 60% of those
be independently associated to POI.
cases initially managed conservatively with 7.8% having
CONCLUSION: POI after laparoscopic colectomy is asso- subsequent splenectomy. Average duration of observation
ciated with specific preoperative, intraoperative and postwas 0.8 days (0–8) in splenectomy group verses 10.1 days
operative factors. Minimizing or addressing these factors (3–23) in the successful conservative management group.
may be expected to reduce the incidence of this common There was a single mortality in this cohort due to associated
head injury.
complication.
Mo2133
5 cm. The male to female ratio was 1:1.6 and the average
age and cyst size were 56 years and 1.7 cm respectively.
Seventy-seven of these patients underwent follow up imaging over a mean period of 29 months. Average cyst size
decreased to 1.5 cm yielding a growth rate of –0.23 cm/
month. There were no complications related to the presence of the cyst during the observation period.
Management of Splenic Cysts: Does Size Really Matter?
Christopher Kenney, Yumiko E. Hoeger, Amy K. Yetasook,
John G. Linn, Woody Denham, Joann Carbray, Michael B. Ujiki
Surgery, NorthShore University HealthSystem, Evanston, IL
PURPOSE: To observe the natural history of splenic cysts
Twenty-three patients had a cyst size greater than 5 cm. The
and evaluate their management options.
male to female ratio was 1:3 and the average age and cyst
METHODS: One hundred and eighty-two patients were
size were 50 years and 7.8 cm respectively. Sixteen of these
identified from an IRB-approved database search with
patients underwent follow up imaging over a mean period
radiologic evidence of a splenic cyst over an 11-year period.
of 45 months. Average cyst size decreased to 7.4 cm yieldWe subdivided these patients into those who underwent
ing a growth rate of –0.04 cm/month. One patient, a 95
intervention and those who did not. The patients who
year-old female, with a stable cyst size at 15 months follow
were observed with serial imaging were further divided
up later presented with a ruptured cyst and died during the
into those whose cyst size was greater or less than 5 cm. All
same admission. Her cause of death was not confirmed to
patient records were reviewed for history, diagnostic studbe related to cyst rupture.
ies, operative intervention and outcomes.
CONCLUSIONS: This study presents the largest single series
RESULTS: In the current study, 182 patients were diagto date of patients with splenic cysts managed by aspiration,
nosed with a splenic cyst and eight (4.4%) were included in
operative intervention, or observation. We noted, as have
the intervention group. In this group, all were female with
others, that percutaneous drainage has a high recurrence
mean age and cyst size of 27 years and 7.3 cm respectively.
rate. In addition, we did not find any malignant lesions in
Five of these patients underwent percutaneous aspiration as
the operative specimens and noted a negative growth rate
a first intervention, all of which eventually were operatively
in those cysts that were followed with serial imaging. Our
resected or drained. Pathologic examination of resected
data suggest that the management of splenic cysts should
specimens demonstrated benign lesions in all cases.
be comprised of reserving aspiration for those who are not
The non-intervention group was comprised of 174 patients surgical candidates, resecting lesions that are truly sympwho were stratified by cyst size greater or less than 5 cm. tomatic and observing those that are not, regardless of size.
One hundred and fifty-one patients had a cyst size less than
Tuesday, May 21, 2013
12:00 PM – 2:00 PM
West Hall A
POSTER SESSION I
(NON-CME)
Basic: Colon-Rectal
Tu1755
Microarray Analysis of T-Lymphocyte Gene Expression
After Colorectal Resection
M.C. Shantha Kumara H1, Xiaohong Yan1, Hiromichi Miyagaki1,2,
Sonali A. Herath1, Vesna Cekic1, Richard L. Whelan1
1
Surgery, St Luke Roosevelt Hospital, New york, NY;
2
Gastroenterological Surgery, Osaka University, Suita, Japan
INTRODUCTION: Previous studies have established that
surgical trauma is associated with significant transient alterations in cell-mediated immune function. Surgery-related
immunosuppression may impact the patient’s ability to
deal with infection. Also, tumor growth has been shown in
murine studies to be increased after surgical trauma. Cellmediated immunosuppression after resection of a primary
tumor may impair the host’s ability to eradicate or contain
residual tumors cells. This microarray study of perioperative
T-lymphocyte (TLC) gene expression was undertaken in an
effort to better understand the impact of colorectal resection (CR) on cell-mediated immune function.
METHOD: Patients who underwent elective laparoscopic
right hemicolectomy (RHC) for benign colonic disease
(BCD) who had enrolled in an IRB approved blood/data
bank for whom frozen pre- and postoperative TLC’s were
available were eligible for this study. Benign pathology
patients were chosen in order to determine the impact of
surgical trauma alone, independent of the potential effects
of a cancer on immune function. Preoperative (PreOp)
166
and postoperative day1 (POD1) blood samples were utilized. TLC’s were isolated from the blood using a combination of gradient centrifugation and magnetic micro-bead
separation. TLC’s were subsequently lysed and total RNA
extracted. cRNA was made from RNA hybridized to HGU133APLUS oligonucleotide array. PreOp vs POD1 expression data was analyzed via Limma paired analysis to find
differently expressed genes. (p > 0.05 significant) and consistency of significance was analyzed via Empirical Bayes
statistics (B > 0 Sig.). Clinical data is presented as mean ± SD.
RESULTS: Nineteen patients (12 males/7 female, mean age
65.8 ± 12.8 years) met the entry criteria. The mean incision length was 7.8 ± 3.5 cm and mean length of stay was
6.3 ± 2.6 days. All TLC expression data met the affymetrix
data QC standards. A total of 39 genes showed significant
changes on POD1; 21were up-regulated and 18 were down
regulated (B = 0.05–5.3). The expression changes of 7 genes
in this group were strongly significant (ABCG-1, TMEM49,
FAM100B and PIM1 were upregulated and IFI44L, STAT1
and UCP2 were down regulated; P = 0.02 and B = 4.1–5.3).
Enrichment analysis confirmed that these gene changes
were likely to have significant effects on 7 signaling pathways and 3 functional categories i.e.; cell proliferation,
hematological function and immune response.
METHODS: A total gastrectomy followed by esophagojejunostomy was performed on rats in order to induce
chronic duodenal content reflux esophagitis. The animals
were sacrificed sequentially, at the 20th, 30th and 40th week
after surgery and their esophagi were examined. Primary
antibodies against CD68 (pan-macrophage; BMA Bio),
CD163 (M2; AbD Serotec), pStat3 (Cell Signaling), Foxp3
(Treg; eBioscience) were used to evaluate the expression and
localization of the inflammatory response.
RESULTS: At 20–30 weeks post-surgery, squamous proliferative hyperplasia (PHP) and Barrett’s metaplasia (BM)
were observed. Adenocarcinoma (ADC) associated BM
(Figure 1A,B) and squamous cell carcinoma (SCC) were
observed 40 weeks post-surgery. Numerous CD68 positive
macrophages were identified surrounding PHP and BM at
20 weeks and surrounding ADC and SCC after 40 weeks
(Figure 1C). In contrast, few CD163 positive macrophages
infiltrated into the PHP, BM, ADC and SCC after 40 weeks
(Figure 1D). The PHP, BM, ADC and SCC lesions exhibited
some pStat3-positive cells (Figure 1E). A few Foxp3-positive
cells were detected near carcinoma lesions after 40 weeks
(Figure 1F).
CONCLUSION: Surgical trauma affected gene expression
of circulating TLC’s in the immediate postoperative period.
Altered gene expression may impact TLC growth and proliferation as well as immune function. These changes must be
validated at the protein level and additional patients studied. Also, the duration of these changes, after surgery, must
be determined. Finally, a similar study in cancer patients is
also needed.
Basic: Esophageal
Tu1756
The Inflammatory Microenvironment in DuodenoEsophageal Reflux Induced Esophageal Carcinogenesis
in a Sequential Rat Model
Tomoharu Miyashita1,2, Masayoshi Munemoto1,
Furhawn A. Shah2, John W. Harmon2, Takashi Fujimura1,
Daisuke Matsui1, Masanobu Oshima3, Tetsuo Ohta1
1
Department of Gastroenterologic Surgery, Kanazawa University
Hospital, Kanazawa, Japan; 2Department of Surgery, Johns Hopkins
Bayview Medical Center, Baltimore, MD; 3Division of Genetics, Cancer
Research Institute, Kanazawa University, Kanazawa, Japan
CONCLUSIONS: Our data showed that macrophages
infiltrate the esophagus at the early inflammatory stage of
carcinogenesis. In the inflammatory microenvironment,
characteristic of the activated pStat3 pathway, M2 phenotype macrophages infiltrate and contribute to tumor development. Furthermore, Treg was induced by tumor relating
to process of carcinogenesis.
167
Tuesday
Poster Abstracts
BACKGROUND: Macrophages play an important role in
tumorigenesis. Macrophages are polarized to either the classical M1 type or alternative M2 type. Tumor-associated macrophages (TAMs) are polarized to M2 or M2-like types and
have been shown to promote the progression and metastasis of cancer. We hypothesized that TAMs in an inflammatory microenvironment induced by duodenal content
reflux without carcinogens may promote the development
of esophageal carcinomas.
Tu1757
Positional Changes in the Gastroesophageal Valve
May Explain Why Upright Reflux Occurs Earlier Than
Bipositional Reflux
% Male
Age
BMI
% with atypical symptoms
% with respiratory
symptoms
Abnormal GEJ shape on
endoscopy
% with positive
DeMeester score
Acid exposure upright
Acid exposure supine
Ben M. Hunt, Ralph W. Aye, Oliver J. Wagner,
Alexander S. Farivar, Brian E. Louie
Thoracic Surgery, Swedish Medical Center and Cancer Institute,
Seattle, WA
INTRODUCTION: The severity of gastroesophageal reflux
disease (GERD) has been shown to correlate with the Hill
classification of the gastroesophageal valve (GEV). As GERD
worsens and the GEV deteriorates, patients progress from
upright to bipositional reflux. We hypothesized that there
may be significant changes in the configuration and function of the GEV depending on patient position as an explaHill Grade
nation for the earlier occurrence of upright GERD.
METHODS: We prospectively enrolled 47 consecutive
patients with reflux symptoms in an IRB-approved observational study. Patients with prior foregut surgery or hiatal
hernias >4 cm were excluded. Manometry was performed
in upright, right lateral decubitus, and left lateral decubitus
positions. Endoscopy was started in left lateral semi-recumbent position, and patients were repositioned upright partway through the endoscopy. Photographs were obtained
of the GEV for grading in each position. During 48-hour
ambulatory pH testing, information was gathered on
whether patients were upright or supine. Outcomes were
analyzed by type of GERD: upright or bipositional, and also
by patient position.
RESULTS: There were 16 patients with upright and 31
with bipositional GERD. Age, BMI, atypical GERD symptoms, and respiratory symptoms were not significantly different between the groups except that patients with purely
upright reflux were more likely to be female. Patients with
bipositional reflux on pH testing were more likely to have
a deformed gastroesophageal valve on endoscopy in either
position (see Table). There were no significant manometric differences between the groups. On pH testing, patients
with predominately upright reflux had less esophageal acid
exposure by every measure (including number of patients
with a positive DeMeester score) than patients with bipositional reflux (see Table).
Abnormal GEJ shape on
endoscopy
LES basal pressure
(mmHg)
Acid exposure (% of time)
Patients with
Upright Reflux Only
(n = 16)
13%
Patients with
Bipositional
Reflux (n = 31)
55%
p
0.006
57
31
63%
56%
50
30
53%
47%
0.18
0.76
0.76
0.94
48%
57%
0.05
56%
97%
0.001
6%
8%
Upright (n = 47)
2.9
64%
14%
2%
Recumbent (n = 47)
2.4
46%
0.0004
0.0003
p
0.002
0.0003
14.7
8.3
0.006
11%
6%
0.00007
Basic: Hepatic
Tu1758
Sirt1/PGC1a/Nrf2 Pathways Mediate Improvements in
Oxidative Stress in Rat Liver After RYGB
Yanhua Peng, James Z. Lee, Michel Murr, Steven Rakita
College of Medicine, University of South Florida, Tampa, FL
BACKGROUNDS: Oxidative and inflammatory stress in
the liver contributes to liver injury, increased cardiovascular risk and insulin resistance. Our previous study shows
that Roux-en-Y Gastric Bypass (RYGB) improves oxidative
stress in liver through Nrf2, an important transcription factor for anti-oxidative stress. We also found that LKB/AMPK/
Sirt1 expression was increased in liver after RYGB. Here, we
postulate that Sirt1 and Nrf2 work synergistically to attenuate oxidative and inflammatory stress in the liver after
RYGB on obese rats.
METHODS: Expression of TNFD, IL-6, glutathione-S-transferase (GST), Sirt1, PGC1D, Nrf1, and Nrf2 within the liver
was measured in rats from RYGB and sham weight-matched
control cohorts. The nuclear to cytosolic ratios of Sirt1,
Nrf2, and NF-NB were measured as well. A corresponding set
of in vitro experiments were done in the Kuffper cell line
RKC1. The cells were treated with glucose and/or fatty acids
in different doses to mimic gluocotoxicity and lipotoxicity.
The cells were then treated with siRNA to knock down Sirt1.
Afterwards, the expression levels and ratios of the above
CONCLUSION: Patients with primarily upright reflux on mentioned factors were measured.
pH testing had a more normal reflux barrier than those with
bipositional reflux, both endoscopically and on pH testing.
Endoscopically, the GEV becomes deformed when patients
are moved to the upright position and functionally there is
more esophageal acid exposure when patients are upright.
These findings suggest that positional changes in the GEV
may be responsible for the earlier onset of upright reflux.
Endoscopically, Hill grade and other measures of valve
deformity worsened when patients moved from a semirecumbent to an upright position. Manometrically, LES
mean basal pressure, LES mean residual pressure, and UES
mean basal pressure were higher in the upright position
compared to either left lateral or right lateral position. LES
length and hiatal hernia length did not change based on
position. On pH testing, all patients had more acid exposure when upright than when supine (see Table).
168
RESULTS: RYGB up-regulated Sirt1, PGC1D, Nrf1, Nrf2 and
GST in liver (p < 0.001), decreased NF-NB, TNFD, IL-6 and
NOX2/4 (p < 0.001) compared to the sham weight match
control. In RKC1 cells, Sirt1 depletion down-regulated
PGC1D, Nrf1, Nrf2 and GST (p < 0.001). In contrast NF-NB,
TNFD, IL-6 NOX2/4 (p < 0.001) were increased significantly.
Tu1760
Podoplanin Expressing Fibroblasts Enhance the Tumor
Progression of Invasive Ductal Carcinoma of Pancreas,
and Podoplanin Expression Was Affected by Cultured
Condition
CONCLUSIONS: We suggest that the Sirt1/PGC1D/ Nrf1/ Koji Shindo1, Shinichi Aishima1, Kenoki Ohuchida2,
Nrf2 pathways in liver may help to attenuate oxidative and Kazuhiro Mizumoto2, Masao Tanaka2, Yoshinao ODA1
inflammatory stress after RYGB procedure. Correcting the 1Anatomic Pathology, Graduate School of Medical Sciences,
dysregulation of these molecules will benefit patients with Kyushu University, Fukuoka, Japan; 2Surgery and Oncology, Graduate
obesity-induced metabolic syndromes.
School of Medical Sciences, Kyushu University, Fukuoka, Japan
Basic: Pancreas
Tu1759
A CD166 Negative Subpopulation of Pancreatic Cancer
Cells Has Strong Invasive and Migratory Activity
Kenji Fujiwara1, Kenoki Ohuchida1, Koji Shindo1,2,
Daiki Eguchi1, Shingo Kozono1, Takao Ohtsuka1, Shunichi Takahata1,
Shinichi Aishima2, Kazuhiro Mizumoto1, Masao Tanaka1
1
Departments of Surgery and Oncology, Graduate School of Medical
Sciences, Kyushu University, Fukuoka, Japan; 2Department of
Anatomic Pathology, Graduate School of Medical Sciences, Kyushu
University, Fukuoka, Japan
BACKGROUND: CD166 expression is correlated with
prognosis in several cancers. However, its significance in
pancreatic cancer is not clear. The aim of this study is to
clarify the significance of CD166 expression in pancreatic
cancer.
METHODS: We performed flow cytometry to analyze
expression of CD166 in pancreatic cancer cell lines. We also
analyzed the functional differences between CD166 + and
CD166– cells using invasion, migration and proliferation
assays. We performed immunohistochemistry to investigate CD166 expression in surgically resected pancreatic
cancer tissues.
METHODS: We investigated Podoplanin expression in
fibroblasts involved in pancreatic cancerous tissue using
immunohistochemistry (IHC). We established primary
cultured fibroblasts as CAFs of fresh pancreatic adenocarcinoma tissue by out-growth method, and analyzed
Podoplanin expression of CAFs using qRT-PCR and flow
cytometry. We sorted CAFs by Magnetic Activated Cell Sorting (MACS) according to the expression of Podoplanin, and
compared Podoplanin + CAFs with Podoplanin- CAFs by
migration assay and invasion assay in co-culture with pancreatic cancer cell lines. In addition, we performed qRT-PCR
to elucidate differentiation between them. We also compared Podoplanin high-expressing CAFs with Podoplanin
knocked down CAFs by siRNA to clarify the own function of Podoplanin. Next, we investigated the Podoplanin
inducible condition by a time course of expression analysis
using total starvation medium (EBSS), and DMEM added by
recombinant growth factors or several percentages of FBS.
RESULTS: IHC showed that the frequency of Podoplanin
expression (>30%) in fibroblasts was associated with lymphatic invasion, venous invasion, tumor size (>3 cm), histological grade, pT, and a shorter survival time (P < 0.001).
Podoplanin expression in cultured CAFs showed heterogeneity (ranging from 0 to 95%) by flow cytometry. Podoplanin + CAFs showed significantly high expression of
CD10 and MMP3 compared with Podoplanin- CAFs, and
co-culture experiments using sorted CAFs showed that
Podoplanin + CAFs enhanced the ability of cancer cells in
migration and invasion compared with Podoplanin- CAFs
(P < 0.05), while knock down of Podoplanin showed no
CONCLUSION: Our findings suggest that CD166- cells effect on migration and invasion assay. Podoplanin expresexhibit more aggressive behavior and activation of Zeb1 sion in CAFs was up-regulated in the condition of starvamay play a role in this behavior, although further investi- tion and lower concentration of growth factors or FBS.
gation is needed.
169
Tuesday
Poster Abstracts
RESULTS: In flow cytometry, CD166 was expressed in pancreatic cancer cells in wide range (0–99.5%). In invasion
assay, the invasiveness of CD166- cells was greater than that
of CD166 + cancer cells (p < 0.05). In migration assay, the
migratory activity of CD166– cells was greater than that of
CD166 + cancer cells (p < 0.05). In proliferation assay, there
was no significant difference between CD166 + pancreatic
cancer cells and CD166– cells. The analysis of real-time
quantitative RT-PCR revealed that epithelial-mesenchymal
transition activator Zeb1 mRNA was over-expressed in
CD166- cells (p < 0.001 compared with that in CD166 +
cells). In immunohistochemistry, there was no significant
difference in prognosis between CD166 high staining group
(15 patients; 48.4%) and CD166 low staining group (16
patients; 51.6%).
BACKGROUND: An interaction between cancer cells and
surrounded cancer associated fibroblasts (CAFs) plays an
important role in the progress of cancer. Pancreatic cancer
is characterized by a growth of abundant fibrous or connective tissue, called “desmoplasia”, and hypovascular environment inducing hypoxic and undernutritional condition. In
pancreatic cancer, CD10 + myofibroblast-like activated Pancreatic Stellate Cells (PSCs) enhance the progression of pancreatic cancer by secreting high levels of MMP3 (Ikenaga,
et al. Gastroenterology 2010). Podoplanin, usually used as
a lymphatic vessels marker (D2-40), had been described as
a predictor of prognosis in various types of cancer when it
was expressed in involved stromal fibroblasts.
CONCLUSION: Despite Podoplanin in CAFs had no function of own to affect cancer cells, Podoplanin + CAFs
enhanced the progression of pancreatic cancer cells by coexpression of CD10 and MMP3. Podoplanin expression was
up-regulated in the condition of starvation and lower concentration of growth factors or FBS.
Clinical: Biliary
CONCLUSIONS: A transparent validated national registry with good compliance is a valuable tool to analyze and
improve treatment strategies in benign surgery with low
complication rates.
REFERENCES
1. Enochsson L et al. Gastrointestinal endoscopy 2010;72 (6):
1175–1184, 1184 e1171–1173.
2. Lundstrom P et al. Journal of gastrointestinal surgery
2010;14 (2):329–334.
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3. Palsson SH et al. ISRN gastroenterology 2011;2011:
507389.
Online Transparency, Validation and Implementation
of Research Findings: Cornerstones in Building a
Quality Registry—Report from the Swedish Registry of
Gallstone Surgery and ERCP
4. Persson G et al. The British journal of surgery 2012;99
(7):979–986.
5. Tornqvist B et al. BMJ 2012;345: e6457.
Lars Enochsson1, Gunnar Persson2
1
Department of Surgical Gastroenterology, Division of Surgery, CLINTEC,
Karolinska Institutet, Stockholm, Sweden; 2Department of Surgery,
County Hospital Ryhov, Jönköping, Sweden
Tu1508
Creation and Evaluation of a Novel Device for
Rapid and Safe Removal of the Gallbladder Through
BACKGROUND: Cholecystectomy (laparoscopic or open) Laparoscopic Port Sites
is one of the most frequent operations performed by general surgeons. Since the complication rate is low it has been
difficult to evaluate the effects of different treatment strategies on the outcome due to lack of statistical power. This is
in contrast to major surgery like in pancreatic or esophageal
cancer where high complication rates make it easier to analyze the effects of major treatment changes. The Swedish
Registry of Gallstone Surgery and ERCP (GallRiks) started in
2005 in order to be able to monitor the effect of different
treatment strategies on the outcome. The aim of this paper
is to present the impact that data from the registry has had
in changing treatment strategies in cholecystectomy in
Sweden.
METHODS: GallRiks is Supported by The National Board
of Health and Welfare and The Swedish Surgical Society.
There are approximately 60,000 cholecystectomies and
40,000 ERCP registered in the database during the period
2005–2011. Data are validated at every hospital in Sweden
every third year to ensure good data quality. Each hospital has access to online reports where the outcome of their
cholecystectomies and ERCP is compared with Sweden as
a whole. The compliance of the registry in Sweden is good
(>85%).
RESULTS: This validated database has led to the initiation of many research projects. The results are published
in peer-reviewed scientific journals as well as presented at
local meetings for users and general presentations at the
annual Swedish surgical week. The findings appear to have
an impact on treatment strategies. Thus,the use of antibiotic prophylaxis decreased in Sweden from 23% to 14%
after the publication of Lundström (2) that showed this
to be ineffective in elective cholecystectomy. The administration of thromboembolic prophylaxis has decreased by
18% after presentation of a study by Persson (4) proving
this to increase bleeding complications in laparoscopic
cholecystectomy.
Joshua M. Judge1, Gina Petroni2, William H. Guilford3,
Craig L. Slingluff1, Peter T. Hallowell1
1
Surgery, University of Virginia, Charlottesville, VA; 2Public Health
Sciences, University of Virginia, Charlottesville, VA; 3Biomedical
Engineering, University of Virginia, Charlottesville, VA
OBJECTIVE: To obtain preliminary data on the safety
and usefulness of a novel device for extracting large and
difficult-to-remove gallbladders during laparoscopic
cholecystectomy.
BACKGROUND: A common source of frustration during
laparoscopic cholecystectomy involves extraction of the
gallbladder through a port site smaller than the gallbladder
itself. Current techniques risk rupture of the bag or gallbladder and can be time consuming, leading to increased
procedural cost. We developed and tested a novel device for
the safe, minimal enlargement of laparoscopic port sites to
extract large, stone-filled gallbladders from the abdomen.
This device is a stainless-steel device with a vertical retraction blade and a linear aperture in the handle that admits
a scalpel, which can be advanced along the back side of the
vertical blade, enabling a controlled sharp enlargement of
the laparoscopic port site and rapid removal of the gallbladder. Additionally, we sought to estimate the proportion of
patients whose gallbladders are difficult to extract from the
abdomen.
METHODS: This IRB-approved, single institutional, single
surgeon study was offered to patients presenting for laparoscopic cholecystectomy with diagnoses high risk for difficult gallbladder extraction (those with cholelithiasis with
or without complicating features). When gallbladder extraction was attempted, if successful without enlargement of
the port site, the device was not used. If the gallbladder
could not be removed with gentle traction on the specimen bag, and enlargement of the port site was considered,
the device was used. The time required for extraction, from
170
insertion of the device until complete specimen removal,
was recorded. The study surgeon provided Likert scores for
perceived utility of the device in each case. Patients were
seen in follow-up irrespective of device use and assessed for
pain level, cosmetic effect, and infectious complications.
Time for Extraction of Gallbladder with Use of Extraction Device
Prototype (patients 1–8)
Final device (patients 9–20)
Total (n = 20)
Mean (Sec)
120
24
63
Median (Sec)
70
24
32
Range (Sec)
27–416
10–42
10–416
METHODS: The Nationwide Inpatient Sample was searched
for gallstone ileus patients (ICD-9 = 560.31) from 1998–
2010. Only patients who underwent intestinal enterotomy
(ICD-9 45.00–45.03) were included in this study. Variables
studied were age, sex, length of stay, hospital teaching status, hospital charges, mortality, diagnoses and procedures.
Data for patients who underwent cholecystectomy during
their hospital stay (ICD-9 51.21–51.24) were compared to
patients who did not.
RESULTS: Over 13 years, 4,253 patients were hospitalized
with gallstone ileus and had an intestinal enterotomy with
a mean of 327 cases per year. Mean age was 74.9 years; 1,234
were male (29%) and 3,019 were female (71%). 861 patients
(20.2%) underwent cholecystectomy during the same hospital visit. 89.8% underwent open cholecystectomy, 6.3%
open partial cholecystectomy, 3.5% laparoscopic cholecystectomy and 0.5% laparoscopic partial cholecystectomy.
Mean mortality rate was 6.1%. Diagnoses and mortality
rates associated with increased risk of death were aspiration
pneumonia (37.3%), septicemia (31.3%), respiratory failure
(28.1%), pneumonia (27.5%), acidosis (19.9%), heart failure
(16.9%), COPD (14.4%), mental disorders (12.6%), atrial
fibrillation (12.0%) and post-operative infection (11.1%).
Comparison of Cholecystectomy and No Cholecystectomy
Length of Stay (Days)
Oblique view from the top of the device.
RESULTS: Thirty-nine patients were enrolled in the study.
For twenty (51%) there was difficulty extracting the gallbladder, requiring use of the device. Average extraction time
for the first 8 patients was 120 seconds. After a planned
interim analysis, an improved device was produced and
used in the next 12 patients, for whom the average extraction time was 24 seconds. There were no adverse events.
Post-operative pain rating and incision cosmesis scores
were comparable between patients with or without use of
the device. No wound infections or other wound complications were encountered.
Hospital Charges
Mortality
Cholecystectomy
14.8
No Cholecystectomy
11.6
$75,009
10.4%
$53,208
5.0%
CONCLUSION: Difficult gallbladder extraction during
laparoscopic cholecystectomy occurs in a large proportion
of patients. The study device can safely and rapidly extract
impacted gallbladders through the abdominal wall port site
and is judged a useful tool by the study surgeon.
Tu1509
CONCLUSION: Gallstone ileus is more common in older
women and was mostly treated by enterotomy alone. However, 20% of patients underwent cholecystectomy during
their initial hospital visit. Most patients who underwent
Greg Burgoyne, Richard Heitmiller
Department of Surgery, MedStar Union Memorial Hospital, Baltimore, MD cholecystectomy underwent an open procedure. The length
of stay, hospital charges and mortality rate were all greater
INTRODUCTION: Gallstone ileus is a challenging and
in patients who underwent a cholecystectomy during their
uncommon disease process. No guidelines have been estabinitial hospital stay. The mortality rate is also increased in
lished regarding the timing of cholecystectomy in the manpatients who have underlying co-morbid conditions or
agement of gallstone ileus. We review a national database
who develop infectious complications such as septicemia,
to evaluate the impact patients undergoing cholecystecpneumonia and wound infections.
tomy in their initial hospital stay.
Gallstone Ileus: Impact of Cholecystectomy During the
Initial Hospital Visit
Tuesday
Poster Abstracts
171
Tu1510
Tu1511
Clear Anterior and Posterior View of Calot’s Triangle,
Display of Critical View of Safety and Demonstration
of Cystic Duct-Gallbladder Junction Are Necessary to
Prevent Intraoperative Cystic Duct Misidentification
During Laparoscopic Cholecystectomy
Does Initial Laparoscopic Cholecystectomy Influence
the Outcomes of Definitive Oncologic Resection for
Gallbladder Cancer?
Chris Brown, Rami Radwan, Ashraf M. Rasheed
General/Upper GI Surgery, Gwent Institute for Minimal Access Surgery,
Newport, United Kingdom
INTRODUCTION: Bile duct injury (BDI) is the most serious of all complications during laparoscopic cholecystectomy (LC). It leads to significant mortality and morbidity,
even following a successful repair. Misidentification of the
bile duct as a cystic duct is the main cause of ductal injury.
Despite recognition of the importance of correct cystic duct
identification in prevention of BDI, the UK practice lacks an
agreed systematic method for “Safe Cystic Duct Identification”. The aim of this questionnaire is to survey terms used
to describe the techniques utilised for intra-operative anatomical identification of the cystic duct among practising
UK hepatobiliary surgeons and members of ALS (Association of Laparoscopic Surgeons).
Rana M. Ballo, Mina Saeed, Shaun Daly, Maria C. Mora Pinzon,
Amanda B. Francescatti, Steven D. Bines, Keith W. Millikan,
Jonathan Myers, Minh B. Luu
General Surgery, Rush University Medical Center, Chicago, IL
BACKGROUND: Incidentally discovered gallbladder cancer after routine laparoscopic cholecystectomy (LC) commonly requires a completion operation for proper oncologic
resection. There are concerns that a LC prior to definitive
resection may negatively affect perioperative morbidity and
survival. We aim to compare perioperative outcomes and
survival between patients undergoing a single, initial oncologic resection versus those whose gallbladder cancer is
incidentally diagnosed after LC, therefore requiring staged,
completion surgery.
METHODS: An observational, cohort study of patients
undergoing resection of gallbladder cancer was conducted
between 2003 and 2012. Twenty patients were evaluated
based on the operative treatment required: single, initial
oncologic resection (n = 9) or staged, completion oncologic resection (n = 11). Pre-operatively, all single surgery
patients were suspected to have gallbladder cancer, while
none of the staged operation patients were suspected to
have gallbladder cancer. Nineteen patients received a radical cholecystectomy, segment IV, V liver resection, and
porta hepatis lymphadenectomy. Univariate analysis of
patient demographics, perioperative outcomes and overall
survival were compared using SPSS analytical software v.20
and statistical significance was defined as p < 0.05.
METHOD: A postal questionnaire and an electronic one
were sent to all UK specialist hepatobiliary surgeons and to
ALS members respectively. The questionnaire was designed
to allow the user to select the descriptive terms that best
fit the method used for cystic duct identification during
LC. The survey was constructed utilizing SAGE’s (Society of
American Gastrointestinal and Endoscopic Surgeons) recommendations and included “Triangle of Calot is Displayed
Clearly”, “Triangle of Calot is Displayed Clearly Anteriorly
and Posteriorly”, “Confluence of Cystic to Common Hepatic
Duct Displayed”, “Infundibular Technique Utilized”, “and
Critical View of Safety Demonstrated”. Surgeons were RESULTS: Patient demographics were similar between
the two groups. Post-operative staging was not statistically
invited to add any comments or recommendations.
different and consisted of one unknown, two stage I, four
RESULTS: 74 postal questionnaires (72.5% return) from stage II, one stage IIIA, eleven stage IIIB and two stage IV.
consultant HPB surgeons were completed and returned. Mean operative time for definitive R0 resection was 221.2
The most prevalent descriptive term or terms used to minutes for single and 248.0 minutes for staged surgery
describe intraoperative cystic duct identification meth(p = 0.555). Median blood loss was greater in staged than
odology included “triangle of Calot is displayed clearly
single surgery (900 mL versus 750 mL, respectively) but was
anteriorly and posteriorly” and “critical view of safety demnot significant (p = 0.23). Furthermore, the increased blood
onstrated” (72% selection rate) followed by “infundibular
technique utilized” (49% selection rate). The majority of loss did not lead to a significantly greater number of units
additional comments related to utilization of intra-oper- of blood transfused, mean of 1.75 units for staged versus
ative fluorocholangiography when anatomy is in doubt 0.73 units for single surgery (p = 0.18). No 30-day postand to avoid clipping or cutting until the anatomy is clear. operative complications occurred in patients receiving sin133 electronic questionnaires were completed by 6 Clini- gle surgery compared to three complications in the staged
cal Fellows (4.5%), 28 ST/SpRs (21.2%) and 98 Consultants surgery group (p = 0.089). The single surgery group had
(74.2%). The frequency of descriptive terms used was as fol- one 30-day mortality. Although the 1-year survival rate for
low: ‘Calot’s Triangle identified & Demonstrated’ (70.8%) single surgery patients was 28.6% versus 57.1% in staged
followed by ‘Demonstration of Strasberg’s Critical View of patients (p = 0.592), the 2-year survival rate was 14.3% for
both groups (p = 0.999). Median survival for single surgery
Safety’ (24.2%) and lastly ‘Infundibular technique’ (5%).
patients was 15.4 months versus 14.4 months for staged
CONCLUSION: Clear anterior and posterior view of Calot’s surgery patients (p = 0.255).
triangle, display of critical view of safety and demonstration of cystic duct-gallbladder Junction (infundibular tech- CONCLUSION: Single versus staged resection of gallnique) are necessary to prevent intraoperative cystic duct bladder cancer demonstrates no significant difference on
perioperative morbidity or survival. Therefore, initial lapamisidentification during laparoscopic cholecystectomy.
roscopic cholecystectomy does not appear to influence the
Intra-operative fluorocholangiography is recommended
outcomes of definitive oncologic resection for gallbladder
when anatomical identification is in doubt and no clipping
cancer.
or cutting is performed until the anatomy is verified.
172
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Tu1514
Short Term Outcome Results Support Safety and
Effectiveness of a Single Stage Laparoscopic Common
Bile Duct Clearance and Cholecystectomy for
Concomitant Chole- and Choledocholithiasis
Trends in the Management of Acute Cholecystitis:
Prevalence of Percutaneous Cholecystostomy and
Delayed Cholecystectomy in an Elderly Population
Rahulpreet Singh, Ashraf Rasheed
Upper GI Surgery, Royal Gwent Hospital, Newport, United Kingdom
OBJECTIVES: To assess the outcome of laparoscopic clearance of common bile duct stones at an advanced laparoscopic unit in South Wales.
John D. Cull2, Dahlia Rice2, Alexander J. Czubak1,
Eric C. Brown1, Jose M. Velasco1,2
1
Surgery, NorthShore University Health System, Skokie, IL; 2Surgery,
Rush University Medical Center, Chicago, IL
173
Tuesday
Poster Abstracts
BACKGROUND: Management of patients with acute cholecystitis (AC) remains controversial. Published guidelines
METHOD: A prospective database was constructed to recommend early laparoscopic cholecystectomy (LC) as
capture data on laparoscopic common bile duct clearance the preferred treatment option. Percutaneous cholecystoscases and included demographics, imaging, indications, tomy tubes (PCT) had been primarily used in the setting of
technique, ductal access route, success rate, operating time, patients with serious comorbidities, severe cholecystitis in
duration of hospital stay, bile leakage, sub-phrenic collec- the elderly, and in cases where LC can be technically challenging. We reviewed our experience in the management
tion, biliary peritonitis and postoperative jaundice.
of AC in the elderly to identify factors that could influence
RESULTS: Sixty (60) consecutive patients who had an outcomes; specifically, the prevalence of PCT, the timing of
attempt at concomitant laparoscopic cholecystectomy cholecystectomy, and adherence to published guidelines in
and common bile duct clearance populated the database. their management.
(7/60) cases were performed following a failed endoscopic
METHODS: A retrospective review of 806 elderly patients
clearance.
(>65) with the primary diagnosis of biliary disease was perComplete laparoscopic clearance was achieved in (44/60) formed from 2009 through 2011. ICD-9 codes were used.
73.3% of attempted cases, 11/60 (18.3%) were converted Patients were divided into three groups: PCT (Group 1),
to open (due to impacted stone or other intra operative early cholecystectomy (Group 2), and late cholecystectomy
difficulties) and cleared completely; (6/60) 10% failed (Group 3). All three groups were compared with respect
laparoscopic clearance and was referred to post operative to outcome measures and covariates. Logistic regression
endoscopic therapy. 5/60 cases were performed follow- and Fisher exact test were used to determine statistical
ing emergency admission and other 55/60 were planned significance.
procedures.
RESULTS: We reviewed 265 patients with a histologic diagTrans-cystic approach was utilised in 34/60 (56.6%) and nosis of AC. Out of 75 patients who initially had PCT, 64
was successful in 27/34 (79.4%) but failed in 4/34 (11.7%) (24%) underwent interval cholecystectomy, 74 (28%) early
and converted to open with successful clearance in 1, the cholecystectomy, and 127 (48%) delayed cholecystectomy.
remaining 3/34 (8.8%) referred for post operative ERCP.
The mean age of patients was 77 with no statistical differTrans-choledochotomy clearance was used in 26/60 (43.3%) ence among groups. Patients in Group 1 were more likely
cases and succeeded in 19/26 (73.3%) and converted to to have ASA scores of 4 when compared to those in Groups
2 and 3 (p = 0.04). After removing those with an ASA of 4,
open in 7/26 (26%) with successful clearance in all.
no significant difference existed among the three groups
A total of 11 cases (18%) failed complete clearance laparo- with regard to covariates. Regarding outcomes, there was
scopically and converted to open and 8 out of the 11 were no difference in conversion rates, biliary leak, bowel injury,
completely cleared.
need for reoperation, or 30 days mortality among the three
T- tube was used in 2/26 (7.6%) choledochotomy cases and groups. Overall conversion rate in the three groups was
11% with no statistical significance between groups. Comlead to a longer hospital stay.
A Total of 4 (19%) patients had post operative complica- pared to Group 2, patients in Group 1 were five times more
tions, 2 bile leaks, 1 post operative bleed and 1 dislodgment likely (p = 0.04) and those in Group 3 were four times more
likely (p = 0.06) to have a recurrent episode of pancreatitis,
of T -tube. There was no mortality.
cholecystitis and/or cholangitis from the time of diagnosis
CONCLUSION: Laparoscopic common bile duct clearance until operation.
during cholecystectomy followed by ERCP for failure of
ductal clearance is probably the optimal approach. Short
term outcome results support the safety and effectiveness
of laparoscopic CBD clearance approach; but a careful long
term outcome and clinical and biochemical follow up for
all patients undergoing such a procedure is required.
RESULTS: Eighty-four patients, mean age 55, 56% female,
mean BMI 31, were enrolled in the study. Preoperatively
81, and at postoperative time points 66, 59 and 59 patients
provided scores for each question for analysis. The pain
VAS scale revealed statistically and clinically significant
differences from baseline (mean 1.8 + 2.4) to postoperative day one (mean 4.5 + 2.5) and 7 (mean 2.4 + 2.1) (p <
0.0001). Overall scores did not reveal significant changes.
The PROMIS physical subscale and physical T score
revealed clinically and statistically significant differences
from baseline (14.2 + 2.9/46.8 + 7.7) to POD 1 (12.6 + 3/
41.8 + 8.3) (p 0.0067/ 0.0038), driven by answers to a question about everyday physical activities (p = 0.0001). The
LASA scores revealed significant differences from baseline
for pain frequency (p = 0.0017) and severity (p = 0.0009)
whereas fatigue was not different. When change from baseline within subject was assessed, 83% of subjects reported
a clinically meaningful worsening in PROMIS physical T
score on POD 1, which persisted in 73% of patients to POD
CONCLUSION: Despite guidelines recommending early 7. In addition to pain and LASA fatigue and social activity
cholecystectomy, patients in our study were more likely to items were clinically worse in 20% of the patients at POD 7.
have their cholecystectomy delayed after a course of antibiotics or PCT (24%). Patients undergoing PCT placement CONCLUSION: Overall quality of life scores with 7-day
or delayed cholecystectomy did not have a lower conver- recall had limited discrimination for the impact of minision rate when compared to those who underwent early mally invasive procedures. Single items appear more promcholecystectomy, and they were more likely to have recur- ising and change from baseline as a group and within
rent episodes of AC/pancreatitis or cholangitis. Based on subject revealed clinically significant fluctuation in QOL,
our review, patients who are medically fit for an operation especially within the first 7 days postop.
should undergo early cholecystectomy since interval cholecystectomy is not associated with better outcomes. Future Clinical: Colon-Rectal
studies will be aimed at looking at resource utilization and
overall cost in these patients.
8Tu1516
Tu1515
Pre-Diagnosis Aspirin and Statin Use Up-Regulates the
Local Inflammatory Response in Colorectal Cancer:
Implications for Neoadjuvant Treatment
PROMIS for Laparoscopy
Juliane Bingener, Jeff Sloan, David Farley
Division of General Surgery, Mayo Clinic – Rochester, Rochester, MN
INTRODUCTION: As morbidity outcomes have significant
limitations when comparing minimally invasive surgical
procedures, recent trials reported on quality of life outcomes after different cholecystectomy procedures. These
trials did not demonstrate differences of global quality of
life instruments such as SF 36 at one month postoperatively. We wanted to test the performance of an NIH-sponsored Patient-Reported Outcomes Measures Information
System (PROMIS) with previously validated, standardized
PRO measures for use with minimally invasive procedures.
METHODS: From May 2011 through Nov 2012, patients
undergoing basic or advanced laparoscopic procedures
agreed to participate in this IRB approved study. The PROMIS global health short form, validated for 7-day recall and
previously used for 24-hour recall, the Linear Analog Self
Assessment (LASA), validated for 24 hour recall and the
10 mm visual analog scale (VAS) for pain assessment were
obtained preoperatively, 4 hrs after surgery and on postoperative day 1 and 7. Each tool was scored and both the
composite scores and single item responses were compared
over time using the Kruskal Wallis test.
James H. Park, Colin H. Richards, Donald C. Mcmillan,
Paul G. Horgan, Campbell S. Roxburgh
United Kingdom
INTRODUCTION: Increasing evidence suggests a role for
nonsteroidal anti-inflammatory drugs (NSAIDs) including
aspirin and statins as adjuvant treatment in colorectal cancer (CRC), with reduced recurrence and improved survival
in long-term users. Whether this is due to manipulation of
CRC-associated inflammation is unclear. Systemic inflammation, a stage independent predictor of outcome may be
down-regulated by NSAIDs [1]. Furthermore, local inflammation measured by tumour immune cell infiltration, an
independent predictor of disease-free survival, may be upregulated by pre-operative NSAID administration[2].
OBJECTIVE: In a cohort of patients with cancer associated local and systemic inflammatory responses, the aim
was to examine whether aspirin (75 mg) and statins prescribed for cardiovascular disease influenced CRC-associated inflammation.
174
METHODS: A retrospective case note review of a prospectively collected CRC database was performed to ascertain
pre-diagnosis prescription of aspirin and statins; the effect of
aspirin alone or combined aspirin and statin use on the systemic (C-reactive protein, albumin, neutrophil:lymphocyte
ratio and modified Glasgow Prognostic score) and local
(assessment of peritumoural inflammatory infiltrate using
Klintrup-Mäkinen (K-M) grade; assessment of T-lymphocyte (CD3 + ), regulatory T-cell (FOXP3 + ) and cytotoxic
T-cell (CD8 + ) infiltration at the invasive margin, within
the stroma and overall) inflammatory responses were
examined.
RESULTS: Data for 434 patients were available [Table 1].
Pathological variables were similar and systemic inflammation did not differ between groups. Data on the local
inflammatory profile were available for 164 patients.
Although K-M did not differ, aspirin and combined use
were associated with increased tumour margin and overall infiltration of CD3 + lymphocytes. This association was
stronger in patients with local disease (T1-3,N0); compared
to no medication there was a significant increase in invasive margin and overall CD3 + infiltration with aspirin or
combined use (margin: 42.1%, 60%, 100%, p = 0.007; overall: 51.7%, 83.3%, 100%, p = 0.007) and a non-significant
trend towards increased FOXP3 + and CD8 + margin, stromal and overall infiltration.
CONCLUSION: Although K-M grade did not differ, tumour
infiltration of T-lymphocytes was increased by aspirin and
statins, particularly in patients with early stage disease.
Whether commencing these agents following diagnosis,
particularly in patients with an attenuated local inflammatory response, results in similar changes prior to surgery
and the subsequent oncological implications remains to be
determined. Studies to examine whether anti-inflammatory
agents can manipulate colorectal cancer associated inflammation are warranted.
REFERENCES
1. McMillan DC. Proc Nutr Soc. 2008;67 (3):257–6.
2. Lönnroth C, et al. Cancer Immun. 2008;8:5.
Table 1: Patient, Tumour And Inflammatory Characteristics of Patients with Primary Operable Colorectal Cancer (N = 434) According to PreDiagnosis Use of Aspirin or Aspirin And Statin Use
Patient Variables
Male/Female
Colon/Rectal
Neoadjuvant therapy (No/Yes)
Ischaemic heart disease (No/Yes)
Ever smoked (current and ex/never)
CRP > 10 mg/L (No/Yes)
mGPS (0/1/2)
NLR > 5 (No/Yes)
No Medication
Aspirin Alone
Aspirin and Statin
P-Value
147 (49)/154 (51)
178 (60)/119 (40)
261 (89)/32 (11)
198 (93)/14 (7)
111 (55)/92 (45)
25 (60)/17 (40)
23 (55)/19 (45)
37 (90)/4 (10)
17 (68)/8 (32)
5 (21)/19 (79)
45 (49)/46 (51)
53 (59)/37 (41)
82 (92)/7 (8)
22 (29)/53 (71)
27 (37)/46 (63)
0.725
0.77
0.403
<0.005
0.003
64 (70)/27 (30)
64 (71)/14 (15)/13 (14)
54 (89)/7 (11)
0.535
0.974
0.975
Systemic Inflammatory Response
199 (66)/101 (34)
27 (64)/15 (36)
200 (66)/69 (23) /32 (11)
27 (64)/10 (24)/5 (12)
132 (86)/22 (14)
14 (61)/9 (39)
Local Inflammatory Response
K-M Grade (Weak/Strong)
97 (67)/48 (33)
8 (47)/9 (53)
16 (67)/8 (33)
0.615
CD3 + Margin (Weak/Strong)
67 (59)/47 (41)
7 (41)/10 (59)
5 (33)/10 (67)
0.032
CD3 + Stroma (Weak/Strong)
65 (56)/52 (44)
9 (50)/9 (50)
6 (37)/10 (63)
0.175
CD3 + Overall (Weak/Strong)
57 (49)/60 (51)
6 (33)/12 (67)
3 (19)/13 (81)
0.014
FOXP3 + Overall (Weak/Strong)
55 (48)/59 (52)
7 (41)/10 (59)
7 (47)/8 (53)
0.758
CD8 + Overall (Weak/Strong)
61 (53)/54 (47)
9 (53)/8 (47)
7 (47)/8 (53)
0.682
All values given as number of patients (%).Total patient numbers vary due to incomplete data. CRP – C-reactive protein. mGPS: modified Glasgow Prognostic Score.
mGPS is a cumulative score based on CRP and albumin; a score of 1 is given if patients has CRP > 10 mg/L, 2 if CRP > 10 mg/L and albumin <35g/L.
NLR- Neutrophil:lymphocyte ratio
Tuesday
Poster Abstracts
175
8Tu1517
8Tu1518
Increasing the Number of Lymph Nodes Examined
After Colectomy Does Not Improve Colon Cancer
Staging
Smoking Adversely Affects Colon Cancer Survival and
Relapse Rates
Cristina N. Budde, Daniel O. Herzig, Kim C. Lu, Brian S. Diggs,
Karen Deveney, Vassiliki L. Tsikitis
Surgery, OHSU, Portland, OR
OBJECTIVES: Current quality initiatives call for examination of a minimum of 12 lymph nodes in curative colon
cancer resections. The aim of this study was to determine if
the number of nodes resected has been increasing, and if an
increasing number of resected nodes correlates with upstaging of tumors and improved survival.
DESIGN: Review of Surveillance, Epidemiology and End
Results (SEER) data from years 2004–2009 was performed.
All patients who underwent colon cancer resection during
this date range were analyzed. Number of nodes retrieved,
patient stage, and survival by stage were examined. Multivariate analysis was performed, examining stage, cancer
site, age, and number of nodes retrieved.
RESULTS: A total of 131,301 patients met inclusion criteria. An average number of nodes analyzed increased
sequentially with each year examined, from 12 in 2004
to 16 in 2009. Despite greater number of nodes obtained
and analyzed, there was no clinically significant change in
stage, overall survival, or survival by stage. On multivariate analysis, controlling for stage and site of disease, there
was improved survival with increasing nodal retrieval (hazard ratio 0.9840 for each additional node removed, 95% CI
0.9829–0.9852, p < 0.001).
Kellie L. Mathis1, Erin Green2, Daniel J. Sargent2,
Lisa Boardman2, Paul J. Limburg2, Stephen N. Thibodeau2,
Rajesh Pendlimari2, Heidi Nelson1
1
Surgery, Mayo Clinic, Rochester, MN; 2Mayo Clinic, Rochester, MN
OBJECTIVE: To test the hypothesis that ever smokers
would suffer more recurrences and worse overall and disease-free survival than never smokers following colon cancer
resection.
SUMMARY BACKGROUND DATA: Smoking is associated with an increased risk of developing colon polyps,
specifically aggressive polyps, as well as an increased risk
of colon cancer. Large database studies have shown an
increased risk of colon cancer mortality among smokers,
but it is not clear whether this risk is related to differences
in the biology/aggressiveness of the disease or differences in
clinical response to treatment.
METHODS: The medical records of 2540 patients with
resected stage I-III colon cancers treated at a single institution were reviewed. Demographics, tumor and surgical variables, and follow-up information were recorded. Univariate
and multivariate analyses were performed to examine predictors of overall and disease-free survival as well as time to
recurrence of colon cancer.
RESULTS: Tumor variables and chemotherapy administration were similar among smokers and nonsmokers. Overall
survival was significantly higher for never smokers compared to ever smokers (5 year OS 79.8% nonsmokers versus 72.3% ever smokers, p < 0.0001; HR 1.51, 95% CI 1.30
–1.74). Disease free survival was significantly higher for
nonsmokers compared to smokers. Time to cancer recurrence was also significantly influenced by smoking status.
Smoking status remained a poor prognostic factor in multivariate models for overall and disease-free survival as well
as time to recurrence.
Multivariate Predictors of Disease-Free and Overall Survival
Colon cancer stage expressed as a percent of cases each year.
CONCLUSION: The current quality initiative has succeeded in increasing the number of nodes examined in
colon cancer resections, but has not led to upstaging of
tumors. The improved survival seen with higher node
counts was independent of stage, site of disease, or patient
age. This suggests that patient related immunologic factors
might explain the relationship rather than the quality of
the surgical resection. The current quality initiative needs
to be investigated further to determine if surgical quality
or non-modifiable patient factors are responsible for the
improvement in survival.
Disease-Free Survival
Factor
Any smoking
Stage I
Stage II
Stage III
Chemotherapy
Diabetes
Age
Overall Survival
Factor
Any smoking
Stage I
Stage II
Stage III
Chemotherapy
Diabetes
Age
176
Hazard Ratio
1.460
1.00 (referent)
1.303
2.212
0.703
1.181
1.046
Hazard Ratio
1.506
1.00 (referent)
1.257
2.221
0.585
1.206
1.058
95% CI
1.269–1.679
p value
<0.0001
1.090–1.557
1.776–2.754
0.573–0.863
0.987–1.421
1.038–1.054
0.0036
<0.0001
0.0007
0.0796
<0.0001
95% CI
1.301–1.742
p value
<0.0001
1.047–1.509
1.772–2.783
0.470–0.728
0.994–1.464
1.048–1.065
0.0142
<0.0001
<0.0001
0.0578
<0.0001
CONCLUSIONS: This study confirms that ever smokers Tu1520
have worse colon cancer outcomes than never smokers.
Surgeons should refer all smokers with colon polyps or can- Pneumoperitoneum Following Abdominal Surgery:
Can We Distinguish Benign vs. Problematic?
cers for smoking cessation programs.
I. Michael Leitman1, Marissa M. Montgomery1, Joseph E. Sabat1,
Laura Bernstein1, Burton Surick1, Barbara Zeifer2,
8Tu1519
Hristina Natcheva2, Franklin Nwoke2, Charles S. Holland1,
High Definition Colonoscopy Increases Adenoma
Anthony Sorrentino1
Detection Rate
1
Surgery, Albert Einsteil College of Medicine-Beth Israel Medical
Nezar Jrebi, Theodor Asgeirsson, Rebecca E. Hoedema,
Center, New York, NY; 2Radiology, Albert Einstein College of
Donald G. Kim, Nadav Dujovny, Ryan Figg, Martin Luchtefeld
Medicine – Beth Israel Medical Cener, New Yotk, NY
Ferguson Clinic, Grand Rapids, MI
INTRODUCTION: Pneumoperitoneum seen on postopBACKGROUND: The adenoma detection rate (ADR) is a erative imaging presents a diagnostic dilemma. It can be
quality indicator for colonoscopy. High definition (HD) a normal finding secondary to air that was introduced at
imaging has been reported to increase polyp detection rates. surgery, which typically resolves in a matter of days. On
OBJECTIVE: The primary objective of this study was to the other hand, it could also represent a sign of a perfocompare polyp detection rate (PDR) and adenoma detec- rated viscus or an anastomotic leak, which might require retion rate (ADR) before and after the implementation of HD operation. Distinguishing one from the other is critical to
successful management. This study examines clinical and
colonoscopy.
radiological findings in order to determine which are able
METHODS: A retrospective chart review was performed on
to facilitate the distinction of benign versus pathological
two groups of patients aged 48–55 years old, who underpostoperative pneumoperitoneum.
went first time screening colonoscopy. The first group had
their screening with standard definition (SD) colonoscopy METHODS: A retrospective analysis of medical records
in the first 6 months of 2011. The second group had their from a large urban teaching hospital was performed. Imagscreening with HD colonoscopy during the first six months ing studies reporting “pneumoperitoneum,” “free air,” and
of 2012. We compared age, gender, PDR, ADR, average size “free intraperitoneal air,” from July 2006 through June 2012
of adenomatous polyps. Statistical analysis was performed were selected for review. The cases were divided into three
groups: patients who ultimately were returned to the operwith Fischer’s Exact Test and Pearson Chi-Square.
ating room and had findings requiring operative intervenRESULTS: 1268 patients were involved in the study (634
tion, those who were returned to surgery but did not have
in each group). PDR (35.3% vs 45%, p < 0.001) and ADR
evidence of pathology requiring operative intervention,
(19.1% vs 25.4%, p = 0.007) were higher in the HD group.
and those who were managed expectantly. Demographic,
The average size of adenomatous polyp were the same in
physical findings and laboratory studies were recorded. The
two groups (0.57 vs 0.55, p = 0.63). When polyps were catradiological studies were reviewed in an attempt to quanegorized into size groups there was no difference in ADR
tify the amount of free intra-peritoneal air.
between the two timeframes (<5 mm in size ( 45.5% vs
41%), 5–10 mm ( 46.6% vs 56%) and >10 mm (7.7% vs
2.6%), p = 0.15). Polyps were most commonly seen in sigmoid (30.6% vs 30.4%). Multiple polyps (25.6% vs 29%, p =
0.51) were more detected in the HD group.
CONCLUSION: Screening colonoscopy with high definition technology significantly improved both PDR and
ADR. The clinical significance of these findings is unclear
but could be justified if findings result in reduction of
interval colon cancer rates.
177
Tuesday
Poster Abstracts
CT scan with contrast on sixth postoperative day following laparoscopic
sleeve resection demonstrating free air over the liver and around spleen.
RESULTS: 68 patients were found to have postoperative pneumoperitoneum after abdominal surgery. Twenty
patients (29%) underwent re-exploration because of presumed intra-abdominal complication and the remainder of patients were managed by observation alone. Nine
patients had prior open surgery and 11 had minimally
invasive abdominal procedures. At surgery, 14 patients
(70%) were found to have pathologic conditions requiring
intervention. The other six were explored but were found
to have conditions that could have been managed without re-exploration. The patients in each group were similar
with regard to age, gender vital signs, pain score, physical
findings, amount of free air or open vs. laparoscopic procedure. However, patients requiring re-operation were found
to have pneumoperitoneum 5.7 days after initial surgery
compared to postoperative 2.7 days for those that could
be managed expectantly (P = 0.004). 15% of the patients
undergoing re-operation died compared to 19% who were
managed without surgery (P > 0.05), none of which were
related to intra-abdominal pathology. None of the other
variables were found to be significantly different between
groups.
CONCLUSIONS: This study suggests that patients with
postoperative free air still present a diagnostic and therapeutic challenge. However, free air several days following surgery may provide an indication that this finding
should be of greater concern. Such patients have a greater
likelihood of requiring reoperation for the treatment of a
postoperative complication.
METHODS: Cancer-specific mortality was obtained from
our prospectively maintained cancer registry database.1534
patients were diagnosed with CRC between 2005 and
December 2009. Patients were included if they had a complete blood count with differential before any modality of
treatment (surgery or chemotherapy). Exclusion criteria
were: absence of differential blood count before treatment,
patients with bowel obstruction on presentation, patients
with hematoproliferative disease, evidence of infection
at the time of presentation, those treated with steroid or
immunosuppressive medications. Two independent physicians reviewed the charts for the demographic, presentation, laboratory, pathological, management and outcome
variables. Patients were then divided into five equal quintiles according to their pretreatment monocyte count [1st
Mono quintile (Mono ≤0.4k/cc) = 125 patients, 2nd quintile
(Mono 0.41–0.5k/cc) = 114 patients, 3rd quintile (Mono
0.51–0.69k/cc) = 108 patients, 4th quintile (Mono 0.7–0.8k/
cc) = 127 patients and the 5th Mono quintile (Mono ≥ 0.81
k/cc) = 113 patients].
RESULTS: A total of 587 patients met the inclusion criteria.
The 5th monocyte quintile had a significant higher 4-year
mortality compared to the 1st and 2nd monocyte quintiles
(38/113 = 34% vs. 23/125 = 18% and 17/114 = 15%, p values 0.008 and 0.001 according to Fisher’s exact two-tailed
test). In multivariate analysis including the cancer stage,
monocyte count was independent predictor of survival
(Hazard ratio of 1.35, 95% Confidence interval 1.11–1.64,
p = 0.0003). Figure 1 illustrated the trend of higher mortality along the monocyte quintiles.
Tu1521
Pretreatment Elevated Peripheral Blood Monocyte
Count Is a Negative Predictor of 4-Year Cancer-Related
Mortality in Colorectal Cancer Patients
Basem Azab, Neeraj Shah, Steven Vonfrolio, William Lu,
Karen E. Gibbs, Scott W. Bloom
Surgery, Staten Island University Hospital, Staten Island, NY
BACKGROUND: Inflammation plays a major role in cancer biology and outcomes. Studies have demonstrated that
tumors with increased tumor-infiltrating monocyte counts
are associated with tumor angiogenesis and degradation of
extracellular matrix, which increases potential of metastasis. Moreover, prior studies demonstrated the association
between elevated peripheral blood monocyte and cancerrelated survival in various cancer populations (colorectal,
ovarian, mesothelioma, melanoma, leukemia and others).
The prior studies evaluated the monocyte count in the metastatic colorectal cancer patients had limited studies sizes
(<100 cases). The aim of this study is to ascertain the value
of using the circulating monocyte count to predict cancer
related survival among colorectal cancer patients.
Figure 1: The 4-year cancer-related mortality according to the
pretreatment peripheral blood monocyte count among colorectal cancer
patients.
CONCLUSION: Elevated pretreatment circulating monocyte count was a significant predictor of long-term cancer
specific survival among colorectal cancer patients.
178
Tu1522
Tu1523
Antibiotics Alone as Initial Treatment of Sigmoid
Diverticulitis Complicated by Peridiverticular Abscess
Instead of Percutaneous Drainage
Transanal Rectal Tumor Excision Using the SILS Device
Angelo Stuto1, Francesca Da Pozzo2, Andrea Braini1,
Alessandro Favero1
1 st
1 Surgical Department, Az. Osp “SMA”, Pordenone, Italy;
2
General Surgery, Trieste University, Trieste, Italy
Faisel Elagili, Luca Stocchi, Pokala R. Kiran
Colorectal Surgery, Cleveland clinic, Cleveland, OH
BACKGROUND: There is limited data assessing the effectiveness of antibiotic treatment as sole initial therapy (ABX)
instead of percutaneous drainage (PCD) in patients with
large abscess complicating diverticulitis. The aim of our
study was to evaluate outcomes for patients initially treated
with PCD vs. those for patients initially treated with ABX.
METHODS: All patients with a diagnosis of abscess ≥3 cm
in diameter associated with sigmoid diverticulitis admitted to our institution from 1994–2012 were identified
from an institutional, IRB-approved diverticular database.
All patients ultimately underwent surgery. One hundred
fourteen patients were initially treated with PCD and 32
patients were initially treated with ABX. Patients treated
with PCD alone or requiring emergent surgery at admission
were excluded.
RESULTS: Patient characteristics are summarized in the
table and were similar except for larger abscess diameter in
the PCD group. Reasons for ABX included technical inability for PCD based on CT images (n = 15) and surgeon preference (n = 17). All ABX patients requiring urgent surgery
had continued symptoms. No PCD was attempted in this
group. Reasons for urgent surgery in the PCD group besides
continued symptoms (n = 16) were technical failure of
attempted PCD (n = 4) and PCD-related small bowel injury
(n = 1). The two groups had similar incidence of elective
surgery, comparable postoperative outcomes and stoma creation rates.
Variables
Age (years)
Abscess diameter (cm)
Intrabdominal/pelvic location
Urgent surgery for failure of
initial treatment
Elective surgery
Mortality
Morbidity
Postoperative abdomino-pelvic
abscess
Anastomotic leak
Overall stoma rate
Permanent stoma rate
Length of hospital stay (days)
PCD (n = 114)
57 ± 13
7.1 ± 2.6
49/65
21 (18%)
ABX (n = 32)
57 ± 12
5.9 ± 4.0
15/17
8 (25%)
P value
0.9
0.001
0.37
0.21
93 (82%)
3 (2.6%)
42/114 (37%)
6 (5%)
24 (75%)
0
11/32 (34%)
2 (6%)
0.2
1
0.77
1
3/94 (3%)
51 (45%)
16 (14%)
8.2 ± 6.2
2/26 (7%)
11 (34%)
4 (13%)
9.5 ± 11.1
0.5
0.3
0.7
0.6
Rectal Resection with Total Mesorectal Excision (TME) is
nowadays the standard of care for rectal turmors. However local excision of early low risk stage (T1s-T1 with G1
or SM1) could be a safe alternative. Recent literature data’s
support this minimally invasive approach. Transanal Endoscopic Microsurgery (TEM), introduced by Buess, is a minimally invasive procedure for removal rectal lesions that
need dedicated tools. TEM is a safe procedure in terms of
low recurrence rate and correct oncological outcome but
suffer from high cost, long learning curve and possibility
of sphinteric damage induced by rigid protoscope. To avoid
these problems we present a technique for transanal excision using a single-incision laparosocpic port. In SILS-TEM
technique standard laparoscopic instruments are used and
the soft and smaller device prevent sphinteric damage. We
propose SILS-TEM for Tis or T1 Rectal Tumor located from 4
to 12 cm from the anal verge. In all the cases nodal involvement was exclude by Transanal Ultrasound and MRI. In
selected patients we also propose SILS-TEM in case of T3N0
with a complete or nearly complete (less than 20% of Residual Cancer Cells at re-staging) response at neo-adiuvant
therapy (performed within a controlled study protocol). In
12 months experience we performed 10 SILS-TEM: 8 for Tis
or T1 uNo and 2 for complete neoadiuvant RT-CT response
cases. No mayor intraop or post-op complications were
showed. 8 of 10 patients required a prolonged antibiothic
therapy. Hospital discharge was from day 2 to day 4 with
1 case of readmission for pain and minor rectal wounds
problem.
SILS-TEM is a safety and feasible technique for selected
early stage rectal tumors. The technique is easy to perform
and require a short learning curve expecially for surgeons
with laparoscopic skills. No additional costs are needed and
patient comfort is improved.
179
Tuesday
Poster Abstracts
CONCLUSION: Selected patients with peridiverticular
abscess can be initially treated with antibiotics without
adverse consequences on the timing of their operations,
requirements for stoma creation and postoperative
morbidity.
Tu1524
Tu1525
Oversewing Staple-Lines in Primary Ileocolic Resections
for Crohn’s Disease May Reduce Anastomotic
Complication Rates
Long-Term Outcomes of Stenting as a Bridge to Surgery
for Acute Left-Sided Malignant Colonic Obstruction
Maria Widmar, Emily Steinhagen, Dustin Cummings,
Adrian J. Greenstein, Alexander J. Greenstein
Department of Surgery, Mount Sinai School of Medicine, New York, NY
INTRODUCTION: The safety of stapled anastomoses in
resections for Crohn’s Disease (CD) has been supported by
previous studies as producing comparable if not lower anastomotic leak rates. Nevertheless, the overall rate of anastomotic complications in this cohort remains higher than for
non-CD patients. Reinforcing staple-lines by oversewing is
one method which may prevent these complications; however, the efficacy of this practice has not been established.
Fayez A. Quereshy1,2, Jensen T. Poon2, Wai-Lun Law2
1
Department of Surgical Oncology, University Health Network,
University of Toronto, Toronto, ON, Canada; 2Department of Surgery,
Queen Mary Hospital, University of Hong Kong, Hong Kong
INTRODUCTION: Stenting as a bridge to surgery has been
increasingly applied in cases of acute left-sided colonic
obstruction. This study aims to evaluate both the short and
long-term outcomes associated with colonic stenting as a
bridge to surgery in patients with obstructing adenocarcinoma of the colon.
METHODS: Patients with potentially curable acute leftsided colonic obstruction treated with stenting as a bridge
METHODS: We performed a retrospective review from to surgery (28) or with emergency surgical resection (39)
2007–2012 of all patients with Crohn’s Disease who from January 1998 to December 2008 were identified using
underwent primary ileocolic resections (ICR) with stapled a prospectively maintained database. Short-term data on
anastomoses by faculty at The Mount Sinai Hospital. Base- post-operative mortality, morbidity, necessity of intensive
line characteristics including age, length of stay, opera- care, and length of hospital stay were compared. Diseasetive approach and additional procedures (preoperative free and overall survival data were also analyzed.
abscess drainage, additional intraoperative resections) were RESULTS: Patients within the two study arms had similar
assessed. Major anastomotic complications (MACs) were demographic profiles. Patients receiving preoperative stentdefined as leak, disruption, abscess requiring drainage or ing had a higher likelihood of a laparoscopic resection (P <
reoperation within 30 days. Other postoperative complica- 0.001). Further, the emergency surgery group had a higher
tions (OPCs) were defined as ileus, obstruction resolving rate of post-operative complications (P = 0.024), rate of ICU
with conservative treatment, wound infection, pneumonia, admission (P = 0.013), and longer total length of stay (9 vs.
anastomotic hemorrhage and ureteral injury. Chi-square 12 days, P = 0.001). With a median follow-up of 26.5 and
and student’s t-test were used to determine baseline differ- 31.3 months for the stenting and surgical resection groups
ences between the groups, and a logistic regression analysis respectively, there was no difference in overall and diseasewas used to identify significant predictors of MACs.
free survival (overall survival = 30 vs 31 months, P = 0.858;
RESULTS: A total of 225 patients were studied, 119 with DFS = 13 vs 12 months, P = 0.989). As well, there was no
non-oversewn and 106 with oversewn stapled anastomoses. difference in the rate of systemic recurrences (8 vs. 13, P =
Twelve surgeons were represented. Non-oversewn and over- 0.991).
sewn groups were similar in age (34.3 vs. 35.2 years), postoperative length of stay (6.0 vs. 6.4 days), and additional
procedures (32% vs. 39.6%). More patients in the non-oversewn group underwent laparoscopic-assisted procedures
than in the oversewn group (79% vs. 45.3%, p < 0.001).
Overall complication rates (20.2% and 22.6%) and the incidence of OPCs were comparable in both groups, including similar rates of small bowel obstruction and ileus. The
incidence of MACs was significantly lower in the oversewn
group (2% vs. 13.9%, p = 0.004). There were 7 confirmed
anastomotic leaks in the non-oversewn group versus none
in the oversewn group. Multivariate analysis confirmed
that oversewing was an independent predictor of reduced
MACs (p < 0.0001) whereas approach (laparoscopic versus
open) was not.
CONCLUSION: Oversewing staple-lines in primary ileocolic resections for Crohn’s Disease may reduce the rate of
major anastomotic complications. The major anastomotic
complication rate of 2% in the oversewn group closely parallels that of non-CD patients.
180
A 30-year old healthy Ashkenazi Jewish white male presented with intermittent left upper quadrant pain and
cramping for the better part of a year. Pain was reported
to last from several hours to days and was not associated
with diet, bowel function, or activity. Physical examination
was unremarkable. Computed tomography of the abdomen and pelvis revealed pneumatosis of the left colon with
associated blebs/bullae. Subsequent colonoscopy defined
numerous submucosal blebs in his left colon extending to
the splenic flexure. Conservative management was instituted consisting of an elemental diet and 3 months of
oral Flagyl. Overall symptomology improved and repeat
sigmoidoscopic examination demonstrated a decrease in
pneumatosis cystoides coli.
CONCLUSION: Stenting as a bridge to surgery is a safe treatment strategy in the management of patients with acute
left-sided colonic obstruction with improved short-term
outcomes and comparable long-term oncologic results.
Further studies are necessary to fully address the utility of
colonic stenting as a bridge to curative surgery and to establish its definitive role as a treatment strategy
Tu1526
Pneumatosis Cystoides Coli: A Case Report and Review
of the Literature
Ambar Matta
Surgery, TriHealth, Cincinnati, OH
Pneumatosis cystoides coli is an extremely rare condition
with scattered cases reported in the literature. The etiology CT abd/pelvis images, colonosopcy findings.
is largely unknown though hypothesized to be bacterial,
pulmonary, or mechanical in origin. Management options
depend on the clinical presentation. Surgical intervention
is typically reserved for those who ultimately fail conservative management or present in a more urgent or emergent
manner.
Tuesday
Poster Abstracts
181
Tu1527
Tu1528
Colonic Stents as Bridge to Elective Surgery Versus
Emergency Surgery for Left Sided Malignant Colonic
Obstruction: A Meta-Analysis of Randomized
Controlled Trials
Construction of Permanent Ileostomy After Restorative
Proctocolectomy for Ulcerative Colitis
Munenori Nagao, Chikashi Shibata, Hitoshi Ogawa,
Sho Haneda, Shinobu Ohnuma, Hiroyuki Sasaki, Atsushi Kohyama,
Takeshi Naitoh, Koh Miura, Michiaki Unno
GI Surgery, Tohoku University, Sendai, Japan
Naga Swetha Samji1, Sudhir Duvuru1, Anupama Inaganti1,
Rajan Kanth1, Mainor R. Antillon2, Praveen K. Roy1
1
Internal Medicine, Marshfield clinic, Marshfield, WI;
2
Gastroenterology and Hepatology, Oschner Clinic, New Orleans, LA
PURPOSE: Emergency surgery is a traditional treatment
option for patients with malignant left sided colonic
obstruction which involves defunctioning stoma with or
without primary anastomosis. Colonic stenting as a bridge
to elective surgery has been proposed as an alternative
to emergency surgery. Recent randomized controlled trials have assessed the efficacy of colonic stents as a bridge
to elective surgery compared to emergency surgery in the
management of malignant colonic obstruction. We performed a meta-analysis of the RCT’s to compare the efficacy
and safety of stent compared to emergency surgery in left
sided colonic obstruction.
BACKGROUND: Restorative proctocolectomy with ilealpouch anal (canal) anastomosis (IA (C) A) is the standard procedure for ulcerative colitis (UC). However, some patients
require permanent ileostomy because of some complications
after IAA.
AIM: The aim of this study was to clarify the incidence and
clinical feature of the patients who necessitated permanent
ileostomy after IAA for UC.
METHODS: Medical records of the patients who underwent permanent ileostomy after IAA for UC were reviewed
retrospectively. There were 251 patients who underwent
IAA in our department since 1987, and 11 patients (4.4%)
necessitated permanent ileosotomy therafater. We compared backgrounds between patients who required permanent ileostomy (N = 11; ileostomy group) and those who
did not (N = 240; control group). Patients in ileostomy
group were divided into 3 subgroups based on indications
for constructing ileostomy; intractable anal or ano-vaginal
fistula (Group A, N = 4), stricture of IAA (Group B, N = 4),
and severe fecal incontinence (Group C, N = 3). We compared clinical features among these 3 subgroups.
METHODS: Cochrane Central Register of Controlled Trials & Database of Systematic Reviews, PubMed, and recent
abstracts from major conference proceedings were searched
(through 11/12).All the studies assessing the efficacy of
colonic stent as a bridge to elective surgery compared to
emergency surgery are included. Standard forms were
used to extract data by two independent reviewers. Data
regarding the following outcomes were extracted-number
of primary anastomosis, overall stoma rate, success rate, RESULTS: There were no differences between ileostomy
complication rate, infection rate, number of patients with and control groups in the age undergoing IAA, the mean
period from diagnosis as UC to surgical treatment, indianastomosis leakage and mortality rate.
RESULTS: Seven studies met the inclusion criteria (n cation for surgical treatment, severity and spread of UC.
= 341). Mean age ranged from 62–74 yrs. Studies were (Thus, no specific background was found for patients
reported from China, UK, Spain, Singapore, France, Neth- requiring permanent ileostomy after IAA.) The mean age
erlands. Colon stents used were Wallflex of 25 mm and (range) undergoing IAA in group A, B, and C was 25 (17–
Wallstent of 22 mm diameter. All patients had malignant 36), 37 (21–48), and 48 (29–66), respectively. The mean
left sided colon obstruction. Success rate (defined as clinical time interval (range) bewteen the closure of temporary covrelief of obstruction) was higher in surgery group compared ering ileostomy and contruction of permanent ileostomy
to stent group (OR 18.8 95% CI 6.15–57.89, p < 0.0001). in group A, B, and C was 9.5 (3–23 years), 5.8 (2 months—9
Primary anastomosis rate was significantly higher in stent years), and 2.3 (1 month—5 years) years, respectively. Thus
group compared to emergency surgery group (OR 2.8 95% patients who required permanent ileostomy because of fisCI 1.6–4.7, p = 0.0001). Overall stoma rate was lower in tula tended to undergo IAA at relatively young age and had
stent group (OR 0.39 95% CI 0.19–0.8, p = 0.01). Overall long time interval, while those who necessitated permanent
complication rate was significantly lower in stent group ileostomy because of fecal incontinence tended to undergo
compared to surgery group (OR 0.30 95% CI 0.12–0.72, p = IAA at relatively old age and had short time interval.
0.007). There was no significant decrease in infection rate CONCLUSIONS: These results indicate that, in patients
in stent group compared to surgery group (OR 0.54 95% necessitating permanent ileostomy after IAA for UC, the
0.24–1.19, p = 0.12). There was no significant difference surgical indication for permanent ileostomy was associated
in anastomosis leak between two groups (OR 0.73 95% CI- with age undergoing IAA and time interval between the
0.18–2.9, p = 0.67). No significant difference in mortality closure of temporary ileostomy and the contruction of perrate observed between two groups (OR 0.95 95% CI-0.41–
manent ileostomy. The Long term follow-up is important,
2.18, p = 0.91).
because some patients required permanent ileostomy over
CONCLUSION: Success rate (relief of obstruction) was 20 years after restorative proctocolectomy for UC.
higher in emergency surgery group compared to stent
group. Primary anastomosis rate, overall stoma rate and
complication rate was lower in stent group compared to
surgery group. There was no significant difference in infection rate, anastomosis leak and mortality rate in between
the two groups.
182
Tu1529
Tu1531
Stapled Loop Ileostomy Closure: Does Stapler Length
Matter?
Anoscopic Surveillance to Prevent Malignant
Progression of Anal Intraepithelial Neoplasia in HIV
Patients: Is a Simple Approach Effective?
Rahul Narang, Sudhir Kalaskar, Hoong-Yin Chong,
Rama Ganga, Giovanna Da Silva, Steven Wexner, Eric G. Weiss
Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
Harkanwar S. Gill1, Juan Poggio1, Andrew Raissis1,
Jeffrey M. Jacobson2, David E. Stein1
1
PURPOSE: Complications have been reported following Division of Colorectal Surgery, Drexel University College of Medicine,
loop both sutured and stapled loop ileostomy closure; any Philadelphia, PA; 2Infectious Disease, Internal Medicine, Drexel
association between linear cutting stapler (LCS) length and University College of Medicine, Philadelphia, PA
postoperative complications remains unclear. Therefore, PURPOSE: The incidence of Anal Intraepithelial Neoplasia
the aim of this study was to compare the outcomes of sta- (AIN) has risen in HIV patients, and places those patients
pled loop ileostomy closure performed with different LCS at risk for the development of anal cancer. The gold stanlengths.
dard for surveillance and therapy is unclear. The aim of this
METHODS: Medical records of consecutive patients who
underwent stapled loop ileostomy closure from 2006 to
2012 were reviewed from an IRB-approved database. Three
different LCS lengths were evaluated: 55, 75, and 100 mm.
Method of common enterotomy closure, LCS staple height,
pre-operative steroid use, index operative time and method
of access (laparotomy or laparoscopy), and duration of time
from the index operation to ileostomy closure were evaluated. Outcome measures included complications, resolution
of ileus (defined by passage of flatus and bowel movement
with toleration of a diet) and length of hospitalization. Univariate and multivariate analyses were performed.
study was to determine whether physical examination with
anoscopic surveillance in HIV patients diagnosed with AIN
is effective at preventing progression to anal cancer.
METHOD: A retrospective review of HIV positive patients
with AIN, treated with excision and fulguration, was conducted between 2006 through 2012 at our institution. Only
patients with at least one year follow up from index evaluation, documented physical examination and anoscopy
findings, and pathology were included for analysis.
RESULTS: Thirty six patients met inclusion criteria. The
mean age was 41.2 yrs and mean follow up was 30.2 months
(12–65 months). 15 patients (41.6%) had AIN I, 10 (27.7%)
RESULTS: 350 patients (55% males) of a mean age of 46 had AIN II and 11 (30.5%) had AIN III. 26 patients (72.2%)
(15–89) years were included. LCS anastomosis was per- had repeat procedures. Four patients (11.1%) progressed
formed using 55 mm in 20%, 75 mm in 50%, and 100 mm from low grade to high-grade intraepithelial neoplasia (AIN
in 30% of patients. The common apical enterotomy was III). One patient (2.7%) with AIN III developed invasive
closed with a LCS, linear stapler (TA) or sutures. Per sur- carcinoma while under surveillance, and was successfully
geons’ preference, the stapler cartridge was blue (2.5 mm treated with chemoradiation. Complications were seen in
thickness) in 60% and green (3.8 mm thickness) in 40% of two patients (5.5%).
patients. The overall complication rate was 24%, including
postoperative ileus 17% (n = 59), wound infection 5% (n = CONCLUSION: Physical examination with routine anos17), and anastomotic leak 1% (n = 5). LCS length was not copy is a simple, safe and effective method for AIN surveilassociated with ileus (p = 0.49), however patients in whom lance. The progression rates to anal cancer in this cohort
the 100 mm LCS was used had an average one day earlier (2.7%) were compared with those published in high-resoluresolution of ileus: postoperative day (POD) 2 vs 3 (range tion anoscopy surveillance programs (<2%). This is a sim2 to 15) days, p = 0.02) and one day shorter hospitaliza- ple approach that does not require specialized equipment.
tion: (POD 3 (range 2 to 33 days), p = 0.04). Incidences Randomized trials with longer follow up are required before
of post-operative complications did not differ according to a standard can be set.
LCS length when evaluating patients BMI (p = .81), preoperative steroid use (p = 0.92), staple height (p = .74), or
method for common enterotomy closure (p = 0.99). There
were no differences between ileus resolution or length of
hospitalization and operative time for either the index procedure or the ilesotomy closure or index operation method
of access.
183
Tuesday
Poster Abstracts
CONCLUSIONS: The 100-mm LCS was associated with
more rapid resolution of ileus and a shorter duration of hospitalization than were the 55 mm or 75 mm LCSs.
Tu1532
Emergency Department Presentation, Admission and
Surgical Intervention for Colonic Diverticulitis
Eric B. Schneider1, Aparajita Singh2, Shalini Selvarajah1,
Jonathan E. Efron1, Anne O. Lidor1
1
Surgery, Johns Hopkins University School of Medicine, Baltimore, MD;
2
Gastroenterology, University of California, San Francisco,
San Francisco, CA
BACKGROUND: Most previous population-based studies
of diverticulitis are limited to patients aged 65 years and
older. Using a nationally representative sample of emergency department (ED) visits, we sought to describe ED presentation and outcomes among patients of all ages with a
primary diagnosis of diverticulitis.
METHODS: In a retrospective cross-sectional study, the
2009 Nationwide Emergency Department Sample was queried and patients presenting with a primary diagnosis of
colonic diverticulitis were isolated. Demographic variables
admission to inpatient status and surgical intervention
were compared between patients younger than 65 vs. those
65 or older. Standard descriptive statistical analyses were
used and multivariable logistic regression models controlling for gender examined inpatient admission. Unadjusted
logistic regression stratified by gender examined surgical
intervention.
RESULTS: A total of 28,861,047 ED visits were examined,
of which 67,697 (0.23%) occurred among patients with primary colonic diverticulitis. The median age of ED patients
was 57 years and female patients were older than males:
61.5 vs. 53.7 years of age, respectively (p < 0.001). The
majority of patients, 43,859 (64.8%) were under 65. Patient
gender distribution differed significantly between the two
age groups with 49.5% of patients under 65 being female
vs. 68.5% among those 65 or older (p < 0.001). Overall,
36,840 (54.4%) patients were admitted to inpatient status
with older patients more likely to be admitted than those
under age 65 (64.7% vs. 48.8% respectively, p < 0.001).
3,816 patients underwent colon resection, representing
10.45% of admitted inpatients or 5.6% of all ED patients.
There was no difference between the proportions of
younger and older inpatients undergoing surgical resection
(10.5% vs. 10.2% respectively, p = 0.368). Overall, sigmoid
colectomy (73.4%) and left hemi-colectomy (16.7%) were
the most common procedures. In multivariable analysis,
the odds of inpatient admission was higher among older
patients (OR 1.90, 95% CI 1.84–1.97) and, females (OR
1.05, 95% CI 1.02–1.09). In unadjusted analysis of admitted
inpatients stratified by gender, older males demonstrated
similar odds of surgical resection compared with younger
males (OR 0.93 95% CI 0.83–1.03); however, older females
demonstrated 24% increased odds of resection compared
with those younger than 65 (OR 1.24 95% CI 1.13–1.36).
CONCLUSION: Nearly two-thirds of patients presenting
for ED treatment of colonic diverticulitis were under age
65. Just over half of all ED patients were admitted to inpatient care, and approximately 6% of all ED visits for diverticulitis resulted in colectomy. Older women demonstrated
increased odds of surgical resection compared with their
younger counterparts. There was no difference in the odds
of resection across age groups in men.
Tu1533
Potential Factors Associated with the De Novo
Development of Crohn’s Disease of the Small Intestine
in Ulcerative Colitis Patients Undergoing Ileoanal
Pouch
Peng Du1, Bo Shen2
Colorectal Surgery, Cleveland Clinic, Cleveland, OH; 2Department of
Astroenterology/Hepatology, Cleveland Clinic, Cleveland, OH
1
BACKGROUND: While the majority of ulcerative colitis
(UC) patients who undergo total proctocolectomy (TPC)
with ileal pouch-anal anastomosis (IPAA) have favorable
outcomes, a proportion may subsequently develop Crohn’s
disease of the pouch or small intestine de novo that persists even after a permanent ileostomy. The aim of the
study is to evaluate potential factors associated with the de
novo development of CD of the small intestine proximal
to an ileostomy created for pouch failure in patients who
undergo IPAA.
184
METHODS: UC patients who underwent TPC/IPAA and
subsequent long-term/permanent ileostomy (secondary
ileostomy) creation for a failed ileal pouch were compared
to those who underwent TPC/end ileostomy (primary ileostomy). A total of 123 eligible patients were identified from
our Pouch Registry (primary ileostomy group, N = 57 and
secondary ileostomy group, N = 66). Demographic and
clinical variables were compared. Outcomes including the
development of CD, non-CD related strictures, the requirement of the use of CD-related medications, ileostomyassociated hospitalization, ileostomy failure with stoma
revision or relocation, and short-gut syndrome were compared. Step-wise logistic regression models were used.
RESULTS: The median follow-up for the cohort was 5
(range: 2.0–8.0) years. Eighteen pre-stoma factors were compared between the secondary ileostomy and the primary
ileostomy groups. Younger age at diagnosis and surgery of
UC, family history of IBD, extensive UC, toxic megacolon/
fulminant colitis, preoperative symptom of severe diarrhea
(more than 10 times per day), preoperative anti-TNF biological therapy, arthralgia/arthropathy, and staged surgery
were more common in patients who underwent secondary
ileostomy after a failed pouch, than those in the primary
ileostomy group (p < 0.05). There were no differences in
smoking, body mass index, preoperative steroid/immunomodulators use, preoperative history of anemia/blood
transfusion, duration from UC diagnosis to colectomy,
and indication of colectomy (refractory UC vs. neoplasia)
between the two groups (p > 0.05). Adverse outcomes in
both groups are listed in Table 1. Risk factors for de novo
small bowel CD on logistic regression model are listed in
Table 2.
Table 1: Postoperative Outcomes Statistics: Secondary vs. Primary
Ileostomies
Variables
De novo small bowel
CD
CD-related stricture
Non-CD-related
stricture
Stoma relocation/
revision
Postoperative steroid
use
Postoperative
immunomodulator use
Postoperative
anti-TNF biological
therapy
Parastomal hernia
Stoma prolapse
Small bowel
obstruction
Small bowel resection/
stricturoplasty for
strictures
Short-gut syndrome
Postoperative TPN
use
Ileostomy-associated
hospitalization
Post-enterocutaneous
fistula
All cases
(N = 123)
35
Secondary
Ileostomy
Group (N = 66)
30 (45.5%)
Primary
Ileostomy
Group (N = 57) P Value
5 (8.8%)
<0.001
28
15
23 (34.8%)
13 (19.7%)
5 (8.8%)
2 (3.5%)
0.001
0.006
19
15 (22.7%)
4 (7.0%)
0.016
9
8 (12.1%)
1 (1.8%)
0.037
12
11 (16.7%)
1 (1.8%)
0.005
12
10 (15.2%)
2 (3.5%)
0.030
19
8
37
14 (21.2%)
6 (9.1%)
32 (48.5%)
5 (8.8%)
2 (3.5%)
5 (8.8%)
0.057
0.284
<0.001
40
32 (48.5%)
8 (14.0%)
<0.001
4
10
3 (4.5%)
8 (12.1%)
1 (1.8%)
2 (3.5%)
0.623
0.104
47
38 (57.6%)
9 (15.8%)
<0.001
9
6 (9.1%)
3 (5.3%)
0.502
CONCLUSIONS: Some patients with underlying UC who
develop pouch failure develop CD of the small intestine
that might indicate or contribute to an ileostomy. Knowl- Table 2: Risk Factors for De Novo CD in Patients with Primary Ileostomy
edge of the factors associated with development of CD after or Secondary Ileostomy: Multivariable Logistic Analysis
IPAA may allow for an informed choice when evaluating
95% Confidence
patients for IPAA vs. TPC/EI.
Variables
Secondary ileostomy
Family history of IBD
History of preoperative
weight loss
Age at surgery
Age at diagnosis of UC
History of preoperative
transfusion
N
30 (85.7%)
23 (65.7%)
17 (51.5%)
Odds Ratio
8.229
9.144
3.716
Interval
2.432–27.845
3.133–26.688
1.232–11.209
P Value
0.001
<0.001
0.020
123
123
11 (31.4%)
0.986
0.974
2.806
0.951–1.022
0.937–1.012
0.768–10.260
0.450
0.178
0.119
Tuesday
Poster Abstracts
185
Tu1534
RESULTS: A total of 73,516 CR pts were identified; the
breakdown as per BMI was UN, 2,180, 3%; NO, 67,732,
Morbidity and Outcomes of Colorectal Surgery in the
92%; MO, 3,604, 4.9%. In the UN group there is a signifiUnderweight Population: Results from the American
cantly higher proportion of colitis/enteritis pts (UN 20.4%,
NO 9%, MO 5.2%) and obstruction/volvulus pts (UN 8.3%,
College of Surgeons National Surgical Quality
NO 3.3%, MO 2.5%) as well as a much lower proportion of
Improvement Program (ACSNSQIP) Database
diverticulitis cases (UN 8.4%, NO 21.1%, MO 23.4%). The
Rebecca Rhee, Hiromichi Miyagaki, Xiaohong Yan,
percent of UN cancer pts (44%) was modestly but signifiM.C. Shantha Kumara H., Linda Njoh, Vesna Cekic,
cantly lower than the NO (47%) or MO (47.6%) groups yet
Richard L. Whelan
the UN group had more disseminated cases. More UN pts
Surgery, St. Luke’s Roosevelt Hospital, New York, NY
reported weight loss (21.6%) than in the NO (4.7%) or MO
PURPOSE: Whereas, the impact of morbid obesity on (1.7%) groups. Also, more UN pts (13.6%) were on steroids
colorectal resection (CR) outcomes has been studied, there (vs NO, 6.1%; MO, 4.5%, p < 0.05). Finally, the UN group
is limited data concerning CR outcomes in the underweight had a significantly lower mean albumin level and hematopopulation (BMI < 18.5). This study’s goal was to assess the crit. Significantly fewer UN CR’s were done using laparounderweight population (UN) that comes to CR and CR- scopic (LAP) methods than in the other groups (UN 34%,
NO 45%, MO 39%). There were also more total colectomies
related morbidity.
and Hartman’s procedures in UN group (p < 0.05). There
METHODS: The ACS NSQIP database was queried from were significantly more complications in the underweight
2005–2010 for the CR codes. Patients (pts) who, preopera- group (UN) (20.4%) than in the NO group (15.6%), yet,
tively (preop), were ventilator dependent, ASA 5, hypoten- there was no difference between the UN and MO groups
sive, had SIRS, sepsis, and emergent surgery were excluded. (20.1%). The UN group’s rate of transfusions, sepsis, and
Pts were divided into 3 BMI groups: UN, BMI < 18.5; Nor- reoperations were higher than noted in the NO group. Of
mal/Obese (NO), BMI ≥ 18.5 to ≤40; and morbidly obese note, there were significantly fewer superficial surgical site
(MO), BMI > 40. Demographic parameters were assessed as wound infections in the UN vs the other 2 groups (UN
well as surgical indications, comorbidities, preop laboratory 5.6%, NO 8.1%, MO 16%).
data, and complications (including surgical site infections
(SSI), transfusions, reoperation, etc). The statistical meth- CONCLUSIONS: The complication rate was notably higher
ods used were two sample for population proportions for in the UN group which may be related to the higher incicategorical variables and Wilcoxon rank sum tests for con- dence of colitis and obstruction cases and the greater percentage of pts with weight loss and steroid use all of which
tinuous variables.
are associated with high complication rates. Diverticulitis
is rare in UN pts. For unclear reasons laparoscopic methods
were used less often in the UN group.
Gender
Age
Indication
UN vs. NO
P Value
<.0001
0.0034
UN vs. MO
P Value
0.00016
<.0001
1716
497
843
187
90
10
21
240
0.0071
<.0001
<.0001
<.0001
<.0001
<.0001
n.s.
0.0083
<.0001
<.0001
<.0001
<.0001
<.0001
n.s.
569
161
63
93
<.0001
<.0001
<.0001
n.s.
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
n.s.
<.0001
UN (n = 2180)
700/ 1480
62 (16–90)
NO (n = 67732)
33712/ 34020
63 (19–90)
MO (n = 3604)
1334/ 2270
58 (16–90)
Malignant Neoplasm
Benign Neoplasm
Diverticular Disease
Colitis/enteritis
Obstruction/voluvulus
Rectal Prolapse
Perforation/ hemorrhage
Other Benign Disease
960
169
183
444
180
68
13
163
31805
8494
14283
6092
2208
861
254
3735
Current smoker
Steroid intake
Weight loss in last 6 mo
Disseminated cancer
630
297
470
124
11950
4134
3206
2548
Male/Female
Median (range)
Comorbidities
Preoperative data
Hematocrit (Mean ± SD)
35.8 ± 5.3
38.3 ± 5.4
38.1 ± 5.3
Albumin (Mean ± SD)
3.5 ± 0.8
3.8 ± 0.6
3.7 ± 0.6
UN; underweight group (BMI <18.5), NO; Normal/Obese (BMI 18.5 to 40), MO; morbidly obese (BMI > 40), n.s.; not significant
186
UN (n = 2180)
NO (n = 67732)
MO (n = 3604)
UN vs. NO
P value
UN vs. MO
P value
742
2
231
95
1197
436
30682
118
5891
1877
44214
11217
1409
7
242
106
2472
595
<0.0001
n.s.
0.0020
<0.0001
n.s.
<0.0001
<0.0001
n.s.
<0.0001
0.0044
n.s.
0.0008
219
4415
182
<0.0001
<0.0001
Surgical Procedure
Laparoscopic Surgery
Abdominoperinial Resection
Coloproctectomy
Hartmann Procedure
Partial colectomy
Partial colectomy with removal
of terminal ileum
Total colectomy
Complications
Major complication
445
10539
723
<.0001
n.s.
Re-operation
156
3521
227
<.0001
n.s.
Superficial SSI
121
5464
578
<.0001
<.0001
Bleeding/Transfusions
81
1545
95
<.0001
0.0203
Sepsis
116
2639
195
0.0008
n.s.
Septic Shock
45
1026
81
0.0394
n.s.
UN; underweight group (BMI <18.5), NO; Normal/Obese (BMI 18.5 to 40), MO; morbidly obese (BMI > 40), n.s.; not significant, SSI; surgical site infections
Tu1535
Endoscopic Ultrasound Staging of Stenotic Esophageal
Cancers May Be Unnecessary to Determine the Need for
Neoadjuvant Therapy
Stephanie G. Worrell, Daniel S. OH, Christina L. Greene,
Steven R. Demeester, Jeffrey A. Hagen
Keck School of Medicine of Univeristy of Southern California,
Los Angeles, CA
INTRODUCTION: Endoscopic ultrasound (EUS) is an
essential component of pre-operative staging for esophageal cancer. EUS is used to determine which patients should
have primary endoscopic or surgical therapy and which
should have neoadjuvant therapy prior to resection. However, when the EUS endoscope cannot traverse a tumor, the
role of pre-dilatation is controversial. Esophageal dilation of
malignant strictures is associated with potential complications including perforation in 15% of cases. The aim of this
study was to determine the pathologic stage of esophageal
cancer treated by primary surgery without induction therapy when the EUS endoscope could not pass. We hypothesized that when the EUS endoscope cannot traverse the
tumor, locally advanced disease (stage III) is present, and
these patients should proceed to neoadjuvant therapy without the need for pre-dilatation and EUS staging.
187
Tuesday
Poster Abstracts
RESULTS: A total of 27 patients (22 male: 5 female) had
a tumor that would not accommodate the EUS endoscope
and proceeded directly to esophagectomy without induction therapy. The histology was adenocarcinoma in all
patients. The stages of the patients are shown [Table]. The
majority of tumors were T3 (24/27, 89%) and the median
number of metastatic nodes was 6. There were no stage I
tumors, 15% (4/27) were stage II, 81% (22/27) were stage
III, and 4% (1/27) were stage IV due to a resected solitary
METHODS: A retrospective single-institution review was lung metastasis.
conducted of all patients with esophageal cancer under- CONCLUSION: Tumors that cannot be assessed with an
going esophagectomy from August 1988 to June 2012. EUS endoscope due to tumor stenosis will have locally
Patients who received neoadjuvant therapy were excluded. advanced disease that could benefit from neoadjuvant therThe EUS reports were reviewed to determine which patients apy in 85% of cases. In these situations, pre-dilatation of
had a tumor that could not accommodate an EUS endo- the tumor with EUS staging could be omitted when considscope, and the patients who then proceeded directly to ering the risk of potential complications, such as esophaesophagectomy were included for analysis. The pathology geal perforation.
results of these patients were classified based on the revised
7th edition AJCC staging system.
Tu1536
Jackhammer Esophagus in High Resolution
Manometry: Clinical Features and Surgical Implications
Michal J. Lada, Dylan R. Nieman, Michelle S. Han,
Poochong Timratana, Christian G. Peyre, Carolyn E. Jones,
University of Rochester Medical Center, Rochester, NY
INTRODUCTION: The clinical significance of Jackhammer Esophagus, an uncommon esophageal motility disorder characterized by repetitive high amplitude esophageal
contractions, is unclear. It has been increasingly identified
since the introduction of High Resolution Manometry. This
study assessed the clinical features and surgical implications of a diagnosis of Jackhammer Esophagus (JE) via High
Resolution Manometry (HRM).
CONCLUSIONS: Jackhammer esophagus is an uncommon
motility disorder diagnosed in 3.5% of patients with esophageal symptoms. Afflicted patients are predominantly female
and present with chest pain, likely owing to the intensity
of the esophageal contractions. Patients with isolated JE are
managed medically with a constellation of agents including
METHODS: The clinical records and HRM data of 1216 CCBs and nitrates. For patients with JE and concomitant
consecutive patients undergoing HRM between 12/2009 reflux or hiatal hernia, Nissen Fundoplication is an effective
and 9/2012 were reviewed. Patients with previous foregut treatment regardless of the motility findings.
surgery, classic achalasia and distal esophageal spasm were
excluded. Jackhammer esophagus was defined according Tu1537
to the most recent Chicago Classification as ≥1 swallow
with distal contractile integral (DCI) > 8000 mmHg*cm*s. Is Gastric Decompression Necessary for Patient
HRM variables were compared with 35 normal volunteers Receiving Esophagectomy and Gastric Transposition?
via Mann-Whitney U-Test for non-parametric univariate Yang Hu
analysis.
Department of Thoracic Surgery, West China Hospital, Sichuan
RESULTS: Forty-two patients (3.5%) met HRM criteria for University, Chengdu, China
JE, 71% were female with a mean age 59.0 r11.8 years. The BACKGROUND: Gastric decompression (GD) after esophmost common presenting symptoms were chest pain (30%), agectomy and gastric transposition could drainage the gasheartburn (14%) and dysphagia (14%). Other less common tric juice and air retented in intrathoracic stomach, thus
symptoms included regurgitation, abdominal pain, nausea, could prevent the dilation of the stomach, reduce anastocough and shortness of breath. Compared with 35 healthy motic tension and extenuate gastroesophageal regurgitavolunteers, patients with JE not only had significantly ele- tion (GER). Theoretically, this could benefit the healing
vated DCI, but also higher mean lower esophageal sphincter of anastomosis. So GD is routinely used in patients with
resting pressure, intrabolus pressure and integrated relax- esophageal cancer after operation. But is GD really necesation pressure (IRP), (Table). The median number of indi- sary? The dilation of intrathoracic stomach could be previdual swallows with DCI > 8000 mmHg*cm*s per patient vented by gastric tube and a new measure named stomach
was 3.5 (IQR 2.0–6.0). Overall, the IRP was normal in 23 embedment. Moreover, the postoperative volume of gas(55%) and elevated in 19 (45%). An elevated IRP and/or tric decompression is usually less than 300 ml/d, however
positive pH study, suggestive of JE being a secondary motil- the volumn of gastric juice production is about 2L/d. We
ity disorder, was present in 27 of 42 patients. Hiatal Hernia thought this trivial 300 ml fluid might won’t cause severe
(HH), identified endoscopically, was present in 18 patients GER even it hadn’t been drainaged. So GD might be no lon(43%). Abnormal esophageal acid exposure was found in 12 ger essential for surgical patients with esophageal cancer.
patients of whom 4 had elevated IRP (range 18.2–19.8). Of The aim of this study is to confirm this presumption.
the 33 patients treated medically, 30 were trialed on combinations of calcium channel blockers (CCB), nitrates or METHODS: Totally 147 patient were enrolled in this
proton-pump inhibitors (PPI) and 3 received Botox. Eight study. All patient received esophagectomy and gastric tube
patients underwent Nissen Fundoplication ± hiatal hernia reconstruction. After anastomosis, intrathoracic stomach
repair and 1 patient underwent a distal myotomy. Com- was embedded into posterior mediastinum with a medical
plete resolution of chest pain or heartburn was encountered sealant glue. This glue could fix stomach with the organ
in all post-surgical patients, with a median follow-up of 20 surround it and therefore can prevent the dilation of the
stomach. Patient were randomly divided into GD group
days (range 14–364).
and non-gastric decompression group (NGD). Nasogastric
tube was inserted in operation for patient in GD group, and
removed 4 days after operation. However 4 patients in GD
group failed to insert nasogastric tube then be reassigned to
NGD group. Finally we got 72 patient in GD group and 75
patient in NGD group.
188
Indices compared between groups include Overall experience score (OES, with a 1–10 score system on the 3rd day
after operation), maximum transverse diameter of intrathoracic stomach (MTD, with CT, at the level of inferior pulmonary vein on the 3rd day after operation), severity of GER
(with a GER symptom questionnaire on the 3rd day after
operation), the need for insert/reinsert nasogastric tube
after operation, the application of stomach dynamic medicine, pneumonia, anastomostic leakage and postoperative
hospital stay.
RESULTS: No difference was found between groups in any
index except for the OES. When stratified analysis accord-
ing surgical incision was performed, the OES in NGD group
was significant better than that in GD group (p < 0.05).
This outcome indicate that GD couldn’t extenuate GER,
prevent the dilation of the stomach, reduce complication
rate, shorten hospital stay. On the contrary, it diminish the
short-term postoperative life quality.
CONCLUSIONS: GD is no longer necessary for patient
receiving esophagectomy and gastric transposition after the
application of gastric tube and stomach embedment. We
don’t need to consider GD as a routine for patient who is
not in high risk of anstomostic leakage.
Indices Between Groups
Age
Gender (M/F)
Tumor Location (medien/lower)
TNM Staging
(0/I/II/III)
Overall Experience Score
Sweet procedure group
Ivor-Lewis procedure group
Maximum Transverse Diameter of Intrathoracic Stomach (cm)
Severity of Gastroesophageal Reflux (0/1/2)
Need for Insert/Reinsert Nasogastric Tube (n)
Application of Stomach Dynamic Medicine (n)
Pneumonia (n)
Anastomostic Leakage (n)
Postoperative Hospital Stay (d)
GD Group
62.2 ± 7.5
66/6
47/25
3/7/27/35
NGD Group
64.7 ± 5.9
68/7
52/23
2/9/31/33
p Value
0.782
0.831
0.725
0.859
n = 43
6.2 ± 2.6
n = 41
7.5 ± 2.4
<0.001
n = 29
6.1 ± 3.1
n = 34
7.2 ± 3.5
0.001
n = 43
n = 29
7.5 ± 2.1
8.1 ± 2.5
n = 41
n = 34
7.7 ± 1.8
8.2 ± 2.1
0.135
0.398
n = 43
n = 29
40/3/0
26/3/0
n = 41
n = 34
38/3/0
30 /4/0
1.000
1.000
n = 43
n = 29
1
2
n = 41
n = 34
0
1
1.000
0.590
n = 43
n = 29
5
5
n = 41
n = 34
6
5
0.754
1.000
n = 43
n = 29
1
0
n = 41
n = 34
1
1
1.000
1.000
n = 43
n = 29
0
0
n = 41
n = 34
0
0
—
—
n = 43
n = 29
10.3 ± 1.8
11.0 ± 2.7
n = 41
n = 34
10.5 ± 2.3
11.4 ± 2.1
0.691
0.295
Tuesday
Poster Abstracts
189
Tu1538
Toward Improved Staging of Esophageal
Adenocarcinoma in the Era of Neoadjuvant
Chemotherapy: Lymph Node Harvest and Lymph
Node Positivity Ratio Provide Better Survival Models
Dylan R. Nieman, Michal J. Lada, Michelle S. Han,
Poochong Timratana, Christian G. Peyre, Carolyn E. Jones,
Department of Surgery, University of Rochester, Rochester, NY
INTRODUCTION: As pre-operative chemoradiation followed by esophagectomy has become standard therapy in
patients with resectable esophageal adenocarcinoma (EAC),
traditional pathological staging has become a less useful prognostic tool. The 7th edition of the American Joint
Commission on Cancer (AJCC7) staging system for EAC is
derived from data on patients undergoing esophagectomy
without neoadjuvant therapy and classifies lymph node
status by the number of involved lymph nodes. Lymph
node harvest (LNH) and lymph node positivity ratio (LNPR)
have been suggested to be prognostic indicators but have
not found widespread support. In an effort to develop a
valid staging model in the era of neoadjuvant therapy, we
compared the predictive value of LNH and LNPR to AJCC7
staging in a large cohort of patients undergoing resection CONCLUSION: For patients receiving neoadjuvant therfor EAC.
apy, both LNH and LNPR are more predictive of survival
METHODS: The study population consisted of 316 patients than the number of lymph node metastases detected in
who underwent R0 esophagectomy for EAC from 1/00 to esophagectomy specimens. A minimum LNH of 15 is nec12/11 (86% male; mean age 64.0 ± 10.3 years). Survival essary to establish reliable N0 staging in this cohort.
functions were estimated using the Kaplan-Meier method.
Classification thresholds for both LNPR and LNH were Tu1539
derived by recursive partitioning using conditional inference trees comparing survival functions. Based on these What Is the Optimal Time to Measure Lower
analyses, LNPR was stratified and Cox proportional hazards Esophageal Sphincter Parameters in High Resolution
regression models were used to compare predictive value of Impedance Manometry?
lymph node categorization strata.
Michelle S. Han, Dylan R. Nieman, Michal J. Lada,
RESULTS: Median lymph node harvest was 12 (IQR 7–20). Poochong Timratana, Christian G. Peyre, Carolyn E. Jones,
51% of patients were N0, 29% N1, 13% N2. Median overall Thomas J. Watson, Jeffrey H. Peters
survival was 63.4 months (95% CI 40.6–92.3) and 5-year Surgery, University of Rochester Medical Center, Rochester, NY
overall survival was 50.7% (95% CI 45.0–57.2). Eighty-three INTRODUCTION: Resting parameters of the lower esophpatients (26%) received neoadjuvant chemotherapy, radia- ageal sphincter are customarily measured in a “landmark”
tion therapy or both. In patients who received neoadju- frame at the onset of a high resolution impedance motilvant therapy and had no lymph node metastasis identified ity (HRIM) study. We hypothesized that measurement at
(40/83; 48%), recursive partitioning analysis yielded a LNH the completion of the study may give more representative
threshold of 15 for discrimination of survival functions. values. We assessed the utility of a dual-landmark frame
LNH ≥ 15 was associated with a significant survival advan- approach in HRIM interpretation and its effect on patient
tage (3-year survival 95 vs. 38%; p = 0.000022). Similarly, diagnostic classification.
recursive partitioning analysis yielded LNPR categories of
less than 20%, 20–40%, or greater than 40% as significantly METHODS: 50 consecutive HRIM studies were analyzed
discriminant of survival functions. In patients who received independently by 4 experienced esophageal fellows. The
neoadjuvant therapy, LNPR was more predictive of survival overall and intra-abdominal length of the lower esophathan number of positive lymph nodes as categorized by geal sphincter (LES), mean LES resting pressure (LESP), inteAJCC7 (p = 0.00018 vs. 0.033). In the 256 patients who grated relaxation pressure (IRP), intra-bolus pressure (IBP),
received no neoadjuvant therapy, LNH was not a significant mean upper esophageal sphincter pressure (UESP), and Chipredictor of survival after node negative resection, although cago Classification diagnoses were recorded for each HRIM
LNPR was a stronger predictor of survival than the current reading. Each of these parameters was measured using the
conventional method of a landmark frame at the onset of
nodal staging system (p-value 0.000015 vs. 0.05).
190
the study and again using a similar 30-second frame at the
end of the 10-swallow study. Previous data have shown
excellent intra-class correlation coefficients among these 4
readers for HRIM parameters, EGJ diagnosis and esophageal
body diagnosis. Wilcoxon signed-rank test was used to analyze the concordance of the measurements based on the
early or late landmark frames.
Tu1540
Prognostic Factors After Esophagectomy for Squamous
Cell Carcinoma of the Esophagus: Does Tumor Location
Matter?
Tsz Ting Law1, Kwan Kit Chan1, Daniel Tong1, Fion S. Chan1,
Wai Ho Wong1, Lai Wan Dora Kwong2, Simon Law1
RESULTS: There were no differences in LES overall length, 1Surgery, University of Hong Kong, Hong Kong, Hong Kong; 2Clinical
intra-abdominal length, IBP or IRP comparing early vs. late Oncology, University of Hong Kong, Hong Kong, Hong Kong
landmark measurement. Both lower and upper esophageal
sphincter resting pressure were significantly lower when OBJECTIVE: To compare the clinicopathological features
measured at the end of the study (Table). These findings and prognostic factors of supracarinal esophageal cancer
resulted in re-classification of LESP in 12% of studies, 3 each versus infracarinal tumors.
from hypertensive LES to normal and normal to hypoten- BACKGROUND: Supracarinal tumor location is presumed
sive. In 8% (n = 4), IRP measurement changed from normal to have worse prognosis because of unfavorable anatomy
(<14.7 mmHg) to abnormal, reflecting functional outflow for surgical resection, and more difficulty in achieving negobstruction. Manometric evidence of a hiatal hernia that ative lateral as well as proximal margins. With increasing
was present in an early landmark frame was not seen in the use of neoadjuvant therapies however, the impact of tumor
location may be lessened and this has not been adequately
late landmark frame in 14%.
studied.
High Resolution Impedance Manometry Diagnostic Variables,
METHODS: From January 1990 to December 2011, 1130
Dual-Landmark Frame Approach
patients with esophageal cancer underwent resection, 668
Difference
(59.1%) of whom with intrathoracic squamous cell carciDiagnostic Variable
(Mean)
95% CI
P-value*
nomas were analyzed. Eighty-five (12.7%) patients had
supracarinal tumor (group A). Clinico-pathological features
LES length (cm)
–0.03
(–0.23–0.18)
0.8205
were compared with those located more distally (group B).
Intra–abdominal LES length (cm)
0.03
(–0.34–0.39)
0.2238
Multivariate analyses were performed to identify prognosLESP (mmHg)
–3.86
(–5.93––1.79)
0.0006*
tic factors.
IBP (mmHg)
0.07
(–1.2–1.36)
0.2745
RESULTS: More patients in group A received neoadjuvant
chemotherapy or chemoradiotherapy (CRT) (50.6% vs.
36.4%, p = 0.012). Operation took longer (300 mins vs. 275
mins, p = 0.006), and postoperative vocal cord palsies were
more frequent (24.7% vs. 8.4%, p < 0.01). Other complications did not differ and in-hospital mortality rates were
3.5% and 3.3% respectively, p = 0.896. R0 resection was
achieved in 69.4% and 72% respectively, p = 0.615. Median
survival was 15.6 and 20.5 months respectively, p = 0.973.
CONCLUSIONS: A decrease in both upper and lower esoph- Multivariate analysis showed that R1/2 resection (R1/2 vs.
ageal sphincter resting pressure with time is observed dur- R0, HR = 2.43, 95% CI = 1.94–3.04), male gender (male
ing the routine course of HRM studies. This decrease affects vs. female, HR = 1.45, 95% CI = 1.14–1.85) and higher (y)
classification of sphincter parameters in a meaningful sub- pTNM stage (stage III/IV vs. 0/I/II/T0N1, HR = 1.61, 95% CI
set of patients. A dual-landmark frame approach should be = 1.17–2.21) were unfavorable prognostic factors; but not
considered when routinely analyzing HRIM studies.
tumor location. When only group A patients were analyzed,
R1/2 resection (R1/2 vs. R0, HR = 3.73, CI = 1.86–7.46) and
the absence of neoadjuvant chemotherapy or chemoradiotherapy (no CRT vs. CRT, HR = 2.2, CI = 1.20–4.05) were
poor prognostic factors.
IRP (mmHg)
0.01
(–0.93–0.95)
0.3616
UESP (mmHg)
–17.2
(–26.0––8.50) <0.0001*
LES: Lower Esophageal Sphincter; LESP: Mean LES Resting Pressure;
IBP: Intra-bolus Pressure; IRP: Integrated Relaxation Pressure;
UESP: Mean Upper Esophageal Sphincter Pressure;
Mean: The average differences between the late and early landmark frame
measurements; CI: Confidence Interval;
*Wilcoxon signed-rank test P-value <0.05
191
Tuesday
Poster Abstracts
CONCLUSIONS: In the modern era of effective neoadjuvant therapies, survival of patients with supracarinal
tumors is not inferior. Surgery however is more complicated
and more vocal cord palsies result. The use of neoadjuvant
therapies is a favorable prognostic factor for such cancers.
Tu1542
PATIENTS AND METHODS: The records of all patients
who underwent a thoracic endovascular aortic repair
between 2004 and 2012 were reviewed. Patients readmitted
to the hospital for aortoesophageal fistula were identified.
The data about demographics, symptoms, clinical management, surgical or endoscopic therapy and follow-up were
reported.
Long Follow-Up in Patients with Barrett’s Esophagus
Submitted to Fundoplication: What Is the Importance
of the Endoscopic Surveillance?
Sergio Szachnowicz, Francisco C. Seguro, Rubens A. Sallum,
Angela FalcãO, Julio R. Rocha, Ary Nasi, Ivan Cecconello
Department of Gastroenterology, Esophageal Surgical Division –
University of São Paulo Medical School – Brazil, São Paulo, Brazil
BACKGROUND: Barrett’s esophagus is associated to esophageal adenocarcinoma. Endoscopic surveillance of patients
treated surgically or clinically allows early detection of cancer. Some authors concluded that surveillance is not costeffective and does not reduce mortality from cancer.
AIM: We analyze efficacy of endoscopic surveillance in
patients with Barrett’s esophagus submitted to fundoplication.
METHODS: from January 1980 to November 2012, 221
patients with Barrett’s esophagus were submitted to fundoplication to control reflux. Of those, 196 were followed
(mean 82 months) . All patients in our service had routine endoscopic examination each 2 years with multiple
biopsies.
RESULTS: Ten patients (8.9%) showed Barrett’s endoscopic
regression. Three patients (2.6%) were diagnosed with
esophageal adenocarcinoma in this series. Two underwent
prolonged pH monitoring that showed no acid reflux. They
were asymptomatic and had diagnostic of early adenocarcinoma during routine endoscopy 2 (2) and 6 years after
fundoplication. All underwent transhiatal esophagectomy
and are alive (12 to 56 months).
RESULTS: Of the 268 patients who underwent a thoracic
endovascular aortic repair, nine patients (3,4%), in a median
age of 64 years (IQR 49–77), developed an aortoesophageal
fistula after a median time of 2.4 month (IQR 1–16). The
clinical symptom was sudden massive hematemesis in four
CONCLUSION: Besides the related low cost-effectiveness patients, fever and elevated makers of inflammation in five
of endoscopy surveillance, cancer was detected during fol- patients and abdominal pain in one patient. Aortoesophalow up of Barrett’s patients submitted to a successful antire- geal fistula was identified by esophago-gastro-duodenosflux procedure allowing early diagnosis and cure.
copy. Of the nine patients, two patients (22%) underwent
an esophagectomy with gastric pull-up, one patient an
Tu1544
esophagectomy with a delayed colon interposition and the
remaining six patients underwent an endoscopic implantaAortoesophageal Fistula After Thoracic Endovascular
tion of a self-expanding esophageal stents. The two patients
Aortic Repair
after esophagectomy and gastric pull-up are alive with a
Renate Reinhardt1, Wolfgang Niebel1, Gernot M. Kaiser1,
median survival of six and 12 month. The remaining seven
Alexander Dechene2, Andreas Paul1, Arzu Oezcelik1
patients all died due to fatal re-bleeding or mediastinitis in
1
a median time of 12 month after the diagnosis of aortoSurgery, University of Essen, Essen, Germany; 2Gastroenterology and
esophageal fistula.
Hepatology, University of Essen, Essen, Germany
INTRODUCTION: The aortoesophageal fistula is a rare but
devastating complication after thoracic endovascular aortic
repair. There are no clear data in the literature about the
optimal therapy of this complication. The aim of this study
was to report the characteristics, therapy and outcomes of
our patients with aortoesophageal fistula after endovascular
aortic repair.
CONCLUSION: Aortoesophageal fistula is a fatal complication after thoracic endovascular aortic repair. Early diagnosis is essential for the survival of the patients. In our patient
population was the surgical therapy associated with a better
outcome.
192
Tu1545
Tu1546
An Analysis of Predictive Factors and Clinical
Outcomes of Pleural Tears During Laparoscopic
Esophageal Surgery
Sarcopenia: Significant Independent Risk Factor for
Poor Survival Following Esophageal Resection
Aaron S. Rickles2, James C. Iannuzzi2, Dylan R. Nieman1,
Michal J. Lada1, Kristin N. Kelly2, Fergal Fleming2,
Jeffrey H. Peters1, John R. Monson2
1
Surgery, University of Rochester, Rochester, NY; 2Department of
Surgery, Surgical Health Outcomes & Research Enterprise, University
BACKGROUND: Laparoscopic operations on the esopha- of Rochester, Rochester, NY
gus, including paraesophageal hernia (PEH) repair, fundo- PURPOSE: Sarcopenia has been linked to poor survival
plication for gastroesophageal reflux, and myotomy for in several types of cancer including breast, pancreatic, and
achalasia, involve dissecting and opening of the diaph- colorectal. This study examines the effect of sarcopenia on
gramatic crura and mobilizing the mediastinal esophagus. survival outcomes after esophagectomy for cancer.
During these maneuvers, tears in the mediastinal pleura can
METHODS: A retrospective chart review was performed
occur, resulting in capnothorax, and, potentially, hemodyon patients who underwent esophageal resection between
namic or respiratory instability. The incidence of intraoperative pleural tears, their clinical significance, and factors 2005–2012. Pre-operative CT imaging was used to measure
total body fat, abdominal fat, and muscle mass. Muscle
predictive of occurrence have not been studied.
mass area at the level of the third lumbar vertebrae (psoas,
METHODS: A single-surgeon prospective database of lapa- erector spinae, and abdominal muscles) was normalized for
roscopic operations on the esophagus was analyzed. Dur- patient height and sarcopenia was defined by sex-specific
ing each operation, the presence of any recognized pleural values as previously described (38.5 cm2/m2 for females,
tear was recorded, as were any hemodynamic or respiratory and 52.4 cm2/m2 for males). Data was collected on patient,
changes that occurred as a result. These data, along with the tumor, and treatment characteristics. Kaplan-Meier survival
primary operator (resident, fellow, or attending), procedure curves and Cox Proportional Hazards were used to analyze
duration, need for adhesiolysis, EBL, other complications, the primary endpoint of overall survival over 5 years.
and length of stay were all recorded prospectively.
RESULTS: Out of 271 esophageal resections, 131 cases had
RESULTS: 382 laparoscopic operations were performed: CT scans available for analysis, of which 53 patients died
64 PEH repairs, 199 Nissen fundoplications, and 119 Heller over a median follow-up of 22 months. 32.1% (n = 42) of
myotomies. 57 (15%) cases were re-do procedures. Pleural
patients met criteria for sarcopenia and on average sarcopetears occurred in 44 (12%) cases, of which 13 (30% of pleunic patients were older (67 yo. vs. 61 yo., p = 0.002), had
ral tears, 3% of all cases) resulted in a transient increase
less total fat (4168 cm3 vs. 4963 cm3, p = 0.033) and less
in peak airway pressures, decrease in oxygen saturation, or
3
3
decrease in blood pressure. All 13 cases of hemodynamic abdominal fat (1524 cm vs. 1876 cm , p = 0.043), however
there
was
no
statistically
signifi
cant
difference
in waist cirand/or respiratory instability were resolved successfully
cumference
or
body
mass
index
between
the
two
groups.
by decreasing the abdominal insufflation pressure to <10
mmHg. In no case was intra or postoperative tube thoracos- There was also no difference between sarcopenic and nontomy insertion required. Comparing cases with or without sarcopenic groups based on gender, smoking status, comora pleural tear, there were no differences in rates of other bidities, presentation, tumor stage, resection margin status,
complications (5 vs. 12%; p = ns) or length of stay (mean number of locoregional lymph node metastases, leak rates,
1.4 vs. 1.3 days). The incidence of pleural tears was sig- length of hospital stay, and use of neoadjuvant or adjuvant
nificantly different for each procedure: PEH repair (36%), therapy. On Kaplan-Meier analysis sarcopenic patients had
Nissen (11%) and Heller (3%) (p < .05 for each paired com- significantly worse overall survival compared to patients
parison). Re-do and primary operations had a similar inci- with normal muscle mass (log rank = 0.012, Figure 1). 5-year
dence of pleural tears (12% vs. 11%; p = ns). The level of overall survival was 62% for patients with normal muscle
training of the primary operator did not affect the pleural mass and 33% for patients with sarcopenia. After adjusting
tear rate (resident: 8%, fellow: 14%, attending: 12%, p = for differences in patient age and body fat composition in
ns). When patient demographics were compared between cox-proportional survival analysis, patients with sarcopenia
cases with and without pleural tears there were no differ- had twice the risk of death over five years as compared to
ences in gender distribution, age, or BMI. Cases with and patients with normal muscle mass [HR = 2.00; 95% CI =
those without pleural tears did not differ in terms of length, (1.13,3.56), p = 0.018].
EBL, or need for adhesiolysis.
CONCLUSION: Sarcopenia predicts worse overall survival
Ezra N. Teitelbaum1, Thomas K. Varghese2, Eric S. Hungness1,
Nathaniel J. Soper1
1
Northwestern University, Chicago, IL; 2University of Washington,
Seattle, WA
after esophagectomy for cancer. While sarcopenia itself
offers substantial prognostic value, these findings underscore the importance of optimizing patient nutrition and
exercise status as part of the comprehensive cancer care to
improve survival in this vulnerable population.
193
Tuesday
Poster Abstracts
CONCLUSIONS: In this series of laparoscopic esophageal
operations, pleural tears occurred in 12% of cases. Nearly
a third of pleural tears caused transient hemodynamic or
respiratory changes, but in all cases these were successfully managed by decreasing insufflation pressure without
need for tube thoracostomy. Pleural tears occurred more
frequently during PEH repair, but there do not appear to
be other demographic or operative predictors of increased
occurrence.
METHODS: Using the Surveillance Epidemiology and End
Results (SEER) database, we identified all patients diagnosed
with EAC/GEJAC during the years 2000–2009. Patients
were stratified by age: <40 years, 40–60 years, or >60 years.
Patients <40 years were then compared to those >60 years,
and survival outcomes were assessed by the Kaplan-Meier
method and Cox-regression.
RESULTS: Of 15, 816 patients with EAC/GEJAC diagnosed
during the study period, 67.3% (n = 10,641) were >60
years, and 1.7% (n = 269) were <40 years old. The incidence rates in both cohorts did not change over the study
period. When compared to the older cohort, patients <40
years were more likely to be male (p < 0.0001), present with
AJCC stage III/IV disease, p < 0.0001), and receive both
radiation and surgery for curative intent (29 vs. 13.6%, p <
0.001). Patients <40 years had significantly better median
overall survival (OS) and median disease-specific survival
(DSS): 15 vs. 10 months and 14 vs. 12 months, respectively;
p < 0.0001. Stratifying by AJCC stage, younger patients
had superior DSS regardless of stage: stage I: Not reached
(NR) vs. 55 months, p < 0.0001; stage II: NR vs. 25 months,
p < 0.001, stage III: 19 vs. 15 months, p < 0.0001; stage IV:
10 vs. 6 months, p < 0.0001. When stratifying by therapy
delivered, younger patients had superior DSS in the surgery
only cohort (NR vs. 59 months, p = 0.003) and similar survival in the surgery + radiation and radiation alone cohorts.
Cox regression confirmed age <40 is an independent predictor of both improved OS (p < 0.0001) and improved DSS
(p = 0.0007).
Figure 1: Kaplan-Meier analysis of overall survival for sarcopenic (red)
and non-sarcopenic (blue) patients following esophageal resection for
cancer (Log Rank Test = 0.012).
Tu1547
Esophageal and Gastroesophageal Adenocarcinoma
in Young Patients: A Call for a Continued Aggressive
Approach to Both Diagnosis and Treatment
CONCLUSIONS: Based on analysis of the SEER registry,
while EAC/GEJAC remains a rare entity in patients <40
years of age, these patients can be expected to have superior outcomes as compared to older cohorts, especially with
early diagnosis. An aggressive approach to both early diagnosis and treatment of this disease should continue regardless of age
Katherine E. Campbell1, Bin Huang2, Jing Guo2,
Timothy W. Mullett3, Jeremiah T. Martin3, B. Mark Evers4,
Shaun P. Mckenzie5
1
Surgery-General Surgery, University of Kentucky, Lexington, KY;
2
Biostatistics, University of Kentucky, Lexington, KY; 3Surgery –
Cardiothoracic Surgery, University of Kentucky, Lexington, KY;
4
Markey Cancer Center, University of Kentucky, Lexington, KY;
5
Surgery – Surgical Oncoloty, University of Kentucky, Lexington, KY
BACKGROUND: The development of esophageal or gastroesophageal junction adenocarcinoma (EAC/GEJAC) in
patients less than 40 years of age is thought to be associated
with a more aggressive tumor biology and a worse outcome
compared to patients over 40 years. Our objective was to
determine the impact of younger age on survival of EAC/
GEJAC utilizing a nationwide patient registry.
5-Year Overall and Disease-Specific Survival for EAC/GEJAC by Age and AJCC Stage
AJCC Stage
Overall Survival
<40 years
>60 years
Disease-specific
Survival
<40 years
>60 years
NR = Not reached
All Stages
Median
5-Year
(Months)
Survival
Stage l
Median
5-Year
(Months)
Survival
Stage II
Median
5-Year
(Months)
Survival
Stage III
Median
5-Year
(months)
Survival
Stage IV
p Value
15
10
0.22
0.15
NR
31
0.83
0.36
NR
21
0.54
0.24
16
14
0.06
0.12
8
6
0.06
0.02
<0.0001
14
12
0.24
0.20
NR
57
0.65
0.48
NR
25
0.52
0.30
19
15
0.00
0.15
10
6
0.05
0.02
<0.0001
194
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Tu1549
Ligation of Ileocolic Artery Improves the Vascularity
of Future Ileocolonic Conduit for Corrosive Injury
Esophagus
Combined Surgical/Endoscopic (Hybrid) Management
of Acute Esophageal Perforation: A New Technique of
Intra-Operative Stabilization of Endoscopically Placed
Stents
Pradeep Rebala1, Yoganand Dadge1, Subramanyeshwar T. Rao1,
G.V. Rao1, Jagdish Rampal3, Piyal Nag3, Duvvuru N. Reddy2
1
Surgical Gastroenterology, Asian Institute of Gastroenterology,
Hyderabad, India; 2Medical Gastroenterology, Asian Institute of
Gastroenterology, Hyderabad, India; 3Department of GI Radiology,
Asian Institute of Gastroenterology, Hyderabad, India
Artur M. Bodnar1, Andrew S. Ross2, Shayan Irani2, S. Ian Gan2,
Donald E. Low1
1
Department of Thoracic Surgery, Virginia Mason Medical Center,
Seattle, WA; 2Department of Gastroenterology, Virginia Mason
Medical Center, Seattle, WA
BACKGROUND: Between June 2005 and January 2010, 47
patients underwent ileocolonic pullup for corrosive esophageal injury with one death. Of these 46 patients surviving
9 (19.5%) had anastomotic leak and 22 (47.8%) developed
anastomotic stricture. The cause of these strictures and
leak was attributed to ischaemia . Hence we hypothesized
that ligation of ileocolic artery (ICA) improves collateral
blood supply to the future ileocolonic conduit and in turn
decreases the anastomotic leak and stricture rate.
METHODS: A prospective comparative study was conducted between January 2010 to June 2012. All patients
with acute corrosive injuries (grade II and III) who were
potential candidates for esophageal replacement surgery
and willing to undergo ICA ligation at the time of FJ were
included in Group A. During the above period, patients
who did not undergo ICA ligation and underwent ileocolonic interposition were taken as control group (Group B).
BACKGROUND: Endoscopic techniques, particularly
stents, are increasingly utilized for acute management of
esophageal perforation. However, migration remains a problem and extensive chest or abdominal contamination and
placement of enteric drainage or feeding tubes often necessitates open or minimally invasive surgical procedures. This
report describes a method of surgical stent stabilization to
simplify recovery by decreasing stent migration rates.
METHODS: All patients presenting with esophageal perforation between 1991 and 2012 were prospectively entered
into an IRB-approved database. A total of 101 patients were
treated for esophageal perforation during the study period.
Five patients had combined surgical and endoscopic
(hybrid) treatment including placement of transesophageal
or transgastric suture for intra-operative stent stabilization.
Demographic data and level of stricture was not statistically significant in both the groups. Four patients in group
B required tracheostomy, none of the patients in group A
required tracheostomy. CECT angiogram showed improvement in collateral circulation in all Group A patients. No
patient in group A had anastomotic leak and anastamotic
stricture, where as in Group B, 3/12 (25%) had anastomotic leak and 4/12 (33.3%) had anastamotic stricture
requiring dilatation.
CONCLUSION: Acute management of esophageal perforation is increasingly multidisciplinary. Selected patients will
continue to require surgical management for drainage or
enteral feeding. Hybrid procedures provide a simple additional treatment option in selected patients. Surgical stent
stabilization can be done safely and decreases the incidence
of stent migration, which can decrease the need for additional procedures and improve outcomes in these complex
patients.
All patients in group A, multislice CECT angiogram was
done before ICA ligation, 7 days following ICA ligation
and before ileocolonic interposition to document objective
improvement in collateral circulation.
All patients underwent ileocolonic pull up via retrosternal
route after a minimum period of six months following corrosive ingestion. Oral contrast study was done on postoperative day 10 and oral feed was started if there was no leak.
All were followed up every 3 weeks for 3 months and every
month for another 3 months. Barium swallow was done at
3 weeks to document status of anastomosis. Symptomatic
patients with documented anastomotic stricture were subjected for endoscopic dilation.
CONCLUSION: Ligation of ileocolic artery improves
the vascularity of future ileocolonic conduit and in turn
decreases anastomotic leak and stricture rate.
195
Tuesday
Poster Abstracts
RESULTS: Out of twenty three patients with ileocolonic
pull up during the study period, 5 were excluded from the
analysis (2 died and 3 did not complete 6 months follow
up). Out of the remaining 18 patients considered for evaluation, 6 were in group A and 12 were in group B.
RESULTS: The study group comprised 5 patients who
were referred to our institution between December 2005
and June 2012, mean age 52.6 (range 32–75). Two had iatrogenic (1 dilation, 1 post Nissen) and 3 had Boerhaave’s
perforations. Four patients presented at >24 hours and
endoscopic examination documented perforations in the
distal esophagus 3, and EG junction 2. Four patients had
abdominal approaches, 1 had a right thoracotomy. Three
patients had primary repairs and all had drainage as well
as placement of gastrostomy and jejunostomy tubes. Stents
were placed intra-operatively, 3 Wallstents, 1 Niti-S and 1
Celestin tube. All stents were stabilized with transgastric or
transesophageal chromic sutures. No significant migration
occurred. Post-op barium studies done on Day 3–8 showed
no leak in 4 patients and a small leak communicating with
a drain in 1 patient. Stents were removed post-operatively
at 4–8 weeks (mean 5.4). Stent removal was straightforward
and no complications associated with stabilization sutures
were identified. One patient had a small residual fistula
which communicated to a drain. All patients recovered
uneventfully. Mean LOS was 22 days, range 7–54.
Tu1550
Clinical: Hepatic
Safety and Efficacy of Outpatient Percutaneous
Endoscopic Gastrostomy for Patients with Head
and Neck Cancer
Tu1555
Julia M. Boll, Shaun Daly, Jill Smolevitz, Maria C. Mora Pinzon,
Amanda B. Francescatti, Jonathan Myers, Steven D. Bines,
Minh B. Luu
BACKGROUND: Percutaneous endoscopic gastrostomy
(PEG) is commonly used to provide enteral nutrition for
patients with head and neck cancer undergoing radiation
and chemotherapy. The aim of the study was to evaluate
the efficacy and safety of PEG tube placement in these
patients in an ambulatory setting.
METHODS: An observational, cohort study was conducted to identify patients who underwent a PEG procedure between 2008 and 2012. Inclusion criteria included
patients diagnosed with head and neck cancer undergoing
outpatient PEG placement. Patient demographics and perioperative outcomes were analyzed using SPSS analytical
predictive software.
RESULTS: During this study 52 PEG tubes were placed
in patients with head/neck cancer as an outpatient procedure. There were no significant differences in primary
malignancy site. 28.8% were female and 71.2% were male,
with ages ranging from 19–82 and a median age of 58.
Three patients (5.8%) were admitted post-procedure due
to the senior author’s judgment. There were no procedure
related 30-day complications. One patient was re-admitted
for dehydration unrelated to the PEG placement. Seven
(13.5%) patients sought further care for pain control. Five
patients (9.6%) made one post-operative phone call to the
clinic compared to three (5.8%) who made more than one.
There were six patients (11.5%) with long-term complaints;
three complained of discharge, three of abdominal wall
pain, and one of a cracked PEG tube. There were no mortalities within thirty days.
Results of 100 Consecutive Repeat Hepatectomies for
Recurrent Colorectal Liver Metastases
Hannes P. Neeff1, Oliver Drognitz1, Andrea Klock1,
Peter Bronsert2, Ulrich T. Hopt1, Frank Makowiec1
1
Department of Surgery, University of Freiburg, Freiburg, Germany;
2
Department of Pathology, University of Freiburg, Freiburg, Germany
INTRODUCTION: Recurrent colorectal liver metastases
(CRC-LM) are a common phenomenon. This has become
more and more evident with the advent of multimodal
therapies in combination with increased hepatic resection
rates of CRC-LM.
Since complete surgical resection remains the only chance
for cure, even in advanced colorectal cancer, outcomes after
repeat hepatectomies for CRC-LM have to be evaluated in
order to introduce this concept into standard clinical care.
PATIENTS AND METHODS: Since 1999 100 repeat
hepatic resections (62% wedge/segmental, 38% hemihepatectomy or greater) have been performed for recurrent CRCLM in 88 patients. Repeat hepatic resection was carried out
after a median interval of 1.25 years. Resection criteria were
not different from first liver resections. Chemotherapy
including biological agents was given in 89% before repeat
hepatectomy.
This was done in neoadjuvant intent in 38%. 50% of cases
with neoadjuvant treatment were receiving biological
agents.
RESULTS: Margin negative hepatic resection was achieved
in 80%. Overall margin negative resection was 70%. Mortality was 3.0%. Complications rates were 52% overall,
including infection (17%), need for operative re intervention (12%) and hepatic failure (i.e. bilirubin > 6.0 mg/dl)
(5%). Overall five-year survival rate after first repeat hepatic
resection (n = 85) was 50.3%. In univariate analysis, priCONCLUSION: This study demonstrates that placement of mary tumor stage (p < 0.04), major hepatic surgery (p =
PEG tubes in patients with diagnosed head and neck cancer 0.05), postoperative complications (p = 0.05) and overall
can be accomplished safely and effectively in an outpatient margin negative resection including extrahepatic sites (p =
setting. Complication rates were low and patient complaints 0.05) were predictors of survival. Multivariately, primary T
were successfully managed without re-admission. Acknowl- stage (p < 0.05) and tumor size (p < 0.03) were independent
edging the safety profile of ambulatory PEG tube placement predictors of survival.
by general surgeons could lead to an increased percentage
of patients avoiding hospitalization and its subsequent risk
of nosocomial complications and increased cost.
196
CONCLUSION: Despite high rates of recurrence, results
after repeat hepatic resection remain encouraging in terms
of 5-year survival rates. Even under challenging surgical
conditions, repeat hepatectomies can be performed safely
with a high rate of local margin negative resections. Specific
risk factors for patients with recurrent CRC-LM undergoing
repeat hepatectomies could not be found as they resemble
general risk factors for metastatic colorectal disease. Repeat
heaptic resections for recurrent CRC-LM should increasingly be offered to patients who meet standard hepatic
resection criteria.
RESULTS: The base case analysis of a 45 year-old patient
with compensated cirrhosis, a BMI of 45 kg/m2 and no
weight-loss intervention revealed an average survival of
7.93 years. Patients transitioned into lower weight classes
fastest in the RYGB simulation. The average survival for
the weight loss simulations were 9.14, 8.84, and 8.16 years
for RYGB, AGB, and diet and exercise, respectively. Sensitivity analysis of initial BMI revealed that RYGB increased
life expectancy compared to AGB in all patients that were
severely or morbidly obese (all BMIs greater than 35 kg/m2)
and in all patients with a BMI greater that 36.98 kg/m2
compared to one year diet and exercise.
Tu1556
Weight-Loss Interventions for Morbidly Obese Patients
with Compensated Cirrhosis: A Markov Decision
Analysis Model
Bianca Bromberger1, Kristoffel Dumon2, Rashikh A. Choudhury1,
Paige Porrett2, Kenric Murayama2
1
Perelman School of Medicine at the University of Pennsylvania,
Philadelphia, PA; 2Department of Surgery, University of Pennsylvania
Health System, Philadelphia, PA
PURPOSE: With the rising prevalence of obesity, nonalcoholic steatohepatitis is an increasingly common cause
of cirrhosis and indication for liver transplantation. However, since many centers require that patients maintain a
BMI <40 kg/m2 to be eligible for transplantation, many
morbidly obese patients are excluded from this life-saving
therapy. It is currently unknown which weight loss interventions should be utilized in morbidly obese cirrhotic
patients in order to improve transplantation candidacy.
This study therefore aimed to compare the efficacy of three
methods of weight loss in morbidly obese patients with
compensated cirrhosis [Roux-en-Y gastric bypass (RYGB),
Adjustable Gastric Banding (AGB), and one year of diet
and exercise]. We hypothesized that the faster and more
significant weight loss achieved by RYGB would increase
life expectancy.
METHODS: A Markov state transition model was developed to assess the survival benefit of undergoing RYGB,
AGB or one year of diet and exercise in morbidly obese
patients with compensated cirrhosis. The model assumed
that a BMI < 40 kg/m2 was required for patients to be listed
for transplantation. State transition values were obtained
from the literature in order to best estimate the rates of
weight loss, progression of disease, wait-listing and transplantation. The model was analyzed using decision analysis
software (TreeAge Pro 2012). Base-case and sensitivity analyses of pre-intervention BMI and peri-operative mortality
were performed.
Sensitivity analysis of survival post-weight loss intervention based on
initial BMI.
CONCLUSION: In morbidly obese patients with compensated cirrhosis, RYGB is the most effective means to decrease
BMI. Importantly, this intervention leads to increased
life expectancy in this population, potentially because of
improved access to liver transplantation and/or impact on
disease progression.
Tuesday
Poster Abstracts
197
Tu1557
CONCLUSION: Standardization of complex procedures
begins with breaking down the process into measureable
Detecting Performance Variance in Complex Surgical
components. LRH can be performed consistently and reproProcedures: Analysis of a Step-Wise Technique for
ducibly using the same approach of a step-wise technique.
Parenchyma transection had the most variation, and this
Laparoscopic Right Hepatectomy
could be explained by intrinsic liver factors (organ thickJuan Toro, Nathan Lytle, Ankit Patel, John F. Sweeney,
ness, fat content, cirrhosis, etc). The identification of ways
Rachel M. Owen, Edward Lin, Juan M. Sarmiento
to narrow the variance in parenchyma transection, when
possible, became our first focus. Using SS and LM manuBACKGROUND: Laparoscopic Right Hepatectomy (LRH) facturing quality tools in surgery allows the surgeon to
is a technically challenging operation. Complex surgical critically analyze performance and implement specific
procedures can be improved by standardization of opera- improvement goals.
tive technique and uniformity of operating room (OR)
practice, and accomplished by implementation of manufacturing productivity tools such as Six Sigma (SS) and Lean Clinical: Pancreas
Management (LM). Using these strategies allow us to measure performance efficiency, detect unwanted variances,
Tu1560
and implement process improvement.
METHODS: We performed formal LRH beginning in 2008
in the same way we performed the open approach. The
procedure was deconstructed into seven major step-wise
components (right hepatic artery ligation/transection, right
portal vein ligation/transection, retrohepatic IVC dissection, triangular ligament takedown, right hepatic vein ligation/transection, parenchyma transection, hemostasis-bile
leak check) established by two surgeons. All LRHs followed
the same surgical sequence, device use, and OR protocol.
A non-participating surgeon reviewed the video recordings
of the procedures to determine total operative time and
the time for each component step. The variances (standard
deviation) of each operation were calculated (average time
in minutes ± SD).
Cystic Lesions of the Pancreas: Resection Versus
Surveillance
Halle Beitollahi1, Valerie Erath1, Haiyan Sun3, Nicole Woll1,
David L. Diehl2, Amitpal S. Johal2, Joseph A. Blansfield1,
Mohsen M. Shabahang1
1
General Surgery, Geisinger Medical Center, Danville, PA;
2
Gastroenterology, Geisinger Medical Center, Danville, PA; 3Center
for Health Research, Geisinger Health System, Danville, PA
INTRODUCTION: Pancreatic cysts remain a challenge
with respect to diagnosis and management. Pancreatic cysts
are detected with increased frequency because of the widespread use of advanced imaging modalities. The aim of the
study was to perform a clinical comparison of patients with
RESULTS: After implementation of LM for our LRH, 30 pancreatic cysts who underwent resection versus imaging
randomly selected video recordings of the procedure surveillance and differentiate between clinical, imaging,
(excluding biliary reconstruction) were reviewed. The mean biochemical and pathologic characteristics.
total operative time was 114 ± 25 min. The most efficient METHODS: This was a retrospective review of adult
steps of the procedure were IVC dissection (mean 8 ± 3 min) patients with cystic lesions of the pancreas treated in a
and right hepatic vein ligation (mean 9 ± 5). The longest single health system between January 2002 and September
and also the step with the highest standard deviation was 2009. Endoscopic ultrasound (EUS) was required for incluparenchyma transection (35 ± 12). The other steps were sion. An encounter was defined as a clinical visit in which
performed with minimal variations (Table 1). There were pancreatic imaging was performed. Imaging modalities
no intraoperative complications or conversions to open included were EUS, with or without fine needle aspiration
technique.
(FNA), computed tomography (CT), magnetic resonance
(MR) and endoscopic retrograde cholangiopancreatography
Table 1: LRH Total Operative Time and Steps Times (n = 30) *
(ERCP). Symptoms were defined as weight loss or abdominal pain. Demographics, clinical characteristics, imaging
Standard
features, biochemical analysis, procedure, pathology and
Step
Mean
Deviation
Median Range
follow up intervals were analyzed. Only encounters prior
Total operative time
114
± 25
114
78–177
to resection were included in the analysis for the resection
Right hepatic artery ligation
18
±8
17
6–37
group.
Right portal vein ligation
15
±4
15
7–25
Right lobe mobilization
IVC dissection
Right hepatic vein ligation
Parenchyma transection
Hemostasis/Bile leak checking
* Time in minutes
12
8
9
35
16
±4
±3
±5
± 12
± 11
11
7
8
32
14
7–28
3–15
4–22
21–65
4–52
198
RESULTS: The final analysis included 262 patients, 58 in
the resection group (22.1%) and 204 in the surveillance
group (77.8%). Demographics, clinical features and follow
up analysis are included in Table 1; p values and interquartile range (IQR) have been included. The median time to
resection from first encounter was 85.5 days; 52 patients
(89.6%) underwent resection within one year of first
encounter. The most common cyst locations were the pancreatic body and tail (53%). The median number of cysts by
CT was one in both the resection and surveillance groups.
The median initial cyst size by CT in millimeters was 31 in
the resection group and 21.5 in the surveillance group (p
< 0.001). The presence of septation (p = 0.216) or a solid
component (p = 0.957) were not significantly different
between groups. Median cyst fluid carcinoembryonic antigen (CEA) level (ng/ml) was 293.9 in the resection group
and 19.8 in the surveillance group (p = 0.006). Median
cyst fluid amylase (U/L) was 72.5 in the resection group
and 5096 in the surveillance group (p = 0.007). Pathologic
analysis of resected specimens demonstrated 29% of lesions
were malignant, 26% had dysplasia and 45% were benign.
In the resection group the most common diagnoses were
pseudocyst (22.4%) and adenocarcinoma (18.9%) and the
most frequent procedure was distal pancreatectomy (50%).
Table 1: Demographic and Clinical Characteristics of Patients Who
Underwent Resection Versus Surveillance
Characteristic
Female (%)
Deceased (%)
Symptomatic (%)
Median age at
diagnosis in years
(IQR)
Median number of
encounters (range
1–15) (IQR)
Median interval
between encounters
in months (IQR)
Median follow up in
months (IQR)
Total
N = 262
158 (60.31%)
70 (26.72%)
169 (64.5%)
66 (55, 75)
Resection
N = 58
31 (53.45%)
17 (29.31%)
41 (70.69%)
61 (49, 72)
3 (2, 5)
2 (1, 3)
Surveillance
N = 204
P Value
127 (62.25%) 0.226
53 (25.98%)
0.613
128 (62.75%) 0.264
67.5 (55.5, 76) 0.027
3 (2, 5)
<0.001
1.17 (0, 6.9)
16 (3, 35.5)
Pancreatic Insufficiency Following Pancreatic Resection
Travis P. Webb, Joseph A. Blansfield, Mohsen M. Shabahang
Surgical oncology, Geisinger Medical Center, Danville, PA
BACKGROUND: Pancreatic insufficiency (PI), in the form
of endocrine or exocrine insufficiency, is a well-known
complication following pancreatic surgery. Despite this, the
exact incidence is not known and reported rates are widely
disparate.
HYPOTHESIS/OBJECTIVES: To determine and compare
rates of endocrine and exocrine insufficiency following pancreaticoduodenectomy (PD) and left pancreatectomy (LP).
DESIGN: Retrospective cohort.
SETTING: Single institution, tertiary care center.
PATIENTS AND METHODS: Data from 129 consecutive
patients who underwent PD and LP over a six year period
(1/2006–12/2011) were retrospectively reviewed. Exocrine
insufficiency was defined as need for pancreatic enzymes
(PE) following resection. Endocrine insufficiency was
defined as new onset or worsening diabetes mellitus (DM).
RESULTS: There were 129 patients that underwent pancreatic resection: 68 PD, 61 LP. New onset exocrine insufficiency for the entire cohort was 28% (32 of 129 patients).
Exocrine insufficiency was significantly higher in the PD
cohort versus LP (42.6% (n = 29) vs. 4.9% (n = 3), p <
0.001). A significant portion of the population had endocrine insufficiency preoperatively (32.6%, n = 42). New
onset or worsening DM was diagnosed in 16.2% (n = 11) of
PD patients compared to 24.6% (n = 15) of LP patients but
this was not statistically significant (p = 0.16). New onset PI
in any form occurred in 40.3% of patients (52 out of 129).
This was statistically higher in PD patients at 50% (n = 34)
vs 29.5% (n = 18) for LP, (p = 0.02).
CONCLUSION: Pancreatic insufficiency occurs frequently
after pancreatic resection and patients should be counseled
accordingly preoperatively. Clinicians should have a low
threshold to diagnose and treat exocrine and endocrine
insufficiency in the postoperative pancreatic resection
patient.
4.13 (1.73, 1.87 (0.83, 4.73) 4.63 (1.93, 11.69) <0.001
10.5)
10 (1.1, 30.8)
Tu1561
<0.001
CONCLUSION: The data suggests patients who require
resection can be identified early. This is based primarily on
cyst size and elevated cyst fluid CEA. Patients who underwent resection had fewer encounters at shorter intervals.
Tuesday
Poster Abstracts
199
Tu1562
Preoperative Normogram to Predict Discharge
Disposition Following Pancreatic Resection for
Malignancy
Bhavin C. Shah1, Lynette M. Smith2, Chandrakanth Are1
1
Surgery, University of Nebraska Medical Center, Omaha, NE;
2
Biostatistics, College of Public Health, University of Nebraska
Medical Center, Omaha, NE
BACKGROUND: The aim of this study was to develop a
preoperative normogram to predict thedischarge status following pancreatic resection for malignancy.
METHODS: The Nationwide Inpatient Sample (NIS) database (2000–2009) was used. Discharge disposition was
categorized as routine (home without any assistance) or
non-routine (discharge to home with assistance or to skilled
facility). Multivariate logistic regression model was used to
identify variables influencing discharge disposition and a
normogram was created. The training set (2000–2005) was
used to develop the model which was further validated
using the validation set (2006–2009).
RESULTS: A weighted total of 21250 patients (2000–2005)
were used to create a predictive model and 20390 patients
(2006–2009) were used to validate it. The mean total points
for the 2000–2005 dataset was 134.7 (SE = 1.25), which
correspond to approximately a 42% non-routine discharge
which is similar to the actual observed non-routine discharge rate of 43%. The normogram was validated using
the NIS 2006–2009 dataset. The mean total points for the
2006–2009 sample is 128.5 (SE = 1.70) with an observed
non-routine discharge rate of 46%. The concordance index
was found to be 0.67 (95% confidence interval of 0.65 to
069). Calibration plots of the normogram revealed agreement between the observed non-routine discharge prob- Calibration plots for Normogram dataset (2000–2005) and Validation
abilities versus the model predicted non-routine discharge Dataset (2006–2009).
probability. (Figure: 1)
CONCLUSION: This preoperative normogram may accurately predict the chance of a non routine discharge following pancreatic resection for malignancy and may be used as
an adjunctive clinical tool in the preoperative counseling
of these patients.
200
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Tu1564
Pancreatico-Duodenectomy with High Quality Results
in a Medium Volume Centre: What Are the Australian
Definitions of Low Volume?
Predictors of Lymph Node Metastases and Impact
on Survival in Resected Pancreatic Neuroendocrine
Tumors: A Single Center Experience
Jonathan S. Gani, Ephream C. Lye, Donna Gillies
Surgery, John Hunter Hospital, New Lambton Heights, NSW, Australia
Joyce Wong, William J. Fulp, Jonathan R. Strosberg,
Larry Kvols, Pamela Hodul
INTRODUCTION: Controversy about pancreatico-duo- Surgery, Moffitt Cancer Center, Tampa, FL
denectomy (PD) has persisted since it was first performed BACKGROUND: Currently, staging for pancreatic neuby Kausch a century ago and later popularised by Whipple. roendocrine tumors (PNET) considers tumor size, lymph
Evidence that a certain critical caseload volume is required node status, and histologic differentiation. However, the
to undertake this kind of surgery with low mortality has predictive value of these factors as related to overall surbeen the subject of some debate. Definitions of high and vival (OS) remains unclear. This study reviews predictors of
low volume centres and surgeons have been proposed but lymph node (LN) metastases and the impact on survival for
resected PNET.
they differ greatly between health systems and counties.
METHODS: A prospectively maintained database of
patients treated for PNET was reviewed. Patients undergoing surgical resection without evidence of metastatic disease at time of resection were included in this analysis.
Chi-Square Test was used to compare categorical variables
and LN metastases, and Wilcoxon Rank Sum Test was used
METHODS: A ten year retrospective study from the period for continuous variables, both with the exact method using
of October 2002 to October 2012 was undertaken in the Monte Carlo estimation. Univariate and multivariate anal1 public and 2 private hospitals in Newcastle Australia ysis was performed with Cox proportional hazard models
where all the PDs for a regional population of 840000 were and survival calculated with Kaplan Meier curves.
performed.
RESULTS: From 1999–2012, 150 patients underwent surgiRESULTS: 123 pancreatico-duodenectomies were per- cal resection for PNET. The majority (53%) were male, with
formed in this period. The mean number of operations a median age of 56 years (range 17–82). Incidentally disperformed each year including all hospitals combined was covered PNET was the most common presentation (42%),
12.3. This is equivalent to a medium volume centre by followed by abdominal pain (32%). Tumors were uncomEuropean definitions. The number of operations per sur- monly functional (7%). Distal pancreatectomy was pergeon per annum ranged from 0.2 per year to 5.8.
formed in 58%; pancreaticoduodenectomy in 29%, and
83.7% of patients suffered no significant complications, 30 enucleation in 7%. Of 113 (75%) patients with LN data
day mortality was 4.1%. Significant differences were found available for review, 32 (28%) had positive LN (LN + ). Both
between surgeons total significant complication rates age and lymph node retrieval differed in the LN negative
which ranged from 8.6% to 50%. 30 day mortality ranged (LN 0) vs. LN + group, with younger median age (53 years)
from 0% to 50%. 3 surgeons performed >3 operations per and higher median LN count (9 vs. 6) in the LN + group, p =
year. These were all designated medium volume surgeons 0.05 and p = 0.04, respectively. Univariate analysis showed
gender, race, clinical presentation, surgery type, and tumor
and they performed 91% of all PDs in this series (112/123).
size was not predictive of LN + . Presence of perineural (p =
The 3 other surgeons performed 9% (11/123) and were des0.016) and lymphovascular (p < 0.001) invasion, however,
ignated very low volume surgeons. One hospital performed
was more common in LN +. With multivariate analysis,
only 4 PDs during the study period and was designated a only poor/moderate differentiation predicted LN +, with
very low volume hospital (<1 case per annum). When the an odds ratio of 7.3 (95% CI: 1.9, 27.6). Median follow-up
data from medium volume surgeons and medium volume for the cohort was 52 months; estimated median OS was
hospitals was compared with the data from very low vol- 225 months with 5-year OS of 90%. Multivariate analysis
ume surgeons and hospitals there was a statistically signifi- identified older age at diagnosis and poor/moderate differcant difference in overall complication rates and mortality. entiation as factors that negatively impacted OS. 52 (35%)
Exclusion of the low volume surgeons and the low volume patients developed recurrent disease; the majority recurred
institution was associated with a 1.9% 30 day mortality, a with distant metastases (N = 46, 88%), with liver being the
12% significant morbidity and a 31% actuarial 5 year sur- most common site. Of those who recurred, 25 (48%) had
vival for periampullary malignancy.
received adjuvant therapy following resection. Estimated
CONCLUSION: There are both surgeon and hospital vol- median disease free survival (DFS) was 74 months. Only
ume effects on outcome after PD. We have demonstrated poor/moderate differentiation affected DFS. Tumor size and
that specialised Upper GI/HPB surgeons can achieve pan- LN + did not significantly impact survival.
creatico-duodenectomy results in a medium volume centre RESULTS: PNET is an uncommon entity with an unclear
equivalent to those achieved high volume centres.
prognosis based on variables commonly factored into the
staging criteria. In this study, tumor size did not predict LN
+; furthermore, LN + did not predict a worse OS or DFS.
Tumor differentiation appears to be more important in
determining prognosis for resected PNET.
The objective of this analysis was to determine whether it
is possible to deliver pancreatico-duodenectomy at global
standards in a regional city and to see if we can help define
the minimum acceptable number of procedures annually
compatible with providing such a service.
Tuesday
Poster Abstracts
201
Tu1565
CONCLUSIONS: In this very large multi-institution data
set, 30-day mortality for splenectomy for hematologic disMorbidity and Mortality Associated with Elective
eases is as high as 2.1% and is associated with an overall
Splenectomy for Hematologic Disorders
complication rate of 12% for patients with benign conditions and 20% for malignancy. Immediate infectious
Naina Bagrodia, Philip M. Spanheimer, Mary E. Beldingcomplications are common following splenectomy for
Schmitt, Howe R. James, James J. Mezhir
these conditions. A multivariate analysis is underway to
Surgery, University of Iowa, Iowa City, IA
determine the specific variables that can account for the
OBJECTIVE: Published rates of complications for sple- significant morbidity and mortality from splenectomy for
nectomy are very low, however these are single institution hematologic disorders.
series focused on many primary splenic conditions. Our
objective is to evaluate complications following splenecTu1567
tomy for benign and malignant hematologic disorders to
help guide decision making and informed consent for this Perioperative Outcome After Pancreatic Head
procedure.
Resections: Consecutive Single Surgeon Series in a
METHODS: A review of the ACS-NSQIP data set for splenectomy performed from 2006–2009 was performed. Preoperative clinicopathologic variables and postoperative
complications were evaluated. Patients included for analysis had a primary diagnosis of a benign (hemolytic anemia,
thrombocytopenia) or a malignant (leukemia and lymphoma) hematologic condition. Non-elective procedures or
splenectomy performed in addition to another major procedure (e.g., colectomy) were excluded.
Specialized University Hospital and in a Community
Hospital
Ulrich Adam1, Hartwig Riediger1, Ulrich F. Wellner2,
Tobias Keck2, Ulrich T. Hopt2, Frank Makowiec2
1
Department of Surgery, Humboldt-Klinikum, Berlin, Germany;
2
Department of Surgery, University of Freiburg, Freiburg, Germany
Hospital and surgeon volume are potential factors influencing postoperative mortality and morbidity after pancreatic
RESULTS: There were 4,859 splenectomy procedures col- resection. Data on perioperative outcomes of individual
lected from ACS-NSQIP data set during the time period surgeons in different institutions, however, are scarce. We
evaluated, and 1,762 met criteria for analysis. 1,379 (78.3%) evaluated the postoperative outcome after pancreatic head
operations were for benign conditions while the remain- resections (PHR) performed by a high-volume pancreatic
ing 383 (21.7%) were for malignant disease. Patients with surgeon in a high volume university department and (later)
benign conditions were younger, female, more commonly in a community hospital (with almost no prior institutional
diabetic, had higher BMI, and were more often on steroids experience with pancreatic surgery).
preoperatively. Patients with benign disease also had bet- METHODS: We compared the results after PHR personally
ter overall preoperative performance status compared to performed by a single surgeon between 2001 and 10/2006
patients with malignancy. Patients with benign disease in a specialized unit of a German University hospital (n =
more often had laparoscopic procedures (81.8% vs. 39.1%, 86; DeptA) with the results after PHR performed in a Comp < 0.0001).
munity hospital between 11/2006 and 2012 (n = 135;
Overall mortality at 30 days was 1.6% (n = 29) and was DeptB). Before the study period (-2001) the surgeon already
not significantly different for malignant (2.1%) vs. benign had a personal caseload of > 200 PHR. In addition to the 221
(1.5%) disease. The overall complication rate was 13.6% and PHR analyzed here the surgeon also had teached further >
was higher for patients with malignant disease (19.6%) vs. 150 PHR to residents and consulting surgeons. The same
benign disease (11.9%, p = 0.0002) (Table). Infectious com- surgical and perioperative techniques were applied in both
plications (superficial and deep SSI, UTI, sepsis, and pneu- series (e.g. abdominal drains, early enteral feeding, pancremonia) predominated in patients with malignancy (16.0% aticojejunostomy or pancreaticogastrostomy in PPPD) with
the exception of the use of pancreatic duct drains in some
vs. 9.1% for patients with benign disease, p = 0.0002).
patients in DeptB). The data of both series were prospecComplications from Splenectomy for Hematologic Disorders
tively recorded in SPSS-databases.
Variable
Overall 30-day Mortality
Overall Morbidity
Infectious Complications
DVT/PE
Transfusion
Reoperation
Length of Stay
(median days, range)
Benign Disease
n = 1,379 n (%)
21 (1.5)
164 (11.9)
125 (9.1)
33 (2.4)
30 (2.2)
43 (3.1)
3 (6–11)
Malignant
Disease
n = 383 n (%)
8 (2.1)
75 (19.6)
61 (16.0)
11 (2.8)
15 (3.9)
12 (3.1)
5 (8–10)
p-Value
0.37
0.0002
0.0002
0.58
0.06
0.87
0.0005
202
RESULTS: The median age of the patients was lower in
DeptA (59 years vs. 67 years in DeptB; p < 0.001). Indications for PHR (DeptA n = 86/DeptB n = 135) were pancreatic/periampullary cancer (58%/55%), chronic pancreatitis
(31%/28%) and various others (11%/17%). Most PHR were
PPPD (62%/74%) but the percentage of duodenum-preserving PHR decreased in DeptB (26% vs 14%). Vein resections were performed in 17%/21% (n.s.). Mortality rate was
3.5% in DeptA and 3.7% in DeptB (n.s.). Any complication
occurred in 48%/55% (p = 0.25). Pancreatic leak (any grade)
was present in 26%/24% (n.s.) but grade C leaks were more
frequent in DeptA (8% vs 3% in DeptB; p < 0.05). Using the
expanded Accordion classification complications grade 3 or
higher were documented in 14% (DeptA) or 16% (DeptB;
n.s.).
RESULTS:
The following situations were identified and some patients
presented more than one:
1. Issues involving surgical informed consent process
(information, refusal to proposed treatment, cognitive
status and competency, surrogates role in future decisions): 35 (33.33%)
2. Implementation of palliative care: 21 (20%)
3. Advance directives: 15 (14.28%)
4. Advice regarding alternative treatments and “miracle
cures”: 13 (12.38%)
5. Futile treatments: 7 (6.66%)
6. DNR orders: 6 ( 5.71%)
CONCLUSIONS: Surgeon volume and a high individual 7. Truth telling: 4 (3.80%)
experience, respectively, contribute to low mortality and
acceptable complication rates after pancreatic head resec- 8. Challenges to develop a trustful surgeon-patient relationship: 2 (1.90%)
tion. This personal experience may allow for favorable
postoperative outcomes after PHR even in a program with 9. Surgical residents participation in the procedure.
almost no prior experience with pancreatic resections.
2 (1.90%)
All the conflicts were managed satisfactorily, no need for
change of surgical teams was required and no professional
liability claims were filed in the following 23 months.
Tu1568
Ethical Conflicts in the Surgical Treatment of
Gastrointestinal Malignancies
Alberto R. Ferreres, Anibal J. Rondan, Marcelo Fasano,
Natalia Bongiovi, Gustavo Alarcia, Alejo S. Ferreres,
Rosana Trapani
Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina
CONCLUSIONS:
— Ethical guidelines and expertise are needed in the management of gastrointestinal malignancies to achieve adequate and patient-oriented decision making.
— Surgical decision making in these diseases need to
include patient preferences, quality of life and contexINTRODUCTION: Surgical care of patients with diagnotual issues to provide sound surgical judgement, with
sis of gastrointestinal malignancies involve ethical conficts
preeminence of respect for autonomy.
and decision making to manage these issues requires specific knowledge and expertise. The four ethical principles as — Ethical conflicts will probably increase in the future and
surgical ethics knowledge will prove to be at the core of
introduced by Beauchamp and Childress (respect for autonsurgical training.
omy, beneficence, non maleficence and justice) provide a
framework for the solution of these issues when arising in — A change of paradigm is envisioned to achieve and proclinical practice.
vide an optimal surgical care: from the curative model
with the goal of curing to the palliative model with the
OBJECTIVE: To examine prospectively the incidence and
concern to relief suffering.
the cause of ethical conflicts which lead to a surgical ethics
consultation during the process of surgical care of patients
with diagnosis of gastrointestinal malignancies.
METHODS: A total of 105 ethical conflicts through the
treatment care of 100 patients with gastrointestinal malignancies (of a total of 488) were identified during 2010.
Mean age was 58.2 ± 13.7 years (range: 28 to 96), 56 were
females. Two of the authors with expertise in surgical ethics
participated when intervention was requested and assisted
with the conflict management and resolution.
Tuesday
Poster Abstracts
203
Tu1569
Impact of Margin Clearance on Survival After
Pancreaticoduodenectomy for Pancreatic Ductal
Adenocarcinoma: What Is a “True” Negative Margin?
Yasushi Hashimoto, Yoshiaki Murakami, Kenichiro Uemura,
Takeshi Sudo, Naru Kondo, Taijiro Sueda
Department of Surgery, Applied Life Sciences Institute of Biomedical &
Health Sciences, Hiroshima University, Hiroshima, Japan
BACKGROUND: Microscopic involvement of a resection
margin by tumor is associated with a poor prognosis. It is
unclear whether a proximity to resection margins by tumor
confers a survival benefit over margin involved R1 resection
of their pancreatic ductal adenocarcinoma (PDAC) after
pancreticoduodenectomy (PD). The aim is to better understand the impact of resection status on clinical and pathologic staging, and long-term survival after PD for PDAC,
and to explore the prognostic significance of a proximity
to surgical margins.
METHODS: We assessed the relationships between margin involvement (R1), the proximity to resection margins
(R0-close) and outcome in a cohort of 124 consecutive
patients who underwent PD for PDAC between 2002 and
2012. Resected specimens were analyzed according to the
improved standardized pathology protocol which included
permanent section analysis of the surgical margins. R0-close
margin was defined as tumor within 1-mm of the resection
margins and a patient with a margin of greater than 1-mm
was defined as R0-wide margin. Follow-up data on overall
and disease-free survival, presence and site of tumor recurrence were examined.
CONCLUSIONS: These data demonstrate that a margin
clearance of more than 1-mm is important for long-term
survival in a subgroup of patients. Complete histologic
evaluation of the resected PD specimens is important for
prognosis in patients with PDAC who underwent PD. More
aggressive therapeutic approaches that target locoregional
disease such as neoadjuvant radiation therapy may be benRESULTS: Of the 124 patients, the resection margins were eficial in patients with close surgical margins.
positive (R1) in 30 (24%) and negative (R0) in 94 patients
(76%) including 38 patients (31%) with an R0-close resec- Tu1570
tion. Patients with R1 resections had an unfavorable survival compared with those with R0 resections (median, 18 Surgical Management of Pancreatic Neuroendocrine
vs 35 months; P < 0.01), but survival with R0-close margin Tumors: A Single Institution Experience
were comparable to R1 resections: but both groups had a Jeff Kim, Aram N. Demirjian, David K. Imagawa
significantly shorter survival than patients with R0-wide Surgery, University of California-Irvine, Orange, CA
margins (18 vs 32 vs 44 months, respectively; P = 0.02).
Disease-free survival was shorter in R1/R0-close margins INTRODUCTION: Pancreatic neuroendocrine tumors
comparing to R0-wide group (median, 12 vs 19 months; P (PancNET) are a comparatively rare, diverse group of neo= 0.04). By multivariate analysis, predictors of R1/R0-close plasms that account for 1–3% of all pancreatic tumors.
margins were patients underwent portal vein resection and While surgery is clearly the first line therapy for patients
larger tumor size of greater than 20-mm. The pattern of with disease amenable to resection at any stage of presentatumor recurrence had a greater rate of regional metastases tion, there are currently many surgical options. Due to both
in the R1/R0-close margins group comparing to patients the diversity and rarity of the disease, there are limited data
on different surgical outcomes and thus no clearly estabwith R0-wide margins (48% vs 14%; P = 0.01).
lished guidelines supporting one surgical management
option over another exists.
OBJECTIVE: To identify differences in surgical outcomes of
PancNET patients treated with various surgical approaches
that may contribute to better management decisions in
these patients.
204
PARTICIPANTS: Retrospective study of forty-four patients
with histologically confirmed diagnosis of pancreatic neuroendocrine tumor, surgically evaluated at the University of
California Irvine Medical Center (UCI-MC) between January 2003 and August of 2012. Surgical procedures included
both traditional radical resections, such as a Whipple’s procedure, total pancreatectomy and distal pancreatectomy
with splenectomy, as well as organ sparing procedures,
such as distal/segmental pancreatectomy without splenectomy and enucleation. These procedures were performed
via open, laparoscopic, hand-assisted laparoscopic and
robotic assisted approaches. AJCC criteria were used for
tumor staging.
RESULTS: Definitive surgical intervention were aborted
in four patients with metastatic disease during laparoscopy
due to deemed marginal surgical benefit and were excluded
Tumor Stage
IA
IB
II
III
IV
Total
Enucleation
2
0
0
0
0
2
from further analysis. All other patients received definitive
surgical intervention with margin free resection of local
tumor. In one case of enucleation, patient was subsequently
taken back for distal pancreatectomy with splenectomy after
surgical pathology showed positive margins. There was one
Stage IV patient with metastatic liver disease who received
cytoreductive surgery along with regional adjuvant procedures for liver lesions. All 40 patients are still currently alive
with median follow-up of 55.9 month from date of surgery.
One patient who presented with Stage IIB disease recurred
with hepatic disease at 4 months.
CONCLUSION: This data suggests achieving margin free
resection of local tumor regardless of tumor stage, surgical
method and approach leads to excellent 5 year survival rate
with progression free disease.
Distal Pancreatectomy
with Splenectomy
13
6
2
0
1
22
Distal Pancreatectomy
3
1
0
0
0
4
Total Pancreatectomy
0
0
1
0
0
1
Whipple
3
2
3
3
0
11
evidence of new lesion 10 patients were received additional
loco-regional therapy including 4 resections (2 straightforward, 2 after CRT), 6 CRT with S1. With a median follow up
of 17.3 months (7.4–27.2 months) all 10 chemo-responder
with additional loco-regional therapy are alive, while a
median survival time for 13 non-responders was 8.7 months
(Figure 1). Pathologic response of 4 responders with surgical
resection was 50%, 85%, 90%, 90%, respectively.
Tu1571
Role of Additional Loco-Regional Therapy for LongTerm Chemo-Responder by Gemcitabine with S1 for
Advanced Pancreatic Cancer: A Pilot Study
Keita Wada1, Keiji Sano1, Hodaka Amano1, Fumihiko Miura1,
Naoyuki Toyota1, Yoshiko Aoyagi1, Koji Takeshita3,
Fukuo Kondo2, Tadahiro Takada1
1
Surgery, Teikyo University, Tokyo, Japan; 2Pathology, Teikyo
University, Tokyo, Japan; 3Radiology, Teikyo University, Tokyo, Japan
BACKGROUND: Recent advances in adjuvant therapy
in pancreatic adenocarcinoma (PDAC) prolong survival
and increasingly come to encounter long-term chemoresponder without developing new lesions. Is loco-regional
therapy such as chemoradiotherapy and/or surgical resection valid for those patients?
205
Tuesday
Poster Abstracts
METHODS: Since April 2010 twenty-eight patients with
advanced PDAC (17 locally-advanced, and 11 metastatic)
were treated by Gemcitabine with S1 (GS) as a first-line
anti-cancer therapy. Reevaluation was performed at 3- and
6-month after administration of GS therapy and locoregional therapy was considered if new lesions were not
developed. Survival was compared between subgroups
according to clinical response and additional loco-regional
therapy. Pathologic response was investigated among those
CONCLUSION: Although non-randomized data with short
with surgical resection.
follow-up period, additional loco-regional therapy for longRESULTS: GS therapy was feasible with limited toxicterm chemo-responder by Gemcitabine with S1 seems feaity. Clinical response of GS was no CR, 7 PRs (25%), 8 SDs
sible option for advanced PDAC.
(29%), and 13 PDs (46%), accounting response rate of 25%
and disease control rate of 54%. Among 15 patients without
Tu1573
CONCLUSIONS: Metal stents should be considered initially in patients with malignant biliary obstruction
from borderline resectable pancreatic cancer undergoing
extended neoadjuvant chemotherapy due to a decreased
rate of complications and increase in patency.
A Comparative Analysis of Plastic Versus Metal
Endoscopic Biliary Stents in Borderline Resectable
Pancreatic Cancer Patients Undergoing Extended
Neoadjuvant Chemotherapy
Tu1574
Rachel E. Heneghan1, John B. Rose1, Adnan Alseidi1,
Thomas R. Biehl1, Ravi Moonka1, Flavio G. Rocha1,
John A. Ryan1, S. Ian Gan2, Michael Gluck2, Shayan Irani2,
Andrew S. Ross2, Vincent J. Picozzi3, Richard A. Kozarek2,
Scott Helton1
1
Surgery, Virginia Mason Medical Center, Seattle, WA;
2
Gastroenterology, Virginia Mason Medical Center, Seattle, WA;
3
Hematology/Oncology, Virginia Mason Medical Center, Seattle, WA
Plasma Cancer Antigen 19-9 (CA19-9) Levels
Differentiate Patients with Intraductal Papillary
Mucinous Neoplasm (IPMN) Carcinomas from Those
with IPMN Alone
BACKGROUND: Endoscopic biliary stenting is widely
accepted as a treatment for malignant biliary obstruction
from pancreatic cancer. While it is well-established that
patency with metal stents is superior to plastic stents in
patients with malignant biliary obstruction, their relative
clinical efficacy in patients with borderline resectable pancreatic cancer undergoing extended neoadjuvant chemotherapy (>6 months) is unknown. We hypothesized that in
this patient population, initial metal stent placement for
malignant biliary obstruction is associated with a decreased
incidence of biliary complications compared to plastic
stents.
METHODS: All patients with biopsy-proven borderline
resectable pancreatic cancer by AHPBA/SSO consensus
criteria were identified prospectively over a 4-year period
(2008–2012). Patients who did not require biliary stenting were excluded from analysis. A retrospective review of
all stented patients was performed. Patient demographics,
stent history, complications, need for exchange, and time
to operation were analyzed.
RESULTS: Of the 62 patients with borderline resectable
pancreatic cancer, 40 (65%) required preoperative endoscopic biliary stenting for malignant obstruction. Twentyfive of the 40 patients (63%) had plastic stents placed
initially. Twenty-one of the 40 patients (53%) were initially
stented at an outside hospital. Complications requiring
stent exchange (cholangitis, pancreatitis, abscess, cholecystitis, biliary obstruction) occurred significantly more often
in patients with initial plastic stents (76% vs. 13.5%; p =
.001). Mean functional stent time (defined as time from
placement to exchange, resection, or death) was significantly longer in the metal stent cohort (363 vs. 176 days;
p = 0.015). There was no statistical difference in patient
age, sex, tumor size, time to resection, resectability between
metal and plastic stent cohorts. The occurrence of stentrelated complications did not impact resectability.
Daniel Joyce, Gavin A. Falk, Kevin M. El-Hayek,
Sricharan Chalikonda, Gareth Morris-Stiff, Matthew Walsh
Cleveland Clinic Foundation, Cleveland, OH
INTRODUCTION: Invasive adenocarcinoma is a recognized complication of IPMN in particular when the disease affects the main pancreatic duct, however, invasive
carcinoma or high grade dysplasia (HGD) are often only
recognized during histopathological examination of resection specimens. CA19-9 is frequently used in the diagnostic
work-up of pancreatic adenocarcinoma but has not been
well-investigated in IPMN, whereas carcinoembryonic antigen (CEA) is routinely evaluated. The aim of this study was
to evaluate the role of CA19-9 in differentiating between
IPMN carcinomas, IPMN with high-grade dysplasia (HGD)
and IPMN with low/moderate (LGD&MGD) dysplasia.
METHODS: The departmental pancreatic cyst database was
interrogated to identify all patients with a histopathological diagnosis of IPMN. Patients were sub-divided into three
categories based on the degree of neoplastic change: IPMN
carcinoma; IPMN HGD; and IPMN LGD&MGD. Ca19-9 levels were assessed in relation to the 3 categories.
RESULTS: During the period January 2000 to December
2011, 121 patients underwent pancreatic resection for
IPMN. The post operative diagnoses consisted of: IPMN
[n = 41] carcinoma, IPMN HGD [n = 18]; and IPMN LGD/
MGD [n = 62]. 58.3% of patients with IPMN carcinoma
and 18.8% of patients with HGD had an elevated CA19-9,
whereas 9.3% of those with IPMN LGD/MGD had elevated
levels (see Table 1). The sensitivity and specificity of CA 19-9
for IPMN carcinoma or HGD in this group was 58.3% and
88.14% respectively (see Table 2). Overall, of 28 patients
with a CA19-9 above the limit of normal [that being 37
IU/L], 24 (85.7%) had an associated carcinoma or HGD.
206
RESULTS: A total of 820 patients underwent DP, of which
147 (18%) had a pancreatic leak. Leaks were classified as
Median
Percentage
Grade A, B, and C in 57%, 42%, and 1% respectively. The
Number
CA19-9 (IQR)
> ULN
median age at the time of surgery was 59 years (Range
IPMN carcinoma
41
50 (13–136)
58.3%
15–90 years) and 53% were males. Clinical characteristics of
IPMN HGD
18
20 (11–51)
18.8%
patients with regard to age, sex, BMI, smoking status, benign
IPMN LGD/MEG
62
18 (9–25)
9.3%
or malignant disease, diabetic status, or blood transfusion
IQR = Inter-quartile range; ULN = Upper limit of normal
did not differ significantly among the grades of pancreatic
leak. Intra-operative administration of hetastarch was associated with CSL (p = 0.045). The pancreas was transected
Table 2
using the stapler in 51.9%, electrocautery 34.6%, ultrasonic
IPMN Carcinoma/HGD
IPMN carcinoma
scalpel 8.4%, saline coupled radio frequency ablation (RFA)
Sensitivity
58.3%
46.25%
3.17% and scalpel 1.8%. The visible pancreatic duct and/
Specificity
88.14%
90.7%
or parenchyma were oversewn in 73%. In 21.6%, pancreatic stump was treated with the RFA device. Clinically sigPositive likelihood ratio
4.92
4.96
nificant leak was seen in 3.4% of patients whose pancreas
Negative likelihood ratio
0.47
0.59
was transected with a stapler and oversewn versus 15.3%
Positive predictive value
37.89
54.74
of patients in whose pancreas was stapled. Patients whose
Negative predictive value
75.00
85.71
pancreas was transected using the scalpel or an energy
CONCLUSIONS: CA19-9 would appear to be a useful test device and treated with RFA had a 13.3% CSL rate. Panin the assessment of IPMN and the identification of an ele- creas transected using a stapler and the stump treated with
vated level of this tumour marker indicates a significant risk RFA had a 19.2% CSL rate, whereas oversewing a pancreatic
of associated carcinoma or HGD, even if there is no radio- margin that had been treated with the RFA device had a
28.6% clinically significant leak rate. A patient with tranlogical evidence of cancer
sected margin treated with oversewn relative to a patient
whose pancreas transected with stapler and oversewn was
Tu1575
at highest risk for CSL [p = <0.001, OR 11.5 (CI 3.1–42.4)].
In univariate models, the use of the RFA device and overPancreatic Stump Leak After Distal Pancreatectomy:
sewing of the pancreatic duct were predictors of a CSL (p <
Predictors and Outcomes
0.05). On evaluating various modes of transection, there
1
1
2
Ashwin S. Kamath , Florencia G. Que , William S. Harmsen ,
was interaction of RFA with oversewing and stapling with
1
1
1
Saada A. Seidu , Dilpreet Singh , Christian Arroyo Alonso
oversewing of the pancreatic stump (p < 0.001)].
1
General Surgery, Mayo Clinic, Rochester MN, Rochester, MN;
CONCLUSION: Among various methods available for pan2
Biomedical Statistics and Informatics, Mayo Clinic, Rochester MN,
creatic transection during DP, many of them recent techRochester, MN
nologies, none have a clinical superiority. Using the stapler
INTRODUCTION: Clinically significant pancreatic leak to transect the pancreas has a higher rate of clinically sigcontinues to complicate distal pancreatectomies (DP). We nificant leak as compared to treating the transected stump
report the outcomes of various methods of pancreatic tran- with RFA. Using the RFA device in addition to a stapler or
section and management of the pancreatic stump at our oversewing the transected margin has a higher rate of cliniinstitution.
cally significant leak and should not be attempted. RanMETHODS: Retrospective review of all patients undergo- domized trials of newer technologies to help solve this age
ing DP from 01/1999 to 07/2010. Leaks were retrospectively old dilemma are necessary.
classified according to the strict ISGPF guidelines. Grade B
and C leaks were grouped as clinically significant (CSL).
Table 1
Tuesday
Poster Abstracts
207
Tu1576
predictor of complications and early mortality for patients
undergoing surgical operations. The Surgical APGAR was
initially found to correlate with major complications following pancreaticoduodenectomy; however, this study
refutes these findings. Herein, we show that the Surgical
APGAR does not predict major morbidity or mortality for
patients undergoing pancreaticoduodenectomy for pancreatic adenocarcinoma. Still, intuitively, patients benefit
from short operations without hemodynamic instability
and blood loss or transfusions.
Surgical APGAR Score Does Not Predict
Morbidity and Mortality for Patients Undergoing
Pancreaticoduodenectomy for Pancreatic
Adenocarcinoma
Paul Toomey, Sharona B. Ross, Charles Tkach,
Nicholas J. Sarabalis, Kenneth Luberice, Kaulin Jani,
Alexander Rosemurgy
INTRODUCTION: The Surgical APGAR was published
in 2007 as a simple method for predicting postoperative
morbidity and mortality for patients undergoing General
Surgery operations. The Surgical APGAR consists of three
objective measures of an individual’s intraoperative course:
the lowest heart rate, the lowest mean arterial blood pressure (MAP), and the estimated blood loss (EBL). The Surgical
APGAR was shown to predict major morbidities for patients
undergoing pancreaticoduodenectomy; the purpose of
this study was to validate that the Surgical APGAR predicts
major morbidity and mortality for patients undergoing
pancreaticoduodenectomy for pancreatic adenocarcinoma.
Tu1577
Rectus Abdominis Atrophy After Ventral Abdominal
Incisions: Midline Versus Chevron
Yalini Vigneswaran, Mark Talamonti, Steve Haggerty,
John G. Linn, Woody Denham, Mathew Zapf, Joann Carbray,
Michael B. Ujiki
Surgery, NorthShore University HealthSystem, Evanston, IL
PURPOSE: To investigate rectus atrophy after abdominal
surgery through a midline versus Chevron incision.
METHODS: Patients who underwent pancreaticoduodenectomy for pancreatic adenocarcinoma from 1991–
2012 are prospectively followed. Anesthesia records were
reviewed and the lowest heart rate, lowest MAP, and the
EBL of the operations were recorded. The Surgical APGAR
scores were calculated using the proposed algorithm. Major
morbidities were classified using Clavien scores and the
in-hospital mortality was assessed. Data are presented as
median, mean ± standard deviation. Correlations were calculated using logistic regression analysis and p-values <0.05
were considered significant.
METHODS: We performed a retrospective analysis of all
patients that underwent open pancreaticobiliary surgery at
our institution between 2007 and 2011. Of the 210 patients
included in the study, 180 underwent an operation through
a midline incision and 30 through a Chevron incision. The
two groups were defined by patient demographics, preoperative albumin, diagnosis, type of operation and adjuvant
therapies. We measured rectus abdominis muscle thickness
on preoperative and follow-up CT scans to calculate percent atrophy of the muscle after surgery. We additionally
recorded incisional hernias as reported by the radiologist
on the postoperative CT scan.
RESULTS: 392 patients underwent pancreaticoduodenectomy for pancreatic adenocarcinoma. The median lowest
heart rate was 64, 64 ± 10.5, the median lowest MAP was 64
mmHg, 63 mmHg ± 7.9, the estimated blood loss was 500
bpm, 650 bpm ± 601.3, and the Surgical APGAR was 6, 6 ±
1.4. The lowest heart rate, lowest MAP, or EBL did not independently or in combination correlate with Clavien scores.
There was no correlation between Surgical APGAR and Clavien scores (Table: p = NS) or mortality.
RESULTS: The two groups, midline and chevron, had
patient populations of similar characteristics with average
follow up of 18.1 and 24.5 months respectively. The midline group demonstrated significantly less average rectus
atrophy, 2.90% compared to the chevron group with 21.8%
atrophy (p < 0.001). Additionally there was no statistical
difference between the number of incisional hernias on
CT scan for the midline group, 8.33% versus 6.67% in the
chevron (p = 0.76).
CONCLUSIONS: Pancreatic cancer is the fourth leading
cause of cancer death in the United States and has the
highest fatality rate. Complications with pancreaticoduodenectomy for pancreatic adenocarcinoma remain high
and contribute to poor survival. Scoring systems to predict
complications after surgical intervention have been developed but have been cumbersome to calculate, inaccurate,
and impractical. The introduction of the uniquely simple
Surgical APGAR provided hope for a practical prospective
CONCLUSIONS: Patients who underwent an open operation through a midline incision demonstrated significantly
less atrophy as compared to those patients who underwent
an operation through a Chevron incision. This resulting
atrophy is most likely secondary to the disruption of the
intercostal nerves and innervation to the rectus abdominis
with Chevron incisions, which is avoided during midline
incisions. Additionally our results showed there was no significant difference between the groups for other morbidities
such as incisional hernias. Thus from our experience a midline incision is associated with less postoperative changes
and should be the preferred abdominal incision. Additional
studies may be conducted to further evaluate the morbidity
associated with rectus abdominis atrophy.
208
Tu1578
The Incidence of Pancreatic Fistula Following Distal
Pancreatectomy for Cancer Rises with Increased
Manipulation of the Pancreatic Remnant
8Tu1579
Nursing Homes: No Place for Bowel Obstructions with
Hernias
Alan A. Thomay1, Victor H. Barnica2, James C. Watson1,
Karen Ruth1, John P. Hoffman1
1
Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA;
2
Surgery, Mercy Health Medical Center, Philadelphia, PA
INTRODUCTION: Recent advances in operative technique and post-operative care have resulted in low mortality following distal pancreatectomy (DP). However, rates of
pancreatic fistula (PF) remain as high as 40%. This study
was performed to determine trends for pancreatic remnant closure and identify potential risk factors for PF at our
institution.
METHODS: Data from every patient undergoing DP from
2007 to present were retrospectively reviewed. Primary outcome was PF, classified according to ISGPF. Other variables
included patient demographics, neoadjuvant therapy, operative details, complications, and pathologic examination.
Differences in variables by PF status were assessed with Chisquare, Fisher exact, and t-tests as appropriate. A p-value
< .05 was considered significant.
Justin Lee, Peter E. Miller, Allan Mabardy, Alan W. Hackford,
Kevin O’Donnell
Surgery, St. Elizabeth Medical Ceneter, Tufts University School of
Medicine, Boston, MA
INTRODUCTION: Best practices encourage early diagnosis and treatment of bowel obstruction due to abdominal
wall hernias. Delay in care is associated with incarceration
and potential strangulation. The purpose of this study was
to compare outcomes of bowel obstruction due to abdominal wall hernias in elderly patients living in long-term care
facilities (LCF).
METHODS: The Nationwide Inpatient Sample for 2009
was used to identify hospitalizations due to bowel obstruction with abdominal wall hernias (age > 65). Outcomes
of gangrenous bowel and bowel resection were compared
based on whether the patients were transferred from LCF.
Economic analysis included length of stay (LOS) and total
hospital charges (THC). Multivariate logistic regression
RESULTS: 89 patients underwent DP during the study analysis was used to identify independent risk factors for
interval, 79% of which had pathologically confirmed gangrenous bowel or bowel resection.
malignancy with the most common being pancreatic ductal (21%) and renal cell (17%). Mean age was 61 years, 79% RESULTS: 30,828 bowel obstruction with hernia cases were
were Caucasian, 50% were male, and 1/3 were obese (BMI > identified. Patients living in LCF were more likely to pres30). Only 25% received chemotherapy and 11% radiation. ent with gangrenous bowel (5.8% vs 2.2%, OR 2.734, P =
Operatively, 74% had concomitant splenectomy, 48% had 0.008). LCF patients were also more likely to require bowel
at least one other procedure, and 95% had a drain. Pan- resection (24.5% vs 15.7%, OR 1.750, P = 0.003). Mortalcreatic transection was accomplished by: electrocautery ity was significantly higher for the LFC patients (13.0% vs
alone (12.4%), transection and oversewn (39.3%), stapled 3.7%, OR 3.906, P < 0.001). Gangrenous bowel or bowel
(36.0%), stapled and oversewn (12.4%). Mean hospital resection resulted in increased median LOS (9 days vs 4
length of stay was 8.3 days, but increased by 3 full days if days) and mean THC ($88,611 vs $44,987, P < 0.001). MulPF was present (10.2 vs 6.9 days). Overall PF rate was 43%, tivariate logistic regression analysis adjusting for Medicare
with 2/3 requiring percutaneous intervention. PF rate was coverage, poorest median income, urban location, psychino different in the electrocautery alone (37.1%), transec- atric disorders, and depression found LCF residence to be
tion and oversewn (36.4%), and stapled (40.6%) groups. an independent risk factor for gangrenous bowel or bowel
However, the rate of PF was nearly double in the stapled resection (OR 2.766, P < 0.001).
and oversewn cohort (72.7%) with no difference if omen- CONCLUSION: Patients with bowel obstruction due
tum was used to cover the remnant.
to abdominal hernias living in LCF are at a significantly
CONCLUSIONS: The ideal closure method for the pancre- increased risk of developing gangrenous bowel and requiratic remnant following DP remains unknown. These data ing bowel resection. Potential delay in diagnosis may condemonstrate that PF incidence rises with increased manipu- tribute to delay in presentation resulting in significant
lation of the pancreatic remnant. Thus, when utilizing a morbidity and mortally.
stapled closure, separate ligation of the pancreatic duct
should be avoided.
Tuesday
Poster Abstracts
209
Tu1580
Features of Patients Undergoing Re-Exploration
Early Post-Operative Small Bowel Obstruction: Open vs. Features
Active malignancy
Laparoscopic
Naeem Goussous, Kevin M. Kemp, Michael P. Bannon,
Michael L. Kendrick, Boris Srvantstyan, Martin D. Zielinski
OBJECTIVE: The window for safe re-operation in early
post-operative (<6 weeks) small bowel obstruction (SBO)
is short and intimately dependent on elapsed time from
the initial operation. Laparoscopic procedures create
fewer inflammatory changes than open laparotomies. We
hypothesize that it is safer to re-operate for early SBO after
laparoscopic procedures than open.
METHODS: Review of patients who underwent exploration for early post-operative SBO from 2003 to 2009 at a tertiary referral center. Based on the initial operation, patients
were classified as ‘open’ or ‘laparoscopic’. The Revised
Accordion Severity Grading System was used to define complications as minor (1–2) or severe (3–6). P < 0.05 was considered significant.
RESULTS: There were 189 patients (age 55 years, 48%
male); 130 open and 59 laparoscopic. Adhesive disease was
the most common cause of early SBO with the open group
having the greatest rate (tables 1 and 2). The open group
also had a greater rate of malignancy, days to re-operation,
severity of complications, length of stay after re-operation
(LOS) and persistent SBO at 6 weeks. There was no difference in the rates of minor complications, enterotomy,
strangulation, re-reoperation, enterocutaneous fistula and
mortality. 25% of the laparoscopic procedures were successfully completed laparoscopically at the reoperation and
were more commonly caused by a focal source. 82 patients
(63 open, 19 laparoscopic) underwent reexploration ≥14
days. Within this subgroup, there were more severe complications (25% vs 5%) after open procedures with equivalent
mortality (4% vs 0%).
Causes for Early Post-Operative SBO
Early Post-Op
SBO Cause
Adhesive
External hernia
Internal hernia
Stricture
Volvulus
Malignant
Open n = 130
65%
16%
8%
5%
5%
1%
Lap n = 59
42%
27%
10%
14%
7%
0%
P
<0.01
0.08
0.57
0.03
0.54
0.34
Days to reoperation
Severe complications
Minor complications
Re-reoperation
Mortality
Days after reoperation
Persistent SBO at 6 weeks
Focal cause of obstruction
Strangulation obstruction
EC Fistula
Enterotomy
Open n = 130
42%
13
24%
18%
6%
5%
10
8%
63%
2%
2%
7%
Lap n = 59
12%
10
10%
23%
7%
0%
9
0%
85%
7%
0%
12%
P
<0.01
0.02
0.03
0.40
0.87
0.09
0.02
0.03
<0.01
0.21
0.24
0.44
CONCLUSION: Initial laparoscopic approaches confer a
lower rate of adhesive disease and severity of complications
compared to open when operating for early post-operative
SBO. Reoperation should be undertaken prior to 14 days,
particularly after open procedures, as the complication
severity continues to increase as time elapses from the date
of initial operative intervention.
Tu1581
Laparoscopic Versus Open Surgical Management of
Small Bowel Obstruction: An Analysis of Short-Term
Outcomes
Fady Saleh1, Timothy Jackson1,2, Allan Okrainec1,2
1
General Surgery, University Health Network, Toronto, ON, Canada;
2
Surgery, University of Toronto, Toronto, ON, Canada
BACKGROUND: The application of laparoscopy in acute
care surgery continues to expand. Adhesive small bowel
obstruction has traditionally been managed via an open
approach although appropriately selected patients may
benefit from laparoscopy.
OBJECTIVE: The objective of this study is was to compare
short-term post-operative outcomes in patients with adhesive small bowel obstruction (SBO) treated laparoscopically
versus with laparotomy.
METHODS: Using the (2005–2010) ACS NSQIP Participant Use Files, patients with a post-operative diagnosis
of adhesive SBO were selected for inclusion in this study.
Patients were excluded if they had a bowel resection or
other concomitant procedures. Data on cases converted to
laparotomy was not available. Both univariate analyses and
multivariate logistic regression were performed to compare
the open and laparoscopic groups for 30-day morbidity and
mortality outcomes.
210
RESULTS: 4,760 patients with adhesive SBO were identified in the dataset: 3,847 (80.1%) treated with laparotomy,
and 919 (19.3%) via a laparoscopic approach. Mean operative time was similar in both groups. There were a total of
275 (7.2%) wound infections in the open group compared
to 6 (0.7%) in the laparoscopic group corresponding to an
OR (95% CI, P-value) of 11.7 (5.30–32.35, P < 0.001). The
mortality and overall complications were 87 (2.3%) and
877 (22.8%) in the open group compared to 7 (0.6%) and
91 (9.9%), with respective unadjusted OR 3.02 (1.40–7.76,
P = 0.003) and 2.70 (2.14–3.42, P < 0.001). Using our multivariate model, the adjusted OR for overall complications
was 2.27 (1.80–2.87, P < 0.001) favoring the laparoscopic
group. The mean post-operative length of stay was 8.4 days
after the open approach, compared to 3.8 after the laparoscopic approach (P < 0.001).
Table of 30-Day Post-Operative Complications
Complication
Wound
Infectious
Respiratory
Thromboembolic
Renal
Neurologic
Cardiac
Bleeding
Mortality
Major
Complications
Overall
Complications
Open N (%)
275 (7.2)
459 (12.0)
155 (4.0)
72 (1.9)
33 (0.9)
15 (0.4)
40 (1.0)
85 (2.2)
87 (2.3)
643 (16.7)
Laparoscopic
N (%)
6 (0.7)
53 (5.8)
10 (1.1)
7 (0.76)
0 (0.0)
3 (0.3)
6 (0.7)
6 (0.7)
7 (0.6)
81 (8.8)
Unadjusted
OR (95% CI)
P-Value
11.7 (5.30–32.35) P<0.001
2.2 (1.65–3.03) P<0.001
3.8 (2.01–8.16) P<0.001
2.49 (1.14–6.23) P = 0.018
N/A
P = 0.005
1.20 (0.34–6.46) P = 0.778
1.60 (0.67–4.64) P = 0.279
3.44 (1.51–9.68) P = 0.002
3.02 (1.40, 7.76) P = 0.0033
2.08 (1.62, 2.69) P<0.001
877 (22.8)
91 (9.9)
2.70 (2.14, 3.42) P<0.001
Tu1582
Laparoscopic Hand Assited Small Bowel Resection for
Carcinoid Tumor: Are Outcomes Equivalent to the
Open Technique?
Tarek Waked, Wael Khreiss, Florencia G. Que
INTRODUCTION: Small bowel carcinoids account for
42% of neuroendocrine tumors within the GI tract. The
finding of these tumors should be followed by an in-depth
search for additional primary tumors which may be found
in a third of patients. These can only be detected by close
inspection and palpation in many cases. Traditionally, laparoscopic resections are regarded as inadequate since they
negate the ability to evaluate the small bowel in a tactile
fashion and therefore carry the risk of incomplete resection
and missed primary tumors. Here we present a retrospective
review from a single institution by comparing laparoscopic
hand assisted (LHA) and open small bowel resection for carcinoid tumor.
METHODS: A retrospective review of 243 patients that
underwent either open or laparoscopic hand assisted small
bowel resection for carcinoid tumor between October 1999
and October 2010 was performed. The incidence of carcinoid
related postoperative diarrhea, mean number of tumors
resected, mean number of lymph nodes resected and
median disease free survival was compared between both
groups.
CONCLUSION: In patients where laparoscopy was feasible,
the laparoscopic approach resulted in significantly fewer
complications and shorter length of stay. This should be
interpreted within the context of a retrospective study with
inherent selection bias, inability to control for all patient
characteristics, and the inability to identify patients who
required conversion from the laparoscopic approach. Further work is needed to better define appropriate patient
selection criteria to guide the broader application of laparoscopy in the treatment of SBO.
RESULTS: A total of 243 patients were included in this
cohort: (225 open, 18 Laparoscopic hand-assisted). Median
follow up was 670 days. Mean number of resected primary
tumors was 3.4 and 5.3 for open and LHA, respectively
(p value = 0.03) . Mean number of resected lymph nodes
was comparable among the groups (11 for open and 14 for
LHA, p value = 0.23). Postoperative carcinoid related diarrhea was also comparable among both groups (open 49%,
LHA 61%, p value = 1.0). The 5 year disease free survival was
58.5% for the open group and 67.7% for the LHA group (p
value = 0.18). There was no statistical significance between
the groups in mean number of lymph nodes resected, postoperative diarrhea, or 5 year disease free survival, however,
there was a statistical difference in the mean number of
resected tumors favoring the LHA group.
CONCLUSION: Laparoscopic hand assisted small bowel
resection for carcinoid tumors is a safe alternative with
comparable outcomes to the open technique.
Tuesday
Poster Abstracts
211
Tu1583
Mortality Associated with Postoperative Bleeding
in Patients Undergoing Roux-en-Y Gastric Bypass: A
Nationwide Analysis over a Decade
Marwan Abougergi, Nitin Kumar, John R. Saltzman,
Christopher C. Thompson
Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA
INTRODUCTION: Bariatric gastric bypass surgery techniques have evolved over the past decade in an effort to
minimize complications. One serious immediate complication after Roux-en-Y gastric bypass (RYGB) is postoperative
bleeding. We examined the impact of postoperative bleeding on patient outcomes after RYGB and studied the trend
over the past decade.
METHODS: We used the Nationwide Inpatient Sample
(NIS) to calculate outcomes every 5 years from 2000 to 2010.
The NIS is the largest nationally representative publically
available inpatient database in the United States. Patients
were included if they had an ICD-9 CM code indicating
an open or laparoscopic RYGB. Exclusion criteria were age
<18, previous weight loss surgery, history of a GI malignancy, inflammatory bowel disease, infectious colitis, and
non-elective admission. Significant bleeding was defined as
ICD-9 CM code for packed red blood cell transfusion postoperatively. Bleeding-related endoscopy rate was defined as
the difference in percent endoscopy between patients with
and without postoperative bleeding. Additional length of
stay and additional charge were defined as the difference in
median length of stay and charge, respectively, between the
patients with and without postoperative bleeding. Charge
was adjusted for inflation using the consumer price index,
and is presented in 2010 US dollars. Comorbidities were
identified using the Charlson comorbidity index.
RESULTS: The incidence of RYGB increased markedly
from 2000 to 2005, and then stablized from 2005 to 2010.
The proportion of laparoscopic RYGB has increased from
0% in 2000 to 90% in 2010. Although the mean age has
remained consistent, age distribution has broadened over
time, and the comorbidity burden has grown. Over time,
the proportion of surgeries done at teaching or urban hospitals decreased. Postoperative bleeding rate increased by
33% between 2000 and 2010, as did the bleeding-attributable risk of shock. However, bleeding-attributable mortality
decreased over time, as did the rate of endoscopy and reoperation for bleeding. Additional length of stay secondary to
postoperative bleeding has decreased over time; however,
total length of stay and total financial burden related to
postoperative bleeding have increased steadily and in 2010
they were 3681 person-days and $37 million, respectively
(Table 1).
2000
2005
2010
Number of RYGB Surgery
Any RYGB
23,697
88,571
71,199
Open RYGB
100%
27%
10%
Laparoscopic RYGB
0%
73%
90%
Median age (IQR)
41 (33–48)
42 (34–51)
44 (35–53)
Female
84%
82%
79%
Charlson
0: 67% 1: 25% 2: 5% 0: 57% 1: 34% 2: 7% 0: 50% 1: 37%
comorbidity index
2: 10%
Teaching hospital
79%
55%
58%
Urban hospital
98%
97%
92%
Any RYGB
Postoperative Bleeding
1.8% (426 patients) 2.2% (1956 patients)
Open RYGB
1.8% (426 patients)
3.1% (751 patients)
—
1.9% (1209 patients)
Laparoscopic RYGB
2.4% (1681
patients)
5.6% (412
patients)
2.0% (1269
patients)
1.9%
Bleeding-attributable
4.1%
1.64%
risk of death
0.0%
1.8%
2.0%
risk of shock
Reoperation for
26.6%
14.8%
6.8%
bleeding
Endoscopy for
5.0%
8.9%
3.5%
bleeding
3.1 1325
2.1 4010
2.2 3681
LOS (median, days):
LOS (patient-days):
Bleeding-attributable Median: $34,722 Median:$17,191 Total: Median:
hospitalization
Total: $14,791,572
$33,625,596
$22,104 Total:
charge (Indexed
$ 37,156,824
to 2010 USD)
CONCLUSION: The number of patients undergoing RYGB
has substantially increased from 2000 to 2005, and has since
stabilized. The postoperative bleeding rate has increased
substantially since 2000, but bleeding-attributable mortality, rate of endoscopy and rate of reoperation for bleeding
has decreased. The total length of stay and financial burden of postoperative bleeding in patients undergoing RYGB
continue to increase.
212
Tu1584
Tu1585
Minimally Invasive Approach to Small Bowel
Resection: An Opportunity for Improved Patient
Outcomes and Mortality Based Upon the ACS-NSQIP
Database
Laparoscopic vs. Open Recurrent Inguinal Hernia
Repair: A NSQIP Analysis
Karen E. Gibbs
Andrew M. Popoff, Shaun Daly, John D. Cull,
Amanda B. Francescatti, Louis Fogg, Jonathan Myers,
Keith W. Millikan, Steven D. Bines, Minh B. Luu
PURPOSE: Small bowel resection is a commonly performed surgical procedure for both benign and malignant
disease. The advantages of laparoscopic versus open surgery
are well established in the literature; however, a majority
of small bowel resections are performed using an open
technique. To date, no study has reviewed the ACS-NSQIP
database to determine the utilization of laparoscopy for
small bowel resection nationally. The purpose of this study
is to determine the incidence of laparoscopic small bowel
resection and to compare the safety of a minimally invasive
technique to an open technique.
OBJECTIVES: Inguinal hernia recurrence after surgical
repair is still a rather common occurrence in large published series. Current data indicates rate of recurrence ranging 0.2–10%. The optimal approach for repair of a recurrent
inguinal hernia is still in question.
We sought to query the NSQIP database to ascertain the
national trends in the approach to recurrent non-obstructed
inguinal hernias.
METHODS: The NSQIP database was queried for laparoscopic or open recurrent inguinal hernia repair from 2007
to 2009. Age, gender and comorbidities were quantified and
outcomes data collected. Specifically, morbidity, mortality,
length of stay and operative times were examined. Statistical analysis was then performed. A p-value of <0.05 was
METHODS: A retrospective, cohort study was performed considered significant.
comparing patients undergoing a minimally invasive small RESULTS: A total of 3874 patients were identified who
bowel resection to an open technique. Patients were identi- were diagnosed with recurrence of inguinal hernia, out
fied utilizing a CPT code driven search of the ACS-NSQIP of which 2692 underwent open hernia repair, while 1182
database between 2007 and 2011. Demographic charac- underwent laparoscopic repair.
teristics and postoperative complications were evaluated
Open Repair Laparoscopic Repair
between the two groups. Univariate analysis was performed
N = 2692
N = 1182
P-Value
with significance defined as a p-value ≤ 0.05.
CONCLUSION: Despite the advantages of minimally
invasive surgery, a large majority of operations for the
resection of small bowel are performed via a traditional
open approach. This discrepancy is likely not explained
entirely by patient factors. The data suggest an opportunity for improved patient outcomes and improved mortality rates with widespread adoption of minimally invasive
approaches to small bowel resection.
Age
Male gender
Diabetes on Insulin
HTN
COPD
CHF in 30 days
History of MI in 6 months
Prior PCI
Prior CABG
PAD
ESRD
Smoker
Steroid use
Partially Dependent
Totally Dependent
BMI
ASA III or above
60.4 ± 15.7
2539 (94.3%)
40 (1.5%)
1111 (41.3%)
97 (3.6%)
6 (0.2%)
4 (0.1%)
182 (6.8%)
208 (7.7%)
23 (0.9%)
20 (0.7%)
502 (18.6%)
42 (1.6%)
28 (1.0%)
4 (0.1%)
26.2 ± 4.2
46 (1.7%)
57.1 ± 14.9
1117 (94.5%)
10 (0.8%)
390 (33%)
21 (1.8%)
0
1 (0.1%)
49 (4.1%)
54 (4.6%)
5 (0.4%)
2 (0.2%)
206 (17.4%)
14 (1.2%)
2 (0.2%)
1 (0.1%)
26.4 ± 4.3
12 (1.0%)
<.001
0.880
0.020
<.001
.002
0.187
1
0.001
<.001
0.215
.034
0.391
0.465
0.015
0.015
0.309
0.114
Superficial SSI
Deep incisional SSI
Pneumonia
Return to OR
UTI
MI
DVT
Operative time (min)
Length of stay (days)
Open Repair
N = 2692
9 (0.3%)
2 (0.1%)
2 (0.1%)
24 (0.9%)
9 (0.3%)
1 (0%)
7 (0.3%)
65.7 ± 34
0.25 ± 0.91
Laparoscopic Repair
N = 1182
5 (0.4%)
1 (0.1%)
1 (0.1%)
8 (0.7%)
8 (0.7%)
0
0
72 ± 36
0.30 ± 1.6
P-Value
0.772
1
1
0.568
0.184
1
0.214
<0.001
0.281
213
Tuesday
Poster Abstracts
RESULTS: 19,344 patients underwent a small bowel resection. Of these patients, 1,719 (9%) underwent a laparoscopic small bowel resection and 17,625 (91%) underwent
an open resection. The mean age of patients in the minimally invasive group was 57.5 compared to 62.7 years in
the open group. A majority of patients undergoing small
bowel resection were female (54%) and of the patients who
underwent laparoscopic small bowel resection, 54% were
female. The mean body mass index in the minimally invasive versus open groups was 27.3 and 27.4, respectively.
There was a statistically significant lower rate of complications in the minimally invasive group (p = 0.001). In the
minimally invasive group, the risk ratio for a postoperative
wound infection compared to the open approach was 0.31
(0.24–0.40), for postoperative sepsis was 0.39 (0.28–0.53),
for postoperative septic shock was 0.24 (0.10–0.37), for
postoperative pneumonia was 0.36 (0.26–0.50), for postoperative myocardial infarction was 0.43 (0.22–0.8) and for
postoperative DVT requiring therapy was 0.31 (0.16–0.57).
The in-hospital 30-day mortality rate for a minimally invasive resection was 1.7% compared to 6.4% for an open
resection (p = 0.001).
CONCLUSION: It appears that 30% of recurrent inguinal
hernias were repaired laparoscopically. Both laparoscopic
and open approaches to repair of recurrent inguinal nonobstructed hernias have comparable profile of patient
population, safety and complications. The final choice of
surgical approach should be made based on the surgeon’s
preference.
Clinical: Stomach
RESULTS: In the third group—ketamine hydrochloride,
the average length of stay (ALOS) was 6 days, in the second
group—hospitalist, it was 6.5 days and in the first group—
non-hospitalist, ALOS was 10 days. There was no statistical difference for the adjunctive ketamine hydrochloride
group than the hospitalist service (p = 0.753) and but the
ketamine (and also as previously reported, the hospitalist)
were significantly lower than the non-hospitalist Surgery/
GI service (SOC) group (p = 0.010.) (See Table).
Ketamine
Tu1586
Adjunctive Ketamine Therapy May Help Reduce Length
of Stay in Selected Patients Undergoing Foregut Surgery
Shuja Yousuf2, Yana Nikitina2, Ike Eriator3, Kenneith Oswalt3,
Timothy J. Beacham3, Anand Prem3, Wanda J. Keahey6,
Archana Kedar2, Mubina Isani5, Thomas S. Helling4,
Christopher J. Lahr4, Thomas L. Abell1
1
Digestive Diseases, University of Louisville Medical Center, Louisville,
KY; 2Digestive Diseases, University of Mississippi Medical Center,
Jackson, MS; 3Anesthesiology, University of Mississippi Medical Center,
Jackson, MS; 4Surgery, University of Mississippi Medical Center,
Jackson, MS; 5Surgery, University of North Carolina, Chapel Hill, NC;
6
Medication Management Specialists Inc, Jackson, MS
BACKGROUND: We have previously reported that the
length of stay (LOS) for the postoperative elective gastric
electric stimulation (GES) for gastroparesis (Gp) patients is
reduced when admitted to a hospitalist service, campared to
traditional standard of care (SOC) Surgery/GI service. One
issue for prolonged LOS for postoperative Gp patients has
been post-operative pain and ketamine hydrochloride has
been shown, when used adjunctively, to assist in pain management. Since underlying chronic and pre-existant pain
often often is aoosciated with prolonged LOS in patients
undergoing surgical intervention for GES, we examined
whether the use of low dose ketamine hydrochloride could
further reduce LOS in gastroparesis (GP) patients undergoing GES placement.
METHODOLOGY: Using a pre-established and ongoing database, we examined three groups of patients, all
undergoing the identical operation for placement of gastric electrical stimulators: the first group–16 patients on a
combined Surgery/GI service with the use of adjunctive
ketamine hydrochloride, via an anesthesia based care protocol (the ketamine group): the second group–16 patients
receiving hospitalist service care post-operatively (hospitalist group), and the third group –16 patients on a combined
Surgery/Gastroenterology (GI) service receiving standards
of care (SOC) without the use of ketamine hydrochloride
(non-hosptalist group). Patients receiving ketamine hydrochloride were matched, by primary diagnosis and IDIOMS scores for health resource utilization (NGM 2005; 17:
35–43), with the other 2 groups. All data were analyzed by
group, reported as mean and standard deviation values, and
compared by student t-tests.
Patient Service
Non-hospitalist with ketamine
hydrochloride
Hospitalist service
Non-hospitalist service
Mean of LOS ± SD
6.0 ± 3.4
P Value
------
6.5 ± 5.3
10 ± 4.7
0.75
0.01
CONCLUSION: We conclude that adjunct low dose ketamine hydrochloride may reduce the length of stay in
patients with gastroparesis, many of who have a chronic
pain disorder, when undergoing foregut surgery.
Tu1588
Vitamin D Deficiency Is a Risk Factor for Persistent
Type 2 Diabetes After Roux-en-Y Gastric Bypass
Andrew A. Taitano, Brian Binetti, Tejinder P. Singh,
Avinash S. Bhakta
General Surgery, Albany Medical Center, Albany, NY
INTRODUCTION: A growing body of evidence links vitamin D deficiency to obesity as well as metabolic syndrome
and insulin resistance. Vitamin D deficiency and insufficiency is common in patients after gastric bypass surgery,
though little is known about its relationship to glycemic
control in this population.
METHODS: Between January 2005 and December 2011,
203 patients with type 2 diabetes mellitus (T2DM) underwent laparoscopic roux-en-y gastric bypass (LRYGBP) at our
institution. We retrospectively evaluated demographics,
hemoglobin A1C levels, 25-hydroxy vitamin D levels, and
medication lists.
RESULTS: Average age was 49.8, average duration of
T2DM was 7.9 years, 74.5% were women, and 89.2% of the
patients were caucasian. Average length of follow-up was
2.8 years. Postoperative pharmacologic therapy for T2DM
and/or hemoglobin A1c levels above 6.9 were seen in 24.7%
of patients at last follow-up. Postoperative vitamin D levels consistently under 30 ng/mL were seen in 13.0% of
patients. These patients were more than twice as likely to
have persistent T2DM at last follow-up (RR 2.24, CI 1.31 to
3.88, p < 0.01).
CONCLUSION: Postoperative vitamin D insufficiency and
deficiency is associated with persistence of T2DM after gastric bypass surgery. Aggressive supplementation with vitamin D may improve outcomes in these patients.
214
Tu1589
Tu1590
Endoscopic Management Options for Strictured Vertical Is There Optimal Surgery Time After Endoscopic
Banded Gastroplasty
Resection in Early Gastric Cancer?
Nathan E. Conway1, Lee L. Swanstrom2, Kevin M. Reavis2
Providence Cancer Center, Portland, OR; 2Gastrointestinal &
Minimally Invasive Surgery, The Oregon Clinic, Portland, OR
1
Da Hyun Jung1, Moo Jung Kim1, Jie-Hyun Kim1, Yong Chan Lee2,
Jong Won Kim3, Seung Ho Choi3, Woo Jin Hyung4, Sung Hoon Noh4,
Young Hoon Youn1, Hyojin Park1, Sang in Lee1
1
Department of Internal Medicine, Gangnam Severance Hospital,
Yonsei University College of Medicine, Seoul, Republic of Korea;
2
Internal Medicine, Yonsei University College of Medicine, Seoul,
Republic of Korea; 3Surgery, Gangnam Severance Hospital, Yonsei
University College of Medicine, Seoul, Republic of Korea; 4Surgery,
Yonsei University College of Medicine, Seoul, Republic of Korea
215
Tuesday
Poster Abstracts
INTRODUCTION: Vertical banded gastroplasty (VBG) is
a restrictive bariatric procedure performed by creating a
stapled proximal gastric pouch with a lesser curvature outlet, reinforced with a prosthetic band. Popular in the 1980s,
this procedure can result in a fixed outlet obstruction and
progressive pouch dilation over time. The standard method
of revision has traditionally been a complex and difficult
operation. We report our experience with endoscopic man- BACKGROUND/AIMS: Endoscopic resection (ER) is
being increasingly recognized worldwide as a major curaagement of strictured VBG.
tive option for selected cases of early gastric cancer (EGC).
METHODS: Three patients with previous VBG presented However, additive surgery is mandatory for the cases that
with persistent nausea and vomiting. All underwent pre- have undergone non-curative ER. The aim of this study was
operative workup demonstrating high-grade gastric pouch to evaluate the effect of the time interval between ER and
outlet obstruction. Endoscopic gastric band division was surgery on oncological safety and surgical outcomes.
planned for all patients. An endoscope was passed transorally and was used to identify the common wall between METHODS: We analyzed 154 patients who underwent
the gastric pouch and distal stomach; this was marked with additive gastrectomy after ER due to non-curative resection
a submucosal injection of blue dye to maintain orienta- between January 2007 and December 2011 at Severance and
tion. Using a combination of a needle knife cautery and Gangnam Severance Hospital. Patients were divided into 2
a pull type sphincterotome for both antegrade and retro- groups according to the median time interval between ER
grade approaches, an incision was made from the strictured and additive surgery such as group A (≤ 29days) and group
opening along the stapled common wall of the stomach. In B (>29 days). We retrospectively evaluated the clinicopathone case, the gastric band was unable to be divided in this ological characteristics, clinical outcomes, and operative/
manner, as it was probably polypropylene vs silastic. In this postoperative outcomes. We also analyzed subgroup which
case, an endoscopic gastrogastrostomy was performed from underwent gastrectomy by experienced surgeons. Expethe proximal pouch to the distal stomach, using the staple rienced surgeon was defined as surgeon with more than
line of the gastroplasty as a landmark. A second endoscope five years of surgical experience for gastrectomy in order to
was used to provide transillumination and improved visual- adjust surgeon’s experience factor.
ization, similar to the technique used in the creation of per- RESULTS: Of the 154 patients, 78 (50.6%) were in group A
cutaneous endoscopic gastrostomy tubes. An opening was and 76 (49.4%) in group B. There was no difference of clinimade by a direct puncture between the proximal pouch and copathologic characteristics and oncological recurrence
the distal stomach directly through the staple line using the except for tumor size (A: 2.49 ± 1.63 cm vs. B: 1.81 ± 1.16
needle knife. Using the dual endoscopes, we were able to cm, P = 0.002). Operation time (A: 222.41 ± 79.26 min vs.
visualize entry of the needle knife into the distal stomach B: 175.46 ± 71.88 min, P < 0.001), estimated intra-operative
across the common wall. This tunnel was dilated with a 12 blood loss (A: 152.21 ± 217.64 cc vs. B: 68.01 ± 164.16 cc,
mm endoscopic balloon over a wire followed by placement P = 0.007), time to start liquid diet (A: 3.27 ± 1.20 day vs.
of a 105 mm (length) by 23 mm (diameter) fully covered B: 2.70 ± 1.03 day, P = 0.002), post-operative hospital day
stent.
(A: 10.50 ± 9.37 day vs. B: 7.17 ± 4.49 day, P = 0.006), and
RESULTS: The procedure was well tolerated. Operative time of hemovac removal (A: 3.79 ± 3.17 day vs. B: 2.28 ±
time was between 35 and 135 min. Upper gastrointestinal 3.66 day, P = 0.007) were statistically different between two
contrast studies on the first postoperative day revealed reso- groups. There were no local recurrence and 3 cases of dislution of the outlet obstruction. All patients were discharged tant recurrence during follow-up period (A: 22.81 ± 14.55
within three days. The patients tolerated resumption of diet vs. B 30.61 ± 17.27, P = 0.003). The surgical time of 3 cases
and are doing well 6 weeks following the procedures. The was 8 days, 8 days, and 100 days after ER, respectively. The
results was also similar in subgroup which underwent gasstent was removed after 9 weeks without sequelae.
trectomy by experienced surgeons.
CONCLUSIONS: Endoscopic reversal of VBG is feasible
and safe. The material from which the band was fash- CONCLUSIONS: The time interval between ER and addiioned directly affected the ease and ability with which it tive surgery may be associated with operative and postwas divided; soft silastic was easy and polypropylene mesh operative outcomes though there is no association with
impossible to divide, which necessitated direct puncture oncological recurrence. A large-scale prospective study and
though the common gastric wall. The biliary sphinctero- long term follow-up should be necessary to recommend the
tome was well suited for the procedure and the use of two optimal surgery time after ER in EGC.
upper endoscopes permitted safe transillumination for the
procedure.
Tu1591
Tu1592
Duodenal Switch Provides Superior Intermediate-Term
Weight Loss Compared to Gastric Bypass in the SuperObese (BMI > 50 kg/m2)
Hand Grip Strength, Depression, Anxiety, and Stress in
a Bariatric Surgery Population
Marc A. Ward1, Yong Huang2, John C. Alverdy1,
Vivek N. Prachand1
1
Surgery, University of Chicago Medicine, Chicago, IL; 2University of
Chicago, Chicago, IL
Natalia Leva, Carl Dambkowski, Chris S. Crowe,
John M. Morton
BACKGROUND: Abnormal hand grip strength has been
associated with increased mortality and depressive/anxiety
OBJECTIVES: Although Roux-en-Y gastric bypass (RYGB) disorders. This study’s aim is to determine a relationship
is the most common bariatric operation performed in between hand grip strength, weight loss, BMI, comorbidithe U.S., recent data suggest inadequate weight loss rates ties, and depression, anxiety, and stress in a bariatric surapproaching 40% in super-obese patients (BMI > 50 kg/ gery population.
m2). We previously reported the first large single institu- METHODS AND PROCEDURES: Demographic, preop,
tion series directly comparing the short-term weight-loss and 3 month postop data were prospectively collected on
outcomes in super-obese patients following biliopancreatic 35 consecutive laparoscopic surgeries (18 roux-en-Y-gastric
diversion with duodenal switch (DS) and RYGB up to 3 years bypass, 15 sleeve gastrectomy, and 2 adjustable gastric
following the operation. Here we report an intermediate- band) at a single academic institution. At each clinic visit,
term analysis of this comparison up to 8 years after surgery. patients enrolled in the study participated in a hand grip
METHODS: All super-obese patients undergoing DS or strength test using a hand dynamometer. Participants also
RYGB between August 2002 to October 2005 were identi- filled out a Depression, Anxiety, Stress Scales (DASS) Survey
fied from a prospective database. Two sample t-tests were preoperatively and 3 months postop. Demographic, weight
used to compare weight loss, decrease in BMI, and excess loss, absolute hand grip strength, and hand grip as a perbody weight loss (EBWL) after surgery. Chi-squared analy- centage of established norms were compared to DASS scores
sis was used to determine the rate of successful weight loss by student t-tests and regression analyses using GraphPad
Prism6 software.
(EBWL > 50%) at all time points.
RESULTS: 350 super-obese patients [DS (n = 198), RYGB (n RESULTS: At 3 months postop, 74.3% of patients com= 152) were identified. There was an equal 30 day mortality pleted hand grip and survey tests. Patient demographics
between the two groups (DS, 1 of 198; RYGB, 0 of 152; P not included an average BMI 46.1, age 43.7, 52.6% white, and
significant). A total of 6 additional patients were excluded 3.9 total preoperative comorbidities. Major pre-op comorfrom the analysis (5 DS patients underwent revision due to bidities included hypertension 55.3%, diabetes 39.5%,
nutritional issues, 1 RYGB was converted to DS for insuf- hyperlipidemia 44.7%, sleep apnea 47.4%, and depression
ficient weight loss). There was a significantly lower BMI 26.3%. Average operative time was 134.2 minutes. Hand
following the DS procedure compared to the RYGB at all grip strength was maintained at 3 months postop despite
time points (4yr, 33 vs. 39; 5–6yr 33 vs39; yr7–8, 36vs 41). massive weight loss. No correlation was found between
Total weight loss and % EBWL were also statistically greater preoperative hand grip strength and percent excess weight
for the DS. In addition, the likelihood to achieve successful loss at 3 months (r2 = 0.0014; p = 0.42). Participants with
weight loss (EBWL > 50%) is significantly greater following hand grip strength below normal had lower operative times
the DS at all time points (4yr, 83% vs. 56%; 5–6yr 86% vs (111.2 ± 35.9) than those with hand grip strength above
normal (154.8 ± 43.3; p < 0.01). Moreover, a positive cor48%; yr7–8, 68% vs 22%).
relation was observed between adjusted preoperative hand
CONCLUSIONS: DS has superior intermediate-term weight grip strength and operative time, with greater adjusted
loss outcomes in the super-obese compared to the RYGB.
hand grip strength correlating with longer operative time
(r2 = 0.193; p < 0.01). BMI alone, however, was not correlated with operative time (r2 = 0.0262; p = 0.16). A relationship was observed between preop hand grip strength
and preoperative total DASS score, with weaker hand grip
correlating to higher (worse) DASS scores (p < 0.01). Furthermore, greater improvements in hand grip strength 3
months postop correlated with greater improvements in
DASS score (p < 0.01).
CONCLUSIONS: Hand grip had a positive relationship
with operative time independent of BMI. Greater hand
grip strength was correlated with lower DASS scores preoperatively and at 3 months postoperatively. Improvements
in hand grip strength were correlated with improvements
in DASS scores suggesting that bariatric surgery patients’
hand grip strength might be a marker for their psychological strength. Further investigation will reveal associations
between hand grip and longer-term weight loss and comorbidity improvement.
216
8Tu2131
The Clinical Utility of the Local Inflammatory
Response in Colorectal Cancer
Colin H. Richards1, Campbell S. Roxburgh1, Arfon G. Powell1,
Alan K. Foulis2, Paul G. Horgan1, Donald C. Mcmillan1
1
Department of Surgery, Glasgow University, Glasgow, United Kingdom;
2
Department of Pathology, University of Glasgow, Glasgow, United
Kingdom
BACKGROUND: The host immune response is important
in the prevention of tumour progression in solid organ
cancers but is not utilised in clinical practice. The aim was
to evaluate the clinical utility of the local inflammatory
response in patients with colorectal cancer.
METHODS: Three hundred and sixty-five patients with
primary operable colorectal cancer were included. The local
inflammatory response was assessed using three different methods; (1) individual immune cells (CD3 +, CD8 +,
CD45R0 +, FOXP3 + ); (2) a composite immunohistochemistry-based score (Galon Immune Score); (3) a histopathological assessment (Klintrup-Makinen grade). Relationships
with tumour and host characteristics were established and
the prognostic value of each method compared.
RESULTS: A strong infiltration of tumour infiltrating
lymphoctyes (TIL’s) was associated with improved cancer
specific survival. When specific T-cell subtypes were considered, CD3 + was the strongest predictor of survival at
both the invasive margin (CD3 + IM) and tumour stroma
(CD3 + ST) while CD8 + was the strongest predictor in the
cancer cell nests (CD8 + CCN). Infiltration of TIL’s was
associated with early tumour stage, an expanding growth
pattern and lower levels of venous invasion but was not
influenced by host characteristics or systemic inflammation. The Galon Immune Score and the Klintrup-Makinen
grade were strongly related to individual T-cell infiltration
and all three methods exhibited similar survival relationships in both node-positive and node-negative disease.
Figure 1: Kaplan-Meier survival curves demonstrating the cancer
specific survival of patients with primary operable colorectal cancer
according to the application of proposed immune scores. Clockwise from
top left; CD + IM, CD8 + CCN, K-M grade and the Galon Immune Score
(strong to weak infiltration are shown top to bottom).
CONCLUSION: A coordinated adaptive immune response
is an important factor in predicting outcome in patients
with colorectal cancer. By comparing different methodologies we have provided a foundation on which to develop a
standardised approach for assessing tumour inflammatory
cell infiltrate.
Tuesday
Poster Abstracts
217
value (NPV) for the mortality and bowel ischemia were analyzed. PASW Statistics 18 was utilized for statistical analysis.
Tu2132
Can Serum Lactate Predict the Outcome of Patients
Who Underwent Emergent Exploratory Laparotomy for
Acute Abdomen?
Kaori Ito, Cheryl Anderson, Marc D. Basson
Surgery, Michigan State University, East Lansing, MI
BACKGROUND: Serum lactate is a biomarker that predicts mortality in patients with non-cardiogenic circulatory
shock like sepsis or severe trauma. Some reports suggest
using the serum lactate to predict the prognosis in patients
with acute abdomen, but this is not well understood. We
hypothesized that the preoperative serum lactate level
can help to predict the postoperative outcome in patients
undergoing exploratory laparotomy for acute abdomen.
METHODS: Medical records of 293 consecutive patients
who underwent emergent exploratory laparotomy for acute
abdomen from 2007 through 2010 were reviewed. Patients’
demographics, preoperative laboratory tests including
white blood cell counts (WBC), serum lactate, postoperative diagnosis, Systemic Inflammatory Response Syndrome
(SIRS) Score, the American Society of Anesthesiologists
(ASA) physical status classification, postoperative in-hospital mortality were reviewed. These factors were compared
between patient who died in hospital after the exploration
and who survived, as well as between patients with bowel
ischemia and without bowel ischemia. Sensitivity, specificity, positive predictive value (PPV), and negative predictive
RESULTS: Two hundred and two patients who had
recorded preoperative serum lactate (s) were included in
the study. The preoperative serum lactate was checked only
once in 130 patients and more than once in 72 patients.
For patients with serial lactates, the trend over time was
recorded. Postoperative diagnoses were small bowel
obstruction (n = 67, 33%), large bowel obstruction (n = 44,
22%), bowel ischemia (n = 38, 19%), perforated gastric or
duodenal ulcers (n = 31, 15%), colonic perforation (n = 13,
6%), acute diverticulitis (n = 19, 9%), others (n = 21, 10%),
and negative exploration (n = 3, 1%). There were 34 (17%)
postoperative in-hospital mortalities (The median time
between surgery to death: 6.5 days [Range: 0–102]). All 3
patients who underwent negative laparotomy had a normal
serum lactate (s) preoperatively. As shown on Table 1, the
persistent abnormal or up-trending serum lactate was seen
more frequently in patients in who died in hospital after
exploration (53% vs 26%, p = 0.002); as well as, in patients
with bowel ischemia (46% vs 28%, p = 0.090) . The serum
lactate had the similar specificity and NPV to SIRS score,
ASA class and WBC; however, had the lower sensitivities
than other factors.
CONCLUSION: Normal or down-trending serum lactate
strongly predicts postoperative survival in patients who
undergo emergent exploratory laparotomy for acute abdomen, although persistently elevated serum lactate does not
necessarily predict mortality. It may be useful prognostic
information for patients and families if combined with
other factors.
Table 1
Mortality
Bowel Ischemia
No
Survived
Died
P value
Sensitivity, Specificity,
PPV, NPV
No
Yes
P value
Sensitivity, Specificity,
PPV, NPV
SIRS Score 2
Yes
No
96
9
69
24
0.001
73%, 58%, 26%, 91%
86
74
19
19
0.677
50%, 54%, 20%, 82%
ASA class 4 or 5
Yes
No
127
5
36
28
<0.0001
85%, 78%, 44%, 96%
116
43
16
21
0.001
57%, 73%, 33%, 88%
218
WBC (cells/L)
>12,000 or <4,000
Yes
No
100
11
64
22
0.003
67%, 61%, 26%, 90%
95
64
16
22
0.049
58%, 60%, 26%, 86%
Lactate Persistent
Abnormal or Trend Up
Yes
124
18
44
16
0.002
53%, 74%, 29%, 89%
118
46
22
16
0.09
42%, 72%, 26%, 84%
Tu2133
Translational Science: Stomach
Anatomic Landmarks as a Reliable and Reproducible
Guide for the Laparoscopic Sleeve Gastrectomy
Tu2134
Peter Nau, David B. Lautz, Ozanan R. Meireles
MGH, Boston, MA
Mesothelin Expression and Its Clinicopathological
and Prognostic Significance in Gastric and GastroINTRODUCTION: Medical attempts at durable weight loss Esophageal Junction Cancer
are fraught with failures related to durability and lack of
clinically significant outcomes. Metabolic surgery promotes
long-term weight loss and resolution or improvement of
obesity-related comorbidities. The laparoscopic sleeve gastrectomy (LSG) is currently the fastest growing metabolic
procedure in the world. Standardization of the procedure
has yet to be adopted by the bariatric surgical society. We
have identified reliable anatomic landmarks for the safe
and reproducible creation of the gastric sleeve independent
of body habitus.
METHODS: Anatomic landmarks identified include the
pylorus, location of the incisura, the crossing lesser curvature vessels, the left crus and the angle of His. The procedure begins by lysing the gastrocolic ligament beginning
6–8 cm from the pylorus with the Harmonic Scalpel. This
location coincides with the transition between the gastric
body and antrum based on anatomic landmarks from the
incisura angularis and vagus nerve. Dissection is continued
proximally ligating the short gastric vessels and posterior
gastric attachments from the retroperitoneum to facilitate
exposure of the left crus and mobilization of the stomach.
Belsey’s fat pad is then dissected so as to identify the angle
of His and expose the gastroesophageal junction to ensure
proper stapler placement while dividing the stomach. A 1.2
cm (36 French) gastroscope is then used as a guide to identify the boundaries of the lesser curvature as excess adipose
tissue often obscures this landmark. A linear stapler is used
to divide the stomach. Variable staple heights decreasing
from 4.1 mm to 3.5 mm are used as the transection line
moves cephalad. Using the angle of His as the target of the
proximal staple line eliminates the risk of retained fundus,
creating a gastric sleeve with the same caliber as the esophagus. The transection margin is then inspected for integrity
during gastroscopy and positive pressure pneumogastrium
for identification of leaks and discerning of sleeve anatomy.
Hugo Santos-Sousa1,2, Lara Marcos-Silva3, JoãO Pinto-De-Sousa1,2,
Leonor David3,4, José Costa-Maia1
1
Department of Surgery, Centro Hospitalar de Sao Joao, Porto,
Portugal; 2Department of Surgery, University of Porto Medical School,
Porto, Portugal; 3Institute of Molecular Pathology and Immunology
of the University of Porto (IPATIMUP), Porto, Portugal; 4University of
Porto Medical School, Porto, Portugal
BACKGROUND: Mesothelin (MSN) is expressed both in
normal mesothelium and in several types of malignant
tumors. In recent literature there are conflicting results on
the role of MSN expression in gastric cancer. In this study
we evaluated the clinicopathological and prognostic significance of MSN expression in gastric and gastro-esophageal
junction (GEJ) cancer.
METHODS: Tissue specimens from 104 gastric and GEJ
cancer patients who were submitted to surgical resection
in our institution were immunohistochemically evaluated.
The intensity of MSN expression in tumor cells was analyzed and the location of immunostaining was classified
into membrane and/or cytoplasmic expression.
CONCLUSION: Obesity has become a problem of epidemic
proportions in westernized societies. As the LSG becomes
more commonplace, standardization will be essential for
safe, reliable and reproducible results. Arbitrary bougie
sizing has been the classic approach for calibrating sleeve
size. This technique has the potential to result in dysphagia and reflux when to narrow or suboptimal weight loss if
too wide. Moreover, the inclusion of remnant fundus at the
gastroesophageal junction may be susceptible to enlargement with an associated s ataple line failure. Using the
endoscope and the aforementioned anatomic visual cues
have been successfully used to tailor a gastric sleeve with a
caliber mirroring that of the esophagus and without a gasCONCLUSIONS: MSN expression in gastric and GEJ cantric cuff at the proximal margin.
cer was correlated with several clinicopathological features (namely GEJ location, fungating and ulcer-fungating
tumors, intestinal type, serosal invasion, lymph node
metastasis) and cytoplasmic MSN expression was an independent prognostic factor in R0 cases of our series.
219
Tuesday
Poster Abstracts
RESULTS: MSN was positive in 42 (40.4%) cases and MSN
expression was correlated with tumor location (61.3% of GEJ
cancers), macroscopic appearance (48,8% of fungating and
ulcer-fungating tumors), Lauren histological classification
(52% of intestinal type tumors), tumor invasion depth (pT,
7th edition of TNM classification) [57.5% of T4a tumors],
lymph-node metastasis (pN) [46.3% of positive lymph node
metastasis] and pathological stage. The cytoplasmic MSN
expression, which was identified in 39 cases, was correlated
with the same clinicopathological features of overall MSN
expression and furthermore to the presence (41.1%) of lymphatic invasion. On the other hand, the membrane MSN
expression was observed in 23 cases and was correlated only
with tumor location and Lauren classification. For the survival analysis, only 89 cases of R0 resection were included (4
cases of gastric stump tumors were excluded of this analysis). The median follow-up of this group of patients was 20.5
(1–252) months (mos) and the median overall survival was
21 mos (5-year and 10-year survival were 32.5% and 30.7%,
respectively). Despite that the survival curves according to
MSN expression were different (18 vs. 34 mos; p = 0.07),
only the cytoplasmic MSN expression was significantly associated (p = 0.024) to poorer survival (15 vs. 26 mos). Multivariate analysis revealed that cytoplasmic MSN expression
was one of the independent prognostic factors (HR 1.769;
95% CI 1.00–3.13; p = 0.05) together with pT, macroscopic
appearance and venous invasion.
2014 ANNUAL MEETING
Be sure to join us for next year’s Annual Meeting—
mark your calendars now!
May 2–6, 2014, Chicago, Illinois
SSAT
500 Cummings Center, Suite 4550
Beverly, MA 01915
Telephone: (978) 927-8330
Facsimile: (978) 524-8890
E-Mail: [email protected]
Web Site: www.ssat.com
SCHEDULE-AT-A-GLANCE
All rooms at the Orange County Convention Center West Building unless otherwise indicated.
indicates a ticketed session requiring a separate registration and fee.
indicates a session offering CME with self-assessment.
FRIDAY, MAY 17, 2013
7:30 AM – 2:45 PM
10:00 AM – 11:00 AM VIDEO SESSION III
RESIDENTS & FELLOWS RESEARCH CONFERENCE
By invitation only)
300
SATURDAY, MAY 18, 2013
8:00 AM – 4:55 PM
MAINTENANCE OF CERTIFICATION COURSE
Evidence Based Treatment of Colorectal Diseases
208ABC
10:00 AM – 11:30 AM DDW COMBINED CLINICAL SYMPOSIUM
(AASLD-Accredited)
Therapeutic Approaches in NAFLD
Sponsored by: AASLD, AGA, SSAT
2:00 PM – 3:30 PM
4:00 PM – 5:30 PM
110
DDW COMBINED CLINICAL SYMPOSIUM
(ASGE-Accredited)
Endoscopic Evaluation and Management of IBD
Sponsored by: ASGE, AGA, SSAT
420 (Chapin Theater)
(ASGE-Accredited)
Addressing the Controversies in Barrett’s Esophagus
Sponsored by: ASGE, SSAT, AGA
SUNDAY, MAY 19, 2013
7:30 AM – 8:00 AM
OPENING SESSION
303ABC
8:00 AM – 9:00 AM
PRESIDENTIAL PLENARY A (PLENARY SESSION I)
303ABC
8:00 AM – 9:30 AM
DDW COMBINED RESEARCH FORUM
(AGA-Accredited)
IBD
9:15 AM – 10:00 AM
PRESIDENTIAL ADDRESS
Peer Review
(AGA-Accredited)
Bariatric Surgery as the Treatment of Metabolic Syndrome
Sponsored by: AGA, SSAT, AASLD
203AB
303ABC
10:15 AM – 11:00 AM PRESIDENTIAL PLENARY B (PLENARY SESSION II)
303ABC
11:00 AM – 11:45 AM DORIS AND JOHN L. CAMERON GUEST ORATION
AMA: Looking to the Future
303ABC
11:00 AM – 11:45 AM
DDW POSTER TOUR:
ESOPHAGEAL AND STOMACH (non-CME)
West Hall A
12:00 PM – 2:00 PM
POSTER SESSION I (non-CME)
West Hall A
12:30 PM – 1:45 PM
MEET-THE-PROFESSOR LUNCHEON
Operative and Endoscopic Management
of Benign Biliary Stenosis
203AB
2:00 PM – 3:30 PM
CONTROVERSIES IN GI SURGERY A
DEBATE 1: HIPEC: Critical in the Management
of Peritoneal Surface Malignancies?
DEBATE 2: Reverse Approach (Liver Resection First) in Patients
with Synchronous Colorectal Liver Metastases
304AB
2:00 PM – 3:30 PM
Management of Benign Liver Lesions
Sponsored by: SSAT, AASLD, AGA
2:00 PM – 4:00 PM
VIDEO SESSION I
2:00 PM – 4:30 PM
STATE-OF-THE-ART CONFERENCE
Evolving Management in Pancreatic Cancer
2:00 PM – 4:45 PM
PLENARY SESSION III
300
303ABC
308D
MONDAY, MAY 20, 2013
304AB
(AGA-Accredited)
Managing Post-Operative Complications in the IBD Patient
Sponsored by: AGA, SSAT, ASGE
415 (Valencia A)
11:00 AM – 11:45 AM MAJA AND FRANK G. MOODY STATE-OF-THE-ART LECTURE
Cholecystectomy: Can We Do Better?
11:00 AM – 11:45 AM
303ABC
DDW POSTER TOUR: HPB (non-CME)
West Hall A
12:00 PM – 2:00 PM
POSTER SESSION II (non-CME)
12:30 PM – 1:45 PM
MEET-THE-PROFESSOR LUNCHEONS
Enhance Recovery Protocols for Elective Colon and Rectal Surgery
Writers Workshop Part 1: Writing
West Hall A
205B
205A
2:00 PM – 3:00 PM
QUICK SHOTS SESSION II
303ABC
2:00 PM – 3:30 PM
CONTROVERSIES IN GI SURGERY B
DEBATE 3: Preoperative Therapy for Resectable
Pancreas Adenocarcinoma: Timing Matters
DEBATE 4: Nissen Fundoplication: Does It Create
More Problems than It Solves?
2:00 PM – 3:30 PM
(AASLD-Accredited)
Management of Surgical Risk in Patients with Cirrhosis
Sponsored by: AASLD, SSAT
2:00 PM – 3:45 PM
PLENARY SESSION V
3:00 PM – 4:30 PM
SSAT/ASCRS JOINT SYMPOSIUM
303ABC
Evolving Issues and Strategies in the Managment of Diverticular Disease
4:00 PM – 5:00 PM
CLINICAL WARD ROUNDS II
Cysts of the Pancreas: Observe, Resect, or Drain—
How to Pick the Right Option for Every Patient … the First Time
4:00 PM – 5:00 PM
QUICK SHOTS SESSION III
4:00 PM – 5:30 PM
Achalasia Treatment: Botox, Balloon, LAP Myotomy, or POEM
Sponsored by: SSAT, ASGE, AGA
5:00 PM – 6:00 PM
ANNUAL BUSINESS MEETING (Members Only)
7:00 PM – 9:00 PM
MEMBERS RECEPTION
304AB
415 (Valencia BC)
308D
304AB
308D
415 (Valencia A)
303ABC
Cuba Libre Restaurant
TUESDAY, MAY 21, 2013
6:30 AM – 7:45 AM
BREAKFAST WITH THE EXPERT
Complex Paraesophageal Hernia Repair:
Tricks for the Giant Hiatus Key Steps to Do It Safely
104A
7:30 AM – 9:30 AM
SSAT/ISDS JOINT BREAKFAST SYMPOSIUM
You Did Your Best, and It Still Leaked! Modern Management of GI Leaks
8:00 AM – 9:30 AM
PLENARY SESSION VI
8:00 AM – 9:30 AM
(AGA-Accredited)
Diagnosis and Management of Early Pancreatic Cancer
9:30 AM – 12:00 PM
PLENARY SESSION VII
303ABC
308D
415 (Valencia BC)
308D
415 (Valencia BC)
(ASGE-Accredited)
Management of Pancreatic Necrosis: When to Scope, Poke, or Cut
Sponsored by: ASGE, SSAT, AGA
10:30 AM – 12:00 PM SSAT HEALTH CARE QUALITY & OUTCOMES COMMITTEE PANEL
If You Cannot Measure It, You Cannot Improve It:
Developing a Quality Metric for Complex GI Surgery
304AB
11:00 AM – 11:45 AM
DDW POSTER TOUR: SMALL BOWEL
AND COLON-RECTAL (non-CME)
West Hall A
12:00 PM – 2:00 PM
POSTER SESSION III (non-CME)
West Hall A
12:00 PM – 3:00 PM
KELLY AND CARLOS PELLEGRINI SSAT/SAGES
JOINT LUNCHEON SYMPOSIUM
Management and Rescue from Complications Following
Complex Upper GI Surgery: Stents, Clips, and Beyond
12:30 PM – 1:45 PM
MEET-THE-PROFESSOR LUNCHEON
Writers Workshop Part 2: Reviewing
303ABC
2:00 PM – 3:30 PM
Current Multi-Modality Approach to GE Junction Tumors
Sponsored by: SSAT, ASGE, AGA
308D
2:00 PM – 4:00 PM
BEST OF DDW 2013 (non-CME)
6:30 AM – 7:45 AM
BREAKFAST WITH THE EXPERT
Primer for the General Surgeon and
Management of the Bariatric Surgery Patient
205C
7:30 AM – 9:15 AM
VIDEO SESSION II: BREAKFAST AT THE MOVIES
8:00 AM – 9:00 AM
CLINICAL WARD ROUNDS I
Role of Trans-Anal Surgery for Rectal Cancer
8:00 AM – 9:30 AM
SSAT PUBLIC POLICY AND ADVOCACY COMMITTEE PANEL
Will There Be a General Surgeon When You Need One?
Solutions and Taking Back General Surgery
308D
9:15 AM – 10:45 AM
SSAT/AHPBA JOINT SYMPOSIUM
Strategies for Parenchymal Preservation in Patients
Undergoing Hepatic Resection for Metastatic Colorectal Cancer
9:45 AM – 11:00 AM
PLENARY SESSION IV
9:45 AM – 11:00 AM
QUICK SHOTS SESSION I
303ABC
304AB
300
303ABC
205A
415 (Valencia BC)
304AB