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THE SOCIETY FOR SURGERY
OF THE ALIMENTARY TRACT
53rd
Annual
Meeting
May 18-22, 2012
San Diego Convention Center
San Diego, California
Program Book
Abstract Supplement
Table of Contents
Schedule-at-a-Glance .............................................................................................................2
Sunday Plenary and Video Session Abstracts ........................................................................4
Monday Plenary and Video Session Abstracts .....................................................................17
Tuesday Plenary, Video, and Quick Shot Session Abstracts.................................................51
Sunday Poster Session Abstracts ..........................................................................................61
Monday Poster Session Abstracts .......................................................................................110
Tuesday Poster Session Abstracts .......................................................................................158
THE SOCIETY FOR SURGERY
OF THE ALIMENTARY TRACT
PROGRAM BOOK ABSTRACT SUPPLEMENT
FIFTY-THIRD ANNUAL MEETING
San Diego Convention Center
San Diego, California
May 18–22, 2012
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
VIDEO SESSION I:
2
PRESIDENTIAL
ADDRESS
PRESIDENTIAL
PLENARY B
(PLENARY SESSION II)
STATE-OF-THE-ART
LECTURE
DDW CCS:
GI Mgt of Pt
w/Obesity
DDW CCS:
Mgt of Pt @ High
Risk for Colon CA
PRESIDENTIAL
PLENARY A
(PLENARY SESSION I)
MEET-THEPROFESSOR
LUNCHEONS
Exhibit
Hall
DDW CCS:
Mgt of Fecal
Incontinence
28cd
POSTER SESSION I (authors available @ posters 12:00 PM - 2:00 PM)
28ab
Difficult Bile
Duct Stone
27b
CONTROVERSIES IN
GI SURGERY
DEBATES A: C Diff
Colitis; Pancreatic
Cystic Neoplasms
26ab
CLINICAL
WARD
ROUNDS I:
SATURDAY, MAY 19, 2012
STATE-OF-THE-ART
CONFERENCE:
Technological Advances in
the Surgical Treatment of
Colon and Rectal Cancer
PLENARY SESSION III
Other
Robotic, Endoscopic, &
Adv. Laparoscopic GI Sx
28abcd
DDW CTS:
Probiotics in
Health & Disease
28ab
DDW CCS:
Tx of Early GI
CA
FRI, MAY 18, 2012
MAINTENANCE OF CERTIFICATION COURSE:
Evidence Based Treatment of Hepatopancreatobiliary Diseases
RESIDENTS & FELLOWS RESEARCH CONFERENCE
(by invitation only)
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Schedule-at-a-Glance
SUNDAY, MAY 20, 2012
Other
OPENING SESSION
MEET-THEPROFESSOR
LUNCHEONS
3
BEST OF DDW
DDW CCS:
Can You
Eliminate
Barrett's?
DDW CCS:
Mgt of HCC
TUESDAY, MAY 22, 2012
Exhibit
28cd
Hall
MEET-THEPROFESSOR
LUNCHEONS
28ab
DDW CCS:
Endoscopic
Biliary
Complications
POSTER SESSION III (authors available @ posters 12:00 PM - 2:00 PM)
HEALTH CARE &
QUALITY
OUTCOMES
PANEL: GI Sx Cost
Curve
27b
SSAT/ISDS JOINT
B'FAST
SYMPOSIUM:
Optimizing Outcomes
Other
PLENARY SESSION VII
DDW CCS:
Disorders of the
Esophagus
MONDAY, MAY 21, 2012
SSAT/SAGES JOINT
LUNCHEON SYMPOSIUM:
Foregut Motility
DDW CCS: Mgt
of Complicated
Crohn's
PLENARY
SESSION VI
CLINICAL
WARD
ROUNDS I:
Diverticulitis
Exhibit
Hall
Pancreatic Cystic
Neoplasms & IPMN
GUEST
ORATION
POSTER SESSION II (authors available @ posters 12:00 PM - 2:00 PM)
VIDEO
SESSION III:
HPB &
Foregut
VIDEO SESSION II:
BREAKFAST AT
THE MOVIES
28cd
DDW CCS:
GI Sx &
Endoscopy
CONTROVERSIES IN
GI SURGERY
DEBATES B: Band /
Morbid Obesity; 360 v
Partial Fundoplication /
GERD
Benign Liver
Neoplasms
SSAT/AHPBA
JOINT
SYMPOSIUM:
PUBLIC POLICY
& ADVOCACY
PANEL
28ab
CLINICAL
WARD
ROUNDS III:
QUICK
SSAT/ASCRS
SHOTS
JOINT
SYMPOSIUM: SESSION
Ulcerative Colitis
II
PLENARY
SESSION IV
27b
ANNUAL
BUSINESS
MEETING
PLENARY
SESSION V
26ab
QUICK
SHOTS
SESSION
III
7:00 AM
7:15 AM
7:30 AM
7:45 AM
8:00 AM
8:15 AM
8:30 AM
8:45 AM
9:00 AM
9:15 AM
9:30 AM
9:45 AM
10:00 AM
10:15 AM
10:30 AM
10:45 AM
11:00 AM
11:15 AM
11:30 AM
11:45 AM
12:00 PM
12:15 PM
12:30 PM
12:45 PM
1:00 PM
1:15 PM
1:30 PM
1:45 PM
2:00 PM
2:15 PM
2:30 PM
2:45 PM
3:00 PM
3:15 PM
3:30 PM
3:45 PM
4:00 PM
4:15 PM
4:30 PM
4:45 PM
5:00 PM
5:15 PM
5:30 PM
5:45 PM
QUICK
SHOTS
SESSION I
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Schedule-at-a-Glance
Other
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
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 20, 2012
8:15 AM – 9:15 AM
28ab
PRESIDENTIAL PLENARY A
(PLENARY SESSION I)
287
provided an additional six million patient visits. Texas hospitals have saved $100 million /year which has allowed
them to deliver more charity care ($500 million/year),
expand patient safety programs (58%), subsidize shortfalls in government programs such as Medicaid (46%),
raise salaries for nurses and increase nurse staffing (46%),
and maintain, improve or add new equipment (39%). In
conclusion, medical liability reform enacted by the Texas
Legislature in 2003, has afforded Texans an increased ability to access health care and would appear to be an ideal
tort reform template for adoption by the other 49 states.
Texas Tort Reform Increased Access to Health Care
Ronald M. Stewart1, Lisa Rocheleau2, Kenneth Sirinek1
1. Surgery, UTHSCSA, San Antonio, TX; 2. Boone & Rocheleau,
San Antonio, TX
Prior reports have confirmed that comprehensive tort
reform in Texas (2003) has resulted in fewer malpractice
claims and lawsuits against physicians and a reduction in
the cost of both insurance premiums and the associated
litigation fees. We hypothesize that Texas medical liability
reforms have achieved the Legislature’s intent of improving
statewide access to critical health care services. The positive impact on physician manpower has been monumental
with 21,000+ new medical licenses issued since tort reform
(62% for past 3 years compared to the 3 years pre-tort
reform). The number of new licenses issued by the Texas
Medical Board in 2008 was 3,600 (a record high) compared
to 2000 for the year 2001 (lowest for the preceding 10
years). Eight in ten Texas hospitals have reported that it
is now easier to recruit medical specialists in the wake of
tort reform. Since 2003, 218 new obstetricians have come
to Texas with 27% practicing in medically underserved
areas and all 254 counties now have at least one obstetrician. Similar increases have occurred in neurosurgery,
emergency medicine, cardiology, cardiovascular surgery,
orthopedic surgery, pediatrics, and geriatrics. Eleven counties have their first general surgeon and 24 counties have
added at least one general surgeon. The Rio Grande Valley,
a former hotbed of medical malpractice claims, has seen an
influx of 220 physicians. Although impossible to document
except from medical society hearsay, there has been a positive manpower impact from the physicians who reversed
their decision to retire as a result of tort reform implementation. The Texas Medical Association has estimated that
this additional physician manpower since tort reform has
288
Enhancement of the Small Bowel Obstruction Model
with the Use of the Gastrografin Challenge Test
Naeem Goussous, Patrick W. Eiken, Micheal P.P.Bannon,
Martin D. Zielinski
Mayo Clinic, Rochester, MN
BACKGROUND: Based on previous published data on
small bowel obstruction (SBO) management, a three feature model has been adopted in our institution predicting the need for exploration. Obstipation combined with
mesenteric edema and lack of the small bowel feces sign
on computed tomography (CT) were associated with the
need for exploration. Patients with 2 or less features were
managed non-operatively and administered a Gastrografin
(GG) challenge.
HYPOTHESIS: We hypothesize that the (GG) challenge
test, when used in combination with the predictive model,
will decrease the rate of explorations in patients not meeting the criteria for immediate operation.
METHODS: IRB approval was obtained to review patients
admitted with SBO from November 2010 to September
2011. Presenting with signs of strangulation or all three fea-
4
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
tures, and those who had an abdominal operation within
6 weeks of admission were excluded. All patients had an
abdominal/pelvic CT scan and GG challenge upon diagnosis. GG patients were compared to historic controls managed without the GG (July to December 2009). Successful
GG challenge was considered as the presence of contrast in
the colon after an 8 hour plain abdominal film or a bowel
motion. Data is presented as medians or percentages. Significance was considered at p < 0.05.
290
Attila Dubecz1, Michael Schweigert1, Rudolf J. Stadlhuber1,
Norbert Solymosi2, Jeffrey H. Peters3, Hubert J. Stein1
1. Surgery, Klinikum Nurnberg, Nurnberg, Germany;
2. Veterinary Medicine, Szent István University, Budapest,
Hungary; 3. Division of Thoracic and Foregut Surgery, Department
of Surgery, University of Rochester School of Medicine and
Dentistry, Rochester, NY
RESULTS: One hundred and thirty three patients with a
diagnosis of SBO were identified (47% male) with 54 receiving GG (study) and 79 historic control patients. There was
no difference in age (71 vs 65 years), prior SBO (52% vs
47%), diabetes mellitus (20% vs 18%), history of malignancy
(35% vs 41%) or cardiac disease (29% vs 37%). Both groups
had similar number of previous abdominal operations (2
vs 2). The presence of mesenteric edema (67% vs 76%), the
lack of small bowel feces sign (50% vs 48%) and obstipation (24% vs 22%) were similar in both groups. Patients in
the GG group had a lower rate of abdominal exploration
(26% vs 43% p = 0.044) and fewer complications (11% vs
33% p = 0.004) compared to the control group. There was
an equivalent number of strangulation obstructions (4% vs
10%), bowel perforation (4% vs 4%), length of hospital stay
(4 vs 7 days), days from admission to operation (5 vs 3) and
mortality (9% vs 6%). 46 patients had a successful GG challenge with 8 failures. There was a higher rate of exploration
in patients with a failed challenge compared to those who
passed (88% vs 15%, p < 0.001).
BACKGROUND: The value of lymphadenectomy in most
localized gastrointestinal (GI) malignancies is well established. Our objective was to evaluate the time-trends of
lymphadenectomy in GI cancer and identify factors associated with inadequate lymphadenectomy in a large population-based sample.
METHODS: Using the National Cancer Institute’s Surveillance Epidemiology and End Results-Database (1998–
2008), a total of 342,792 patients with surgically treated
GI malignancy(esophagus: 13,471; stomach: 21,094; small
bowel: 10,588; colon: 243,982; rectum: 41,683; pancreas:
11,974) were identified. Adequate lymphadenectomy
was defined based on review of pusblished data and was
defined as: 23 esophagus, 15 stomach, 12 small bowel, 12
colon, 12 rectum and 12 pancreas. The median number of
lymph nodes removed and prevalence of adequate and/or
no lymphadenectomy for each cancer type were assessed
and trended over the 10 study years. Multivariate logistic
regression was employed to identify factors predicting adequate lymphadenectomy.
CONCLUSION: The use of the GG challenge enhanced the
SBO prediction model by decreasing the need for exploration in patients not meeting the criteria for immediate
operation. Patients who failed the GG challenge test were
much more likely to undergo exploration.
RESULTS: The median number of excised nodes improved
over the decade of study in all types of cancer; esophagus:
from 7–13, stomach 9–12, small bowel 3–6, colon 9–15,
rectum 8–13 and pancreas 7–11. Further the percentage
of patients with an adequate lymphadenectomy (median
42.3% for all types) steadily increased and those with
zero nodes removed (median 7.1% for all types) steadily
decreased in all types of cancer, although both remained
far from ideal. By 2008, the percentage of patients with adequate lymphadenectomy was 16.4% for esophagus, 37.4%
for stomach, 31.4% for small intestine, 72.7% for colon,
58.2% for rectum and 49.9% for pancreas. Men, non-white
race, patients >65 yrs, or those undergoing surgical therapy
earlier in the study period and living in areas with high
poverty rates were significantly less likely to receive adequate lymphadenectomy (all p < .0001).
289
Laparoscopic Total Gastrectomy with Multi-Organ
Resection for Large Gastric Cancer
Amanda K. Arrington, Marjun Philip N. Duldulao,
Alessio Pigazzi, Joseph Kim
Surgical Oncology, City of Hope National Medical Center, Duarte, CA
Despite the wide acceptance of laparoscopic surgical techniques, its use for higher staged gastric cancer has been limited. Laparoscopic total gastrectomy poses many complex
challenges, in particular the construction of the esophagojejunal anastomosis. This video shows the resection of a
large gastric cancer in an otherwise healthy 53 yo male that
required total gastrectomy, distal pancreatectomy, splenectomy, and transverse colectomy. Thus multi-organ resection and total gastrectomy, including the construction of
an esophagojejunal anastomosis, can safely and efficiently
be performed laparoscopically.
CONCLUSIONS: Lymph node retrieval during surgery
for GI cancer remains inadequate in a large proportion of
patients in the United States although the median number
of resected nodes increased over the last ten years. Gender,
socioeconomic and racial disparities in receiving adequate
lymphadenectomy were observed.
5
Sunday
Abstracts
Time-Trends and Disparities in Lymphadenectomy
for Gastrointestinal Cancer in the United States: A
Population-Based Analysis of 342,792 Patients
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
10:30 AM – 11:15 AM
28ab
PRESIDENTIAL PLENARY B
(PLENARY SESSION II)
372
ment failure) served as the end point for statistical analysis.
Putative risk factors for symptom recurrence were analyzed
by univariate analysis and by using Cox’s multiple hazards
regression.
Hiatal Hernia, Barrett’s Esophagus and Long-Term
Symptom Control After Laparoscopic Fundoplication
for Gastresophageal Reflux
RESULTS: According to Kaplan-Meier estimates the rate
of reflux symptom recurrence was 15% after 108 months,
11% in cases without intestinal metaplasia, but 43% in
patients with long-segment (33 cm) Barrett’s esophagus
(BE; p < 0.0001). Reflux symptoms recurred in 22% of cases
with a hiatal hernia (HH) 33 cm before operation, but only
in 7% with smaller or absent HH (p = 0.005). Multivariate analysis revealed a relative risk of 6.6 (CI 3.0) for longsegment BE and of 3.0 (CI 1.7) for HH 33 cm. A strong
statistical interaction was found between HH 33 cm and
long-segment BE: the small group (n = 18) of cases exhibiting both risk factors revealed an exaggerated recurrence
rate of 72% at 108 months.
Joumanah Hafez1,2, Johannes Lenglinger2, Friedrich Wrba3,
Marcus Hudec4, Christiane Wischin2, Johannes Miholic2
1. Department of ENT, Martin Luther University Halle, Medical
Faculty, Halle/Saale, Germany; 2. Department of Surgery, Medical
University Vienna, Vienna, Austria; 3. Department of Pathology,
Medical University Vienna, Vienna, Austria; 4. Department of
Scientific Computing, University of Vienna, Vienna, Austria
OBJECTIVE: To determine the long-term symptom control after laparoscopic fundoplication for gastroesophageal
reflux disease (GERD), and possible prognostic factors.
DESIGN, SETTING AND PATIENTS: A cohort of 271
patients, operated at a university hospital from 1996
through 2002, was eligible for evaluation after a median
interval of 102 months (range, 12 to 158).
CONCLUSIONS: Laparoscopic fundoplication for symptomatic GERD provided a long-lasting abolition of reflux
symptoms in 231 of 271 (85%) patients. HH 33 cm and
long-segment BE materialized as independent prognostic
factors favoring recurrence.
MAIN OUTCOME MEASURES: The time between operation and recurrence of reflux symptoms (i.e. time to treat-
Univariate Analysis of Putative Risk Factors for Symptom Recurrence
Variable
n
% Recurrence After 36 Months
% Recurrence After 108 Months
All patients
271
7%
15%
Total (Nissen) n = 197
7%
16%
Partial (Toupet) n = 74
7%
14%
Mode of fundoplication
0.49
Intestinal metaplasia
DeMeester’s score
Hiatal hernia
Contraction amplitudes
p-Value (Log-Rank Test)
<0.001
Absent n = 199
3%
11%
Short segment BE n = 43
12%
16%
Long segment BE n = 29
28%
43%
<50 n = 209
5%
10%
≥50 n = 62
15%
28%
<3 cm n = 93
5%
7%
>3 cm n = 153
10%
22%
<62 mmHg n = 131
10%
19%
>62 n = 138
6%
12%
Gender, age, LES pressure and operation time period were not significant.
6
0.001
0.005
0.07
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Variable
Risk Ratio
Lower CL
Upper CL
p-Value
HH ≥ 3 cm
3.8
1.7
10.2
<0.001
BE ≥ 3 cm
6.6
3.1
13.5
<0.001
Nissen vs.
Toupet
1.0
0.7
1.5
0.91
Propensity
score
0.97
0.6
1.2
0.85
CONCLUSIONS: Ventral hernia repair is associated with
overall financial losses. Inpatient synthetic mesh repairs are
essentially budget neutral. Outpatient repairs and inpatient
repairs without mesh result in net financial losses. Inpatient biologic mesh repairs result in a negative contribution margin and striking net financial losses. Cost-effective
strategies for managing ventral hernias in a tertiary care
environment need to be developed in light of the financial
implications of this patient population.
373
374
Financial Implications of Ventral Hernia Repair at an
Academic Institution
Impact of MRSA Nasal Colonization on Surgical Site
Infections Following Major Gastrointestinal Surgery
Drew Reynolds, Daniel L. Davenport, Ryan L. Korosec,
J. Scott Roth
Department of Surgery, University of Kentucky, Lexington, KY
Harry T. Papaconstantinou, Marcela Ramirez, Michelle
Marchessault, Cara Govednik-Horny, Daniel Jupiter
Surgery, Scott & White Memorial Hospital, Temple, TX
INTRODUCTION: Complicated ventral hernias are often
referred to tertiary care centers. Hospital costs associated
with complex hernia repairs include direct costs (mesh
materials, supplies, non-surgeon labor costs), and indirect
costs (facility fees, equipment depreciation, and unallocated labor). Operative supplies including mesh represent
a significant component of direct costs, especially in an era
of proprietary synthetic meshes and biologic grafts. We aim
to evaluate the cost-effectiveness of complex abdominal
wall hernia repair at a tertiary care referral facility.
PURPOSE: The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) colonization is increasing, and
is an important pathogen in surgical site infections (SSI).
Nasal-swab testing is effective for identifying patients with
MRSA colonization, and has been shown to be predictive
of SSI in cardiac and orthopedic surgery cases. However,
the role of MRSA colonization on SSI following major gastrointestinal (GI) surgery is not known. The purpose of this
study is to determine if MRSA colonization affects SSI after
major GI surgery.
METHODS: Cost data on all consecutive open ventral hernia repairs (CPT Codes 49560, 49561, 49565, and 49566)
performed between July 1, 2008 and May 31, 2011 were
analyzed. Cases were analyzed based upon hospital status
(inpatient vs. outpatient) and whether the hernia repair
was a primary or secondary procedure. We examined
median net revenue, direct costs, contribution margin,
indirect costs, and net profit/loss. Among primary hernia
repairs, cost data was further analyzed based upon mesh
utilization (no mesh, synthetic, or biologic).
METHODS: In 12/2007, we began universal nasal swab
testing for MRSA colonization within 24 hrs of admission.
MRSA-colonized patients were placed on contact precautions and isolated. We retrospectively reviewed the charts
of all patients undergoing major GI surgery (esophagus,
stomach, hepatobiliary, pancreatic, duodenum, small
bowel, colon and rectum) from 12/2007 to 8/2009. Patients
were grouped according to nasal swab test results as MRSAcolonized (MRSA+), methicillin-sensitive Staphylococcus
aureus-colonized (MSSA+) or not colonized (Negative).
Data analyzed included demographics, incidence of SSI,
organisms cultured from the wound, length of hospital
stay (LOS) and mortality.
RESULTS: 415 patients underwent ventral hernia repair
(353 inpatient, 62 outpatient). 173 patients underwent
ventral hernia repair as the primary procedure. 180
patients underwent hernia repair as a secondary procedure. Median net revenue ($17,310 vs. $10,360, p < 0.01)
and net losses (3,430 vs. 1,700, p < 0.01) were significantly
greater for those who underwent hernia repair as a secondary procedure. Among primary ventral hernia repairs, 46
were repaired without mesh; 79 were repaired with synthetic mesh and 48 with biologic mesh. Median direct costs
for cases performed without mesh were $5,432; median
direct costs for those using synthetic and biologic mesh
were $7,590 and $16,970, respectively (p < .01). Median
net losses for repairs without mesh were $500. Median
net profit of $60 was observed for synthetic mesh based
repairs. The median contribution margin for cases utilizing
biologic mesh was –$4,560 and the median net financial
RESULTS: A total of 1137 patients were identified and
grouped according to nasal swab results; 897 (78.9%) Negative, 167 (14.7%) MSSA+, and 73 (6.4%) MRSA+. The mean
age was 59.5 years, 44.5% were men, 47.9% had colon or
rectal operations, and 9% were emergent operations. There
with no significant difference between groups. There were
101 patients identified with SSI (8.9%), and the MRSA+
group was associated with a higher rate of SSI when compared to Negative and MSSA+ groups (13.7% vs. 9.4% vs.
4.2%; p < 0.05). Wound culture results were identified in
92 (91.1%) patients with SSI. When SSI was present the
MRSA+ group had a significantly higher rate of MRSA
positive wound cultures when compared to non-MRSA
colonized patients (70% [7/10] vs. 8.5% [7/82]; p < 0.0001).
7
Sunday
Abstracts
loss was $8,370. Outpatient ventral hernia repairs with and
without synthetic mesh resulted in median net losses of
$1,560 and $230, respectively.
Multivariate Analysis (Cox’s Multiple Hazards Model) of Prognostic
Factors for Time to Symptom Recurrence
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
The mean LOS was 12.5 days for MRSA+ group, and was 4
days longer than Negative and MSSA+ groups (8.8 and 7.6
days, respectively; p < 0.001). Although the presence of SSI
significantly increased LOS from 6.2 days to 15.7 days (p
<0.001), there was no difference in LOS for patients with
SSI between nasal swab groups (p = 9.2). Overall mortality was 4.0% (45/1137) and deaths were evenly distributed
between nasal-swab groups.
CONCLUSIONS: Our data suggest that MRSA nasal colonization is associated with a longer LOS and an increase in
incidence of SSI in patients undergoing major GI surgery.
Furthermore, when SSI occurred, MRSA nasal colonization
was strongly predictive of MRSA-associated SSI. Preoperative nasal swab test with decolonization of MRSA+ patients
may decrease LOS and reduce the incidence of MRSA-associated SSI after major GI surgery. A cost benefit analysis is
required.
2:15 PM – 4:30 PM
26ab
VIDEO SESSION I: ROBOTIC, ENDOSCOPIC, AND
ADVANCED LAPAROSCOPIC GI SURGERY
519
521
Robotic Assisted Excision of Pelvic Neurofibroma
Single-Anastomosis Duodeno-Ileal Bypass with Sleeve
Gastrectomy (SADI-S): A Simplified Duodenal Switch
with Metabolic Orientation
Celeste Y. Kang, Alessio Pigazzi
Surgery, University of California Irvine School of Medicine, Irvine, CA
Andrés Sánchez-Pernaute, Miguel Angel Rubio Herrera,
Elia Pérez-Aguirre, Pablo Talavera, Antonio J. Torres
Surgery, Hospital Clínico San Carlos, Madrid, Madrid, Spain
A 55 year old male with a recent history of left renal cell
carcinoma underwent laparoscopic partial nephrectomy.
During the work up, a 3 cm pelvic mass was also found. A
robotic assisted excision of the pelvic mass was performed.
The rectum was mobilized by entering the presacral plane
between the mesorectum and the presacral fascia. The dissection was carried down distally to the level of the pelvic
floor until a cystic mass was noted. The mass was carefully dissected out using monopolar and bipolar cautery
until the mass was excised in its entirety. Final pathology
revealed a benign neurofibroma. This video emphasizes the
technique, feasibility and safety of this procedure.
Single-Anastomosis Duodeno-Ileal Bypass with Sleeve Gastrectomy (SADI-S is a simplified duodenal switch in which
a loop duodeno-ileostomy is performed instead of the classical Roux-en-Y diversion. The preservation of the pylorus
makes unnecessary the bile diversion. The operation is
simpler, shorter and has the advantage of less number of
anastomosis and no mesenteric opening. SADI-S has been
performed in our Department since May-2007 over more
than 100 patients. The mean long-term excess weight is
around 100%, with only 1% of failures and 3% cases of
recurrent hypoproteinemia. Long remission of diabetes is
obtained in more than 90% of the cases.
520
Single Incision Laparoscopic Right Hemicolectomy
with Intracorporeal Anastomosis
522
Celeste Y. Kang, Steven Mills, Alessio Pigazzi
Surgery, University of California Irvine, Orange, CA
Robotic-Assisted Esophageal Epiphrenic Diverticulectomy,
Myotomy and Dor Hemi-Fundoplication
A 69 year old female with a tubular adenoma near the
hepatic flexure undergoes a single incision laparoscopic
right hemicolectomy. Using a 3 cm periumbilical incision
and a single access port is inserted. The colon is mobilized
in a medial to lateral fashion. The ileocolic pedicle and the
right branch of the middle colic artery are divided. The
bowel is divided proximally and distally. The specimen is
removed though the single port with no need to lengthen
the incision. A 60 mm linear stapler is used to create a side
to side anastomosis. The enterotomy is closed intracorporeally in two layers. This video emphasizes the feasibility of
intracorporeal anastomosis during single access colectomy.
Daniel K. Tong, Simon Law, Fion S. Chan
Surgery, The University of Hong Kong, Hong Kong, Hong Kong
A 57-year-old woman presented with intermittent dysphagia and occasional regurgitation for 6 months. Pre-intervention investigations included contrast upper GI study,
endoscopy and manometry that showed a 4 cm epiphrenic
diverticulum located at the lower esophagus facing the
right side. Manometry revealed an increased lower esophageal sphincter resting pressure. Diverticulectomy, myotomy and Dor hemi-fundoplication was performed using
Robotic-assistance. The operative steps included isolation
of the diverticulum with sparing of the vagi, diverticulectomy by using a linear stapler, anterior myotomy and a Dor
180 degree anterior hemi-fundoplication.
8
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
523
Laparoscopic Reversal of Roux-en-Y Gastric Bypass to
Treat Recalcitrant Hyperinsulinemic Hypoglycemia
Jacob A. Greenberg1, Dawn B. Davis2, Haggi Mazeh1,
Guilherme M. Campos1
1. Surgery, University of Wisconsin School of Medicine and Public
Health, Madison, WI; 2. Medicine, University of Wisconsin School
of Medicine and Public Health, Madison, WI
The video presents technical steps for Laparoscopic Reversal
of Roux-en-Y Gastric Bypass (RYGB) to normal anatomy,
and results of pre and post-op metabolic testing. The
patient underwent RYGB at another institution (BMI 46).
Two years after RYGB (BMI 25), presented with recalcitrant
hyperinsulinemic hypoglycemia episodes and hypoglycemia unawareness. A laparoscopic gastrostomy was placed
in the excluded stomach. A meal test (MT) administered
orally and through the gastrostomy showed altered insulin
and glycemic responses through the RYGB. Laparoscopic
reversal was performed. Patient symptoms subsided; and
6 months later (BMI 29), a MT showed normal insulin and
glycemic profiles.
526
Per-Oral Endoscopic Myotomy (POEM): Techniques for
Successful Submucosal Dissection
Eric M. Pauli, Jeffrey M. Marks, Jeffrey L. Ponsky
Surgery, University Hospitals Case Medical Center, Cleveland, OH
Recently, a new endoscopic method for reducing lower
esophageal sphincter pressure in achalasia patients, per-oral
endoscopic myotomy (POEM), has been developed. The
most difficult part of POEM is the submucosal dissection,
which spatially separates the mucosa and the musculature
and provides an intact tissue plane for secure esophageal
closure. The purpose of this video is to review six technical pearls identified over our series of POEM patients that
permit successful, reproducible creation of the submucosal
tunnel.
524
Transanal NOTES Sigmoidectomy in a Cadaver Model
Ezra N. Teitelbaum, Fahd O. Arafat, Byron F. Santos,
Eric S. Hungness, Anne M. Boller
Surgery, Northwestern, Chicago, IL
527
This video shows a transanal hybrid natural orifice transluminal endoscopic surgery (NOTES) sigmoidectomy performed in a cadaver model using a TEM proctoscope. We
employ a combined laparoscopic and endoscopic technique to place a stapler anvil in the proximal colon prior to
initiation of colon dissection. This allows for a completely
intra-corporeal anastomosis to be performed without the
need for colon exteriorization. Techniques for occluding
the rectal lumen with a purse-string suture, performing a
full thickness dissection at the rectosigmoid junction, and
creating a colorectal anastomosis through the TEM proctoscope are also shown.
Thoracoscopic Esophageal Leiomyoma Enucleation
Jason Richardson, Ninh T. Nguyen
Surgery, University of California Irvine Medical Center, Orange, CA
This is a video presentation of a patient who was incidentally found to have an esophageal mass. EUS revealed a
25 × 14 mm hypoechoic submucosal lesion at 28–30 cm
arising from the muscularis propria with normal overlying mucosa and no obvious nodal involvement. FNA demonstrated spindle cells. A thoracoscopic enucleation was
performed and is featured in this video. Final path was
consistent with leiomyoma. Port positioning, endoscopy,
esophageal mobilization, mass enucleation, and muscular
layer reapproximation are featured in this video.
525
Robotic-Assisted Transduodenal Resection of
Ampullary Tumor with Bile and Pancreatic Duct
Reconstruction
John Prodromo1, Mehmet F. Can3, Jennifer R. Bonfili3,
Dev Patel1, Herbert Zeh1,2, A. James Moser1,2
1. University of Pittsburgh School of Medicine, Pittsburgh, PA;
2. Division of Surgical Oncology, University of Pittsburgh Medical
Center, Pittsburgh, PA; 3. University of Pittsburgh Medical Center,
Pittsburgh, PA
A 75 year old woman presented with recurrent pancreatitis and endoscopic evidence of a duodenal papillary mass
that did not show high grade dysplasia extending up the
9
Sunday
Abstracts
common bile duct. Follow up after endoscopic ampullectomy demonstrated recurrence of the lesion. The adenoma
was then resected using a robotic-assisted transduodenal
approach with bile and pancreatic duct reconstruction.
This case demonstrates the ability to establish precise
excisional margins and to remove lesions that cannot be
resected endoscopically via the use of robotic assistance.
This method demonstrates an alternative option to avoid
the morbidity associated with pancreaticoduodenectomy
for benign lesions.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
2:15 PM – 5:00 PM
27b
PLENARY SESSION III
CONCLUSION: IOC remains a frequently used procedure.
In a national study, most surgeons appear to be using IOC
selectively. A 10% minority of surgeons appear to approach
IOC as mandatory. Intriguingly, a surgeon’s routine use of
IOC is correlated with increased rates of post-surgical procedures, and is associated with increased overall complications, with no additional decrease in CBD injury rate.
Further studies are warranted to determine if additional
surgeon, patient, or perioperative factors contribute to the
apparently unhelpful effect of compulsory IOC.
528
Is Routine Intraoperative Cholangiogram Necessary in
the 21st Century? A National View
Elizaveta Ragulin-Coyne1, Elan R. Witkowski1, Zeling Chau1, Sing
Chau Ng1, Heena P. Santry1, Mark P. Callery2,
Shimul A. Shah1, Jennifer F. Tseng1,2
1. Surgical Outcomes Analysis & Research, University of
Massachusetts Medical School, Worcester, MA; 2. Department
of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
528a
INTRODUCTION: Intraoperative cholangiogram (IOC)
can define biliary ductal anatomy. Routine IOC has been
proposed previously. However, as the “critical view of
safety” technique has become widespread, current practice
and outcomes of IOC are unclear.
Quality Assessment in Pancreatic Surgery: What Might
Tomorrow Require?
Brian T. Kalish1, Charles M. Vollmer2, Tara S. Kent1,
William H. Nealon3, Jennifer F. Tseng1, Mark P. Callery1
1. Surgery, Beth Israel Deaconess Medical Center, Boston, MA;
2. Surgery, University of Pennsylvania, Philadelphia, PA;
3. Surgery, Vanderbilt University, Nashville, TN
METHODS: Nationwide Inpatient Sample 2004–2009 was
queried for patients with acute/urgent biliary disease undergoing laparoscopic and/or open cholecystectomy; IOC was
quantified. We limited analyses to states with consistent
coding of provider and hospital ID data, and excluded surgeons performing <10 cholecystectomies/year. We dichotomized surgeons into a high-IOC group (top 10%, using
yearly ratio of IOC/cholecystectomy frequency) vs. standard group (lower 90%). Our outcomes included bile duct
injury, overall complications, in-hospital mortality, length
of stay (LOS), use of additional studies such as endoscopic
retrograde cholangiopancreatography (ERCP), and hospitalization cost. Statistical analysis included weighted univariable and multivariable analysis, and Cochran-Armitage
trend test.
INTRODUCTION: The Institute of Medicine (IOM)
defines healthcare quality across six domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and
equitability. Traditional quality metrics in high-acuity
surgery (volume and mortality) cannot alone measure or
satisfy these domains. We asked experts in pancreatic surgery (PS) whether broader quality metrics are needed, how
important they might be, and whether they align to contemporary IOM healthcare quality domains.
METHODS: Together with a professional market research
firm, we created and distributed a web-based survey to pancreatic surgeons. These experts were identified through PS
specialty societies, and verified by survey demographics.
Respondents (Rpds) ranked 62 proposed PS quality metrics on level of importance (LoI). Next, Rpds aligned each
metric to one or more IOM quality domains (MDA, multidomain alignment). Descriptive statistics were used to
summarize responses. To calculate and rank relative quality scores, points were awarded for LoI (4-Essential, 3-Very
important, 2-Somewhat important, 1-A Little important,
0-Not important) and MDA (1 point/each aligned domain).
LoI Scores and MDA Scores for a given quality metric were
averaged together to render a Total Quality Score (TQS =
LoI + MDA/2) normalized to a 100-point scale.
RESULTS: 518488 nationally weighted patients underwent cholecystectomy; 33.9% had IOC. Over time, IOCs
utilization increased (31% to 34%, p < 0.0001), annual
number of cholecystectomies remained stable. 12,527
non-weighted annual surgeon volumes were included in
analysis. On average, each surgeon performed 31.9 cholecystectomies and 7.9 IOCs annually, with mean annual
surgeon-specific IOC/CCY ratio of 0.23. The high-IOC (top
10%) group used IOC for 100% of cases. Of note, 25% of
surgeons used IOC for at least half of cases. Comparing
high-IOC group to standard group, high-IOC had no difference in bile duct injury (0.25% vs. 0.27% for standard
group, p = 0.2; a higher rate of overall complications: 7.2%
vs. 6.9%, p = 0.04; and no difference in mortality 0.4% vs.
0.4% p = 0.8). Patients of high-IOC surgeons had shorter
LOS, 3.9 vs. 4.2 days, p = 0.002, and were more likely to use
additional procedures: ERCP 16.0% vs. 13.1%, p = <0.0001.
RESULTS: 106 surgeons (21%) completed the survey (82%
North America and 84% Academic). On average, Rpds and
their institutions perform 43 and 114 pancreatic operations
10
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
530
High Grade Dysplasia and Adenocarcinoma Are Frequent in Side-Branch Intraductal Papillary Mucinous
Neoplasm Measuring Less Than 3 cm on Endoscopic
Ultrasound
Joyce Wong1, Jill Weber1, Barbara A. Centeno3, Shivakumar
Vignesh2, Cynthia L. Harris2, Jason B. Klapman2, Pamela Hodul1
1. Surgery, H. Lee Moffitt Cancer Center, Tampa, FL;
2. Gastroenterology, H. Lee Moffitt Cancer Center, Tampa, FL;
3. Pathology, H. Lee Moffitt Cancer Center, Tampa, FL
BACKGROUND: Surgical resection for intraductal papillary mucinous neoplasm (IPMN) of the pancreas has
increased over the last decade. While IPMN with main duct
communication are generally recommended for resection,
indications for resection of side-branch IPMN (SDIPMN)
have been less clear. We reviewed our single-institutional
experience with SDIPMN and indications for resection.
METHODS: Patients who underwent resection for IPMN
were identified from a prospectively maintained IRB
approved database. Patients with main pancreatic duct
communication were excluded. Outcome, clinical and
pathologic characteristics were correlated with endoscopic
ultrasound (EUS) findings.
RESULTS: From 2000 to 2010, 105 patients who underwent pre-operative EUS evaluation and resection for
SDIPMN were identified. The mean age was within the sixth
decade of life, and there was a slight female predominance
(55% vs. 45%). The most common presenting symptom
was abdominal pain (N = 47, 45%), followed by jaundice (N
= 24, 23%) and weight loss (N = 24, 23%). Only 10 patients
(10%) were asymptomatic at presentation; 8 (80%) had suspicious features on EUS. Of the total cohort, few patients
had intracystic septations (N = 27, 26%) or presence of
mural nodules (N = 2, 2%) on EUS. Of 39 patients who
had invasive pancreatic ductal adenocarcinoma (PDAC)
on final pathology, EUS-fine needle aspiration (EUS-FNA)
demonstrated malignancy in only 21 (54%).
CONCLUSIONS: We propose a 12-item “Quality Scorecard” for PS based on rank-scoring of quality metrics that
PS experts view as both highly important and aligned with
more than one IOM healthcare quality domain. While the
actual performance thresholds for these metrics require further definition and validation, they may reveal quality to
an extent that volume and mortality alone cannot.
Top Pancreatic Surgery “Quality Scorecard” Metrics by Total
Quality Score (TQS)
Metric
TQS
Multidisciplinary services for pancreatic diseases
63
Major complication rate
60
Peri-operative mortality (0–90 days)
59
Overall complication rate
57
Incidence of post-operative hemorrhage
55
Venous thromboembolism (VTE) prophylaxis
54
Patients with malignancy who undergo adjuvant therapy
54
Readmission rates (30 day, 90 day, total)
54
Incidence of post-operative pancreatic fistula
54
Timely and appropriate peri-operative antibiotics
53
Survival rates (1 yr and 5 yr post-operative)
52
Timing from diagnosis to surgical consultation
51
EUS evaluation of cyst size was correlated with final pathology. Of 70 patients with EUS cyst size <3 cm, 12 (17%) had
a pre-operative EUS diagnosis of malignancy. Final pathology revealed 24 (34%) to have PDAC: 1 of 7 (14%) patients
with cyst size <1 cm, 2 of 19 (11%) with cyst size 1–2 cm,
and 21of 44 (48%) with cyst size 2–3 cm. 15 of 35 (43%)
patients with cyst size >3 cm had PDAC on final pathology. Of the patients with cyst size <3 cm, 16 (23%) had
high-grade dysplasia on final pathology: 3 of 7 (43%) with
cyst size <1 cm, 3 of 19 (16%) with cyst size 1–2 cm, and
10 of 44 (23%) with cyst size 2–3 cm. Seven of 35 (20%)
patients with cyst size >3 cm had high-grade dysplasia on
final pathology.
Although overall survival (OS) at 48 months stratified by
EUS cyst size did not significantly differ between groups,
patients with PDAC on final pathology had significantly
11
Sunday
Abstracts
per year, respectively. By descriptive analysis, 90% of Rpds
indicated a definite or probable need for improved quality
metrics in PS. 81% of Rpds indicated a definite or probable value for a “Quality Scorecard” in PS. Of 13 PS quality
metrics rated as Essential by >25% Rpds, 10 aligned most
strongly to the IOM Safety domain. 22/62 proposed metrics
aligned to more than 1.75 IOM Domains, and were rated
by >50% Rpds as High LoI (Essential or Very Important;
Figure). 12 proposed scorecard metrics (Table) emerged
with the highest TQS. Those related to mortality, to the
rate and severity of complications, and to access to multidisciplinary services for pancreatic disease had the highest
TQS. Technical and peri-operative metrics had intermediate TQS. Metrics related to patient satisfaction with care,
costs of care, and patient demographics had the lowest
TQS. The least represented IOM domains were equitability,
efficiency, and patient-centeredness.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
worse OS compared to non-invasive pathology. A total of 8
patients (8%) developed recurrent disease, all of whom had
PDAC on final pathology.
and sporadic IBD. 4. Alteration of the ZO-1 protein by the
SNP may lead to conformational changes or alterations in
binding sites that make it resistant to degradation in IBD.
Further study of the changes in the ZO-1 protein by a mutation at rs260526 may lead to a better understanding of the
role of ZO-1 in IBD.
CONCLUSION: EUS is a helpful modality for the diagnostic evaluation of SDIPMN. Considering the high incidence
of malignancy as well as high-grade dysplasia in SDIPMN
greater than 2 cm, EUS features should be used in conjunction with other clinical criteria to guide management decisions. Patients with SDIPMN greater than 2 cm that do not
undergo surgical resection may benefit from more intensive surveillance.
532
Ostomy Creation Significantly Increases ER Visits and
Hospital Readmission After Colorectal Resection
Lisa S. Poritz1, Arthur Berg2
1. Surgery, The Milton S. Hershey Medical Center, Hershey, PA;
2. Biostatistics and Bioinformatics, The Milton S. Hershey Medical
Center, Hershey, PA
531
Mutation in ZO-1 Is Associated with Protection from
Familial Inflammatory Bowel Disease
INTRODUCTION: Readmission after colorectal (CR) surgery continues to be a significant problem and quality of
care issue. The purpose of this study was to identify factors
predictive of readmission after CR surgery.
Lisa S. Poritz, Leonard R. Harris, Arthur Berg, Tara M. Connelly,
John P. Hegarty, Sue Deiling, Zhenwu Lin, Rishabh Sehgal
Surgery, The Milton S. Hershey Medical Center, Hershey, PA
INTRODUCTION: Inflammatory bowel disease (IBD)
is thought to occur due to an environmental insult in a
genetically susceptible individual. Multiple genetic variants have been identified to be associated with IBD. The
tight junction complex (TJ) is part of the intestinal epithelial barrier and has been shown to be altered in patients
with IBD. The purpose of this study was to identify genetic
variants in the TJ complex that may be associated with IBD.
METHODS: 30% (computer generated list) of the records
of all patients admitted to the CR service at our institution from July 2008—June 2011 were reviewed for patients
undergoing colorectal resection. Patients who died within
60 days of surgery or were discharged to hospice were
excluded. All others were then subdivided into 2 groups:
those patients that were either re-admitted or visited the
emergency room (ER) within 60 days after discharge and
those patients that did not. Additional data abstracted
from the medical record included total length of stay (LOS),
post-operative LOS (POD), diagnosis subcategorized into
malignant, diverticulitis, IBD, other benign disease; procedure subcategorized into colon resection, rectal resection,
combined resection; presence of an ostomy, laparoscopic
or open (converted procedures were in the open category),
surgeon, admission type (urgent/emergent or elective),
and patient age. Univariate and multivariate analysis was
performed.
METHODS: DNA from members of our IBD registry was
previously collected and stored. Initially 284 members
of our IBD registry and non-diseased controls underwent
genotyping for 25 TJ single nucleotide polymorphisms
(SNP) on an IlluminaTM platform. Genes studied coded
for both transmembrane and membrane associated proteins. Based on initial screening results, a total of 670 IBD
patients and non-diseased controls were genotyped for the
rs260526 SNP by polymerase chain reaction (PCR). IBD
patients were subdivided into familial (at least one family
member with IBD besides the index patient) or sporadic
(no family members with IBD). Three genetic models (general, additive, and dominant) were used to quantify the initial genotyping. For rs260526, groups were compared with
a two-sided Fisher’s exact test.
RESULTS: 242 patients met criteria. Data is shown in the
table. 74 (30.6%) patients were readmitted or visited the
ER within 60 days of discharge. Diagnosis, type of resection, approach (lap vs open), age, and type of admission
were not different between patients readmitted and those
that were not. Presence of an ostomy (ileostomy or colostomy) was the most significant factor associated with readmission, with 77% of the readmitted patients having an
ostomy (p = 0.0000014). Surgeon performing the procedure, LOS, and POD, were also significant factors determining readmission on univariate analysis and all remained
statistically significant on multivariate analysis. The most
common reasons for readmission were nausea, vomiting,
abdominal pain, and dehydration. 53/74 (72%) of the readmitted patients had at least one of these as their diagnosis.
129/242 (53%) of the patients in this series had an ostomy
post-operatively, likely due to the large number of patients
with IBD and rectal cancer. Emergent or urgent procedures
were not a significant risk factor for ostomy creation. The
image shows probability of readmission with increasing
LOS for patients with and ostomy (top curve) and without
(bottom curve). Bands are 95% confidence intervals.
RESULTS: Of the 25 initial SNPs only rs260526, a SNP in
the ZO-1 gene, was shown to be statistically significant by
all three genetic models when comparing IBD patients to
non-diseased controls. ZO-1 is a key protein in the TJ complex and has been shown to be altered in IBD. Therefore,
additional IBD patients and non-diseased controls were
genotyped for rs260526 by PCR. When the IBD patients
were subdivided, this ZO-1 SNP was found to be statistically
significant when comparing patients with familial IBD to
non-diseased controls, p = 0.0213, OR = 0.468, Cl = [0.225,
0.911]). The mutation was more common in the non-diseased controls, and therefore protective against IBD.
CONCLUSIONS: 1. Of all the TJ SNPs studied, only a
mutation in the ZO-1 gene was associated with IBD. 2.
This SNP was found to be protective against the development of familial IBD. Lack of significance of this SNP in
sporadic IBD supports a different pathogenesis for familial
12
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
533
Costs Associated with Colorectal Resection: Does Body
Mass Index and Obesity Adversely Impact Resource
Utilization?
John P. Cullen, Pokala R. Kiran, Ryan Williams
Department of Colorectal Surgery, Digestive Disease Institute,
Cleveland Clinic Foundation, Cleveland, OH
INTRODUCTION: Obesity rates have soared drastically in
recent years and complications of obesity lead to increased
health-care costs. Whether costs after colorectal surgery are
specifically higher for obese patients has however not previously been assessed. The aim of this study was to compare
direct costs for obese and non-obese patients undergoing
colon resection.
Probability of Readmission: Top line: with ostomy, bottom line: without
ostomy Shaded areas are 95% confidence intervals
Readmission
No
Readmission
74
168
55.12 ± 1.94
55.71 ± 1.20
IBD
27
45
Malignancy
30
77
Diverticulitis
8
33
Other Benign
9
13
Colon
44
117
Rectal
27
44
Multiple
3
7
43/14/17
56/16/95
0.0000034
Total patients
Age (years, mean ±
standard error)
Diagnosis
p value
METHODS: All patients undergoing elective open partial
colectomy at a single high-volume colorectal unit over
the last 3 years were identified. Patients with metastatic
malignancy were excluded. Patients were stratified based
on increasing body mass index (BMI) and matched for age,
gender and ASA class. Data relating to operation, length
of stay (LOS) and complications and costs were compared.
Subgroup analysis was performed on underweight and
morbidly (BMI >40) obese patients.
0.562
0.138
Type of resection
0.255
RESULTS: A total of 285 complete charts for patient undergoing partial colon resection were reviewed. Groups were
similar with regards to age, gender, ASA class and procedure.
Cancer and diverticulitis were the main diagnoses across all
groups, except for the underweight group, where Crohn’s
disease predominated and this group was excluded from
further analysis. Mean LOS was similar between groups.
Obese patients had greater mean hospital costs ($14803)
than non-obese ($12992) but this difference was not significant (p = 0.82). Wound infection rate approached 45%
in the morbidly obese group and was only 8% in patients
who were not obese. The overall morbidity, wound infection and costs progressively increased with increasing BMI
(table). Morbidly obese patients had significantly increased
overall morbidity and costs when compared to non obese
patients (p = 0.04).
Ostomy
Ileostomy/colostomy/no
ostomy
Any ostomy/no ostomy
57/17
72/95
0.0000014
Open/Laparoscopic
50/24
117/50
0.762
A
22
75
B
14
28
C
9
26
D
29
38
LOS (days, mean ±
standard error)
11.22 ± 1.22
7.49 ± 0.30
0.00608
POD (days, mean ±
standard error)
9.81 ± 1.09
6.79 ± 0.24
0.0168
Surgeon
0.0395
Admission type
CONCLUSION: For patients undergoing elective colon
resection, obesity leads to increased direct costs, with the
morbidly obese having the greatest costs. The increased
costs are likely due both to operating room costs and to
the increasing higher overall morbidity, especially wound
infection associated with increasing BMI. This risk should
be accounted for in future health care policy including
reimbursement and resource allocation strategies.
0.363
Emergent/urgent
16
28
elective
56
140
13
Sunday
Abstracts
CONCLUSIONS: The most significant predictive factor
for readmission in this study was an ostomy. Ostomies are
frequently used with elective and urgent CR and decreasing their use may not be prudent. However, the creation
of each ostomy should be evaluated for necessity by the
surgeon. Quality improvement projects should be directed
at assessing readiness of ostomy patients for discharge and
adequacy of support at home.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Group
Underweight (n = 18)
Non Obese (n = 185)
Obese (n = 64)
Morbidly obese (n = 18)
BMI (kg/m2)
<20
20–30
31–39
40–64
Age (years)
53
58.7
60.3
56.7
ASA class
1.7
2.3
2.5
2.6
Gender (% female)
55%
50%
55%
60%
Overall Morbidity
26%
35%
31%
72%
Wound infection
4%
8%
11%
44%
Total Direct Costs ($)
11450
12992
14803 (p = 0.82)
18980 (p = 0.04)
Nursing Costs ($)
2320
2498
3061 (p = 0.02)
2903 (p = 0.17)
OR costs ($)
678
1007
1127 (p = 0.78)
2340 (p < 0.01)
Pharmacy Costs ($)
972
751
1274 (p = 0.09)
1307 (p = 0.03)
with complications following non-operative management
including bowel obstruction, fistula, clostridium difficile
infection and lower GI bleed.
534
Natural History of Acute Diverticulitis: Low Risk of
Recurrence Following Non-Operative Management in
a Population-Based Study
CONCLUSION: Conservative management of diverticulitis results in a low rate of recurrence, further supporting a
non-operative approach. The only predictor of recurrence
was patient comorbidity. Non-operative management is
associated with a low rate of complications.
Jennifer D. Stanger, George Roxin, Anthony R. MacLean,
William D. Buie
Department of Surgery, University of Calgary, Calgary, AB, Canada
535
BACKGROUND: The natural history of acute diverticulitis
remains poorly understood, and the role of surgical intervention is controversial. The purpose of this study was to
determine the rates of recurrence and associated complications following non-operative management of acute diverticulitis in a population-based setting.
Visceral Fat Volume Better Than BMI at Risk Stratifying
Colorectal Cancer Patients
Aaron S. Rickles, James C. Iannuzzi, Andrew-Paul Deeb,
Fergal Fleming, John R. Monson
Surgery, University of Rochester, Rochester, NY
METHODS: All patients admitted to an adult hospital in
a large urban area between January 2007 and March 2010
were identified using a health records search (ICD-10 codes
K 572, 573, 578 and 579). Patients who underwent emergency surgery were excluded. Demographic, clinical, radiologic, treatment, complication and recurrence data were
collected. Data was analysed with logistic regression; a twosided p-value of 0.05 was considered significant.
INTRODUCTION: The extent to which obesity effects
colorectal cancer outcomes has been inconsistent in the literature, which may be a result of BMI being a poor descriptor of fat distribution. Compared to subcutaneous adipose
tissue, visceral adipose tissue is more metabolically active,
leading to a chronic inflammatory state and increasing the
risk for diabetes, cardiovascular disease, and tumorigenesis.
In addition, men and women distribute fat differently, thus
leading to differences in outcomes based on BMI. The aim
of this study is to describe the effect of visceral obesity on
colorectal cancer outcomes between gender groups.
RESULTS: A total of 645 patients presented with acute
diverticulitis. 502 patients were managed non-operatively
(49 percutaneous drains, 456 antibiotics). Median age
of patients was 55 (range 24–103), 51% of patients were
female, median follow-up was 34 months (range 14–50).
Seventy eight patients (15.5%) required acute readmission
to hospital, of which 67 (85.9%) were related to recurrent diverticulitis. 14 (20.9%) patients required urgent
surgical intervention. Of the remaining 53 patients managed non-operatively, 8 (15.1%) required a second acute
readmission (6 due to recurrent diverticulitis, 2 requiring
surgery). On univariate analysis only a Charlson Comorbidity score of 1 or greater was a predictor of recurrence
(p = 0.02). Of the 559 total admissions for diverticulitis
managed non-operatively, there were 51 (9.1%) in hospital
complications (Dindo-Clavien grade 1 = 20, grade 2 = 25,
grade 3 = 6). 10 (1.9%) patients were readmitted to hospital
METHODS: We conducted a retrospective chart review of
colorectal cancer patients who underwent surgery at our
institution between 2003 and 2010. Patient selection was
restricted to those who had a pre-operative CT scan of the
abdomen and pelvis. Exclusion criteria included emergency surgery, metastatic cancer, and patients with IBD or
HNPCC. CT scans were used to measure visceral fat volume
(VFV) using Carestream PACS 10.2 (Carestream Health,
inc.). Patients with a BMI ≥30 were considered obese and
viscerally obese patients were defined as those with a VFV
greater than the mean. Linear regression was used to ana-
14
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: A total of 233 patients met inclusion criteria,
75 Stage I (32%), 77 Stage II (33%), and 81 Stage III (35%).
The mean age was 67, mean BMI 28.5, and mean VFV 1637
cm3. There was no significant difference in BMI between
males and females (28.1 vs. 28.9, p = 0.294), however males
had significantly more visceral fat than females (1867 cm3
vs. 1371 cm3, p = 0.0001). In addition, BMI proved to be a
poor descriptor of visceral obesity on linear regression (r2 =
0.314, see Figure1). When analyzing disease free survival at
three years (DFS3yr) there was no difference between obese
and non-obese patients based on BMI. When analyzing
outcomes based on VFV, non-obese females with Stage II
cancer had significantly better DFS3 yr compared to viscerally obese females (86.3% vs. 60.0%, p = 0.034) although
there was no significant difference in DFS3 yr amongst
males.
METHODS: Patients ≥18 years of age treated at our institution for CDC of any severity were consecutively enrolled.
CDC was defined as symptoms of colitis with a positive PCR
stool test. Each bacterial isolate was studied for virulence
factors: tcdC mutation, binary toxin and ribotype 027 by
PCR, and the presence of toxins A and B using restriction
fragment length polymorphism. Chi Square tests, t-tests
and logistic and linear regression were used to determine
which virulence factors predicted the number of recurrent
episodes and the need for admission to the hospital for
treatment.
RESULTS: Sixty-nine patients (male: 57%) were studied, with a mean age of 64 ± 13 years. Twenty-one (30%)
patients were initially diagnosed as outpatients, while the
remainder developed CDC during hospitalization. A majority of patients harbored at least one virulence factor (Table
1). There was no difference (p > 0.05) between virulence
factors among inpatients and outpatients. Binary toxin
was the single virulence factor independently associated
with CDC recurrence (p = 0.02). A higher number of CDC
recurrences was also observed with toxin A (p = 0.01) and
tcdC mutation (p = 0.001) when either was present with
binary toxin, with the combination of binary toxin and
tcdC mutation being the strongest predictor, increasing
the number of recurrences by an average of two episodes.
The need for hospital admission for CDC recurrence was
strongly associated with tcdC mutation (p = 0.04), binary
toxin (p = 0.02) and ribotype 027 (p = 0.02). The combination of toxins A, B and binary toxin exerted an additive
effect by increasing risk of readmission three-fold when all
three toxins were present (p = 0.02). No resistance to metronidazole or vancomycin was encountered based on measurement of minimum inhibitory concentrations.
Figure 1: Linear regression of Visceral fat Volume and BMI.
CONCLUSION: This novel method for risk stratification
demonstrates that visceral obesity decreases three year disease free survival for women with stage II colorectal cancer
and should be considered in the discussion of chemotherapy use in these patients. Further study is necessary to
delineate the effect of visceral obesity in men at various
stages of colorectal cancer.
Association of Virulence Factors with Recurrence And Admission
for C. Difficile Colitis
Incidence
(n = 69)
Association
with Recurrence
(p Value)
Association
with Admission
(p Value)
61 (88%)
0.56
0.78
Virulence Factor
Toxin A
536
Predicting Recurrence of C. difficile Colitis Using
Bacterial Virulence Factors: Binary Toxin Is the Key
David B. Stewart, Arthur Berg, John P. Hegarty
Surgery/Division of Colon and Rectal Surgery, Penn State Hershey
Medical Center, Hershey, PA
Toxin B
66 (96%)
0.73
0.60
Binary toxin
42 (61%)
0.02
0.02
tcdC mutation
39 (56%)
0.18
0.04
Ribotype 027
26 (38%)
0.32
0.02
CONCLUSIONS: 1) Binary toxin is an independent predictor of CDC recurrence, which has not previously been
reported. 2) The combination of binary toxin and tcdC
mutation is associated with the highest number of CDC
recurrences, such that their combined presence is associated with a 70% recurrence rate. 3) C. difficile which produces binary toxin may require longer antibiotic regimens
to prevent disease recurrence.
BACKGROUND: Recurrence of C. difficile colitis (CDC)
is common, yet the ability to predict CDC recurrences is
virtually non-existent. Certain C. difficile virulence factors
have been implicated in the development of severe forms
of CDC, including toxins A and B, binary toxin, tcdC
mutation (leading to higher toxin production) and certain
strains of the bacteria such as ribotype 027. However, the
15
Sunday
Abstracts
role these factors play in the development of CDC recurrence is unknown. This study tested the hypothesis that
bacterial virulence factors predict CDC recurrence and the
need for admission to the hospital.
lyze the correlation between BMI and VFV, and independent sample t-test and Kaplan-Meier survival curves were
used for outcome analysis.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
537
Table 1: Comparison of Mean Serosal EGG Values of Primary vs.
Replacement GES in Gastroparesis Patients
Long-Term Effects of Gastric Stimulation on Gastric
Electrical Physiology
Patrick A. Williams1, Yana Nikitina1, Thomas L. Abell1,
Christopher J. Lahr2, Thomas S. Helling2
1. Digestive Diseases, University of Mississippi Medical Center,
Jackson, MS; 2. Surgery, University of Mississippi Medical Center,
Jackson, MS
Frequency
Amplitude
Primary Serosal EGG
5.27
0.33
40
Replacement Serosal EGG
3.75
0.3
24.3
0.000002
0.66
0.002
2.7–3.3
0.50
<10
p-value
Normal EGG values
Freq/Amp
INTRODUCTION: This study evaluates the modeling of
gastric electrophysiology (GEP) tracings during long term
gastric electrical stimulation (GES) for gastroparesis (GP).
Electrogastrography (EGG) via serosal recordings was performed on gastroparesis patients through stimulator leads
prior to stimulation and again with stimulator off at time of
stimulator replacement for battery depletion. We hypothesized that serosal EGG may change over time representing
gastric remodeling from GES.
PATIENTS: 66 patients with gastroparesis underwent
placement of gastric stimulator for refractory symptoms.
EGG was performed after the gastric leads were placed but
before stimulation was begun. Patients underwent continuous stimulation until pacer batteries depleted and the
stimulator was then replaced. At the time of stimulator
replacement, after the stimulator was removed, but before
the new pacemaker was attached, serosal EGG was again
performed using the gastric leads. Mean age at initial GES
placement was 44 years (range: 8–76); current mean age is
49; the majority of the subjects were female (n = 52, 79%).
Only a minority had diabetes-induced gastroparesis (n = 16,
24%); the remainder were either idiopathic, post-surgical,
or sarcoidosis-induced.
Figure 1
CONCLUSION: Long-term gastric stimulation causes
improvement in basal unstimulated gastric frequency
towards normal.
538
METHODS: At the time of GES placement, mucosal EGG
is performed through the GES leads. Once the GES battery
expires, it is replaced. At the time of replacement, EGG is
performed again, and GEP tracings are repeated.
Multivisceral Transplantation: Expanding Indications
and Improving Outcomes
Richard S. Mangus, A. Joseph Tector, Rodrigo M. Vianna
Indiana University School of Medicine, Indianapolis, IN
RESULTS: After a mean of 3.9 years (46 months) of GES
therapy, the mean unstimulated baseline frequency for
gastroparesis patients before initial GES therapy was 5.27
cycles/min (SD = 1.89) and declined to 3.75 (1.58) after
replacement (p = 0.000001), with a mean baseline frequency decrease of 0.03/month (Table 1, Figure 1). The
mean amplitude was 0.33 mV (0.39) before initial GES
therapy and decreased to 0.30 (0.34) afterward (p = 0.66).
The frequency/amplitude ratio was 40.0 (40.7) before initial GES therapy and decreased favorably to 24.3 (25) afterward (p = 0.002).
INTRODUCTION: Multivisceral transplantation (MVT)
includes the simultaneous transplantation of multiple
abdominal viscera including the stomach, duodenum, pancreas and small intestine, with (MVT) or without the liver
(Modified MVT or MMVT). This study reviews the changing indications and outcomes for this procedure over a
7-year period at a university medical center.
METHODS: This study is a retrospective case review of multivisceral transplants performed between 2004 and 2010 at
a single center. All cases were either MVT or MMVT, and
included a simultaneous kidney transplant, if indicated.
Graft failure was defined as loss of the graft or complete
loss of function. Graft function was monitored by laboratory values and serial endoscopy with biopsy.
16
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
50% patient survival during the period from 2004 to 2007,
followed by a 75% patient survival during the period from
2008 to 2010. Primary complications included rejection
(45% MMVT and 15% MVT), infection (>90% in the first
year), graft versus host disease and post-transplant lymphoproliferative disorder.
RESULTS: During the study period, 92 patients received
100 transplants including 85 MVT and 15 MMVT. There
were 19 patients who received a simultaneous kidney graft.
There were 24 pediatric and 76 adult recipients (range 4
months to 66 years). Indications included short gut with
liver failure, cirrhosis with complete portal mesenteric
thrombosis, slow growing central abdominal tumors, intestinal pseudoobstruction and frozen abdomen. All patients
received antibody-based induction immunosuppression
with calcineurin inhibitor-based maintenance immunosuppression. At a median follow-up of 36 months, 1-, 3and 5-year graft survival is 75%, 64% and 64%. There was
a learning curve with this complex procedure resulting in a
CONCLUSION: Indications for MVT and MMVT have
broadened to include patients with slow growing tumors,
complete portomesenteric thrombosis and abdominal catastrophes not amenable to other surgical therapy. Outcomes
continue to improve with many patients returning to full
functional status and enjoying long-term survival.
7:30 AM – 9:15 AM
28ab
VIDEO SESSION II: BREAKFAST AT THE MOVIES
582
583
Right Hepatectomy with Caval Thrombectomy After
Neoadjiuvant Therapy-TACE and Sorafenib-for HCC
with Caval Thrombosis
Hybrid Laparoscopic Total Colectomy/Robotic
Extralevator Abdominoperineal Resection
Celeste Y. Kang, Alessio Pigazzi
Surgery, University of California Irvine, Orange, CA
Alfredo Guglielmi, Andrea Ruzzenente, Elisabeth Baldiotti,
Tommaso Campagnaro, Calogero Iacono
Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy
A 26 year old female with a large cecal polyp and rectal
adenocarcinoma involving the spincter in the setting of
newly discovered familial adenomatous polyposis undergoes a hybrid laparoscopic/robotic total colectomy with
extralevator abdominoperineal resection. An oncologic
colon resection with high vessel ligation is performed laparoscopically followed by robotic e-APR. Total mesorectal
excision is performed and the levator fibers are divided at
their origin laterally on the pelvic side wall. The dissection
is carried out in the ischiorectal space as far distally as possible utilizing the robotic arms. This video emphasizes the
technique, feasibility and safety of this procedure.
A patient affected by HCV-related cirrhosis and multiple
HCC in the right hepatic lobe with caval vein thrombosis is
described. Considered the good response to treatment with
TACE and sorafenib, the patient underwent to right hepatectomy and caval thrombectomy with anterior approach
and total vascular exclusion. The specimen revealed complete necrosis of hepatic nodules and caval thrombus. After
one year, recurrence appeared near the surgical margin,
successfully treated with RFA. Six months later, CT scan
revealed three HCC nodules in the left lobe. A TACE was
performed with complete response. Two years after surgery,
the patient is alive and without recurrence.
17
Monday
Abstracts
Monday, May 21, 2012
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
584
587
Per-Oral Esophageal Myotomy (POEM) and Subsequent
Salvage Laparoscopic Heller Myotomy
Laparo-Endoscopic Transgastric Resection of a
Submucosal Mass at the Gastro-Esophageal Junction
Ezra N. Teitelbaum, Nathaniel J. Soper, Eric S. Hungness
Surgery, Northwestern University, Chicago, IL
Neil Ghushe, Parambir S. Dulai, Thadeus Trus
Dartmouth-Hitchcock Medical Center, Lebanon, NH
This video shows two procedures performed on the same
patient: a per-oral esophageal myotomy (POEM) and subsequent salvage laparoscopic Heller myotomy after recurrence of dysphagia. The POEM portion illustrates the key
steps of this novel procedure and shows intra-operative
bleeding that may have led to the patient’s eventual clinical failure. The patient underwent a laparoscopic Heller
myotomy four months later which is shown in the second
part. We see that the prior POEM had not created significant mediastinal or submucosal adhesions. This is the first
evidence that patients who fail POEM can then undergo
laparoscopic Heller myotomy without significant added
operative difficulty.
The management of gastric submucosal masses adjacent
to the gastro-esophageal junction presents an interesting
therapeutic challenge. Wedge resection is not possible in
this location without compromising the lower esophageal
sphincter or esophagus. Endoscopic submucosal dissection
provides an inadequate deep tissue margin. We present a
combined laparo-endoscopic approach for transgastric
resection of this type of lesion.
581
The Standardization of Laparo-Endoscopic Single Site
(LESS) Cholecystectomy
Sharona B. Ross1,2, Alexander S. Rosemurgy2, Michael H. Albrink1,2,
Edward Choung2, Scott F. Gallagher10, Jonathan M. Hernandez1,
Santiago Horgan 14,18, Michael Kia20, Jeffrey M. Marks6,
Jose Martinez17, Yoav Mintz12, Harold Paul2, Aurora D. Pryor3,
David W. Rattner7,8, Homero Rivas9, Kurt E. Roberts5,
Eugene Rubach15, Steven D. Schwaitzberg8,19, Lee L. Swanstrom16,
John F. Sweeney11, Erik Wilson13, Harry Zemon4, Natan Zundel21
1. Surgery, University of South Florida, Tampa, FL; 2. Tampa
General Hospital, Tampa, FL; 3. Surgery, Stony Brook University,
New York, NY; 4. Surgery, North Shore Lij Hospital, New Hyde
Park, NY; 5. Surgery, Yale Medical Group, New Haven, CT;
6. Surgery, University Hospitals Case Medical Center, Cleveland,
OH; 7. Surgery, Massachusetts General Hospital, Boston, MA;
8. Surgery, Harvard Medical Group, Boston, MA; 9. Surgery,
Stanford School of Medicine, Stanford, CA; 10. Surgery, Forsyth
Medical Center, Winston-Salem, NC; 11. Surgery, Emory University,
Atlanta, GA; 12. Surgery, Hadassah Hebrew University Medical
Center, Jerusalem, Jerusalem, Israel; 13. Surgery, The University
of Texas Medical School at Houston, Houston, TX; 14. Surgery,
University of California, San Diego, CA; 15. Surgery, New Jersey
Medical School, Newark, NJ; 16. The Oregon Clinic, Portland,
OR; 17. Surgery, University of Miami Health Systems, Miami,
FL; 18. Surgery, UC San Diego Medical Center, San Diego, CA;
19. Cambridge Health Alliance, Cambridge, MA; 20. Surgery,
McLaren Regional Medical Hospital, Flint, MI; 21. Florida
International University College of Medicine, Miami, FL
585
Hiatal Mesh: When the Crura Cannot Be Closed
Tatyan M. Clarke, Ross F. Goldberg, Armando Rosales-Velderrain,
Steven P. Bowers
Surgery, Mayo Clinc – Florida, Jacksonville, FL
The value of mesh-buttress over approximated crural musculature in hiatal hernia repair remains a topic of continued research and debate. However, there are situations in
which mesh use is essential. When the crura are fibrotic,
immobile, or damaged, and in the case of unusually large
defects, crural re-approximation is not feasible and a meshbridge repair is indicated.
Presented here are 3 cases where mesh is deemed necessary
and appropriate. First, a case of fibrotic crura after hiatal
hernia recurrence. The second case describes the technique
of repair for a large para-hiatal hernia. The final case demonstrates repair of hiatal hernia occurring years after transhiatal esophagectomy.
586
Minimally-Invasive Robot-Assisted Modified Appleby
Resection for Pancreatic Adenocarcinoma
Joel Baumgartner, Mehmet F. Can, Herbert Zeh, A. James Moser
University of Pittsburgh Medical Center, Pittsburgh, PA
Selected patients with pancreatic adenocarcinoma involving
the celiac trunk may derive prolonged survival benefit from
surgical resection. We report two patients who underwent
robot-assisted modified Appleby resection after chemoradiation. Median age was 82. Median duration of surgery was
374 minutes, median EBL 225 and 11 day length of stay.
Surgical margins were negative in both patients. The most
severe morbidity was Clavien grade 3 gastric ischemia that
resolved with bowel rest. The other patient had an ISGPF
grade C pancreatic leak requiring endoscopic drainage.
Robot-assisted minimally invasive modified Appleby resection can be completed safely with acceptable morbidity and
mortality.
This video presents a standardized approach to LESS cholecystectomy. Bupivacaine was injected at the umbilicus. A 12
mm vertical incision was made. A 4-trocar port was inserted.
A 5 mm deflectable tip laparoscope was utilized. With specific placement as denoted in the video, a bariatric length
grasper and a bent grasper retracted the gallbladder. A window was developed between the gallbladder and the liver
bed, promoting the “critical view.” The cystic duct and artery
were divided and the gallbladder removed. The diaphragm
was irrigated with bupivacaine solution. The umbilical defect
was closed in a figure-of-eight fashion. This video promotes
a standardized approach to LESS cholecystectomy.
18
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
10:00 AM – 11:15 AM
27b
PLENARY SESSION IV
Robotic-Assisted Rectal Dissection for Restorative
Proctectomy for Ulcerative Colitis
Brian Bello, Marie C. Ziesat, Konstantin Umanskiy,
Alessandro Fichera
The University of Chicago Medical Center, Chicago, IL
Robotic-assisted rectal dissection for cancer has been welldescribed, but experience in patients with inflammatory
bowel disease is lacking. The inflamed, friable tissue of the
ulcerative colitis patient adds an element of complexity
to the rectal dissection during a restorative proctectomy.
Robotic assistance can aid in visualization and maneuvering within the limited space of a narrow pelvis. At our institution, we use the robot to safely perform the complete
circumferential rectal dissection in patients with inflammatory bowel disease. We depict a robotic-assisted rectal
dissection during a restorative proctectomy in a thirty-one
year old female patient with ulcerative colitis.
RESULTS: 85 patients were identified that had complete
PPI/H2 data available. The data is shown in the table. There
was a statistically significant increase in the use of daily PPI/
H2 in patients without pouchitis. There was also a statistically significant increase in the use of antacids more than
one time per week in patients without pouchitis. There was
no association between the use of PPI/H2 and the use of
antacids. Occasional use of PPI/H2 did not alter the rate
of pouchitis. None of the other variables were statistically
significantly different between groups (see Table).
669
Chronic Use of PPI and H2 Antagonists Decreases the
Risk of Pouchitis After IPAA for Ulcerative Colitis
Lisa S. Poritz1, Rishabh Sehgal1, Arthur Berg3, Lacee Laufenberg1,
Christine Choi1, Emmanuelle Williams2
1. Surgery, The Milton S. Hershey Medical Center, Hershey, PA;
2. Gastroeneterology, The Milton S. Hershey Medical Center,
Hershey, PA; 3. Biostatistics and Bioinformatics, The Milton S.
Hershey Medical Center, Hershey, PA
No
Pouchitis
Pouchitis
PPI/H2 antagoinist: Never (Y/N)
26/20
28/11
0.178
PPI/H2 antagoinist: Daily (Y/N)
15/31
5/34
0.041
PPI/H2 antagoinist: Occasional (Y/N)
5/41
6/32
0.534
Antacid use (<1/week/ ≥1/week)
22/12
24/3
0.0381
PSC (Y/N)
5/25
2/24
0.436
Extraintestinal manifestations (Y/N)
14/21
14/13
0.443
Smoking
Never
INTRODUCTION: Pouchitis is one of the most common
long term complications after ileal pouch anal anastomosis
(IPAA) for ulcerative colitis (UC). One common theory of
pathogenesis is bacterial overgrowth in the pouch. Proton
pump inhibitors (PPI) and H2 antagonists (H2) are commonly used in the general population for control of gastric
acid. The change in pH of the stomach effluent caused by
anti-acid therapies may lead to alteration of the enteric bacteria population in the gastrointestinal tract and is known
to be associated with small bowel bacterial overgrowth. We
hypothesize that chronic use of PPI or H2 antagonists will
alter the incidence of pouchitis after IPAA for UC.
p Value
0.568
25
18
Quit
7
8
Current
3
1
Use of Probiotics (Y/N)
7/37
11/26
Use of NSAIDS > 1/week (Y/N)
14/21
8/19
0.435
Use of fiber supplementation (Y/N)
7/28
8/19
0.257
Use of anti-diarrheal medication (Y/N)
19/16
14/13
1
Use of immunosuppressive
medications (Y/N)
5/30
4/23
1
0.182
CONCLUSIONS: 1) Our data suggests that the daily use
of PPI or H2 antagonists is associated with a decreased
risk of pouchitis and may be protective against pouchitis
in patients with IPAA for UC. 2) Occasional use of these
agents did not seem to afford the same protection. 3. Regular antacid use provided similar protection as PPI and H2
antagonists. 4. This data suggests that altering the acid content/pH of the GI tract may influence the development of
pouchitis, possibly by altering the bacterial flora. Further
work to identify the changes in fecal flora is warranted.
METHODS: Patients who had undergone IPAA for UC at
least 2 years ago were identified from our familial inflammatory bowel disease registry. They were classified as having no history of pouchitis (no attacks of pouchitis since
IPAA 2 or more years ago) or pouchitis (documented episodes of pouchitis in the medical record by biopsy and/
or endoscopy and response to antibiotic therapy). Patients
were then contacted and questioned about use of PPI, H2,
and antacids. PPI and H2 were classified as never used,
daily use, or occasional use (1/month-2/week). Antacid use
19
Monday
Abstracts
was classified as less or more than once a week. Patients
were also questioned about known risk factors for pouchitis including tobacco use, extraintestinal manifestations of
IBD, primary sclerosing cholangitis (PSC) and the use of
NSAIDS. Data on the use of fiber supplementation, antidiarrheal medications, probiotics, and immunosuppressive
medications was also obtained. Two-sided Fisher’s exact
test was used to compare groups.
668
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
670
RESULTS: Of the 308 BDI: 223 (72%) were active (ActBDI),
77 (25%) were passive (PassBDI), and 8 (3%) followed
CBDE with T-tube. The level of biliary injury is shown in
the second table; injury to proximal bile ducts was more
common with ActBDI. Fewer PassBDI (16%) than ActBDI
(34%) were recognized intra-op (P = 0.006). Factors limiting visibility (inflammation, bleeding, etc) were more
common in PassBDI (Table); while what were thought to
be abnormal anatomic findings (additional ductal/tubular structures, arteries, vessels, abnormal biliary anatomy)
were more common in ActBDI (Table). The surgeon’s intraoperative sense-making also differed: a deliberate search for
possible BDI was more common in ActBDI than in PassBDI
(Table); cases were more commonly opened for compromised visibility with PassBDI (Table); and ActBDI were
more commonly identified intra-op among all BDI cases as
well among those converted to a laparotomy. Certain cues
inhibited BDI detection. Detection of all BDI was less common in cases with bleeding (9% vs 36%, bleeding vs none,
P < 0.0001), and when multiple factors limited visibility
(BDI detection: 35% no visibility issues, 28% one issue, but
only 11% with two or more factors limiting visibility, P <
0.0001).
The Prevention of Laparoscopic Bile Duct Injuries:
Delineation of the Principal Active and Passive
Mechanisms of Bile Duct Injury
Lygia Stewart1,2, John G. Hunter3, Lawrence Way2
1. Surgery, UCSF / SF VAMC, San Francisco, CA; 2. Surgery,
UCSF, San Francisco, CA; 3. Surgery, OHSU, Portland, OR
INTRODUCTION: The most common mechanism of
major bile duct injury (BDI) involves misidentification of
the CBD as the cystic duct, which is then deliberately transected. A common, but less frequent, mechanism occurs
when the hepatic duct is injured during dissection in the
triangle of Calot that is unknowingly too close to the common hepatic duct. Both mechanisms involve misperception, but one is active and the other passive. We analyzed
the two to find clues that would help improve prevention.
METHODS: 433 lap cholecystectomies (125 uncomplicated, 308 BDI) were studied. BDI were categorized according to the type: active (deliberate transection of common
bile duct mistaken for the cystic duct) and passive (lateral
injuries during dissection too close to the common hepatic
duct). Operative reports were examined for sensemaking
cues and clinical factors.
Active and Passive BDI Characteristics
Visibility Issues
Irregular Anatomic
Cues
Surgeon Sensemaking
Active BDI N = 223
Passive BDI N = 77
No BDI N = 125
P Value
Bleeding
35 (17%)*
28 (36%)*
7 (6%)*
<0.0001
Inflammation
75 (34%)
45 (58%)*
39 (31%)
<0.0001
One or more
81 (36%)
63 (82%)*
43 (34%)
<0.0001
Extra/Abnormal Artery or Vessel
87 (39%)*
18 (23%)*
11 (9%)*
<0.02
Extra Bile Duct/Tubular Structure
59 (26%)*
3 (4%)
1 (1%)
<0.0001
Abnormal Biliary Anatomy
76 (34%)*
13 (17%)
11 (9%)
<0.008
Search BDI
43 (19%)*
4 (5%)
0
0.006
Identify BDI
75 (34%)*
12 (16%)
0
0.004
Open visibility issues
15 (7%)
20 (26%)*
0
<0.0001
Open concern anatomy/BDI
17 (8%)
1 (1%)
0
0.085
18/32 (56%)*
5/21 (23%)
—
0.026
BDI identify w/conv open
* Significant factors BDI = bile duct injury
Distribution of Injuries
Above Bifurcation
Involvement
Lobar Ducts
Isolated Right
Ductal Injury
30(13%)
26(12%)
11(5%)
17(8%)
57(74%)
6(8%)
1(1%)
0
13(17%)
8(100%)
0
0
0
0
CBD/CHD
Bifurcation
Active BDI
139(62%)
Passive BDI
BDI after T-tube
20
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
670a
Gastroesophageal Reflux Disease (GERD) and Antireflux
Surgery (ARS): What Is the Proper Preoperative
Work-Up?
N = 134
Reflux score
GERD+ (78 pts)
GERD– (56 pts)
p
48 ± 37
6±4
<0.0001§
Brian L. Bello, Marco Zoccali, Roberto Gullo, Arunas E. Gasparaitis,
Mustafa Hussain, Fernando A. Herbella, Marco G. Patti
University of Chicago, Chicago, IL
Heartburn
(57) 73%
(35) 62%
0.193*
Regurgitation
(48) 61%
(26) 46%
0.083*
Dysphagia
(39) 50%
(31) 55%
0.540*
BACKGROUND: Many surgeons feel comfortable performing ARS on the basis of symptomatic evaluation,
endoscopy and esophageal manometry, while a pH monitoring is seldom obtained.
Reflux on BE
(37) 47%
(17) 30%
0.047*
Hiatal Hernia on BE
(31) 40%
(18) 32%
0.368*
Esophagitis
(6) 16%
(5) 20%
0.477*
AIMS: To analyze the sensitivity and specificity of symptoms, barium esophagogram, endoscopy and manometry
as compared to pH monitoring in the preoperative evaluation of patients for ARS.
LES pressure (mmHg)
18 ± 10
25 ± 26
0.37§
(53) 68%
(45) 80%
0.110*
Normal peristalsis
§Wilcoxon-Mann Whitney test; *Chi-square test; BE = barium esophagram;
LES = lower esophageal sphincter; reflux score normal <14.7 Continuous
variables are expressed as mean ± standard deviation.
PATIENTS AND METHODS: 134 patients referred for
ARS with a diagnosis of GERD based on symptoms, endoscopy, barium esophagogram and manometry. Ambulatory
24 hour pH monitoring was performed preoperatively in
all of them.
CONCLUSIONS: The results of this study showed that:
(a) symptoms were unreliable in diagnosing GERD; (b) the
presence of reflux or hernia on esophagogram did not correlate with reflux on pH monitoring; (c) endoscopy had
low sensitivity and specificity; and (d) manometry was
mostly useful for positioning the pH probe and rule out
achalasia. We conclude that ambulatory pH monitoring
should be routinely performed in the preoperative workup of patients suspected of having GERD in order to avoid
useless ARS.
RESULTS: Based on the presence or absence of GERD on
pH monitoring, patients were divided into two groups:
GERD+ (n = 78) and GERD– (n = 56). The groups were compared with respect to the incidence of symptoms, presence
of reflux and hiatal hernia on esophagogram, endoscopic
findings, and esophageal motility.
21
Monday
Abstracts
There was no difference in the incidence of symptoms
between the two groups (p = NS). Within the GERD+ group,
37 patients (47%) had reflux at the esophagogram and 41
(53%) had no reflux. Among the GERD- patients, 17 (30%)
had reflux and 39 (70%) had no reflux. Therefore, the
sensitivity of esophagogram was 47% and the specificity
was 70%. A hiatal hernia was present in 40% and 32% of
patients respectively. Esophagitis was found at endoscopy
in 16% of GERD+ patients and in 20% of GERD- patients,
accounting for a sensitivity of 16% and a specificity of
80%. Esophageal manometry showed no difference in the
pressure of the lower esophageal sphincter or the quality
of peristalsis. Ambulatory 24-hour pH monitoring clearly
separated the 2 groups (Table).
CONCLUSIONS: This study highlights differences in BDI
mechanisms and possible means of prevention. Most surgeons are aware of the perceptual trap of misidentifying
the CBD for the cystic duct, but passive injury has been
less completely elucidated. These data show that PassBDI
were less often detected, and identification of all BDI was
hindered when visibility was impaired (mainly by bleeding
or inflammation). Thus, when the surgeon’s attention was
occupied by inflammation or bleeding, consideration of an
injury to the bile duct was inhibited. Increased emphasis
on this risk factor should help prevent passive injury to the
common hepatic duct.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
672
desaturation (RAD) was defined as the first O2 desaturation event occurring within a 5-minute interval following
a reflux episode. Values are expressed as median ±IQR.
A Novel Method for the Diagnosis of Reflux-Related
Respiratory Symptoms: Normalization of RefluxAssociated Oxygen Desaturations Following Nissen
Fundoplication and Establishment of Normal Values
RESULTS: Patients with typical symptoms had a median
of 65, those with respiratory symptoms 64 and normal subjects 26 distal reflux events/24 hours. There was no significant difference in reflux events extending proximally in the
3 groups; 47% (380/804) typical, 45% (1411/3166) respiratory and 41% (114/276) in normal subjects. The number
of distal reflux events associated with O2 desaturation was
significantly greater in patients with respiratory symptoms
14 (9–20) than those with typical symptoms 5 (1–6; p <
0.001) or normal subjects 2 (1–5; p < 0.001). This was also
true for the number of proximal RADs: 7 (4–13) in patients
with respiratory symptoms versus 2 (0–3; p < 0.001) with
typical symptoms and 1 (0–2; p < 0.001) in normals. Repeat
study in 8 post-Nissen patients showed marked improvement with RADs approaching those of normal subjects in
6/8; 20 (9–20) distal pre-operative versus 3 (2–5; p = 0.05)
post-operative; and 12 (2–15) proximal pre-operative versus 2 (0–2) post-operative. Two post-operative patients were
found to have recurrent GERD; minimal improvement
and/or worsening in the number of RADs were identified
in each patient. Using a threshold of 95th %tile of normal
subjects, the number of RADs equaled or exceeded normal
in 81% (38/47) of patients with respiratory symptoms.
Candice L. Wilshire, Renato Salvador, Boris Sepesi, Stefan Niebisch,
Thomas J. Watson, Virginia R. Litle, Christian G. Peyre,
Carolyn E. Jones, Jeffrey H. Peters
Thoracic and Foregut Surgery, University of Rochester Medical
Center, Rochester, NY
BACKGROUND: Current diagnostic techniques aimed at
establishing gastroesophageal reflux disease (GERD) as the
underlying cause in patients presenting with respiratory
symptoms are poor. We previously reported preliminary
data suggesting that quantifying the association between
reflux events and oxygen desaturation may be a useful
discriminatory test. The aim of this study was to further
refine the proof of principle by assessing whether antireflux
surgery normalizes reflux-associated desaturations and to
establish normal values.
METHODS: Forty seven patients with GERD-related respiratory symptoms, 10 with typical symptoms, and 11 normal
subjects underwent simultaneous 24-hour multichannel intraluminal impedance (MII)-pH and pulse-oximetry
monitoring. Eight patients returned for post-Nissen studies. Acid reflux episodes were defined as pH <4 5 cm (distal)
or 20 cm (proximal) above LES and non-acid episodes as
a drop ≥50% from baseline in impedance 3, 5, 7 or 9 cm
above LES (distal) and 15 or 17 cm above LES (proximal).
Oxygen (O2) desaturation events were defined as a drop in
O2 saturation <90%, or a decrease ≥6%. Reflux-associated
CONCLUSIONS: These data provide further proof of principle that measurement of the association between reflux
events and oxygen desaturation may be a useful discriminatory test in GERD patients presenting with primary
respiratory symptoms, and may predict response to antireflux surgery.
10:00 AM – 11:15 AM
26ab
QUICK SHOTS SESSION I
extent, including portal vein invasion and lobar atrophy,
has been proposed. The aim of this study was to evaluate
current staging systems for hilar cholangiocarcinoma and
identify clinical factors associated with improved survival.
673
Staging and Survival of Resected Hilar Cholangiocarcinoma: An Analysis of 80 Consecutive Patients
METHODS: In this retrospective cohort study, clinical and
pathologic characteristics were obtained for all resected
patients with Bismuth-Corlette Type IIIa and IIIb hilar
cholangiocarcinoma from 1993 to 2011. Patients were
stratified by the 7th edition AJCC TNM staging parameters and by the modified Blumgart staging system which
includes portal vein invasion and presence of lobar atrophy. Univariate and multivariate analyses were used to test
effects of clinicopathologic factors and staging systems on
overall survival.
Victor M. Zaydfudim, Clancy J. Clark, Michael L. Kendrick,
Florencia G. Que, Kaye M. Reid Lombardo, John H. Donohue,
Michael B. Farnell, David M. Nagorney
Division of Gastroenterologic and General Surgery, Mayo Clinic,
Rochester, MN
INTRODUCTION: Predicting long-term survival in hilar
cholangiocarcinoma is difficult. The revised AJCC staging
system has not been extensively evaluated and may not
correlate with clinical outcomes. An alternative staging
system which incorporates factors related to local tumor
22
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
674
RESULTS: Eighty consecutive patients (median age 64
years (range 36–82), 64% male) underwent an anatomic
hepatectomy with a bile duct resection and reconstruction
for Bismuth-Corlette IIIa (51%) and Bismuth-Corlette IIIb
(49%) cholangiocarcinoma. Margin negative resection was
achieved in 94% of resections; 30-day mortality was 10%.
Median follow-up was 26 months (range 0–181 months)
with overall median survival of 34 months. Twenty-three
percent of the patients had well-differentiated cholangiocarcinoma. The AJCC staging system stratified patients
into following groups: T1–26%, T2–58%, T3–16%; N0–61%,
N1–39%; Stage I-20%, Stage II-30%, Stage III-50%. None of
the patients had distant metastases at the time of resection. Kaplan-Meier estimates did not demonstrate an association between survival and AJCC staging parameters (all
p ≥ 0.121). Blumgart staging system stratified patients into
following groups: Blumgart T1–58%, Blumgart T2–41%;
one patient had a Blumgart T3 cholangiocarcinoma with
invasion into portal vein bifurcation. Univariate analyses
demonstrated an association of survival with tumor grade
(p = 0.033) and Blumgart T-stage (p = 0.010). One- and fiveyear survival estimates for Blumgart T1 and Blumgart T2/
T3 were 86% and 47% vs. 74% and 17% (p = 0.010). After
adjusting for tumor grade, Blumgart T2/T3 stage correlated
with increased likelihood of mortality (HR = 1.93, 95%CI:
1.09–3.42, p = 0.024).
Value Analysis of Single Incision Laparoscopic
Cholecystectomy
Michael Cameron, Vic Velanovich
Surgery, University of South Florida, Tampa, FL
METHODS: The direct supply costs for both SILS-C and LC
from our institution were obtained. In addition, the extant
literature on SILS-C was review for operating room costs, as
well as measures of quality pertaining to pain control and
cosmesis were obtained. The incremental costs of each unit
of improvement in quality were calculated.
RESULTS: The direct supply costs of SILS-C was $1,582.90
compared to $753.30 for LC. Published operating room
costs were $2,109 for SILS-C compared to $2,069 for LC.
However, average reimbursement was $5,602 for SILSC compared to $6,403 for LC. Assessment of pain varied
among study, however, standardizing assessment of pain
across studies was done, with SILS-C having a 0.1 unit
improvement, for a cost of $400 per unit improvement
using published operating room costs. Assessment of cosmesis yield a cost for unit improvement varied between
$32-$40. These costs would be more is just the direct supply costs were the primary driver of value and reimbursement is less.
CONCLUSIONS: It does not appear that SILS-C provides
value for the patient and hospital. Improved pain control
and cosmesis is not consistent among studies published,
and the costs for each unit improvement variable depending on which costs data are important, but consistently
higher. Couple this with less reimbursement, the value of
SILS-C is questionable.
CONCLUSIONS: While the current AJCC TNM staging
system did not predict survival in the current study, the
Blumgart staging system which emphasizes portal vein
invasion and lobar atrophy predicted overall survival independent of other clinical and pathologic factors. Inclusion
of lobar atrophy into the T classification might improve
accuracy of the AJCC system, and help define prognosis in
patients with hilar cholangiocarcinoma.
23
Monday
Abstracts
BACKGROUND: Single incision laparoscopic surgery
(SILS), particularly laparoscopic cholecystectomy (SILS-C),
has been advocated as both a means of improving standard 4-port laparoscopic cholecystectomy (LC) and as a
stepping-stone to natural orifice trans-luminal endoscopic
surgery (NOTES). Data has been conflicting as to whether
SILS-C accomplishes its main goals of improved cosmesis
and less pain, while meeting all other requirements of a
cholecystectomy. We performed a value analysis of SILS-C
compared to standard LC using the generally accepted definition of value = quality/costs.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
675
676
A Randomised, Single Blind Study of Miniports
(3 mm) Versus Conventional Ports in Laparoscopic
Cholecystectomy
A Tool for Risk Adjusting Colorectal Surgery Pay for
Performance Models: Cr-POSSUM Scoring
Mark Bignell, Edward Cheong, Michael P. Lewis, Michael Rhodes
General Surgery, Norfolk and Norwich University Hospital,
Norwich, United Kingdom
Jasna Coralic, Kirthi Kolli, Anjali S. Kumar
Section of Colon and Rectal Surgery, Washington Hospital Center,
Washington, DC
INTRODUCTION: Single incision laparoscopic cholecystectomy (SILC) is said to provide improved cosmesis with
a reduction in postoperative pain, but involves a change
in operative technique. We have conducted a single-blind,
randomised controlled trial study of cosmetic outcome and
post-operative pain comparing laparoscopic cholecystectomy (LC) using either 3 mm or 5 mm ports.
BACKGROUND: Pay for performance (P4P) models are an
emerging way of holding physician payment accountable
for quality of care. Current reimbursement methods entail
standard payments based solely on procedure performed.
As P4P models are instituted, the current payment system
does not account for individual patient morbidity and
mortality risks.
METHODS: 80 patients with symptomatic gallstones were
recruited from a single centre and randomised to a LC using
either a 10 mm and three 5 mm ports (control) or a 5 mm
port and three 3 mm ports. The 5 mm port was extended as
necessary at the end of the operation to facilitate removal
of the gallbladder. Operative details, time and pain scores
at 1h, 6h, and 1 week and analgesia required in the 1st
week were collected.
HYPOTHESIS: A simplistic, validated, peri-operative risk
stratification score (Cr-POSSUM) for lower intestinal surgeries can be used as a risk adjustment tool for reimbursement integrating expected outcomes.
METHODS: We analyzed single institution retrospective
data for four colorectal and three surgical oncology surgeons over a systematic period spanning from 2006–2010
for colorectal cases and captured data for 179 patients. CrPOSSUM scores were calculated for each patient and t-test
analyses were performed using STATA10.
Statistical analysis was undertaken using a paired t-test or
fisher’s exact test as appropriate.
RESULTS: Cr-POSSUM scores for each organ system had
broad ranges for small bowel (0.38–25.98), colon (0.68–
57.56), rectal (2.30–40.83), and cytoreduction (4.17–24.84)
surgeries which attest to the vast array of patient mortality despite undergoing similar surgeries. As expected, there
was a significant difference in scores among those who had
post-operative complications and those who did not (p <
0.005). Cytoreductive and rectal surgery had a significant
difference in Cr-POSSUM score (p < 0.001) when compared
to other organ systems. Surgeons whose practice involved
a high percentage of cytoreductive and/or rectal surgeries
had higher mean Cr-POSSUM scores (p < 0.005) and higher
complication rates.
RESULTS: 40 patients were recruited to each group. The
mean age of the 3 mm group was 53 (±14) compared to
52 (±12) in the control group (p = 0.89). There were 11
males in the 3 mm group vs. 4 in the control group. One
patient in the control group was converted to open whilst
2 patients in the 3 mm group had a 3 mm port converted
to a 5 mm port and 4 patients required the insertion of
a 10 mm and 5 mm ports. The mean operative time was
49 minutes (±12, range 24–120 mins) in the 3 mm group
versus 46 minutes (±19, range 21–124 mins) in the control
group (p = 0.40). There was no statistical difference in the
day case rate between the 2 groups. The pain scores in the 3
mm group at 1h, 6h, and 1 week were 2.5 ± 2.1, 3.2 ± 2.2,
and 0.8 ± 2.2 versus 4.2 ± 2.9, 3.3 ± 2.4, and 2.1 ± 2.4 in
the control group (p Value = 0.003, 0.63, and 0.002). The
mean daily analgesia score, calculated using the WHO pain
ladder to attribute each class of analgesia a value, was 3.47
(± 3.2) in the 3 mm group vs 5.21 (±4.8) in the control
group (p = 0.008).
CONCLUSION: When evaluating a surgeon’s performance
based on outcomes, the Cr-POSSUM score should be used
for risk adjustment in P4P models for lower intestinal surgeries. Current reimbursement systems to not account for
individual patient risk.
CONCLUSION: The use of 3 mm ports is technically feasible in patients undergoing LC for gallstones with comparable operating times to conventional LC with reduced
pain scores and need for analgesia.
24
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
CRPOSSUM
n
Mean Cr-POSSUM Score (Range)
P-value
% Post-Op Complications
small bowel
29
4.1 (0.4–26.0)
0.09
34%
colon
65
5.6 (0.7–57.6)
0.3
29%
rectal
27
7.9 ( 2.3–40.8)
0.2
40%
cytoreduction
35
9.8 (4.2–24.8)
0.002
37%
CRS Doctor 1 (26% rectal)
27
6.6 (0.3–40.8)
0.8
56%
CRS Doctor 2 (20% rectal)
53
5.8 (0.3–57.6)
0.5
28%
Organ System
Highest Volume Physicians (case volume %)
25
4.8 (0.5–19.6)
0.3
16%
Surg Onc Doctor 2 (94% cytoreduction)
37
9.3 (0.7–24.8)
0.007
39%
Monday
Abstracts
Surg Onc Doctor 1 (8% rectal)
RESULTS: For pts with local and regional CC, 181,035 had
confirmed LN examinations. For Stages I-III, there has been
a dramatic improvement in compliance for pts with >12
LNs harvested over the recent two 5-yr periods (19, 21, 18%
respectively, p < 0.0001) whereas previously only a 5–7%
increase occurred over time (see Table). This rise in compliance had the greatest effect on the increased survival trend
for stage II CC with minimal change for those with Stage
I and Stage III CC. Irrespective of LN examined there has
been a significant increase in OS for all stages over time
(p < .0001).
677
A 21-Year Analysis of Lymph Node Trends in Colon
Cancer: Do Quality Measures Really Matter?
Danielle M. Hari1, Alexander Stojadinovic2,3, Anna M. Leung1,
Connie Chiu1, Myung-Shin Sim1, Anton Bilchik4,5
1. Surgical Oncology, John Wayne Cancer Institute, Santa Monica,
CA; 2. Surgery, Walter Reed National Military Medical Center,
Bethesda, MD; 3. Surgery, United States Military Cancer Institute,
Bethesda, MD; 4. Surgery, California Oncology Research Institute,
Santa Monica, CA; 5. Surgery, David Geffen School of Medicine at
University of California, Los Angeles, CA
CONCLUSIONS: In the largest time-dependent assessment
of LN examination in CC, significant improvements in surgical quality measures have occurred over the past decade
for Stage I, II and III. These measures have translated into
improvements in OS particularly for Stage II disease. LN
yield alone is not an adequate QM for pts with stage I and
III CC.
BACKGROUND: Lymph node (LN) number has been
endorsed as a quality measure (QM) in colon cancer (CC)
because of the impact on survival. However, the current
mandate requiring >12 LNs has been questioned. We evaluated whether compliance of this QM has improved and
whether this has impacted overall survival (OS).
METHODS: The Surveillance, Epidemiology, and End Results
(SEER) Database was queried to identify patients (pts) with
pathologically confirmed, localized and regional CC (Stage
I-III) diagnosed between 1988 and 2008. Interval trends in
lymph node (LN) harvest and OS were evaluated over time
(Year Strata (YS): 1988–1993, 1994–1998, 1999–2003 and
2004–2008).
1988–1993
> 12 LN
(% Pts)
Stage I
15.84%
Stage II
Stage III
1994–1998
5-yr OS
> 12 LN
(% Pts)
76.45%
19.04%
36.16%
68.69%
50.57%
45.54%
1999–2003
5-yr OS
> 12 LN
(% Pts)
78.22%
25.72%
40.79%
70.24%
47.13%
48.57%
25
2004–2008
5-yr OS
> 12 LN
(% Pts)
5-yr OS
80.54%
44.44%
83.27%
46.21%
71.67%
66.88%
74.26%
52.80%
52.80%
70.65%
56.96%
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
678
METHODS: After IRB approval, we conducted a retrospective review of all gracilis muscle transpositions performed
for complex fistulas and perineal defects from 1/2001–
9/2011. Patients were divided into three groups: rectovaginal fistulas, rectourethral fistulas and perineal defects.
Recognizing Risk: Colectomy in the Growing Chronic
Renal Failure Population
James C. Iannuzzi, Andrew-Paul Deeb, Abhiram Sharma,
Aaron S. Rickles, John R. Monson, Fergal Fleming
University of Rochester Medical Center, Rochester, NY
RESULTS: 97 gracilis transpositions were performed in 86
patients. 43 interpositions were performed in 33 females
for rectovaginal fistulas and 5 for pouch-vaginal fistulas;
52% had a mean of 1.5 (1–4) failed repairs prior to gracilis
interposition. The overall success rate was 89%; with an
18% post-operative complication rate. 4 patients required
a second gracilis interposition. All Crohn’s disease-associated fistulas (7) healed; however 42% required further
procedures. 48 interpositions were performed in 42 males
for rectourethral fistulas primarily due to prostate cancer treatment (95%); 29% had a mean of 1.2 (1–3) failed
repairs prior to gracilis interposition. The overall success
rate was 95%; with a 26% post-operative complication rate.
6 patients required a second gracilis interposition. 6 transpositions were performed for reconstruction of perineal
defects in 2 females and 4 males; 33% had a mean of 1.5
(1–3) failed repairs prior to gracilis transposition. The overall success rate was 100% with a 33% complication rate.
BACKGROUND: Projections indicate that the number of
people living with chronic end stage renal disease (ESRD)
will double in the next 10 years. An increasing incidence
portends a growing surgical challenge given the high risk
from immunosuppression, haemostatic abnormality, and
nutritional deficiency secondary to renal failure. There
exists a paucity of high quality data on the ESRD population in abdominal surgery. The authors sought to define
the risk of elective colectomy in ESRD using a large and
representative national clinical database.
METHODS: The American College of Surgeons National
Surgical Quality Improvement Program database was queried from years 2005 to 2010 for all colectomies. Patient
demographics, preoperative risk factors and intraoperative
variables were recorded. The primary end point was mortality at 30 days in dialysis dependent chronic renal failure
patients. Chronic renal failure was defined by dialysis use
prior to index admission excluding patients with acute kidney injury within 48 hours of colectomy. Univariate (chisquared), and multivariate analysis (linear regression) were
performed to determine predictors of mortality.
CONCLUSION: Gracilis muscle transposition is a versatile
and effective technique for treatment of complex fistulas
and reconstruction of perineal defects.
680
RESULTS: The study population included 1685 ESRD
patients undergoing colectomy, 750 were elective and 935
emergent. Median age was 65, median ASA score was 4 and
there were 850 men (50.4%). Overall mortality and morbidity was 27.5% and 54.9%. Emergent surgery was associated with an increased mortality {36.3% vs. 16.5% (p >
0.0001)} and morbidity {66.5% vs. 40.4% (p > 0.0001)}
when compared to elective surgery. Eight factors were independent predictors of 30-day mortality: age greater then
75, functional status, pulmonary, cardiac, hepatic, neurologic comorbidity, intraoperative time, and hypoalbuminemia. Hypoalbuminemia doubled the mortality risk (odds
ratio 2.0 95% CI [1.4, 3.2]).
Hospital Readmission for Fluid and Electrolyte
Abnormalities Following Ileostomy Construction:
Preventable or Unpredictable?
CONCLUSION: This study demonstrates that colorectal
surgery in ESRD confers a greater morbidity and mortality than previously described. Preoperative optimization of
other organ systems and nutritional status will reduce the
event rate in elective surgery in patients with ESRD.
METHODS: Retrospective chart review was performed on
patients who had an ileostomy created for any surgical disease by two board-certified colorectal surgeons at a single
tertiary institution January 2008—June 2011.
Dana M. Hayden, Maria C. Mora P, Amanda B. Francescatti,
Sarah C. Edquist, Matthew R. Malczewski, Jennifer M. Jolley,
Marc I. Brand, Theodore J. Saclarides
General Surgery, Rush University Medical Center, Chicago, IL
BACKGROUND: Ileostomy creation has perioperative and
postoperative complications, including re-hospitalization
for fluid and electrolyte abnormalities. Although several
studies have identified predictors of this morbidity, readmission rates remain high.
RESULTS: 154 patients were included in this study; 71
(46.1%) were female. The mean age and BMI were 49
(range 16–91 years) and 26.9 (13–52), respectively. The
most common indications for ileostomy creation were
cancer (39.6%) and inflammatory bowel disease (48.1%).
115 (74.7%) patients had loop ileostomies constructed; 80
(51.9%) were performed laparoscopically and 7.8% were
created emergently. The readmission rate for fluid and
electrolyte abnormalities was 20.1%, which was 43.7%
of total re-hospitalizations. Gender, older age, and BMI
were not associated with readmission. Laparoscopy, loop
ileostomy and emergency surgery were also not predictive.
679
Gracilis Transposition Is a Good Option for the
Treatment of Complex Perianal Fistulas and
Unhealed Perineal Wounds
Marylise Boutros, Karla Arancibia, Neha Hippalgaonkar,
Fabio Potenti, Giovanna DaSilva, Steven Wexner
Colorectal Surgery, CCF, Weston, FL
PURPOSE: We reviewed our experience with gracilis transposition for treatment of complex fistulas and reconstruction of perineal defects.
26
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
of life—at 1 year after treatment. Secondary outcome measures included retreatment, generic quality of life (SF-36),
achalasia symptoms, esophageal emptying quantified by
timed barium esophagram (TBE), and abnormal 24 hour
ambulatory esophageal pH monitoring (24h pH, as defined
by pH <4.0 for >4.0% of the total time). We enrolled sufficient subjects to detect a clinically significant difference
between treatment groups (20 points in the 0–100 ASQ
scale). Patients were analyzed according to their assigned
treatment group.
Follow up data were available for 22 subjects who were
initially assigned to PD and 23 who were assigned to HM.
There were no major differences between the groups at
baseline. Five subjects required re-treatment, all of whom
were initially assigned to PD (22.7%, 95% confidence
interval [CI] 7.8% to 45.4% as compared with 0%, 95% CI
0% to 14.8%, P = 0.02). The mean improvement in ASQ
at 1 year, analyzing the last pre-re-treatment observation
for re-treated subjects, was 20.9 (standard deviation [SD]
18.0) among PD patients as compared with 27.5 (SD 21.1)
among HM patients (mean difference 6.6, 95% CI–5.2 to
18.4). Six months after treatment, the mean improvement
in TBE percent emptying after 5 minutes was 30.4% among
PD patients as compared with 19.7% among HM patients
(mean difference 10.7%, 95% CI–16.7% to 38.2%). Among
patients who had 24h pH at 6 months, none treated by
HM had abnormal acid exposure (95% CI 0% to 16.8%) as
compared with 9.1% (95% CI 1.1% to 29.2%) among PD
patients (P = 0.17). None of the changes in measured symptoms or quality of life scores were significantly different
between treatment groups. The reduction in lower esophageal sphincter resting pressure was significantly larger
among patients assigned to HM (25.5 mmHg [SD14.4] as
compared with 14.2 mmHg [SD 17.6], mean difference 11.3
mmHg, 95% CI 0.4 mmHg to 22.2 mmHg).
CONCLUSIONS: Our results show that only neoadjuvant
therapy was significantly associated with hospitalization
for fluid and electrolyte abnormalities. Therefore, this morbidity does not appear to be preventable. Our study implies
that home regimen and follow-up are the main determinants of readmission. Prospective studies focused on diligent stoma monitoring by patients and physicians may be
the key to decreasing readmission rates.
680a
Randomized Controlled Trial of Disease-Specific
Quality of Life After Laparoscopic Heller Myotomy and
Pneumatic Dilatation for Newly Diagnosed Achalasia
Among healthy patients newly diagnosed with achalasia,
HM does not result in a clinically significant improvement
in quality of life as compared with PD. Patients treated initially by PD are significantly more likely to require re-treatment as compared with patients treated initially by HM.
David R. Urbach , Gail E. Darling , Nicholas E. Diamant ,
Paul P. Kortan1, George A. Tomlinson1, Wayne Deitel1,
Audrey Laporte1
1. University of Toronto, Toronto, ON, Canada; 2. Queen’s
University, Kingston, ON, Canada
1
1
2
Pneumatic dilatation and laparoscopic Heller myotomy
with partial fundoplication are both commonly performed
for the treatment of achalasia. It is not known whether one
procedure is superior with respect to disease-specific quality of life.
We randomly assigned 50 healthy persons aged 18 years
or older who were newly diagnosed with achalasia to
either laparoscopic Heller myotomy with partial fundoplication (HM) or to pneumatic dilatation (PD) with a
30 mm balloon at 4 Canadian cities (Kingston, Toronto,
Edmonton and Calgary). The primary outcome measure
was the Achalasia Severity Questionnaire (ASQ) score—a
validated disease-specific measure of health related quality
27
Monday
Abstracts
Inflammatory bowel disease and specifically Crohn’s disease were not significant, nor was previous intestinal resection. Cancer was strongly associated with readmission
(X2 = 4.73, p = 0.03) as was neoadjuvant therapy (X2 =
9.20, p = 0.01); after logistic regression, only neoadjuvant
remained significant. Examination of potential predictors
showed preoperative use of narcotics, fiber, stool softeners,
laxatives and anti-diarrheals were not predictive. Preoperative and discharge renal function, sodium and magnesium
levels were not significantly associated; however, increased
mean potassium level upon discharge trended toward significance (4.21 versus 4.05, p = 0.089). Stoma and urine
output on the day of discharge were not associated with
readmission; number of days with ileostomy output >1500
ml/24 hours was also not significant. Length of hospitalization, postoperative ileus, obstruction or sepsis was not
predictive. Postoperative chemotherapy and radiation were
not statistically significant. 52 (34%) patients were given
anti-diarrheals and 22 (14.4%) were given fiber supplements; neither correlated with readmission. 103 (66.9%)
patients had stoma reversal; 4 had ileostomy closure early,
but only 2 of these patients were readmitted for fluid and
electrolyte abnormalities.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
683
682
Comparison of Perioperative Outcomes After Per-Oral
Esophageal Myotomy (POEM) and Laparoscopic Heller
Myotomy
Iron Deficiency Anemia Is a Common Presenting
Issue with Giant Paraesophageal Hernia and Resolves
Following Repair
Eric S. Hungness1, Ezra N. Teitelbaum1, Byron F. Santos1,
Fahd O. Arafat1, John E. Pandolfino2, Nathaniel J. Soper1
1. Surgery, Northwestern University, Chicago, IL;
2. Gastroenterology, Northwestern University, Chicago, IL
Philip W. Carrott, Sheraz Markar, Jean Hong, Donald Low
Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA
BACKGROUND: Giant Paraesophageal hiatal hernias
(PEH) are most commonly associated with symptoms of
chest pain, early satiety and GERD. However, Iron-deficiency anemia is an under-appreciated condition associated
with giant PEH. The aim of this study was to evaluate the
incidence of iron-deficiency anemia in a cohort of patients
with giant PEH and assess the incidence of resolution associated with operative PEH repair.
INTRODUCTION: Per-oral esophageal myotomy (POEM)
is a novel procedure for the treatment of achalasia creating
a myotomy across the esophagogastric junction (EGJ) without skin incisions. To date, no study has compared POEM
perioperative outcomes with the surgical standard-of-care,
laparoscopic Heller myotomy (LHM).
METHODS: A review was conducted of a single-institution
database to compare outcomes after POEM and LHM. 11
patients underwent POEM from 8/2010—11/2011 under
the following IRB-approved inclusion criteria: age 18–85,
no prior treatment for achalasia, and non-sigmoid esophagus. 50 patients were identified who had undergone LHM
from 3/2004—7/2011 and fit these same criteria. T-tests
and Fisher exact tests were used to compare results.
METHODS: Between 2000 and 2010, 270 patients underwent operative repair of PEH and were prospectively
entered into an IRB-approved database. From this cohort,
123 (45.6%) patients demonstrated a pre-existing diagnosis of iron-deficiency anemia. 77 patients had a documented pre-operative hemoglobin level (Hb) consistent
with iron-deficiency anemia and a follow-up Hb level at
least 3 months following surgery and constituted the study
population.
RESULTS: There were 7 (64%) and 26 (52%) male patients
in the POEM and LHM groups respectively (p = ns). POEM
patients were younger (36 ± 11 vs. 50 ± 16 years; p < 0.01).
BMI and ASA classifications were similar. There was no difference in duration of symptoms prior to surgery (2 ±5 vs.
2 ± 3 years). POEM and LHM had similar procedure times
(121 ± 42 vs. 126 ± 29 min; p = ns). POEM had less EBL (≤10
ml in all cases vs. 91 ± 55 ml; p < .001) but LHM had longer
myotomy lengths (8.0 ± 1.1 vs. 8.5 ± 0.7 cm; p = .04). Pain
scores were similar on the day of surgery (3.3 ± 3.1 vs. 2.1 ±
2.3; p = ns) and on POD#1 (2.5 ± 2.8 vs. 2.1 ± 2.3; p = ns).
Patients used similar amounts of narcotics on the day of
surgery (4.8 ± 5.2 vs. 2.8 ± 4.3 mg morphine equivalents; p
= ns) and POD#1 (6.9 ± 7.7 vs. 4.6 ± 5; p = ns) despite the
fact that fewer POEM patients received ketorolac (18% vs.
78%; p < .001) due to concern for potential post-op bleeding in the sub-mucosal tunnel. Length of stay was similar
(2.3 ± 3.6 vs. 1.6 ± 2.9 days; p = ns) and all POEM patients
except for one were discharged by POD#2. No mortalities
and 1 major complication occurred in each group: a POEM
patient had a contained leak at the EGJ requiring laparoscopic drain placement and a LHM patient had a delayed
esophageal leak requiring thoracotomy for drainage and
repair. 3 (27%) minor complications occurred in POEM
patients, compared with 7 (14%) in LHM patients (p = ns).
Per-protocol post-op high-resolution manometry (HRM)
and timed barium esophagram (TBE) at six weeks showed
that POEM patients had decreased basal expiratory EGJ
pressures (12 ± 7 vs. 25 ± 10 mmHg, p = .04) and relaxation
pressures (15 ± 3 vs. 29 ± 17 mmHg, p < .05) and decreased
contrast column heights at 1, 2 and 5-minutes (4, 2 and 2
vs. 17, 16 and 11 cm), although only significantly at 1 and
2-minutes (p = .02 and .004). LHM patients did not routinely undergo repeat HRM or TBE.
RESULTS: From the cohort of 77 patients with documented pre-operative iron-deficiency anemia, 72 (94%)
underwent elective PEH repair, with a median age was 75
(range 39–91). Cameron erosions were endoscopically documented preoperatively in 25 patients (32%). The average
preoperative Hb value was 11.8 (7.6–16). Postoperatively
at 3–12 month follow-up, the average Hb level was 13.2
(10.7–17), and at more than 1 year follow-up it was 13.6
(9.2–17.2) (P < 0.05). Furthermore 90% of patients had a
rise in post-operative hemoglobin level by at least 1g/dL.
Anemia was fully resolved postoperatively (Hb ≥ 12.0 in
females, ≥14.0 in males) in 55 (71%) patients. This resolution was observed more commonly in women (40/50, 80%)
than men (15/27, 56%, P < 0.05). Also younger patients
(<70 years) were more likely to resolve their anemia (29/33
vs. 26/44; P < 0.05) and have a greater post-operative
Hb (14.0 vs. 13.0 g/dL; P < 0.05) than older patients. 40
patients required preoperative iron supplementation, 29
(73%) were able to discontinue iron following surgery.
There was no significant difference in the resolution of anemia in patients with or without Cameron erosions (19/25
vs. 36/52, p = 0.54).
CONCLUSION: This single institution study shows a high
incidence of iron-deficiency anemia (45.6%) in patients
with giant PEH. Elective repair results in resolution of
the anemia and discontinuation of iron supplementation
therapy, in more than 70% of patients. This improvement
in Hb is independent of the presence of pre-operative
Cameron erosions. This study demonstrates the clinical
and potential economic benefits of elective PEH repair of
patients with Giant PEH and iron-deficiency anemia.
28
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
CONCLUSIONS: POEM is a feasible procedure for creating an endoscopic myotomy for the treatment of achalasia. POEM and LHM appear to have similar perioperative
outcomes. Further data are needed to define and compare
long-term functional outcomes after POEM.
esophagus parameters were recorded by giving 10 swallows
of 5 mL of water at 30-second intervals. The analysis was
performed with the commercial dedicated software. Fourteen individuals also underwent a concomitant transnasal
pharyngoscopy.
684
RESULTS: Manometric parameters are depicted in Table 1.
The correlation between HRM plots and pharyngeal anatomic landmarks is shown in Figure 1.
Anatomo-Physiology of the Pharyngo-Upper
Esophageal Area in Volunteers at the Light of High
Resolution Manometry: Defining Normal Values
Monday
Abstracts
Luciana C. Silva1, Fernando A. Herbella1, Luciano R. Neves1,
Fernando P. Vicentine1, Sebastião Pannocchia1, Marco G. Patti2
1. UNIFESP, Sao Paulo, São Paulo, Brazil; 2. Department of
Surgery, University of Chicago, Chicago, IL
INTRODUCTION: High resolution manometry (HRM)
is a recent and valuable tool in the assessment of esophageal motility. The experience with this technology in the
evaluation of pharyngeal and upper esophageal disorders is
still incipient. This study aims to: (a) define normal values
for pharyngo-upper esophageal motility, and (b) correlate
HRM plots with pharyngeal anatomic landmarks.
METHODS: 29 healthy individuals (mean age 30 years,
62% males) underwent HRM with a solid-state catheter
with 36 circumferential sensors spaced 1 cm apart positioned to record from the base of the tongue to the esophagus. Pharyngeal, upper esophageal sphincter and proximal
CONCLUSION: Normal values for pharyngeal, upper
esophageal sphincter and proximal esophagus parameters
have been determined. These results may be applied in
future studies.
Manometric Values
Pharynx
Upper Esophageal Sphincter
Proximal Esophagus
Peak pressure at 2 cm above
mid UES
203,8 (160–225,6)
Basal pressure
88,5 (65,72–119,55)
Amplitude 2 cm below mid UES
64,3 (51,7–100,4)
Contraction duration at 2 cm
above mid UES
471 (349–697)
Residual pressure
4,1 (0,85–-7,77)
Amplitude 4 cm below mid UES
65,7 (45,7–76,5)
Start at 2 cm above mid UES to
UES start
–494 (–541 –419)
Relaxation time to nadir
198 (169,7–264)
Amplitude 6 cm below mid UES
35,05 (18,8–47,3)
Start at 2 cm above mid UES to
UES nadir
-235 (-355– –181)
Ralaxation duration
698,5 (629,7–773,2)
Start at 2 cm above mid UES to
UES end
212 (183–269)
Recovery duration
475 (380,2–561,5)
Data presented as median (interquartile range)
29
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
10:00 AM – 11:15 AM
28cd
VIDEO SESSION III: HPB & FOREGUT VIDEOS
685
First, laparoscopic hepatoduodenal lymphadenectomy was
performed. Lymphadenectomy started at proper hepatic
artery and continued towards celiac artery. Next, liver segment IVb and V were resected laparoscopically with a 2 cm
margin.
Robotic Assisted Duval Procedure for Pancreas Divisum
and Cystic Neoplasm
John Rodriguez, Sricharan Chalikonda, Au Bui, Jessica Titus,
Matthew Walsh
Surgery, Cleveland Clinic, Cleveland, OH
The patient was discharged home in 2 days. Pathology: no
evidence of tumor in liver or lymph nodes.
We present the case of a 35 year old female that was referred
for management of recurrent pancreatitis. On pre-operative
evaluation she was found to have pancreas divisum with a
long narrowed segment of the main pancreatic duct. On
further review of MRCP images, a cystic lesion was found
in the proximal duct. Our therapeutic goals consisted of
resection of the cystic lesion and drainage of the proximal
duct. She was taken to the operating room and a robotic
assisted Duval procedure was successfully completed. We
believe that this approach is safe and offers the benefits
of minimally invasive surgery for this complex pathology.
688
Laparo-Endoscopic Single Site (LESS) Distal
Pancreatectomy and Splenectomy with
Extraction Port
Alexander S. Rosemurgy2, Harold Paul2, Krishen Patel2,
Edward Choung2, Sharona B. Ross1,2
1. Surgery, University of South Florida, Tampa, FL; 2. Tampa
General Hospital, Tampa, FL
This is a video of a single incision distal pancreatectomy
with splenectomy. A 12 mm vertical incision was made
at the umbilicus. A 5 mm deflectable tip laparoscope was
utilized. The stomach was mobilized and the gastrocolic
omentum was divided. A retractor lifted the liver and the
dissection was carried along the inferior border of the pancreas toward the caudal tip of the spleen. The pancreas was
divided utilizing a reinforced laparoscopic linear stapler.
The specimen was delivered via extraction bag using a 2.2
cm lateral incision. The diaphragm was irrigated with bupivacaine solution. The umbilicus was closed in a figure-ofeight fashion. There was no notable scar.
686
A Year in the Life of a Tubulovillous Adenoma:
Combined Endoscopic and Laparoscopic Management
Niket Sonpal, Amit Jain, Patrick Saitta, Truptesh H. Kothari,
Gregory B. Haber, Paresh C. Shah
Lenox Hill Hospital, Hauppauge, NY
A 39-year-old male with a large symptomatic tubulovillous
adenoma of the first and second portion of the duodenum
was initially managed by endoscopic submucosal resection
(EMR). The majority of the adenoma was excised by EMR
in two stages. However, follow up endoscopy revealed persistent adenoma with regrowth to about 30% circumferential involvement of the duodenum and proximity to the
ampulla. A laparoscopic trans-duodenal local resection was
then performed with primary repair of the medial and lateral duodenum avoiding a pancreaticoduodenectomy with
excellent oncologic and clinical results.
689
Transduodenal Resection of a Ampullary Adenoma
Robert Grützmann, Marius Distler
Surgery, University Hospital Dresden, Dresden, Germany
Ampullary tumors display a favorable prognosis compared with other periampullary tumors. This prognostic difference can be attributed to the early presentation
and easy diagnosis by upper gastrointestinal endoscopy
and simultaneous histological verification and to biological differences that may determine the prognostic superiority of these tumors. The therapy of choice is complete
resection. In benign cases this can be achieved either by
endoscopic resection or surgical transduodenal resection,
whereas malignant tumors should be treated with a pancreatic head resection and lymphadenectomy. Here we
describe the technique of transduodenal resection of a adenoma of the papilla of Vater.
687
Laparoscopic Partial Hepatectomy with Hepatoduodenal
Lymphadenectomy for Early Gallbladder Cancer
Ziad Awad, Keyur A. Chavda
University of florida, Jacksonville, FL
Our case is 61year old female with T1b adenocarcinoma
of gallbladder found incidentally after laparoscopic cholecystectomy for chronic cholecystitis. CT scan showed no
evidence of liver lesion.
Two 12 mm and four 5 mm ports were used.
30
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
2:15 PM – 3:15 PM
28ab
QUICK SHOTS SESSION II
Post Roux-en-Y Gastric Bypass Biliary Dilation: Natural
Process or Significant Entity?
Kevin M. El-Hayek1, Poochong Timratana1, Joseph Meranda2,
Hideharu Shimizu1, Bipan Chand1
1. Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland,
OH; 2. Imaging Institute, Cleveland Clinic, Cleveland, OH
728
BACKGROUND: Changes in the biliary system after gastric bypass are not well defined. Dilation may be normal
or due to biliary tract pathology, that latter of which is
problematic to manage because access to the biliary tree
following gastric bypass often requires specialized care due
to altered anatomy. The purpose of this study is to review
patients who underwent imaging of their biliary system
both before and after Roux-en Y gastric bypass in an effort
to elucidate the effect this operation has on hepatic duct
diameter.
First Time Colonoscopy in the Elderly Yields a High
Rate of Curable Colorectal Cancer
Therese Kerwel1, Theodor Asgeirsson2, Donald G. Kim2,
Nadav Dujovny2, Rebecca Hoedema2, Heather Slay2, Ryan Figg2,
Martin Luchtefeld2
1. Department of Colorectal Surgery, Grand Rapids Medical
Education Partners/MSU, Grand Rapids, MI; 2. Department of
Colorectal Surgery, Spectrum Health Medical Group/Ferguson
Clinic, Grand Rapids, MI
METHODS: Using an IRB approved database, patients who
underwent laparoscopic Roux-en Y gastric bypass from
6/1/2010 and 9/30/2011 were evaluated. Those with imaging both before and at least 3 months after gastric bypass
were analyzed. Patients who underwent remote cholecystectomy prior to gastric bypass during this time period were
included in subgroup analysis. Data collected included
patient demographics, operative details, post-operative
weight loss, and time interval between surgery and second
imaging. Indications for post-operative imaging included
abdominal symptoms. For purposes of this study, all imaging was re-reviewed by a radiologist whereby the common
hepatic duct was measured at the level of the porta hepatis
to determine interval changes.
PURPOSE: The use of screening colonoscopy in the elderly
has become controversial with the USPSTF recommendation against routine screening in adults aged 76 to 85 years
as well as lack of Medicare reimbursement. However, early
detection of colorectal cancer in healthy elderly patients
may prevent morbidity and mortality from late presentation. This study aims to determine cancer detection rates
in the elderly undergoing outpatient index colonoscopy
and cancer detection for repeat colonoscopy in the same
population.
METHODS: We identified 903 outpatient exams in
patients 76 to 85 years over a 2-year period (1/09–12/10).
Patient demographics, exam indication and gross findings
were noted. Inpatient and outpatient charts were reviewed
for the pathology reports and previous history of colonoscopy in the subjects.
RESULTS: A total of 551 patients underwent Roux-en Y
gastric bypass during the study period. Of these, 82 had
biliary imaging both before and after surgery. Thirty-three
patients had post-operative imaging at least 3 months following gastric bypass. Mean age was 44 years (21–65) and
79% were female. There were 8 patients who had remote
cholecystectomy prior to gastric bypass and 25 patients
with gallbladders. In all 33 patients, mean hepatic duct
diameter was 5.2 ± 2 mm and 7.1 ± 2.6 mm pre-operatively
and post-operatively respectively (p < 0.01). Patients with
prior cholecystectomy had hepatic duct diameters of 7.9 ±
1.3 mm and 9.5 ± 3.5 mm pre-operatively and post-operatively respectively (p = 0.3). Patients who had not previously
undergone cholecystectomy had hepatic duct diameters of
4.3 ± 1.1 mm and 6.4 ± 1.8 mm pre-operatively and postoperatively respectively (p < 0.01). Overall excess weight
loss was 26.8% at a mean follow-up of 8 months (3–14).
RESULTS: Indications for all exams were as follows:
screening (19.7%), surveillance (34.0%), symptom clarification (25.6%), and multiple symptoms or indications
(12.0%). Carcinoma detection rate was 2.3%, adenoma
detection rate 23.8% and normal exam or insignificant
polyps 70.3%. Among patients documented to be undergoing colonoscopy for the first time, the carcinoma detection
rate was 9.4% (5/53), this was statistically significant when
compared to the rest of the group who had all previously
had a colonoscopy (P = 0.01). Carcinoma detection rate was
5.4% if the previous colonoscopy was 10+ years prior. 63%
of the carcinomas found in the index colonoscopy group
and in patients undergoing repeat colonoscopy 10+ years
31
Monday
Abstracts
CONCLUSIONS: Hepatic duct diameter increases after Rouxen Y gastric bypass. Patients with prior cholecystectomy
have a trend toward increased hepatic duct diameter, though
this change was not statistically significant. A better understanding of this phenomenon may limit the need for further work-up in patients with incidentally detected biliary
dilation and help to redefine what is considered normal
and abnormal in this population.
727
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
later were stage 1 or 2 and 38% were in stage 3. There were
no cases with metastasis. Subjects who had a previous colonoscopy within 3 years and 4–5 yrs ago had a 2.8% (6/213)
and 0% carcinoma detection rate respectively. When colonoscopies are stratified by indication, anemia had the highest yield with 3.9% rate of carcinoma followed by GI blood
loss at 3.3%. Indications predicting a low yield were single
symptoms such as altered bowel habits, abdominal pain or
weight loss (rate 0%). Screening and surveillance had rates
of 1.7% and 2.3%, respectively.
appendicitis (n = 22,50%), followed by nonspecific abdominal pain (n = 10, 22.7%), increasing abdominal girth,
and incidental diagnosis (n = 5, 11.4%). Nineteen patients
(43.2%) had a CT score of zero, 20 patients (45.5%) had
a socre of one, and 5 patients (11.4%) a score of two. The
mean PCI was 8.2 (range 0–27). A total of 22(50%) patients
were upstaged when surgically explored, mostly in patients
with a CT score of zero (n = 6, 27.3%) and one (n = 13,
59.1%). Preoperative variables including age, sex, tumor
marker levels, PCI score, or presentation with a perforated
appendix did not predict upstaging of disease burden. Estimated blood loss and PCI were associated with upstaging
(OR = 1.007, 1.782 and p-value = 0.023, 0.0007 respectively). For the entire cohort, the median survival was 22
months. Patients with CT score zero had a 25th percentile
survival of 34 months, compared to those with a score of
1 (23 months), and a score of two (18 months). With a
median follow-up 23 months, twenty two patients (50%)
remain disease free, 11 patients (25%) are alive with disease
and 8 patients have died due to disease recurrence.
CONCLUSIONS: The majority of outpatient exams in the
elderly reveal insignificant findings, demanding too much
from limited resources. However, detection of carcinoma
according to timing of the most recent exam has a much
higher yield than indication. The highest rates of carcinoma are among elderly patients undergoing outpatient
colonoscopy for the first time or after more than 10 years
and results in acceptable rates of curative colorectal cancer
resection. Early detection should reduce the morbidity of
late presentation and surgical emergencies often seen in
this population. Further guidelines designed to efficiently
utilize resources should focus on minimizing redundant
exams unlikely to yield significant results while supporting
screening exams with high yield.
CONCLUSION: Accurate assessment of disease burden for
early stage PMP remains challenging. Our data indicates
that approximately 50% of patients with no evidence of
disease or minimal amount of disease can be upstaged at
surgery. Based on this we recommend laparoscopic exploration and possible cytoreductive surgery and hyperthermic
chemoperfusion (HIPEC) for all patients with appendiceal
cancer.
729
Pre-Operative Imaging Does Not Accurately Stage
Patients with Early Stage Appendiceal Cancer
Mohammed A. Alzahrani, Hanseman Dennis, Jeffrey Sussman,
Syed A. Ahmad
Surgical Oncology, University of Cincinnati, Cincinnati, OH
730
Pelvic Radiation Increases the Risk of Ileal Pouch
Failure in Patients with Colorectal Cancer Complicating
Inflammatory Bowel Disease
INTRODUCTION: Pseudomyxoma perotenei(PMP)is a
rare clinical entity that mainly originates from appendiceal
tumors. A subset of patients are referred after management
of their primary tumor (i.e.appendectomy) for evaluation of
cytoreductive surgery (CRS)and hyperthermic intraperitoneal chemoperfusion(HIPEC).Some of these patients have
no visible disease on radiographic imaging and the value of
further surgery in this subset remains controversial.
Xianrui Wu1, Pokala R. Kiran1, Feza H. Remzi1, Saurabh Mukewar2,
Bo Shen2
1. Department of Colorectal Surgery, The Cleveland Clinic
Foundation, Cleveland, OH; 2. Department of Gastroenterology,
The Cleveland Clinic Foundation, Cleveland, OH
BACKGROUND: The impact of preoperative radiation
therapy on pouch function and survival has NOT been
studied in ulcerative colitis (UC) patients with colorectal
cancer (CRC) who undergo restorative proctocolectomy
with ileal pouch-anal anastomosis (IPAA). The aim of this
study was to evaluate pouch outcomes in UC-CRC-IPAA
patients with or without preoperative radiation therapy.
METHODS: Our single institution’s Peritoneal Cancer
Database was reviewed over a ten year period.During this
time over 200 patients were treated with appendiceal cancer.We identified 44 patients who meet the criteria for none
or minimal residual disease at pre-operative imaging. A CT
scoring system incorporating the peritoneal carcinomatosis
index (PCI) was devised where a score of zero denoted a
normal scan, a score of one signified a possible minimal
disease, and a score of two denotes a more obvious localized disease. This cohort of patients was reviewed for basic
demographic,clinical,and pathological features. Operative
treatment and postoperative course were also highlighted.
METHODS: Patients with UC-CRC who underwent restorative proctocolectomy with IPAA from 1984–2009 were
evaluated. Patients who underwent IPAA for medically
refractory IBD or familial adenomatous polyposis, and
patients whose initial pouch configuration was other than
J or S type were excluded. Pouch failure was defined as the
requirement of permanent diversion or pouch excision.
The effect of pelvic radiation on pouch related outcomes
was evaluated.
RESULTS: Forty four patients, 15 males and 29 females,
with a mean age of 50.4 years met the inclusion criteria
for none or minimal disease according to the proposed
CT score. The commonest initial presentation was acute
32
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
All
Cases
Without
Pelvic
Radiation
With
Pelvic
Radiation
63
52
11
Adenocarcinoma
54
44 (84.6%)
10 (90.9%)
Mucinous adenocarcinoma
9
8 (15.4%)
1 (9.1%)
Synchronous dysplasia,
n (%)
34
31 (59.6%)
3 (27.3%)
Characteristic
Number of patients
Histologic type, n (%)
P Value
0.69
Histologic grade of tumor,
n (%),
0.051
0.43
Poor
20
16 (32.7%)
4 (50.0%)
Well to moderate
37
33 (67.3%)
4 (50.0%)
Tumor location, n (%)
0.005
Rectum
26
17 (32.7%)
9 (81.8%)
Colon
37
35 (67.3%)
2 (18.2%)
0 + I + II
35
33 (63.5%)
2 (18.2%)
III + IV
28
19 (36.5%)
9 (81.8%)
Neo-adjuvant
chemotherapy, n (%)
6
0 (0.0%)
6 (54.5%)
<0.001
Adjuvant chemotherapy,
n (%)
26
29 (36.5%)
7 (63.6%)
0.176
TNM stage, n (%)
0.008
Configuration of pouch,
n (%)
0.10
J pouch
50
39 (75.0%)
11
(100.0%)
S pouch
13
13 (25.0%)
0 (0.0%)
Method of anastomosis,
n (%)
CONCLUSIONS: Pelvic radiation even before IPAA creation is significantly associated with poor pouch outcomes
in this small sample-sized, yet the largest study in the literature. This information needs to be considered and discussed
with patients with prior RT undergoing IPAA. Further, the
potential oncological benefits of chemo-radiation should
be carefully balanced against any potential adverse effects
on functional results on a case by case basis when deciding
management of UC patients with CRC.
0.73
Stapled
31
25 (51.0%)
6 (60.0%)
Hand-sewn
28
24 (49.0%)
4 (40.0%)
Hospitalization, days
8.1±3.5
8.0±3.6
8.1±2.8
0.95
Pelvic abscess, n (%)
9
7 (14.9%)
2 (22.2%)
0.63
Pouch fistula/sinus, n (%)
8
7 (14.9%)
1 (11.1%)
0.77
Pouch stricture, n (%)
16
14 (29.8%)
2 (22.2%)
0.72
Chronic pouchitis, n (%)
18
12 (25.5%)
6 (66.7%)
0.024
Pouch/ATZ neoplasia, n (%)
7
6 (12.8%)
1 (11.1%)
0.89
33
Monday
Abstracts
RESULTS: A total of 63 pouch patients with confirmed
UC-CRC were included (37 male and 26 female). Mean age
at pouch surgery was 46.9 ± 10.6 years. Of the 63 patients,
loop ileostomy was not closed in 2 patients, and 5 were lost
to follow-up. Of the 56 patients eligible for final analysis, 9
patients received pelvic radiation. Among them, 5 patients
had neo-adjuvant radiation, 2 received adjuvant radiation
after colectomy but before IPAA, while 2 had prior radiation for previous cervical cancer. Pouch failure occurred
in 13 patients after a median follow-up of 66.4 (range:
2.7–322.2) months, and 4 (30.8%) of them had radiation
therapy. Causes of pouch failure included pouch/anal transition zone (ATZ) cancer (n = 4), chronic pouchitis (n = 3),
pouch stricture (n = 3), pelvic abscess (n = 2), and incontinence (n = 1). Pelvic radiation correlated significantly
with chronic pouchitis (p = 0.024). There was, however, no
association between pelvic radiation and pouch/ATZ cancer, pouch stricture, pelvic abscess, and pouch fistula/sinus
(p > 0.05, Table). Kaplan-Meier analysis revealed that pelvic
radiation was associated with poor pouch outcome (logrank test, P < 0.001, Figure). The impact of pelvic radiation
on pouch outcome was further confirmed in the subgroup
analysis of rectal cancer patients (log-rank test, P = 0.020,
Figure).
Demographic and Clinicopathological Characteristics
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
731
cally sizes to the esophageal lumen. One to two ablations
were performed in separate areas in each patient in mucosa
proximal to the tumor. After resection, the ablation sites
were removed as a full-thickness block and examined histologically by a central study pathologist. Symptoms were
assessed prior to ablation, on the day of and 3 days after
the procedure using a standardized questionnaire with a
10-point scale.
Initial Human Experience with a Novel Throughthe-Scope Cryoballoon Device for Mucosal Ablation
Steven R. DeMeester1, Omar Awais3, Jacques J. Bergman2,
Kimberly S. Grant1, Blair A. Jobe3, Stefan Niebisch4,
Jeffrey H. Peters4, Dirk Schölvinck2, Mark I. van Berge
Henegouwen2, Bas L. Weusten2
1. Surgery, Univ. of Southern California, Los Angeles, CA;
2. Gastroenterology, Academic Medical Center, University of
Amsterdam, Amsterdam, Netherlands; 3. Surgery, University
of Pittsburgh, Pittsburgh, PA; 4. Surgery, University of Rochester,
Rochester, NY
RESULTS: Twenty-one ablations were performed in 13
patients for 6, 10, 12 or 14 seconds, and the esophagus was
removed 0, 4 or 7 days after the procedure. The ablation
was in squamous mucosa in 12 patients and in dysplastic
Barrett’s in 1 patient. There were no adverse events and no
perforations. No pain was present in 78% of patients the
day of the procedure and in 89% of patients 3 days after
the procedure. The mean scores for pain on the day of and
at 3 days after the procedure were 0.89 and 0.2 respectively.
Swallowing difficulty was present in 11% on the day of and
in 22% at 3 days after the procedure. The mean scores for
swallowing difficulty on the day of and at 3 days after the
procedure were 0.3 and 0.6 respectively. Details of the histology are shown (Table).
INTRODUCTION: Ablation of Barrett’s with high-grade
dysplasia has become standard. The most common ablation technique uses radiofrequency energy, but a drawback
is the requirement that the devices be used either separate
from or attached to the outside of an endoscope. An alternative is cryoablation, but current cryotherapy devices are
cumbersome, require gastric venting, and ablation depth is
difficult to standardize. A device that goes down the working channel of an endoscope that delivers a uniform and
reproducible ablation would potentially be safer and more
user-friendly. The aim of this study was to assess depth of
injury related to time of ablation using a novel throughthe-scope balloon-based cryotherapy device.
CONCLUSIONS: Ablation with a novel cryoballoon device
for 10–14 seconds results in substantial mucosal injury with
minimal pain or impaired swallowing. Depth of necrosis
was maximal at day 4 and was typically into the superficial
muscularis propria. By 7 days the injury was resolving, a
finding similar to previous work with this device in animals. Major advantages of this device include the ability
to standardize the ablation along with the ease of use and
quickness of the procedure. Future studies will assess the
risk of stricture and efficacy for Barrett’s ablation with this
device.
METHODS: Patients with esophageal cancer were enrolled
in a multi-center prospective trial evaluating a novel cryoballoon ablation device prior to esophagectomy. The
device is a through-the-scope, highly compliant balloon
catheter that is inflated and cooled by an inert refrigerant
delivered from a handheld unit. The balloon automati-
Day
(Post-Esophagectomy)
0
0
0
0
4
4
4
7
7
7
Ablation time (sec)
6
10
12
14
10
12
14
10
12
14
n
1
1
1
4
4
2
5
1
1
1
30%
80%
50%
3.75%
(0–10)
64%
(25–90)
80%
(65–95)
68%
(50–80)
15%
0
100%
Circumferential mucoscal ablation; Avg
and (range) when n>1
Depth of necrosis* Avg, (range)
1
1
1
1 (0–1)
3 (3–3)
3 (2–4)
3 (2–4)
1
1
2
Adjacent injury* Avg, (range)
0
0
0
1 (0–1)
2 (0–3)
3 (2–4)
2 (0–3)
0
0
2
*Key: 0 = no necrosis; 1 = necrosis only involving mucosa including or superficial to muscularis mucosa; 2 = necrosis into but not through submucosa;
3 = necrosis into superficial muscularis propria; 4 = necrosis involving full-thickness of muscularis propria, no perforation
34
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
732
733
A Multicenter Randomized Trial Comparing Two
Ablation Regimens for Focal Radiofrequency Ablation
of Barrett’s Mucosa Using the HALO90 System
Indirect Costs of Mortality and Morbidity and Direct
Economic Costs in a Randomized Controlled Trial of
Emergency Therapy of Bleeding Esophageal Varices in
Cirrhosis
Marshall J. Orloff1, Jon I. Isenberg1, Florin Vaida2,
Henry O. Wheeler1, Kevin Haynes1, Horacio Jinich-Brook1,
Roderick C. Rapier1, Robert J. Hye1, Wendy Max3
1. Surgery, University of California, San Diego, San Diego, CA;
2. Family and Preventive Medicine/Biostatistics and Bioinformatics,
University of California, San Diego, San Diego, CA; 3. Institute for
Health and Aging, University of California, San Francisco, San
Francisco, CA
OBJECTIVE(S): Economic cost is an important measure of effectiveness of treatment of cirrhosis and bleeding esophageal varices (BEV). There have been no reports
of costs of any form of emergency treatment of BEV. We
examined costs of care in a randomized controlled trial
(RCT) that compared endoscopic sclerotherapy (EST) (n =
106) to emergency portacaval shunt (EPCS) (n = 105), in
unselected, consecutive patients (“all comers”).
BACKGROUND: The currently recommended regimen
for endoscopic focal radiofrequency ablation (RFA) of Barrett’s esophagus (BE) comprises two applications of energy,
cleaning of the device and ablation zone, and two additional applications of energy. A simplified regimen may be
of clinical utility, if it were faster, easier and equally safe
and effective.
METHODS: Diagnostic workup and treatment were
undertaken within 8 hours. Crossover rescue treatment was
applied when primary therapy failed according to clearly
defined criteria. 96% of patients underwent 10+ years follow-up, or until death.
AIM: To compare the efficacy of two focal RFA regimens.
METHODS: In 3 centers, consecutive patients scheduled
for endoscopic focal RFA of BE were enrolled having flat
type BE with at least 2 BE islands or mosaic groups of islands
(each less than the surface area of two HALO90 ablation
catheters). Targeted BE areas were paired according to similar size: one of each area was randomized to the ’standard’
regimen (2 × 15J/cm2-clean-2 × 15J/cm2) or “simplified”
regimen (3 × 15J/cm2-no clean), allocating the second area
automatically to the other regimen. The % surface area of
each target was scored at 2 months by the endoscopist,
who was blinded to patient and regimen type. Patients
underwent RFA every 2 months until complete histological
response of each targeted BE area was achieved for neoplasia and intestinal metaplasia (CR-N; CR-IM). Primary outcome: CR-IM for each target at 2 months (non-inferiority
defined as <20% difference in the paired proportions, sample size calculated at 46 pairs). Secondary outcome: surface
regression (%) for each target at 2 months.
Indirect costs measured by the economic value of premature death (mortality) and by days lost from work (morbidity) were determined from tables of life expectancy, average
earnings at each age, labor force participation rates, and
an integrating computer program. Direct costs were determined from complete data on all inpatient and outpatient
charges by hospitals and physicians for 10 years.
RESULTS: Indirect costs were significantly lower following EPCS than after EST (p < 0.001) based on (1) costs of
mortality measured by shortened life expectancy; and (2)
costs of morbidity incurred by days lost from productive
activities. When added to direct costs (hospitalization, outpatient care, physician services), total costs following EPCS
were significantly lower than after EST (p < 0.001).
RESULTS: Forty-five equivalent pairs of target BE areas
were randomized by Dec ’11, in 40 patients (29 male, age
64 ± 12 years, BE C4M7). The proportion of targets showing CR-IM at 2 months after focal-RFA was 30/45 (66.7%)
for standard and 33/45 (73.3%) for simplified: a difference
of 6.7% (95%CI–12.2 to +25.6). The median surface regression for each target at 2 months was 100% in both groups,
whereas for not completely eradicated areas this was 77.5%
(IQR50–90)% for standard and 75% (IQR50–90) for simplified (p = 1.0). No complications occurred. By Dec ’11,
CR-IM and CR-N was achieved in 91.1% (31/34) and 100%
of patients, whereas 7 patients are under treatment.
CONCLUSIONS: In this RCT of emergency treatment of
BEV in cirrhosis with regular follow-up for 9.6 to 10+ years,
indirect costs (mortality and morbidity) were significantly
lower following EPCS than after EST. Combining indirect
and direct costs, overall costs of EPCS were significantly
less than costs of EST. Results of this first reported analysis
of economic costs of emergency treatment of BEV, when
added to other benefits of EPCS observed in this RCT, provide support for EPCS as a first-line emergency treatment
of BEV.
CONCLUSIONS: The results of this multicenter randomized trial suggest that a simplified 3x15J/cm2 focal ablation
regimen is not inferior to the standard regimen. Therefore,
the simplified regimen may be recommended for residual
Barrett’s islands.
35
Monday
Abstracts
Frederike G. van Vilsteren1, Lorenza Alvarez Herrero2,
Roos E. Pouw1, Kai Yi N. Phoa1, Carine Sondermeijer1,
Mike Visser3, Fiebo J. ten Kate3, Mark I. van Berge Henegouwen4,
Bas L. Weusten2, Erik J. Schoon5, Jacques J. Bergman1
1. Gastroenterology, Academic Medical Center, Amsterdam,
Netherlands; 2. Gastroenterology, St Antonius Hospital, Nieuwegein,
Netherlands; 3. Pathology, Academic Medical Center, Amsterdam,
Netherlands; 4. Surgery, Academic Medical Center, Amsterdam,
Netherlands; 5. Gastroenterology, Catharina Ziekenhuis,
Eindhoven, Netherlands
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
bined procedures were less common in 2009 compared to
2005 (OR; 95% CI, 0.7; 0.5, 0.8), and RYGB+C patients were
more likely to receive an open operation (4.9; 4.4, 5.5), to
have a severe ASA score (1.2; 1.0, 1.3), and be functionally
dependent (2.1; 1.4, 3.0). Post-operatively, the percentage
of RYGB+C patients experiencing a major complication
was significantly greater compared to RYGB alone patients
(6.6% vs 4.9%, P < 0.001). While risk was increased for
RYGB+C patients for developing septic shock (P = 0.02),
acute renal failure (P = 0.01), prolonged intubation (P =
0.001), and return to the operating room (P < 0.001) on
univariate analysis, only return to the operating room was
significant in multivariate adjustment models (1.3; 1.0,
1.7). Overall, RYGB+C was a risk factor for predicting major
adverse events following laparoscopic procedures but not
open (Table). Prolonged LOS was more common among
RYGB+C patients who underwent either laparoscopic
(13.5% vs 9.5%, P < 0.001) or open (14.1% vs 9.6%, P <
0.001) RYGB following adjustment (Table). Overall mortality at 30-days (0.2%) was low and did not vary with concomitant cholecystectomy (0.35% RYGB+C vs 0.19% RYGB
alone, P = 0.16) following adjustment for confounding
variables (Table).
734
Does Concomitant Cholecystectomy at Time of
Roux-en-Y Gastric Bypass Impact Adverse Operative
Outcomes?
Robert B. Dorman1, Wei Zhong2, Anasooya A. Abraham1,
Sayeed Ikramuddin1, Waddah B. Al-Refaie1, Daniel B. Leslie1,
Elizabeth Habermann1
1. Surgery, University of Minnesota, Minneapolis, MN;
2. Biostatistics, University of Minnesota, Minneapolis, MN
BACKGROUND: Previous investigations of the short-term
operative outcomes associated with a concomitant cholecystectomy at time of Roux-en-Y gastric bypass (RYGB)
for obesity are mixed and confined to the biases of singlecenter experiences. Using a robust multi-hospital surgical
database, we sought to determine the influence of concomitant cholecystectomy (RYGB+C), hypothesizing that the
addition of cholecystectomy will adversely impact operative outcomes following RYGB.
METHODS: Patients who underwent a RYGB were identified in the 2005–2009 American College of Surgeons
National Surgical Quality Improvement Program (ACSNSQIP) database. Demographic and outcome variables
were compared between patients that underwent RYGB
alone versus RYGB+C using univariate analysis. Multivariate logistic regression with adjustment for confounding variables was utilized to identify risk factors for major
adverse events, prolonged length of stay (PLOS), and mortality at 30 days. Prolonged LOS was defined as those who
experienced a hospital stay beyond the 90th percentile.
CONCLUSION: The risk for major adverse events is significantly greater for RYGB+C patients following laparoscopic
procedures, and the risk for PLOS is greater for RYGB+C
patients following both open and laparoscopic procedures.
While thirty-day mortality was greater, it was not significantly associated with concomitant cholecystectomy. The
short-term risks identified in this study can assist in decision making when considering concomitant cholecystectomy at the time of RYGB.
RESULTS: We identified 32,946 patients who underwent
RYGB; of these, 1,731 (5.2%) underwent RYGB+C. Com-
Predictors of Major Complications, PLOS, and Mortality After RYGB
Major Events+ N = 32880
Open OR (95% CI)
N = 4276
Laparoscopic OR (95% CI)
N = 28604
Prolonged Length of Stay+
N = 32880 OR (95% CI)
30-Day Mortality
N = 32946 OR (95% CI)
0.8 (0.6, 1.2)
1.3 (1.0, 1.7)
1.5 (1.3, 1.8)
1.2 (0.5, 2.9)
Ref. 1.3 (1.0, 1.7)
0.9 (0.5, 1.6)
Ref. 1.2 (1.0, 1.4)
1.2 (0.9, 1.7)
Ref. 1.3 (1.2, 1.5)
1.9 (1.5, 2.2)
Ref. 1.4 (0.8, 2.4)
2.3 (0.9, 5.9)
Ref. 1.4 (0.9, 1.9)
1.3 (0.9, 1.9) 1.8 (1.2, 2.5)
Ref. 1.0 (0.8, 1.2)
1.3 (1.0, 1.6) 1.3 (1.0, 1.6)
Ref. 1.1 (1.0, 1.2)
1.4 (1.2, 1.6) 1.6 (1.4, 1.8)
Ref. 1.9 (0.8, 4.5)
2.1 (0.8, 5.3) 3.8 (1.7, 8.6)
—
—
0.9 (0.8, 1.0)
2.2 (1.3, 3.8)
Diabetes
1.3 (1.0, 1.7)
1.0 (0.9, 1.1)
1.1 (1.0, 1.2)
2.1 (1.2, 3.5)
Cardiac Co-morb.
1.6 (1.0, 2.5)
1.2 (0.9, 1.6)
1.4 (1.2, 1.7)
3.3 (1.7, 6.6)
Total Events N (%)
366 (8.5)
1224 (4.3)
3213 (9.8)
66 (0.2)
C-Index of model
0.61
0.58
0.62
0.77
Predictors
RYGB+C vs RYGB Alone
Age (Years) 35–49 50–64 ≥65
BMI (kg/m2) 45–49 50–54
55–59 ≥ 60
Open Surgery
Abbreviations: OR, odds ratio; CI, confidence interval; BMI, body mass index; Co-morb., co-morbidities. Significant values are bolded and italicized. Variables also
adjusted for include, but are not limited to, race, sex, pulmonary comorbidities as well as preoperative liver enzymes, white blood cell count, hemoglobin, albumin, and
sodium. Prolonged LOS was defined as those who experienced a hospital stay beyond the 90th percentile. Note: +Only patients discharged alive were included.
36
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
735
hemoglobin values were respectively 5.3%, 5.2%, 5.4%,
and 5.4%. 94% of diabetics with more than 1 year follow
up were under no treatment; glycemia was under 100 mg/dl in
88% of them and glycated hemoglobin under 6% in 92% of
them. The rate of dyslipemia fell from 64 to 20%. No vomits or alkaline reflux have been observed. Mean number of
daily bowel movements is 2.5. Five patients suffered at least
one episode of clinical hypoproteinemia, and 3 of them
presented it recurrently. Two patients have been revised to
a Roux-en-Y duodenal switch with a 3 meter alimentary
limb and a 2 meter common channel. Now no patient has
suffered any intestinal obstruction.
Weight Loss and Metabolic Profiles of Obese Patients
After Single-Anastomosis Duodeno-Ileal Bypass with
Sleeve Gastrectomy (SADI-S)
Andrés Sánchez-Pernaute1, Miguel Angel Rubio-Herrera2,
Pablo Talavera1, Elia Pérez-Aguirre1, Antonio J. Torres García1
1. Surgery, Hospital Clínico San Carlos, Madrid, Spain, Madrid,
Madrid, Spain; 2. Endocrinology, Hospital Clínico San Carlos,
Madrid, Madrid, Spain
Monday
Abstracts
INTRODUCTION: Single-anastomosis duodeno-ileal
bypass with sleeve gastrectomy (SADI-S) is a simplified
duodenal switch in which the duodeno-ileal diversion is
performed in one loop at 200 to 250 cm from the ileo-cecal
valve. Theoretical advantages of the technique are a shorter
operative time, the reduction to only one anastomosis and
the non-opening of the mesentery.
AIM: To analyze the weight evolution and the improvement of the metabolic profiles of obese patients submitted
to SADI-S.
PATIENTS AND METHODS: 102 patients have been
submitted to SADI-S as a primary bariatric operation consecutively since May–2007 (Clinical Trials NCT01463904).
There were 64 women and 38 men. Mean age was 48 years
(22–71), mean weight 119 kg (72–164) and mean excess
weight 53 kg (27–99). There were 65 type-2 diabetics, 41%
of them on insulin therapy. Mean preoperative glycemia
was 153 mg/dl and mean glycated hemoglobin 9.5%. There
were 64 patients with dyslipemia and 57 patients had criteria of metabolic syndrome. The operation was performed
laparoscopically in 96% of the cases. The sleeve gastric
resection was always performed over a 54 French bougie;
the duodeno-ileal anastomosis was performed at 200 cm
from the cecum in the first 50 patients and at 250 cm in
the next 52, to decrease the 6% rate of clinical hypoproteinemia. One self-limited anastomotic leak and 2 gastric
leaks were registered. There were no postoperative deaths.
CONCLUSIONS: SADI-S is a simplified duodenal switch
that offers a satisfactory weight loss and very good metabolic results. The preservation of the pylorus makes unnecessary the performance of a Roux-en-Y diversion. The
technique reduces operative time and postoperative complications, in the short term by reducing the number of
intestinal anastomosis and in the long term by decreasing
the possibility of internal hernia.
RESULTS: Mean excess-weight loss was 78% at 6 months,
94% at 1 year, 100% at 2 years, 93% at 3 years and 108%
at 4 years. Only one patient failed to achieve a 50% excessweight loss. Mean glycemia fell to 94 mg/dl in the first
year, 93 mg/dl in the second one, 91 mg/dl in the third and
95 mg/dl in the fourth postoperative year. Mean glycated
37
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
736
patients was 2. In two patients there was complete resolution of the leak, one requiring a second clip placement. The
third patient had a contained leak following clip placement
that was followed clinically, follow up swallow study at six
days showed improvement, and she was discharged home.
Two patients had gastro-gastric fistulas following roux-en-y
gastric bypass surgery. One of these patients had complete
resolution of the fistula. The other had initial success but
the clip displaced and fistula recurred. Two patients presented with anastomotic leak following colon resection. In
one case the patient had extensive adhesions resulting in a
rigid colon and the Ovesco system on a pediatric scope was
too large to reach the fistula, so the procedure was aborted.
In the second case, the leak was successfully treated with
a single clip. Three patients were successfully treated for
esophageal perforation. One had a 9 mm mid-esophageal
perforation that required staged placement of two clips.
One had two separate distal esophageal perforation sites,
each requiring one clip. The final esophageal perforation was treated with a single clip. The average operative
time for clip placement was 61 minutes. There were no
complications.
Initial Experience with an Innovative Endoscopic
Clipping System
Alisa M. Coker1, Marcos Michelotti1, Nikolai A. Bildzukewicz1,
Takayuki Dotai1, Luciano Antozzi1, Geylor A. Acosta1,
Santiago Horgan1, Bryan J. Sandler1, Mark A. Talamini1,
Thomas J. Savides2, Garth R. Jacobsen1
1. Surgery, UCSD, La Jolla, CA; 2. Gastroenterology, UCSD,
La Jolla, CA
Introduction: There are few options available for treatment
of fistulas, leaks, and perforations endoscopically. Here we
describe our experience with a new endoscopic clipping
system.
METHODS: A retrospective review of all cases using the
Over-The-Scope-Clip system (Ovesco Endoscopy AG, Tuebingen, Germany) between August 2011 and November
2011. Resolution of leak was determined by a swallow
study or CT scan.
RESULTS: The system was utilized in ten patients with
clinically significant gastrointestinal surgical complications. Three patients were referred for treatment of gastric
leaks following a sleeve gastrectomy, two had post-operative colonic leaks, two had gastro-gastric fistulas following
roux-en-y gastric bypass, and three had esophageal perforations. All three gastric leaks occurred just distal to the
GE junction and each had undergone previous attempts
at treatment with other endoscopic methods. The average number of over the scope clips placed in these three
CONCLUSIONS: This over the scope endoscopic clip system is simple to use, safe, and successful in approximating
tissue to treat traditionally difficult surgical complications.
There is a potential for broad applications of this new
technology. Further experience and longer follow up are
needed to assess its indications as related to defect size and
location.
2:15 PM – 4:00 PM
27b
PLENARY SESSION V
based on the surgeon’s assessment of resectability at laparoscopic staging, (e.g. mobile tumors and low lymph node
burden). Our study aim was to determine whether survival is impacted by a selective approach to treatment that
includes minimally invasive esophagectomy (MIE) alone.
806
Propensity Matched Analysis of Surgeon-Driven
Treatment Allocation for Locoregionally Advanced
Esophageal and Gastroesophageal Junction
Adenocarcinoma
METHODS: Patients with stage II or higher EG adenocarcinoma treated with MIE (n = 375; 1997–2009) were
reviewed. Demographics, comorbidities, tumor and treatment variables were abstracted. To determine the probability of treatment assignment to either induction therapy
followed by MIE (E-) or to MIE alone (E+), propensity
scores were calculated. Variables are listed in Table 1. Complete data for the propensity variables were available in
280 patients and 80 closely matched pairs (n = 160) were
generated. Data missingness was random; survival relevant
variables in excluded patients did not differ significantly
from the included patients. Hazard ratios for death were
calculated by stratified Cox proportional-hazards regression model after controlling for age, gender, BMI, smoking
history and age adjusted CCI.
Haris Zahoor , James D. Luketich , Thomas Murphy ,
Michael Gibson2, Manisha Shende1, Dan Winger3,
Tyler J. Foxwell1, Blair A. Jobe1, Katie S. Nason1
1. Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA;
2. Medicine, University of Pittsburgh, Pittsburgh, PA;
3. Clinical and Translational Science Institute (CTSI), University
of Pittsburgh, Pittsburgh, PA
2
1
1
BACKGROUND: Attempts to define the optimal treatment strategy for resectable but locoregionally advanced
esophagogastric (EG) adenocarcinoma have yielded conflicting results. As a result of high local failure rates, most
thoracic oncologists favor induction therapy followed by
surgery. In our center, a selective approach has been used
38
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
single-incision trocar system, a complete mediastinal dissection of the esophagus can be accomplished under direct
vision. This can be performed simultaneously with the
abdominal portion of the esophagectomy. This allows for a
shorter operative time, eliminating the need for single-lung
ventilation, and reducing the risk for postoperative pulmonary complications by avoiding the pleural cavity. Thank
you for considering this video.
RESULTS: MIE was the primary therapy in 47% (n = 178) of
patients and induction therapy in 53% (n = 197; 51% chemotherapy alone and 49% chemoradiation). Chemotherapy included cisplatin (61%), 5-FU (76%), and paclitaxel
(42%). Complete response following induction therapy
was confirmed at MIE in 13%; 44% were node-negative at
resection compared to 20% for MIE alone. Median number of lymph nodes examined was 21 (IQR 15, 29). Median
time to follow-up was 23 months (IQR 11, 38). Adjuvant
therapy was given to 53% of patients following MIE. In the
80 matched pairs, there were 117 deaths (73%; median 18
months, IQR 9, 29). Surgery as primary mode of treatment
was not associated with significantly different hazard for
death after adjusting for age, sex, BMI, smoking history
and age-adjusted Charlson Comorbidity index (0.96; 95%
CI 0.58–1.6). Complete response was not associated with a
significant improvement in median survival (19 versus 17
months; p = 0.24).
808
Nicholas J. Shaheen1, William J. Bulsiewicz1, William D. Lyday2,
George Triadafilopoulos3, Herbert C. Wolfsen4,
Srinadh Komanduri5, Gary W. Chmielewski6, Atilla Ertan7,
F. Scott Corbett8, Daniel S. Camara9, Richard I. Rothstein10,
Bergein F. Overholt11
1. Division of Digestive Diseases, Center for Esophageal Diseases
and Swallowing, University of North Carolina School of Medicine,
Chapel Hill, NC; 2. Atlanta Gastroenterology Associates, Atlanta,
GA; 3. Stanford University School of Medicine, Palo Alto, CA; 4.
Mayo Clinic Florida, Jacksonville, FL; 5. Northwestern Memorial
Hospital, Chicago, IL; 6. Rush University Medical Center, Chicago,
IL; 7. University of Texas Health, Houston, TX; 8. Sarasota
Memorial Hospital, Sarasota, FL; 9. Sisters of Charity Hospital,
Buffalo, NY; 10. Dartmouth-Hitchcock Medical Center, Lebanon,
NH; 11. Gastrointestinal Associates, Knoxville, TN
Variables Included in Propensity Matching
Age
Body Mass Indes
Smoking History
Pack-years smoked
Sex
Surgeon
Alcohol use
Gerd history
Histologically confirmed
Barrett’s
History of MI
History of CHF
History of CABG or
coronary stent
History of vascular
disease
History of renal failure
History of diabetes
requiring treatment
History of pulmonary
disease
History of stroke or TIA
History of malignancy
other than current
History of metastaatic
cancer
History of liver disease
Final pretreatment
clinical stage
Operation status
Prior esophageal
surgery
Esophageal cancer
location
BACKGROUND: Ongoing acid and bile reflux are hypothesized to impair healing and squamous re-epithelialization
after treatment of Barrett’s esophagus (BE) with radiofrequency ablation (RFA). It is unclear if prior fundoplication
improves subsequent safety and/or efficacy of ablation. We
used data from a nationwide registry of patients treated
with RFA for BE to assess the relationship between prior
fundoplication and these outcomes.
CONCLUSION: We found that a selective approach to treatment of EG adenocarcinoma does not negatively impact
patient survival. Complete response rates to induction
therapy in this series were not associated with improved
survival. Our data suggest that surgeon-driven treatment
allocation for locoregionally advanced esophagogastric
adenocarcinoma, including aggressive lymph node dissection, is a reasonable alternative to treating all patients with
induction therapy.
METHODS: The U.S. RFA Registry is a prospective study
of patients with BE treated with RFA at 148 institutions
(113 community-based, 35 academic-affiliated). Information collected in the registry includes demographic data,
histology prior to treatment, endoscopic findings, date
and number of treatment sessions, ablation outcomes, and
complications. Medical therapy with proton pump inhibitors was used in subjects without fundoplication. Our safety
cohort consisted of all patients treated with RFA, while our
efficacy cohort was restricted to subjects who had biopsies ≥12 months after RFA treatment initiation. Complete
eradication of intestinal metaplasia (CEIM) was achieved
if last biopsies demonstrated no IM. We compared safety
and efficacy outcomes between those with a history of fundoplication and those undergoing medical management,
using parametric tests. Safety outcomes included rates of
stricture, bleeding, and hospitalization. Efficacy outcomes
included CEIM, complete eradication of dysplasia (CED),
and number of treatment sessions to CEIM. Efficacy results
are reported for the full cohort and stratified as non-dysplastic BE (NDBE) versus dysplastic BE.
807
Transcervical Videoscopic Esophageal Dissection in
a Two-Field Minimally Invasive Esophagectomy
Ross F. Goldberg, Tatyan M. Clarke, Armando Rosales-Velderrain,
John Stauffer, Horacio J. Asbun, C. Daniel Smith, Steven P. Bowers
Surgery, Mayo Clinic – Florida, Jacksonville, FL
This video report demonstrates a patient undergoing a
2-field minimally invasive esophagectomy using a transcervical videoscopic esophageal dissection. Using a modified
39
Monday
Abstracts
Prior Fundoplication Does Not Improve Subsequent
Safety or Efficacy Outcomes of Radiofrequency
Ablation (RFA): Results from the U.S. RFA Registry
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
RESULTS: Among 5,539 patients receiving RFA, 318
(5.7%) had a prior fundoplication. Of these subjects, 0.9%
developed stricture after RFA and 1.3% were hospitalized.
There were no perforations or clinically significant bleeding
in the fundoplication group. Rates of stricture, bleeding,
and hospitalization were not statistically different (p>0.05)
between patients with and without prior fundoplication
(see Table). In all, 2,135 of 5,539 (39%) had biopsy data
available after 12 months. CEIM and CED were achieved in
78% and 93% of subjects with a fundoplication, and 72%
and 87% of subjects without a fundoplication, respectively
(p > 0.05 for both comparisons). Subjects with prior fun
doplication had similar rates of CED, CEIM, and number
of RFA sessions for eradication when compared to those
without prior fundoplication (see table).
CONCLUSIONS: In the largest reported cohort of patients
treated with RFA for BE, RFA in subjects with a prior fundoplication was safe and effective. However, prior fundoplication was not associated with improved efficacy or reduced
number of ablation sessions, when compared to medical
management using proton pump inhibitors.
Safety and Efficacy Outcomes Among Patients with and without Fundoplication Prior to Treatment with RFA.
Complication Rates Per Patient
Efficacy for all Subjects
Fundoplication
Medical Therapy
N
318
5221
Stricture
0.9%
2.2%
0.14
Bleeding
0
0.4%
0.27
0.18
Hospitalization
1.3%
0.6%
N
139
1996
CEIM
78%
72%
0.18
93%
87%
0.13
2.8 (1.6)
2.8 (1.6)
0.91
CED
RFA treatment sessions, mean (SD)
Efficacy for Nondysplastic BE
N
CEIM
RFA treatment sessions, mean (SD)
Efficacy for Dysplastic BE and IMC
p-value
N
79
875
80%
81%
0.72
2.7 (1.8)
2.6 (1.6)
0.68
60
1121
CEIM
75%
65%
0.13
CED
93%
87%
0.13
3.0 (1.4)
3.0 (1.6)
0.90
RFA treatment sessions, mean (SD)
Complications and outcomes were also compared. Sociodemographic factors were examined as effectors of surgery
location.
809
Nationwide Inpatient Sample: Have Antireflux
Procedures Undergone Regionalization?
RESULTS: A total of 11804 cases were performed in T1 and
8856 in T2. In T1, 41.0% of procedures were performed in a
HVC vs 35.4% in T2. LVC rates increased with time: 20.53%
vs. 26.87% (p < 0.0001). Rural hospitals had decreased surgical volume (19.10% vs. 10.33%, p < 0.0001), while all
urban hospitals increased volumes: teaching (48.23% vs.
51.03%, p < 0.0001) and non-teaching (32.67% vs. 38.64%,
p < 0.0001). Using multivariate regression, the following
were predictors of surgery at a LVC in T1: non-caucasian
race (OR 1.42, p < 0.0001), emergent admission (OR 2.24,
p < 0.0001), living in a zip code with low median income
(OR 1.52 lowest vs. highest, p = 0.0039), increasing age
(p = 0.0002), and increasing concurrent diagnosis number (p = 0.0029). In T2, emergent admission (OR 1.34, p =
0.038), low median income (OR 1.69 highest vs lowest, p <
0.0001), and number of concurrent diagnoses (p = 0.034)
Paul D. Colavita, Igor Belyansky, Amanda Walters, Sofiane El
Djouzi, Alla Zemlyak, Amy E. Lincourt, B. Todd Heniford
General Surgery, Carolinas Medical Center, Charlotte, NC
INTRODUCTION: With improved outcomes demonstrated at high volume centers, many complex surgical procedures have migrated to large, specialized hospitals. The
purpose of this study is to examine the extent of regionalization and outcomes in anti-reflux surgery.
METHODS: The Nationwide Inpatient Sample (NIS) data
were analyzed from 1998–99 (T1) and 2008–09 (T2) for all
antireflux operations in patients with gastroesophageal
reflux symptoms using ICD-9-CM codes. Hospitals were
stratified into high-, mid-, and low-volume centers (HVC,
MVC, LVC) based on annual antireflux surgery volume.
40
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
CONCLUSION: Despite improved results at HVCs, LVCs
have increased their percentage of antireflux operations
over time. The urban non-teaching hospitals have experienced the largest gains in caseload. Overall complication rates have increased with time, possibly due to noted
increased incidence of comorbidities in the patients seeking
antireflux surgery. After controlling for confounding variables, complications remain more likely in LVCs. Regionalization has not occurred over time, but may improve outcomes if supported.
810
Improved Long-Term Survival After Major Resection
for Hepatocellular Carcinoma: A Multicenter Analysis
Based on a New Definition of Major Hepatectomy
Andreas Andreou1, Jean-Nicolas Vauthey1, Daniel Cherqui2,
Eddie Abdalla1, Steven Wei1, Steven Curley1, Alexis Laurent2,
Ronnie Poon3, Jacques Belghiti4, David M. Nagorney5,
Thomas Aloia1
1. Surgical Oncology, MD Anderson Cancer Center, Houston,
TX; 2. Department of Digestive and Hepatobiliary Surgery and
Liver Transplantation, Hôpital Henri Mondor, Créteil, France;
3. Department of Surgery, University of Hong Kong/Queen Mary
Hospital, Hong Kong, China; 4. Department of Surgery, Hôpital
Beaujon, Clichy, France; 5. Department of Gastroenterologic and
General Surgery, Mayo Clinic, Rochester, MN
BACKGROUND: Advances in the surgical management of
hepatocellular carcinoma (HCC) have expanded the indications for curative hepatectomy, including more extensive
liver resections. The purpose of this study was to examine
long-term survival trends for patients treated with major
hepatectomy for HCC.
Improved Survivals After Major Resection of HCC Over Time
CONCLUSIONS: This multinational, long-term HCC survival analysis indicates that expansion of surgical indications to include major hepatectomy is justified by the
significant improvement in outcomes over the past 3
decades observed in both the East and the West.
PATIENTS AND METHODS: Clinicopathologic data
for 1115 patients with HCC who underwent hepatectomy
between 1981 and 2008 at 5 hepatobiliary centers in
France, China, and the USA were assessed. In addition to
other performance metrics, outcomes were evaluated using
resection of ≥4 liver segments as a novel definition of major
hepatectomy.
41
Monday
Abstracts
RESULTS: Major hepatectomy was performed in 539
patients. In the major hepatectomy group, median tumor
size was 10 cm (range:1–27 cm) and 22% of the patients
had bilateral lesions. The TNM Stage distribution included
29% Stage I, 31% Stage II, 38% Stage III, and 2% Stage IV.
The postoperative histologic examination indicated that
chronic liver disease was present in 35% of the patients and
microvascular tumor invasion was identified in 60% of the
patients. The 90-day postoperative mortality rate was 4%.
After a median follow-up time of 63 months, the 5-year
overall survival rate was 40%. Patients treated with right
hepatectomy (n = 332) and those requiring extended hepatectomy (n = 207) had similar 90-day postoperative mortality rates (4% and 4%, respectively, P = .976) and 5-year
overall survival rates (42% and 36%, respectively, P = .523).
Overall survival and postoperative mortality rates after
major hepatectomy were similar among the participating
countries (P > .1) and improved over time with 5-year survival rates of 30%, 40%, and 51% for the years 1981–1989,
1990–1999, and the most recent era of 2000–2008, respectively (P = .004) (Figure). Factors that were associated with
worse survivals included AFP level >1000 ng/mL, tumor
size >5 cm, presence of major vascular invasion, presence
of extrahepatic metastases, positive surgical margins, and
earlier time period in which the major hepatectomy was
performed (all MV P < 0.05).
were independent predictors of antireflux surgery at a LVC.
In T2, mean LOS at a LVC was 4.0 days vs 3.3days at a
HVC (p < 0.0001), but this was not significant in multivariate analysis. Total charges were lower at a LVC ($38000 vs
$41000, p = 0.0032) in multivariate analysis. Complication
rates increased at all centers with time, but were twice as
common in LVCs (6.39% vs. 3.16% at HVCs, p < 0.0001) in
T2. Controlling for confounding variables, complications
remained more likely in LVCs (T1: OR 1.71, p < 0.0001,
T2: OR 1.49, p < 0.0001). In hospital mortality decreased
in all centers with time and did not differ significantly in
either era. Patients at all centers have increased their mean
number of concurrent diagnoses over time(3.92 vs 6.70, p
< 0.0001).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
811
812
Bariatric Surgery: Still Have an Appetite?
Circadian Genes in Pancreatic Ductal Adenocarcinoma:
Alterations and Clinical Correlations
Nayna A. Lodhia, Jaffer M. Kattan, Dylan Gwaltney,
Margaret M. Nkansah, Shushmita Ahmed, John M. Morton
Stanford School of Medicine, Palo Alto, CA
Daniel Relles, Galina Chipitsyna, Terry Hyslop, Charles J. Yeo,
Hwyda A. Arafat
Surgery, Thomas Jefferson University, Philadelphia, PA
INTRODUCTION: Understanding eating patterns in
patients following laparoscopic roux-en-Y-gastric bypass
(LRYGB) is important to determine long term success. The
purpose of this study was to analyze changes eating habits
of patients following LRYGB using the three-factor eating
questionnaire (TFEQ-R18).
BACKGROUND: The circadian rhythm regulates various
metabolic processes, physiologic homeostasis and behavior.
Epidemiologic studies have demonstrated that disruption
of the circadian rhythm is associated with cancer development and tumor progression. Several circadian clock genes
with tightly connected transcriptional feedback loops have
been implicated in loss of cell cycle control, impaired DNA
damage repair, and subsequent tumor formation in multiple cancer models. However, the direct links between aberrant circadian clock gene expression and human pancreatic
ductal adenocarcinoma (PDA) have not been elucidated. In
this study, we investigated the expression profiles of several
circadian clock genes in PDA.
METHODS: Demographic, preoperative, three, six and
twelve month postoperative data were prospectively
obtained for 204 consecutive laparoscopic RNYGB patients
at a single academic institution. All patients enrolled in
the study completed the three-factor eating questionnaire (TFEQ-R18), an 18 question inventory that measures
3 aspects of eating behavior: cognitive restraint, uncontrolled eating, and emotional eating at each clinic visit.
Higher scores in each category indicate a higher degree of
restraint or eating pattern. Patients were compared on the
basis of age, gender and body-mass index (BMI). Data at
pre-operative and TFEQ-R18 scores were analyzed with a
one way ANOVA for continuous variables and chi-squared
analysis for dichotomous variables using Stata/IC 11.1 and
R2.13.1 software.
METHODS: We analyzed the expression of 10 circadian
clock genes in matched invasive human PDA (n = 62) and
surrounding adjacent tissues and in benign lesions (n = 10).
Quantitative real-time polymerase chain reaction (qPCR)
was used to examine the following core clock genes:
(BMAL, Clock, Cry1, Cry2, CK1E, Per1, Per2, Per3, Timeless,
Timeless-interacting protein). Gene expression levels were
correlated with clinicopathological parameters. Receiver
operator curve (ROC) analysis was completed using logistic
regression based on individual circadian genes measured in
tumor and benign samples, and is reported as area under
the ROC curve (AUC). Spearman correlation was used to
assess the relationship between circadian genes within
tumor samples. Univariable Cox models were completed
to assess survival of PDA patients, using the median gene
expression level as stratification factor.
RESULTS: Patient mean demographics included BMI 47,
age 47, 65% white, income $62,100, 78% with private
insurance, and 4 total preoperative comorbidities. Comorbidities included 43% with diabetes, 69% with hypertension, 53% with hyperlipidemia, 46% with GERD, 48% with
sleep apnea, and 41% with depression. By 3 months postoperative, patients saw a significant reduction from their
preoperative BMI to 42.3 kg/m2 (p < 0.01). Patients saw a
significant improvement in cognitive restraint from preoperative to 3, 6 and 12 months postoperative (54.1, 76.8, 73.5,
74.4; p < 0.001); uncontrolled eating (39.3, 10.7, 13.0, 16.7;
p < 0.001); and emotional eating (44.6, 14.0, 16.0, 22.5; p <
0.001). Patients over the age of 50 years had a significantly
higher emotional eating score at 3 months postoperative
(10.0 versus 19.6, p = 0.01); however, these differences were
no longer significant at 6 months postoperative.
RESULTS: In the tumor tissue of PDA patients, compared
to their matched adjacent tissue, expression levels of all
circadian genes were significantly lower (P < 0.05). Benign
tissues also expressed significantly (P < 0.05) higher levels
of all circadian genes when compared to malignant lesions.
Spearman correlations of all 10 genes in tumors showed
significant correlations of their expression levels ranging from 0.57 to 0.93, p < 0.001 in all cases. Univariable
survival analysis indicated that Per2 (p = 0.004), Per3 (p
= 0.007), Cry2 (p = 0.016), Tim (p = 0.016) and CK1E (p =
0.024) are significantly related to survival.
CONCLUSIONS: Patients undergoing LRYGB see significant improvements in their cognitive restraint, uncontrolled eating and emotional eating as early as 3 months
postoperative, at which point their TFEQ-R18 scores are
within population norms for healthy weight individuals.
Eating behaviors may portend future weight maintenance
success.
CONCLUSIONS: Our results reveal for the first time a
disturbed transcription of several circadian genes in PDA.
Elevation of the gene levels in the benign and matched
adjacent tissues may be indicative of their role during the
process of tumorigenesis. Altered expression of Per2, Per3,
Cry2, Tim and CK1E in PDA provides the basis for future
studies to explore their validity as predictive markers of the
outcomes and survival in PDA patients.
42
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
4:00 PM – 5:00 PM
27b
QUICK SHOTS SESSION III
813
814
Repeat Hepatectomy for Recurrent Liver Metastasis
from Gastric Carcinoma
Akio Saiura, Nobuyuki Takemura, Rintaro Koga, Junichi Arita,
Yoshihiro Ono, Ryuji Yoshioka
Cancer Institute Hospital, Tokyo, Japan
Mathias Worni1, Christopher R. Mantyh1, Igor Akushevich2,
Ricardo Pietrobon1, Bryan M. Clary1
1. Surgery, Duke University Medical Center, Durham, NC;
2. Center for Population Health and Aging, Duke University
Medical Center, Durham, NC
BACKGROUND: The efficacy of repeat hepatectomy
for recurrent colorectal liver metastases has been widely
accepted as a treatment of potential cure. However, indication for hepatectomy in cases of gastric cancer liver metastasis (GLM) remains unclear. Moreover, no benefits have been
reported of repeat hepatectomy for intrahepatic recurrence
of GLM. The aim of this study is to clarify the survival benefit of hepatectomy for primary and recurrent GLM.
BACKGROUND: The optimal timing of primary and
metastatic tumor management in patients with synchronous hepatic colorectal metastases remains controversial.
Although simultaneous colorectal/liver resection (SCLR) is
an attractive option, the safety of this strategy has not been
explored outside of small single institutional experiences.
The goal of this investigation was to compare perioperative
outcomes of SCLR with isolated resections utilizing a more
inclusive national clinical database.
AIM: The objective of this retrospective study is to clarify
the indications for and benefit of primary and repeat hepatectomy for GLM.
METHODS: Seventy-three patients underwent hepatectomies for GLM with curative intent from January 1993 to January 2011. Curative surgery was performed in 64 patients
and repeat hepatectomy was done in 14 of 35 patients with
intrahepatic recurrence; in total, 78 liver resections were
performed. Clinicopathological factors were evaluated by
univariate and multivariate analysis among patients who
received curative resection for those affecting survival.
METHODS: National Surgical Quality Improvement Program (NSQIP) data from 2005 to 2009 was examined to
construct descriptive statistics and risk-adjusted generalized linear models. These were used to compare 30-day
postoperative outcomes among patients undergoing SCLR
with colorectal resections (CR) and liver resections (LR)
only in patients with metastatic colorectal cancer.
RESULTS: The cancer-specific 1-, 3-, and 5-year survival
rates after curative hepatectomy (n = 64) for GLM were 87,
50, and 37%, respectively, with a median survival of 34
months. By multivariate analysis, serosal invasion of the
primary gastric cancer and larger tumor (>5 cm in diameter) were found to be independent indicators of poor
prognosis. Forty-three patients developed postoperative
recurrence (67%) after the curative resection for GLM.
Intrahepatic recurrence occurred in 37 patients, corresponding to 86% of all patients with recurrence. A repeat
hepatectomy for intrahepatic recurrence was performed in
14 patients (40%) based on the same indication as initial
hepatectomy for GLM. The actuarial 1-, 3-, and 5-year cancer-specific survival rates after second hepatectomy were
71, 47, and 47%, respectively, with a median survival of 30
months. Three patients have survived more than 5 years
after the repeat hepatectomy.
RESULTS: 3,983 patients with metastatic colorectal cancer
were identified who underwent SCLR (192), LR (1,857) or
CR (1,934). Minor differences in patient demographics were
noted. Patients undergoing SCLR were younger compared
to CR and LR with mean ages of 40.4 years (SD: 10.8), 45.5
(13.5), and 41.7 (11.7), respectively (p < 0.001). Mean number of comorbidities in the SCLR group was 0.63 (SD: 0.89),
in the CR group 0.87 (1.01), and 0.74 (0.89) in the LR group
(p < 0.001). Rectal resection was performed in 45 (23.4%)
SCLR-patients and 269 (13.9%) CR-patients (p < 0.001).
Major hepatectomy (≥ three segments) was performed in
69 (35.9%) SCLR-patients and 774 (41.7%) of LR-patients
(p = 0.12). Median operation time was significantly longer
for SCLR 273 minutes (95% CI: 253–295), in comparison
to CR (172 minutes, 95% CI: 167–176) and LR (223 minutes, 95% CI:217–229). Median length of hospital stay was
significantly longer for SCLR (9.5 days, 95% CI: 8.7–10.4)
than CR (8.1 days, 95% CI: 7.8–8.3) and LR (6.5 days, 95%
CI: 6.3–6.6). Patients in the SCLR group were more likely to
experience postoperative complications (risk-adjusted mean
CONCLUSIONS: GLM patients with tumors <5 cm in
diameter and without serosal invasion of the primary gastric cancer are the best candidate for hepatectomy. Repeat
hepatectomy for recurrent GLM offers a chance of cure as
that after the primary hepatectomy.
43
Monday
Abstracts
Is There a Role for Simultaneous Hepatic and
Colorectal Resections? A Contemporary View from
NSQIP
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
number of complications: 0.69, 95% CI: 0.47–0.90) compared to CR (0.44, 95% CI: 0.39–0.49) and LR (0.34, 95% CI:
0.30–38) (p < 0.001 for CR and LR versus SCLR). Excess complications were dominated by infectious and cardiopulmonary issues (Table). Mortality in patients undergoing SCLR
was not increased compared to patients undergoing LR.
significantly higher than for CR and LR. In addition, the
median operation time and hospital stay is longer for
SCLR than for CR and LR only. However, higher short-term
adverse outcomes in patients undergoing SCLR might be
acceptable since anesthetic risk is decreased and adjuvant
consolidating chemotherapy regimens can be conducted
earlier. Additional population-based investigations are necessary to prove that SCLR is widely beneficial.
DISCUSSION: Among hospitals reporting outcomes to
NSQIP the risk of 30-day adverse outcomes for SCLR is
CR
(n = 1,934, 48.6%)*
LR
(n = 1,857, 46.6%)*
SCLR
(n = 192, 4.8%)*
Risk-adjusted OR
(95% CI) #
Superficial surgical site infection
168 (8.7)
79 (4.3)
14 (7.3)
1.20 (0.62–2.32) 0.53
(0.27–1.04)
0.59 0.07
Incisional surgical site infection
48 (2.5)
13 (0.7)
13 (6.8)
0.42 (0.18–0.98) 0.14
(0.05–0.35)
0.05 <0.001
Organ space site infection
100 (5.2)
95 (5.1)
24 (12.5)
0.41 (0.24–0.69) 0.33
(0.19–0.56)
0.001 <0.001
Any surgical site infection
291 (15.1)
181 (9.8)
45 (23.4)
0.64 (0.42–0.97) 0.35
(0.23–0.53)
0.04 <0.001
Cardiopulmonary complication
120 (6.2)
108 (5.8)
19 (9.9)
0.37 (0.21–0.66) 0.43
(0.25–0.77)
0.001 0.004
Renal/urinary complication
129 (6.7)
85 (4.6)
15 (7.8)
0.59 (0.31–1.10) 0.54
(0.28–1.02)
0.09 0.06
p-Value
DVT/pulmonary embolism
59 (3.1)
45 (2.4)
7 (3.7)
N/A
0.38ç
Septic complication
173 (9.0)
133 (7.2)
26 (13.5)
0.43 (0.26–0.71) 0.39
(0.24–0.64)
0.001 <0.001
Mortality
Intraoperative use of red blood
cell products
89 (4.6)
23 (1.2)
2 (1.0)
N/A
<0.001ç
305 (15.8)
452 (24.3)
53 (27.6)
0.41 (0.27–0.62) 1.12
(0.75–1.67)
<0.001 0.58
*Numbers are given as counts and %. # Reference category SCLR, first estimate CR vs SCLR, second estimate LR vs SCLR. Adjustment for: sex, race, age, BMI,
comorbidity, dyspnea, ASA score, preoperative weight loss, preoperative radio-/chemotherapy, wound classification, hypoalbuminemia, hypercreatininemia, anemia,
and hyponatremia. ç Chi-square test.
hepatectomy after preoperative chemotherapy and clarify
which patients can take advantage from use of CE-IOUS.
815
Usefulness of Contrast-Enhanced Intraoperative
Ultrasonography in Colorectal Liver Metastases After
Preoperative Chemotherapy
METHODS: From January 2011 to August 2011 25 patients
with CRLM, after preoperative chemotherapy, underwent
IOUS and CE-IOUS during hepatectomy. These findings were
compared with preoperative staging imaging, performed with
contrast-enhanced ultrasonography (CE-US), CT and/or MRI.
Andrea Ruzzenente, Tommaso Campagnaro, Simone Conci,
Elisabeth Baldiotti, Marco Costa, Elisabeth Baldiotti,
Calogero Iacono, Alfredo Guglielmi
Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy
RESULTS: Preoperative staging imaging detected a total
of 40 metastatic lesions in 25 patients. In 7 patients (28%),
IOUS detected 19 missed hepatic nodules for a total of 59
lesions (detection rate higher of 47.5% than preoperative
imaging). In 9 patients (36%), CE-IOUS detected further 6
nodules for a total of 65 hepatic lesions detected (detection rate higher of 10.2% than preoperative imaging and
IOUS). All these new detected lesions were removed by an
additional resection and histopathologically diagnosed
as metastases. Moreover, at univariate analysis we found
three factors significantly correlated to dectection of new
nodules with CE-IOUS: more than three metastasis before
chemotherapy (p = 0.022), complete response to chemotherapy (p = 0.03) and size of nodules less than 20 mm after
chemotherapy (p = 0.008).
BACKGROUND AND AIM: Hepatic resection is the only
treatment offering a chance of long-term survival for
patients with colorectal liver metastases (CRLM). Preoperative chemotherapy improves survival and resectability but
reduces accuracy of preoperative staging due to reduction of
size or disappearing of the metastases. Intraoperative Ultrasonography (IOUS) is considered the standard method of
intraoperative staging. Contrast-enhanced intraoperative
ultrasonography (CE-IOUS), using second generation contrast agents, seems to improve detection of liver metastases
after preoperative chemotherapy.
The aim of this study is to evaluate the ability of CE-IOUS
in detecting metastases in patients with CRLM during
44
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
soft glands. Patients randomized to the FF group had a leak
rate of 20% as compared with 19.6% in the SS group (p =
1.000). Fistula grades in both groups were similar: 1A, 8B,
and 1C compared to 1A, 8B and 1C in the FF and SS groups
respectively. Complication rates were comparable between
the two groups. The median length of postoperative hospital stay was 5 days in both groups. There was a trend
towards a higher 30-day readmission rate in the FF group
(28% vs. 17.6%, p = 0.243). Based on conditional probability calculations with 52.5% of enrollment, the probability
of success of the trial given the current trend fell below
50%, and the trial was ended.
CONCLUSION: In patients who undergo surgery for
CRLM, CE-IOUS improves the sensitivity of IOUS to detect
liver metastases enhancing the rate of treatment with curative intent. Patients with multiple nodules, patients who
achieve complete response or with nodule size less than
20 mm after chemotherapy can take advantage with use
of CE-IOUS.
816
Table 1. Demographics of Patients in the Study (FF) and
Control (SS) Group, Showing no Significant Differences
Timothy I. Carter1, Zhi Ven Fong1, Terry Hyslop2, Harish Lavu1,
Wei Phin Tan1, Jeffrey Hardacre3, Eugene P. Kennedy1,
Charles J. Yeo1, Ernest L. Rosato1
1. Surgery, Thomas Jefferson University, Philadelphia, PA;
2. Department of Pharmacology and Experimental Therapeutics,
Division of Biostatistics, Thomas Jefferson University,
Philadelphia, PA; 3. Surgery, Case Western Reserve University,
Cleveland, OH
FF (n = 50)
SS (n = 51)
p-Value
Male
22
19
0.546
Female
28
32
0.546
47
41
0.072
Gender
Race
OBJECTIVE: The objective of the study was to assess the
efficacy of two pancreatic remnant closure techniques—
stapled/sutured closure versus stapled/sutured closure plus
falciform patch and fibrin glue reinforcement—in the setting of a prospective randomized, controlled trial, with the
primary endpoint being pancreatic fistula.
White
SUMMARY AND BACKGROUND DATA: Pancreatic
stump leak following left sided resection remains common.
Despite multiple and varied techniques for closure, the leak
rate averages 30%. A retrospective review by Ferrone et al.
detected a decreased leak rate in patients receiving a traditional closure buttressed with an autologous falciform ligament patch and fibrin glue.
Black
1
3
0.617
Asian
0
1
1.000
Unknown
2
6
Median
62.5
65.0
Mean
62.0
62.3
Range
29–84
20–82
Age
0.969
Table 2. Clinical Outcomes of Patients in the Study (FF) and
Control (SS) Group, Showing no Significant Differences
METHODS: Between April 2008 and October 2011, all
willing patients undergoing distal pancreatectomy at the
authors’ institutions, were consented and enrolled at the
preoperative office visit. Patients were intraoperatively
stratified as “hard” or “soft” glands and randomized to
one of two groups: (1) closure utilizing standard stapling,
suturing, or both (SS) versus (2) stapled, sutured, or both
plus fibrin glue and falciform ligament patch (FF). The
trial design and power analysis (α = 0.05, β = 0.2, power
80%, chi-square test) assumed the FF intervention would
reduce the endpoint (pancreatic fistula) from 30% to 15%
and yielded an accrual goal of 190 patients. Secondary endpoints included length of stay, mortality, readmission, and
ISGPF fistula grade.
FF (n = 50)
SS (n = 51)
p-Value
Grade A
1
1
1.000
Grade B
8
8
1.000
1
1
1.000
5.0
5.0
—
Pancreatic Fistulas
Grade C
Postoperative Hospital
Stay (days, median)
RESULTS: The trial accrued 109 patients, 55 in the control group and 54 in the experimental group. Enrollment
was closed early, following an interim analysis and futility
calculation. Due to insufficient enrollment, patients stratified as having a “hard” gland were excluded (n = 8) from
analysis, leaving 101 patients in the soft stratum. The pancreatic leak rate was 19.8% (20 patients) for patients with
Mortality
1
0
0.495
Readmissions
14
9
0.243
CONCLUSION: The addition of a falciform ligament patch
and fibrin glue to standard stapled or sutured remnant closure did not reduce the rate or severity of pancreatic fistula
in patients undergoing distal pancreatectomy. (ClinicalTrials.gov number NCT00889213)
45
Monday
Abstracts
A Dual-Institution Randomized Controlled Trial of
Remnant Closure After Distal Pancreatectomy: Does
the Addition of Falciform Patch and Fibrin Glue
Improve Outcomes?
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
817
The Prognostic Influence of Resection Margin Clearance
Following Pancreaticoduodenectomy for Pancreatic
Ductal Adenocarcinoma
Nigel B. Jamieson, Nigel Chan, Euan J. Dickson, Colin McKay,
Ross Carter
West of Scotland Pancreatic Unit, Glasgow University Department
of Surgery, Glasgow Royal Infirmary, Glasgow, Lanarkshire, United
Kingdom
INTRODUCTION: The poor overall survival associated
with pancreatic ductal adenocarcinoma (PDAC) despite
complete resection suggests that occult metastatic disease
is present in most at the time of surgery. Resection margin
involvement (R1) following resection is an established poor
prognostic factor. However the definition of an R1 resection varies and the impact of margin clearance on outcome
has not been examined in detail.
Kaplan Meier survival curves illustrating that a cut-off of greater than
1.5 mm identifies a subgroup of patents (15%) with pancreatic ductal
adenocarcinoma with a good prognostic outcome following resection by
pancreaticoduodenectomy.
METHODS: In a cohort of 215 consecutive patients who
underwent pancreaticoduodenectomy for PDAC with curative intent at a single institution between 1996–2010, the
prognostic significance of the proximity of margin clearance was investigated. Microscopic margin clearance was
stratified by 0.5 mm increments from tumor present to
greater that 2 mm. Groups were dichotomized into clear
and involved groups according to the different R1 definitions. Multivariate survival analysis was used to establish
independent prognostic factors. Clearance of individual
margins was also considered.
818
Incidence of Systemic Inflammatory Response Syndrome
After Total Laparoscopic Pancreatoduodenectomy: A
Comparison with Open Pancreatoduodenectomy
Naru Kondo, Clancy J. Clark, Florencia G. Que, Kaye M. Reid
Lombardo, David M. Nagorney, John H. Donohue,
Michael B. Farnell, Michael L. Kendrick
Mayo Clinic, Rochester, MN
RESULTS: Stratification of the minimal clearance distance
revealed that there was no significant difference in the
outcome of patients with tumor ≤1 mm from the margin
when compared to those with tumor ≤0.5 mm from the
margin (P = 0.67, Log-rank test). For the 32 patients (15%)
where the tumor was >1.5 mm from the closest involved
margin there was a significantly prolonged overall survival
(median 49.0 months 95% confidence interval: 25.7–72.3,
P < 0.0001, Log-rank test, Figure 1). This cut-off represented
the optimum distance for predicting long-term survival.
BACKGROUND: Although feasibility of total laparoscopic
pancreatoduodenectomy (TLPD) has been established, a
large scale study comparing the invasiveness of TLPD with
open pancreatoduodenectomy (OPD) has never reported.
PURPOSE: The purpose of this study was to investigate if
TLPD can reduce the postoperative incidence of systemic
inflammatory response syndrome (SIRS) compared with
OPD.
METHODS: A single-institutional retrospective cohort
study of all pancreaticoduodenectomy patients between
2007 and 2010 was performed. The incidence of SIRS was
measured three times a day (at the nearest point of 8, 16
and 24 o’clock) from postoperative day (POD) 1 to POD 5.
The incidence of SIRS on each POD was defined by meeting
the criteria of SIRS at two or more points out of the daily
three measurement points. Perioperative outcomes including the incidence of SIRS were compared between TLPD
and OPD group. The relationship between the clinicopathological factors and the incidence of postoperative SIRS was
investigated using univariate and multivariate analyses.
CONCLUSION: These results demonstrate that margin clearance by at least 1.5 mm identifies a subgroup of
patients with a particularly good outcome. Stratification of
patients into future clinical trials based upon the degree
of margin clearance may identify those patients likely to
benefit from adjuvant therapy.
46
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Recurrence-free survival among R0 resections for IPMN with at least
three months follow up, stratified by invasive pathology. Non-invasive
IPMN includes adenoma (76), borderline or moderate dysplasia (36),
and carcinoma in situ(30). Median follow up was 30.8 months (502
person-years). Invasive IPMN was more likely to recur than non-invasive
tumors (HR 3.7, 95% CI 1.7–8.4), with a median time to recurrence of
13.5 months. Of the 17 non-invasive IPMNs that recurred, four recurred
with invasive disease.
RESULTS: Two hundred and eight patients underwent
resection for IPMN. At presentation, 57% were symptomatic, 20% had a mural nodule or an associated mass, and
median cyst size was 1.8 cm. Sixty-eight (32.7%) operations for high grade disease were performed, of which 33
revealed invasive carcinoma. Among 165 R0 resections
with greater than three months of follow-up we have
observed 26 cases of recurrent disease over 502 personyears (median follow-up time 30.8 months). Nine (39%)
patients originally diagnosed with invasive carcinoma and
17 (12%) patients originally diagnosed with non-invasive
IPMN have recurred. Of the latter, four (23.5%) recurred as
invasive carcinoma. Most disease recurred locally (25/26)
but three individuals had concurrent metastatic disease at
the first observation of recurrence. Median time from initial treatment to recurrence was 18.2 months, but ranged
from 3.7 to 126.8 months. Invasive tumors were more
likely to recur (HR 3.7, p = 0.002) with a median time to
recurrence of 13.5 months. Among non-invasive tumors,
no single histologic feature—including dysplastic changes
at the surgical margin or distant from the primary tumor—
meaningfully predicted recurrence. Seven patients had
a completion pancreatectomy on average 22.7 months
after their initial surgery. Of these, three had low grade or
moderate dysplasia on final pathology and have survived
greater than 34 months after the second operation, compared with median survival of 14.4 months after diagnosis
of recurrent, invasive IPMN.
CONCLUSION: TLPD independently reduced the early
incidence of SIRS after pancreatoduodenectomy. The laparoscopic approach to pancreatoduodenectomy appears
to provide an advantage of less invasiveness compared
with the open approach especially in patients that do not
develop postoperative complications.
819
Predictors of Recurrence in Intraductal Papillary
Mucinous Neoplasm: Experience with 208 Pancreatic
Resections
Megan Winner, Irene Epelboym, Joseph DiNorcia, Minna K. Lee,
James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf
Department of Surgery, Columbia University College of Physicians
and Surgeons, New York, NY
BACKGROUND: Intraductal papillary mucinous neoplasm (IPMN) is being diagnosed and resected with increasing frequency, but little long-term data exist to guide
postoperative management of surgically treated patients.
METHODS: We examined all patients who underwent
surgical resection for IPMN between January 1997 and
April 2011 at our institution. IPMN was categorized as noninvasive low grade (adenoma and borderline dysplasia),
non-invasive high grade (carcinoma in situ), or invasive.
Histologic features of primary and recurrent disease were
examined and we evaluated predictors of recurrence using
Kaplan Meier curves and Cox proportional hazards models.
CONCLUSIONS: Invasive IPMN has a high risk of recurrence, but even low grade tumors may recur with high grade
disease. IPMN can recur remote from the time of primary
surgery and no histologic feature beyond invasion predicts
recurrence risk. Most recurrence is local and completion
pancreatectomy can be associated with excellent survival
if recurrent disease is identified early. We therefore recommend that surveillance of the remnant pancreas continue
after primary resection for all tumor types.
47
Monday
Abstracts
RESULTS: Five hundred twenty-seven consecutive patients
(TLPD n = 125, OPD n = 402) were included in study. Six
patients (5%) with conversion to OPD were included in
TLPD group based on intent-to-treat. The reasons for conversion were the possibility of major venous resection (n =
3), bleeding (n = 1), severe adhesion (n = 1) and expected
difficult reconstruction (n = 1). Compared with patients in
the OPD group, those in the TLPD group had significantly
less preoperative clinical jaundice (42% vs. 53%, P = 0.03),
less adenocarcinoma (58% vs. 70%, P = 0.01), and smaller
pancreatic duct size (3.7 mm vs. 4.2 mm, P = 0.002). Median
estimated blood loss was less for the TLPD group than the
OPD group (200ml vs. 600ml, P < 0.001). However, there
were no differences in postoperative complication (62% vs.
67%, P = 0.3) or clinically relevant pancreatic leak (21% vs.
21%, P = 0.8). The incidence of SIRS in the TLPD group was
significantly less than that of OPD group on POD 1 (9% vs.
24%, P < 0.001). Within a subset of 179 patients without
postoperative complication, the incidence of SIRS in the
TLPD group was significantly less than that of OPD group
on POD 1 (2% vs. 13%, P = 0.01) and POD 2 (4% vs. 15%, P
= 0.03). Multivariate analysis revealed that increased body
mass index (> 27) (HR 1.7, 95% CI 1.1 - 2.6, P = 0.005),
OPD (HR 1.8, 95% CI 1.1 - 2.9, P = 0.01) and postoperative
complication (HR 2.3, 95% CI 1.4 - 3.7, P < 0.001) were
independently associated with SIRS on POD 1 and/or 2.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
820
821
Survival Following Resection of Well-Differentiated
Pancreatic Neuroendocrine Tumors: Examining the
New 2010 WHO Classification
Mechanisms of GLUT2 Activation in Rats In Vivo:
Absence of Evidence for PKC Dependency
Rizwan M. Chaudhry1,2, Mohamed M. Abdelfatah2, Alok Garg2,
Judith A. Duenes2, Michael G. Sarr1,2
1. Surgery, Mayo Clinic, Rochester, MN; 2. Gastroenterology
Research Unit, Mayo Clinic, Rochester, MN
Toshiyuki Moriya , Timothy R. Donahue , Oscar J. Hines ,
James J. Farrell3, Howard A. Reber2, David Dawson4
1. First Department of Surgery, Yamagata University, Yamagata,
Japan; 2. Department of Surgery, University of California Los
Angeles, Los Angeles, CA; 3. Department of Medicine, University
of California Los Angeles, Los Angeles, CA; 4. Department of
Pathology and Laboratory Medicine, University of California Los
Angeles, Los Angeles, CA
1,2
2
2
Absorption of glucose at concentrations exceeding the
capacity of sodium glucose co-transporter 1 (SGLT1) is
attributed to the recruitment of GLUT2 at the apical membrane of enterocytes in vivo. Protein kinase C (PKC) has
been implicated in this process in cell culture and in vitro.
HYPOTHESIS: Activating and inhibiting protein kinase
C (PKC) will increase and decrease, respectively, GLUT2mediated glucose absorption via a mechanism dependent
on the microtubular cytoskeleton.
Introduction: In 2010 the WHO adopted a new grading
system for neuroendocrine neoplasms (NET) of foregut
origin based on proliferation determined by mitotic count
and Ki67 index. Using a large single-institution cohort of
resected pancreatic NETs (PNETs), we have retrospectively
examined the prognostic value of the WHO 2010 classification system, the prior WHO classification system and AJCC
stage for well-differentiated neuroendocrine tumors of the
pancreas.
AIM: To explore the role of PKC in activating GLUT2mediated glucose absorption.
METHODS: Isosmolar glucose-containing solutions were
perfused through isolated, 30-cm segments of jejunum in
anesthetized rats. Carrier-mediated glucose uptake was measured in 10 mM and 100 mM glucose solutions (n = 6 rats,
each) with and without 10 μM chelerythrine (PKC inhibitor), 200 nM PMA (PKC activator), and 10 μM nocodazole
(microtubule disruptor). Carrier-mediated absorption of
glucose was calculated by the difference in amount infused
minus the amount recovered after subtracting passive
absorption (3H-L-glucose) and expressed as mean±SEM; n =
6. After ending the experiment, the mucosa was harvested
rapidly in 4°C temperature; brush border membranes were
isolated and subjected to Western blot analysis.
METHODS: Search of pathology archives identified 114
patients who underwent pancreatic resection for PNETs
at UCLA Medical Center from 1991–2009. Retrospective
review of medical, surgical, and pathology databases was
performed. Correlations between patient survival and various clinicopathologic factors were determined.
RESULTS: By univariate analysis, significant predictors of
disease-specific survival (DSS) in PNETs included positive
margin status (p = 0.019, HR 7.73, 95%CI [1.392–43.01]),
and AJCC stage (Stage I, IIA versus IIB, IV, p = 0.043, HR
6.87, 95% CI [1.06–37.41]). Individually, tumor size, perineural invasion, vascular invasion and functional tumor
status were not significant predictors of DSS in the patient
cohort. In our cohort, the new WHO 2010 classification
scheme did not significantly predict DSS for well-differentiated PNETs (G1 PNETs versus G2 PNETs, p = 0.085, HR
5.35, 95% CI [0.60–48.10]). In contrast, the prior WHO
2000 classification scheme was a significant predictor of
DSS (1.0 + 1.1 PNETs versus 2.0 PNETs, p = 0.048, HR 6.90,
95% CI [1.12–39.62]). We also examined whether WHO
2010 classification and AJCC staging parameters could be
used in combination to better stratify patients into groups
of variable prognostic significance. In stratified analysis of
those patients with node-positive disease, G1 vs. G2 status
showed a non-significant trend towards predicting patient
survival after resection (p = 0.13, HR 5.2, 95%CI [0.6–43.9]).
RESULTS: Inhibition of PKC with chelerythrine chloride
at the 10 and 100 mM glucose concentrations resulted in
a small decrease in carrier-mediated absorption from 2.3 ±
0.2 to 1.9 ± 0.3 μmol/min/30-cm intestine (p < 0.0001) and
10.8 ± 1.8 to 9.0 ± 1.7 μmol/min, respectively. PMA (PKC
stimulant) also decreased absorption at the 10 and 100 mM
perfusates (1.9 ± 0.1 to 1.6 ± 0.2; p < 0.003 and 13.7 ± 1.2 to
11.6 ± 1.5, respectively). Nocodazole (microtubular disruption) decreased carrier-mediated uptake at 10 mM glucose
from 2.1 ± 0.2 to 1.7 ± 0.2 (p < 0.0008) and from 13.5 ± 1.6
to 12.9 ± 1.5 at 100 mM glucose. No significant changes
were observed at the 100 mM glucose perfusate with all
three pharmacologic agents. Western blots of isolated
brush border membranes showed no difference in GLUT2
levels at the 10 and 100 mM glucose concentrations.
CONCLUSIONS: Activation and/or inhibition of protein
kinase C and disruption of microtubular architecture had
minimal effect at the concentration of luminal glucose
when GLUT2 should be maximally translocated. Other
intracellular pathways (such as activation of sweet taste
receptors or voltage-gated Ca2+ channels) may be responsible for increasing GLUT2 activity at the apical membrane.
(Support: NIH Grant DK39337 [MGS]).
CONCLUSIONS: Consideration of both AJCC staging
parameters and WHO 2010 G grade may be useful for the
accurate prediction of DSS in resected, well-differentiated
PNET, particularly for those patients with node-positive
disease. Our findings in this retrospective analysis of a single institution cohort of PNET warrant further prospective
analysis in a larger patient cohort.
48
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
822
Hypoxic Recovery Following Massive Small Bowel
Resection as Measured by Photoacoustic Microscopy
Kathryn J. Rowland1, Junjie Yao2, Lidai Wang2,
Christopher R. Erwin1, Lihong Wang2, Brad Warner1
1. Pediatric Surgery, Washington University in St. Louis School of
Medicine, St. Louis, MO; 2. Biomedical Engineering, Washington
University in St. Louis, St. Louis, MO
Figure 1. * p < 0.05 vs pre-values
METHODS: OR-PAM was used to record vessel diameter,
blood flow, and sO2 of the terminal mesenteric arteriole and accompanying vein within the intestinal wall of
C57B6 mice following a 50% proximal SBR. Measurements
were taken on post-operative day (POD) 1 (n = 3), POD 3
(n = 3), and POD 7 (n = 6) and compared to pre-operative
values (n = 7) and immediately following SBR (10 minutes;
n = 7). All measurements were made 6 cm proximal to the
ileocecal junction and are presented as mean ±SE. A p value
≤ 0.05 was considered significant.
RESULTS: Arterial and venous sO2 dropped immediately
following SBR, as demonstrated in Figure 1. Compared
with pre-operative values, significantly lower arterial and
venous sO2 measurements persisted on POD1. By POD3,
the arterial sO2 recovered to pre-operative values, however
venous sO2 remained significantly lower than pre-operative
values. This low venous sO2 persisted on POD7. Arterial
and venous blood flow decreased significantly immediately
post-SBR, as demonstrated in Figure 2. This trend persisted
on POD1. By POD3 arterial blood flow recovered to preoperative levels, however, venous blood flow significantly
exceeded pre-operative levels. This enhanced venous blood
flow persisted on POD7.
Figure 2. * p < 0.05 vs pre-values
CONCLUSION: Massive SBR results in a relative hypoxic
state within the remnant bowel characterized by a significant reduction in both intestinal blood flow and sO2
. Although hemodynamic recovery is observed by POD3,
a low venous sO2 consistent with increased tissue oxygen
utilization persisted through POD7. These changes may
contribute to villus angiogenesis via triggers for genes
related to a hypoxic milieu.
49
Monday
Abstracts
PURPOSE: Massive small bowel resection (SBR) results
in an adaptive response within the remnant bowel and is
associated with villus angiogenesis. Using optical-resolution
photoacoustic microscopy (OR-PAM), a non-invasive, labelfree, high-resolution hybrid in vivo imaging modality, we
have recently demonstrated an immediate (within 10 minutes) reduction in both intestinal blood flow and arterial
and venous oxygen saturation (sO2) after SBR. The present study sought to determine the duration of resectioninduced intestinal hemodynamic alterations.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
822a
METHODS: This retrospective cohort study comprised 79
MMR gene mutation carriers (18 MLH1, 55 MSH2, 4 MSH6
and 2 PMS2) from the Colon Cancer Family Registry who
had a surgical resection for their first primary rectal cancer.
Age-dependent cumulative risks of metachronous colon
cancer were calculated using the Kaplan-Meier method.
Risk factors for metachronous colon cancer were assessed
using a Cox proportional hazards regression.
Metachronous Colorectal Cancer Risk Following
Surgery for First Rectal Cancer in Mismatch Repair
Gene Mutation Carriers
Aung Ko Win1, Susan Parry2,3, Bryan Parry4, Matthew F. Kalady5,
Finlay A. Macrae6, Noralane M. Lindor7, Robert W. Haile8,
Polly A. Newcomb9, Loïc Le Marchand 10, Steven Gallinger11,12,
John Hopper1, Mark A. Jenkins1
1. Centre for Molecular, Environmental, Genetic and Analytic
Epidemiology, The University of Melbourne, Carlton, VIC,
Australia; 2. New Zealand Familial Gastrointestinal Cancer
Registry, Auckland City Hospital, Auckland, New Zealand; 3.
Department of Gastroenterology, Middlemore Hospital, Auckland,
New Zealand; 4. Colorectal Surgical Unit, Auckland City Hospital,
Auckland, New Zealand; 5. Department of Colorectal Surgery,
Digestive Disease Institute, Cleveland Clinic, Cleveland, OH; 6.
Colorectal Medicine and Genetics, The Royal Melbourne Hospital,
Parkville, VIC, Australia; 7. Department of Medical Genetics,
Mayo Clinic, Rochester, MN; 8. Department of Preventive
Medicine, University of Southern California, Los Angeles, CA; 9.
Cancer Prevention Program, Fred Hutchinson Cancer Research
Center, Seattle, WA; 10. University of Hawaii Cancer Center,
University of Hawaii, Honolulu, HI; 11. Samuel Lunenfeld
Research Institute, Mount Sinai Hospital, Toronto, ON, Canada;
12. Cancer Care Ontario, Toronto, ON, Canada
RESULTS: During 866 person-years of observation
(median 9 years; range 1–32 years) since diagnosis of first
rectal cancer, a total of 21 (27%) carriers were diagnosed
with metachronous colon cancer (incidence 24.2; 95% CI
15.8–37.2 per 1000 person-years). Incidence for carriers
who had an anterior resection (26.8; 95% CI 15.5–46.1 per
1000 person-years) was not different from that for carriers who had an abdominoperineal resection (21.0; 95% CI
10.5–42.1 per 1000 person-years) (P = 0.1). Cumulative risk
of metachronous colon cancer was 19% (95% CI 9–31%) at
10 years, 47% (95% CI 31–68%) at 20 years and 69% (95%
CI 45–89%) at 30 years after surgical resection. There was
no difference in the frequency of surveillance colonoscopy
between the two types of surgery (one colonoscopy per 1.1
(95% CI 0.9–1.2) years after anterior resection vs. one colonoscopy per 1.4 (95% CI 1.0–1.8) years after abdominoperineal resection).
CONCLUSIONS: For carriers of MMR gene mutations diagnosed with rectal cancer, the metachronous colon cancer
risk is substantial and mirrors that seen for carriers who
have undergone segmental resection for primary colon
cancer, despite the majority continuing to receive frequent
surveillance colonoscopy. Whereas total colectomy for primary colon cancer in mutation carriers is appropriate, for
primary rectal cases this strategy has major implications
for continence and need for stoma. Nevertheless, given the
high metachronous risk, this procedure needs serious consideration especially for younger patients.
BACKGROUND: Metachronous colorectal cancer risk for
Lynch syndrome patients with primary colon cancer is high
and total colectomy is the preferred option. However if the
index primary cancer is in the rectum, management advice
is complicated by considerations of worsening bowel function or stoma formation. To aid surgical decision-making,
we estimated the risk of metachronous colon cancer for
Lynch syndrome patients who underwent either anterior
resection or abdominoperineal resection for primary rectal
cancer.
50
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tuesday, May 22, 2012
8:00 AM – 9:30 AM
27b
PLENARY SESSION VI
920
86% and compares favorably to 69% in historical controls.
Subgroup analysis showed that patients receiving 300 million cells per dose tended toward a longer OS compared to
those receiving 100 million cells per dose, 96% vs. 80% (p
= 0.053). As of this analysis, median overall survival has
not been reached. Algenpantucel-L was well tolerated with
no grade 4 or 5 adverse events. There were nine grade 3
adverse events directly or possibly due to the immunotherapy. The most common adverse events were injection site
pain and induration.
Addition of Algenpantucel-L Immunotherapy to
Standard Adjuvant Therapy for Pancreatic Cancer:
A Phase 2 Study
CONCLUSION: Addition of algenpantucel-L to standard adjuvant therapy for resected pancreatic cancer may
improve survival. A multi-institutional, phase 3 study
began patient enrollment in May 2010.
BACKGROUND: Pancreatic cancer portends a poor prognosis with ~4% long-term survival. Among the estimated
20% of patients who have resectable disease, the 1/3/5-year
survival rates approximate only 70%/30%/18%, even with
adjuvant therapy. Better treatment options are needed,
and addition of algenpantucel-L immunotherapy to standard adjuvant therapy is proposed to improve prospects for
survival. Algenpantucel-L is composed of irradiated, live,
allogeneic human pancreatic cancer cells expressing the
enzyme α-1,3 galactosyl transferase (α-GT), which is the
major barrier to xenotransplantation from lower mammals
to humans (e.g., hyperacute rejection). Up to 2% of circulating human antibodies are directed against the α-GT epitope of algenpantucel-L and are the proposed mechanism
of initiating the anti-tumor immune response.
921
Hereditary Pancreatitis: Endoscopic and Surgical
Management
Eugene P. Ceppa1, Henry A. Pitt1, JoAnna Hunter1,
Charles Leys1, Nicholas J. Zyromski1, Frederick J. Rescorla1,
Kumar Sandrasegaran2, Evan L. Fogel3, Lee McHenry3,
James L. Watkins3, Stuart Sherman3, Glen A. Lehman3
1. Surgery, IN University School of Medicine, Indianapolis, IN;
2. Radiology, IN University School of Medicine, Indianapolis, IN;
3. Gastroenterology, IN University School of Medicine, Indianapolis, IN
INTRODUCTION: Hereditary pancreatitis is a very rare
cause of chronic pancreatic inflammation. In recent years
the genetic mutations leading to hereditary pancreatitis
have been characterized. Patients with hereditary pancreatitis present in childhood and, as adults, are reported to
have an extremely high risk of pancreatic cancer. However,
the rarity of this disorder has resulted in a gap in clinical
knowledge. Therefore, the aims of this analysis are to characterize a large series of patients with hereditary pancreatitis and to establish clinical guidelines.
METHODS: Open-label, dose-finding, multi-institutional
Phase 2 study evaluating algenpantucel-L (100 or 300 million cells per dose) + standard adjuvant therapy (RTOG9704, JAMA, 2008: gemcitabine + 5-FU-XRT) for pancreatic
cancer patients undergoing R0/R1 resection. Disease-free
survival (DFS) was the primary endpoint with overall survival (OS) and toxicity being secondary endpoints.
RESULTS: 70 patients with a 21-month median follow-up
received gemcitabine + 5-FU-XRT + algenpantucel-L (mean
12 doses, range 1–14). Demographics and prognostic factors: median age 62 years, 47% female, 81% lymph node
positive, median tumor size 3.2 cm (range 2–15 cm; 25% >
4 cm), and 17% post-operative CA 19–9 ≥180. The primary
endpoints of median and 12-month DFS were 14.3 months
and 63%, respectively, for the entire cohort. These compare favorably to rates of 11.4 months and <50% in historical controls treated with standard adjuvant therapy alone.
Subgroup analysis showed that patients receiving 300 million cells per dose had a longer 12-month DFS compared to
those receiving 100 million cells per dose, 81% vs. 52% (p =
0.02). Overall survival at one year in the entire cohort was
METHODS: Pediatric and adult endoscopic, surgical,
radiologic and genetic databases were searched from
1994–2011. Patients with chronic pancreatitis and genetic
mutations for PRSS-1 or SPINK-1 as well as those with a
significant family history of chronic pancreatitis were
included. Patients with chronic pancreatitis due to other
causes, idiopathic pancreatitis without a positive family
history, and familial pancreatic cancer were excluded. Data
were gathered on genetic testing, endoscopic and surgical
management as well as the occurrence of pancreatic cancer.
RESULTS: Eighty-six patients were identified, and the
mean age at presentation was 17 years. Forty-four (51%)
51
Tuesday
Abstracts
Jeffrey M. Hardacre1, Mary Mulcahy2, William Small2,
Mark Talamonti3, Jennifer Obel3, Caio S. Rocha-Lima4,
Howard Safran5, Heinz-Joseph Lenz6, Elena G. Chiorean7
1. University Hospitals Case Medical Center, Cleveland, OH;
2. Northwestern University, Chicago, IL; 3. Northshore University
Helath System, Evanston, IL; 4. University of Miami, Miami, FL;
5. Brown University, Providence, RI; 6. University of Southern
California, Los Angeles, CA; 7. Indiana University, Indianapolis, IN
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
were female. Genetic testing confirmed the diagnosis in 38
families (44%) while 48 patients (56%) had a significant
family history. In recent years adult patients were counseled to avoid tobacco and alcohol. Eighty patients (93%)
with a median age of 15 years were managed endoscopically with sphincterotomy (69%), stone removal (31%)
and/or stenting of pancreatic duct strictures (85%). In
recent years endoscopic ultrasound was performed in 13
patients (15%) to screen for cancer. Twenty-nine patients
(34%) have undergone 35 operations at a mean age of 19
years. Surgery included 15 drainage procedures (lateral
pancreaticojejunostomy-9, cystenterostomy-3, Duval-2,
sphincteroplasty-1) and 20 resections (proximal-10, distal-9, total-1). Islet transplantation was performed in the
one patient who underwent a total pancreatectomy. While
22 patients (26%) were older than 40 years, only one 67
year old man developed pancreatic cancer and died. The
remaining 85 patients are all alive and cancer free.
(CC3–4) occurred more commonly after TP (29%) than DP
(28%), LPJ (10%), or PD (10%) (p < 0.01). Resections with
IAT did not have a higher overall (66% v. 53%) (p > 0.05)
nor severe (20% v. 16%) complication rate than those
without IAT (p > 0.05). Specifically looking at PD with
and without IAT, length of stay (14 v. 10) and complication rate (72% v. 46%) appeared to be higher, but neither
reached statistical significance (both p > 0.05). There was
no difference in complication rate between TP-IAT and PDIAT (67% v. 72%) (p > 0.05). Overall (CC1–5) and severe
(CC3–4) complication rate was similar when all pancreatic
resections with IAT (65% and 20%) and those without IAT
(53% and 16%) were compared to those undergoing PD for
pancreatic cancer (n = 133, 65% and 20%) (all p > 0.05).
Reoperation for bleeding after IAT was not different than
after PD for pancreatic cancer (p > 0.05). Partial portal vein
thrombosis (4%)after IAT and had no long term sequelae.
CONCLUSIONS: Many children and young adults with
hereditary pancreatitis can be managed initially with endoscopic therapy. When surgery is undertaken, the procedure
should be tailored to the pancreatic anatomy and the cancer risk. With aggressive endoscopic and surgical management as well as avoidance of cocarcinogens the incidence
of pancreatic cancer is surprisingly low in patients with
hereditary pancreatitis.
CONCLUSIONS: Operations for chronic pancreatitis are
well established and pose no greater risk than resections,
specifically PD, for malignancy. Complication rates remain
formidable and mortality rates are low. Improvements to
quality of life after IAT have been documented; furthermore, the addition of IAT to resections for chronic pancreatitis adds no risk when compared to those for malignancy.
At institutions with capability, IAT should be offered to
patients during resection for chronic pancreatitis.
923
924
Islet Cell Autotransplantation and Morbidity After
Operations for Chronic Pancreatitis
Venous Involvement During Pancreaticoduodenectomy: Is There a Need for Redefinition of “Borderline
Resectable Disease”?
John C. McAuliffe, Sandre F. McNeal, Manasi S. Kakade,
Brandon A. Singletary, John D. Christein
University of Alabama at Birmingham, Birmingham, AL
Kaitlyn J. Kelly1, David Kooby3, Alex Parikh4, Clifford S. Cho1,
Emily Winslow1, Charles R. Scoggins2, Syed A. Ahmad5,
Robert C. Martin2, Shishir K. Maithel3, Hong Jin Kim6,
Nipun Merchant4, Sharon M. Weber1
1. Surgery, University of Wisconsin, Madison, WI; 2. Surgery,
University of Louisville, Louisville, KY; 3. Surgery, Emory
University, Atlanta, GA; 4. Surgery, Vanderbilt University,
Nashville, TN; 5. Surgery, University of Cincinnati, Cincinnati,
OH; 6. Surgery, University of North Carolina, Chapel Hill, NC
BACKGROUND: Quality of life studies after pancreatic
resection and islet cell autotransplantation have shown
improvement and already been published. Mortality rates
have improved, but morbidity remains high after pancreatic operations, in particular total pancreatectomy (TP) and
pancreaticoduodenectomy (PD). Few studies have evaluated outcomes after pancreatic operations specifically for
chronic pancreatitis, with or without islet cell autotransplantation (IAT), and compared these to operations for
pancreatic cancer.
INTRODUCTION: The consensus definition of borderline resectable pancreas cancer includes patients with
any venous (SMV-PV) or limited arterial (SMA or GDA/
CHA) involvement. Recent recommendations suggest that
patients with borderline resectable pancreatic adenocarcinoma should receive neoadjuvant therapy to increase the
likelihood of achieving R0 resection. It is established that
a subset of patients with limited venous involvement can
achieve R0 resection by utilizing vein resection. This study
compares outcome of patients who underwent pancreaticoduodenectomy with (VR-PD) or without (PD) vein resection, and is unique because none received neoadjuvant
therapy.
METHODS: A retrospective review for patients undergoing operation for chronic pancreatitis from 2005–2011
by a single surgeon at an academic center. Morbidity was
evaluated to 90 days according to the Clavien Classification (CC). Patients undergoing pancreatic resection with
IAT were evaluated as a subgroup. Both groups were compared to those undergoing similar operations for pancreatic
cancer. Statistical analysis was applied.
RESULTS: Of the 200 patients (55% men, mean age 49
years), ninety-eight underwent resection alone (65 PD, 27
distal (DP) and 6 TP), 67 underwent resection with IAT (47
TP, 18 PD, 2 DP), and 22 underwent drainage with lateral
pancreaticojejunostomy (LPJ). There was no mortality;
however, the overall morbidity rate was 55% (CC 1–5)
and 29% of these experienced a more severe complication requiring intervention (CC 3–4). Severe complications
METHODS: A large, multi-institutional database of patients
who underwent PD without neoadjuvant therapy was
reviewed. Patients who required vein resection due to SMVPV involvement by tumor were compared to those who
underwent PD without vein resection.
52
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Multivariate Analysis of Demographic, Pathologic, and Operative Factors for Patients Undergoing PD for Adenocarcinoma that
May Influence Disease Free (DFS) and Overall Survival (OS)
DFS
OS
Factor
HR
95% CI
P
HR
95% CI
P
Tumor Size (cm)
1.00
0.90–1.10
0.97
1.01
0.92–1.10
0.85
Tumor Grade
<0.05
<0.01
Well
1.66
1.07–2.57
1.93
1.33–2.81
Moderate
1.93
0.77–4.85
1.74
0.80–3.81
Poor
2.06
1.24–3.42
3.03
1.97–4.64
Positive Lymph Nodes
1.57
1.18–2.09
<0.01
1.56
1.22–1.99
0.01
Vein Involvement
1.15
0.78–1.68
0.83
1.20
0.87–1.63
0.26
R1 Margin
1.26
0.94–1.70
0.09
1.80
1.39–2.30
<0.01
Blood Loss (mL)
1.00
—
0.01
1.00
—
<0.01
Adjuvant Chemo
1.19
0.89–1.57
0.25
0.74
0.58–0.94
<0.01
METHODS: We reviewed the medical records of all patients
with pancreatic ductal adenocarcinoma who underwent
pancreaticoduodenectomy (PD) at our institution between
March 1992 and March 2011. We identified patients who
received neoadjuvant (NA) therapy or required major
vascular resection and evaluated demographics, operative characteristics, morbidity, mortality, and survival.
Student’s t- or Mann-Whitney U tests and Chi-squared or
Fisher’s exact tests were used to compare continuous and
categorical variables, respectively. Kaplan-Meier curves and
Cox proportional hazards models were used to compare
survival.
CONCLUSION: This is the largest modern series examining patients with borderline resectable pancreas cancer due
to SMV-PV involvement, none of whom received neoadjuvant therapy. This cohort of patients with vein involvement selected for up-front surgical resection demonstrates
that oncologic outcomes, including R0 rate, local recurrence rate, and DFS, were not compromised when vein
resection was required. These data suggest that up-front
surgical resection is an appropriate option for patients
with isolated vein involvement and calls into question the
inclusion of all SMV-PV involvement within the definition
of “borderline resectable disease.”
925
Neoadjuvant Therapy and Vascular Resection During
Pancreaticoduodenectomy: Shifting the Survival Curve
for Patients with Locally Advanced Pancreatic Cancer
Neoadjuvant (NA) therapy and vascular resection can bring select
patients with initially locally unresectable pancreatic cancer to
pancreaticoduodenectomy with a significant survival benefit. In this
series, median survival of resected NA patients was similar to resected
non-NA patients (24.9 months vs. 19.3 months, p>0.05) and longer than
non-NA patients aborted for locally advanced disease (24.9 months vs.
8.9 months, p < 0.05). Median survival of NA patients aborted for locally
advanced disease was 13.3 months.
Joseph DiNorcia, Megan Winner, Minna K. Lee, Irene Epelboym,
James A. Lee, Beth Schrope, John A. Chabot, John D. Allendorf
Surgery, Columbia University College of Physicians and Surgeons,
New York, NY
BACKGROUND: Neoadjuvant chemoradiation therapy
and more aggressive surgery with vascular resection are two
strategies to bring patients with locally advanced pancreatic cancer to the operating room for potential cure.
53
Tuesday
Abstracts
RESULTS: Of 492 total patients, 70 (14%) underwent
VR-PD and 422 (86%) underwent PD. There was no difference in R0 resection (66% VR-PD vs. 75% PD, p = 0.11) or
local recurrence rate (18% VR-PD vs. 14% PD, p = 0.33), at
a median follow up of 16 months (range 3.0–129.7). There
was no difference in median DFS (10.1 months VR-PD vs.
15.2 months PD, p = NS, HR 1.24 (0.94–1.64)). Positive
margin, increased EBL, advanced tumor grade, and lymph
node involvement, but not vein involvement, were independent predictors of DFS. These same factors, as well as
use of adjuvant therapy, predicted OS (see Table above).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
RESULTS: A total of 600 patients were brought to the operating room for attempted resection. One hundred fifty-four
(25.6%) had received NA therapy for initially unresectable
disease whereas 446 (74.4%) were explored at presentation.
One hundred twenty-four (80.5%) NA patients underwent
successful PD compared to 340 (76.5%) non-NA patients.
The NA patients were younger (62.7 years vs. 67.5 years, p
< 0.001), more often had prior resection attempts (26.6%
vs. 0.9%, p < 0.001), had longer median operative times
(390 min vs. 328 min, p < 0.001), and had higher median
estimated blood loss (1500mL vs. 1000mL, p < 0.001) than
non-NA patients. There were no statistically significant differences in R0 resection rate (82.3% vs. 78.2%, p = 0.34),
median length of stay (9 days vs. 10 days, p = 0.16), morbidity (50% vs. 49.4%, p = 0.91), or mortality (6.5% vs.
2.7%, p = 0.09) between the two groups. Sixty-one percent
of NA patients versus 18.8% non-NA patients required vascular resection (p < 0.001), therefore a subset analysis was
performed. PD with vascular resection resulted in increased
morbidity (54.9% vs. 33.7%, p < 0.001) and mortality (1.8%
vs. 6.3%, p = 0.008), but similar R0 resection rates (74% vs.
81%, p = 0.07) and lengths of stay (10 days vs. 9 days, p =
0.07) compared to standard PD. Median survival of resected
NA patients was similar to resected non-NA patients (24.9
months vs. 19.3 months, p>0.05) and significantly longer
than non-NA patients aborted for locally advanced disease
(24.9 months vs. 8.9 months, p < 0.05). NA patients who
required vascular resection had longer survival than nonNA patients who required vascular resection (23.6 months
vs. 14.4 months, p < 0.05).
CONCLUSION: Many patients with locally advanced pancreatic cancer can be brought to resection through NA
therapy and vascular resection with acceptable morbidity
and mortality. These patients have significantly improved
survival over patients deemed locally inoperable by traditional criteria.
9:30 AM – 12:00 PM
27b
PLENARY SESSION VII
1004
age or reoperation. Hemorrhage was defined as bleeding
requiring reoperation. Hepatic insufficiency was defined
as a peak serum bilirubin level of >7mg/dL at any time
postoperatively.
Greater Complexity of Liver Surgery Is Not Associated
with an Increased Incidence of Liver Related
Complications Except for Bile Leak: An Experience
with 2628 Consecutive Resections
RESULTS: 2628 hepatic resections were performed
between 1997 and 2011 with a 90 day morbidity of 37%
and mortality of 2%. Comparison of case type between
the later and earlier cohorts revealed an increase in complexity over time as evidenced by the greater number of
re-resections (11.2% vs 4.3%; p < 0.001), second stage resection(4.0% vs 0.9%; p < 0.001) and extended right hepatectomies (18.4% vs 14.9%; p = .017) and increasing use
of preoperative portal vein embolization (9.1% vs 5.9%; p
= 0.002) in the later group. Despite this, the incidence of
abdominal collection (2.1% vs 3.4%; p = .031) and hemorrhage (0.3% vs 0.9%; p = .045) decreased and the incidence
of hepatic insufficiency (2.6% vs 3.1%; p = 0.41) remained
stable. In contrast, the rate of bile leak increased (5.9% vs
3.7%; p = 0.011). For the entire cohort, bile leak was associated with increased 90 day mortality (11.1% vs 1.8%; p <
0.001) and increased length of stay (mean 13 vs 8 days; p
< 0.001). Independent predictors of bile leak included bile
duct resection (OR 3.9; p < 0.001), resection of >3 segments
(OR 3.1; p < 0.001), second stage resection (OR 2.5; p =
0.019) and intraoperative blood loss> 1 liter (OR 1.9; p =
0.019).
Robert E. Roses, Giuseppe Zimmitti, Thomas Aloia,
Andreas Andreou, Steven Curley, Jean-Nicolas Vauthey
Surgical Oncology, University of Texas MD Anderson Cancer
Center, Houston, TX
BACKGROUND: Advances in technique, technology and
perioperative care have allowed for the more frequent performance of complex and extended hepatic resections. The
purpose of this study was to determine if this increasing
complexity has been accompanied by a rise in liver related
complications.
METHODS: A large prospectively maintained single institution database of patients who underwent hepatic resection was utilized to identify the incidence of liver related
complications. Patients were divided into two groups of
equal size: an earlier group and a later group (surgery performed before or after 5/18/2006). Patient characteristics
and perioperative factors were compared between the two
groups. Abdominal collection was defined as a non-bilious
fluid collection requiring drainage. Bile leak was defined as
bilious drainage from the postoperative drain or incision
for 3 days or more, or a bilious collection requiring drain-
54
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
1005
Effect of the Artificial Sweetener, Acesulfame
Potassium, a Sweet Taste Receptor Agonist, on
Glucose Uptake in Small Intestinal Cell Lines
Ye Zheng2, Michael G. Sarr1,2
1. Surgery, Mayo Clinic, Rochester, MN; 2. Gastroenterology
Research Unit, Mayo Clinic, Rochester, MN
Activation of sweet taste receptors may enhance glucose
uptake several fold in rat intestine.
AIM: To explore mechanisms of sweet taste receptor activation in glucose uptake in 3 intestinal cell lines. HYPOTHESIS: The artificial sweetener, acesulfame potassium (AceK),
increases glucose uptake via activating sweet taste receptors
to induce translocation GLUT2 to the apical membrane
through the PLC βII pathway.
Complexity of Liver Surgery
Liver Related Complications
0.5–50 mM glucose with and without 10 mM AceK. 14C-Dglucose was used to measure stereospecific, transportermediated uptake and 3H-L-glucose to measure passive
uptake with or without the inhibitors 10 μM U-73122, a
PLC βII inhibitor, 10 μM chelerythrine, a PKC inhibitor,
and 2 μM cytochalasin B, a microtubular system disrupter.
Glucose uptake was stopped by adding ice-cold PBS; cells
were washed with PBS 2 times and solubilized with 0.1 N
NaOH. All experiments were done on at least 3 separate
occasions in triplicate.
CONCLUSIONS: Despite an increasing complexity of
liver surgery, the rates of liver related complications have
remained stable or decreased. An important exception to
this is bile leak which has increased in incidence and is
now a major cause of surgical morbidity. Given the strong
association between bile leak and other poor outcomes, the
development of novel technical strategies to reduce bile
leak is indicated.
RESULTS: In Caco-2 and RIE-1 cells, 10 mM AceK
increased carrier-mediated glucose uptake by 20–30%
at apical glucose concentrations >25 mM (p < 0.05), but
not in the lesser glucose concentrations (<10 mM) nor at
1-min or 10-min incubations. U-73122, a PLC βII inhibitor,
inhibited glucose uptake at the greater (>25 mM) glucose
concentrations during the 5-min incubation; chelerythrine
and cytochalasin B had similar effects. No effect was seen
in IEC-6 cells.
CONCLUSION: The artificial sweetener AceK, a known
sweet taste receptor agonist, has no effect on glucose uptake
in low (<25 mM) glucose concentrations, but increased glucose uptake at greater concentrations (> 25 mM) in our cell
culture models when GLUT2 translocation occurs. The role
of artificial sweeteners on glucose uptake appears to act
in part by effects on the enterocyte itself. (Support: NIH
DK39337-MGS)
55
Tuesday
Abstracts
METHODS: Caco-2, RIE-1, and IEC-6 cells (human, rat,
and rat intestinal cell lines) were seeded on a 24-well plate
at a density of 4x104 cells/cm2 in growth culture media
and left to differentiate for 15 days after confluence. Caco-2
and RIE-1 cells express GLUT2, while IEC-6 cells do not.
Cells were starved from glucose for 1 h and pre-incubated
with and without 10 mM AceK for 30 min. Glucose uptake
was measured by incubating the cells for 1 to 10 min with
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
1006
LIR + ERAS
(n = 20)
LIR + CC
(n = 70)
p
Time to first flatus
(days—mean ± SD)
1.7 ± 0.7
2.8 ± 1.5
0.002*
Antonino Spinelli1, Piero Bazzi1, Matteo Sacchi1, Silvio Danese3,
Gionata Fiorino3, Lorenzo Gentilini5, Alberto Malesci4,
Gilberto Poggioli5, Marco Montorsi1,2
1. Department of Surgery, Istituto Clinico Humanitas IRCCS,
Rozzano Milano, Italy; 2. Department of Surgery, University
of Milan, Milano, Italy; 3. IBD Unit – Department of
Gastroenterology, Istituto Clinico Humanitas IRCCS, Rozzano
Milano, Italy; 4. Department of Gastroenterology, Istituto Clinico
Humanitas IRCCS, Rozzano Milano, Italy; 5. Department of
Surgery, Policlinico S. Orsola – Malpighi – University of Bologna,
Bologna, Italy
Time to first bowel movement
(days—mean ± SD)
3.0 ± 0.9
3.6 ± 1.1
0.03*
Postoperative length of stay
(days—mean ± SD)
5.3 ± 1.6
6.8 ± 3.1
0.04*
Total length of stay
(days—mean ± SD)
5.3 ± 1.6
7.9 ± 3.4
0.001*
Postoperative pain: VAS
Score > 3 on p.o. day 1
(n; %)
8; 40%
19; 27.1%
n.s.°
Postoperative pain: VAS
Score > 3 on p.o. day 2
2; 10%
4; 5.7%
n.s.°
BACKGROUND: Two major innovations have drastically
modified colorectal surgery over the last 20 years: laparoscopy and the introduction of multimodal integrated
perioperative programs (ERAS, Enhanced Recovery After
Surgery, also known as Fast Track programs). ERAS applies
evidence-based concepts to perioperative care of surgical
patients: it aims to reduce surgical stress, allowing a faster
and smoother postoperative recovery. A recent RCT proved
that the combination of laparoscopy with ERAS represents
the best option for colorectal cancer patients. There are surprisingly no data on Crohn’s disease (CD) patients treated
by laparoscopy and ERAS program.
Major complication rate
(bleeding, leakage,
abdominal abscess)
3; 15%
7; 10%
n.s.°
Minor complication rate
(ileus, intraluminal bleeding,
wound infection)
2; 10%
10; 14.3%
n.s.°
Readmissions within 30 days
from discharge
0; 0%
2; 2.8%
n.s.°
Combination of Laparoscopy and Enhanced Recovery
Program Improves Outcomes After Ileocecal Resection
for Crohn’s Disease
* t-test; ° 2-test
1007
METHODS: Twenty consecutive patients planned for ileocecal resection due to stricturing CD at two IBD referral
centers were prospectively enrolled. Patients underwent
laparoscopic ileocecal resection (LIR) and were treated
according to ERAS program (LIR+ERAS group): no preoperative bowel preparation nor fasting, no nasogastric tubes,
no abdominal drains, early removal of urinary catheters,
early feeding and mobilization, multimodal opioid-free
analgesia and restrictive perioperative fluid management.
Enrolled patients were compared with 70 patients treated
by LIR and conventional care (CC) (LIR+CC group),
matched for age, sex, disease presentation, BMI, ASA score,
preoperative therapy.
Predictors of Unsuccessful Laparoscopic Resection of
Gastric Submucosal Neoplasms
RESULTS: See Table.
METHODS: A retrospective analysis was conducted on
patients with attempted laparoscopic resection (n = 69)
and open resection (n = 25) of submucosal neoplasms of
the stomach from October 2002 through October 2011.
Nonparametric statistical tests were used for comparisons
between groups.
Sabha Ganai1, Vivek N. Prachand1, Mitchell C. Posner1,
John C. Alverdy1, Eugene A. Choi1, Irving Waxman1,
Marco G. Patti, Kevin K. Roggin
Department of Surgery, The University of Chicago, Chicago, IL
INTRODUCTION: While minimally-invasive techniques
have an integral role in foregut surgery, their optimal use
in the resection of gastric neoplasms awaits validation in
clinical practice. We hypothesized that conversion of operations to open could be predicted by specific anatomical
and pathological factors.
CONCLUSION: This is the first experience combining
laparoscopic surgery with integrated multimodal ERAS
protocols on CD patients. Our data showed a significantly
faster return of normal bowel function and shorter hospital
stay for the LIR+ERAS group. This suggests that optimized
perioperative care combined with minimally invasive techniques may lead to further improvements in surgical outcomes for CD patients.
56
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Laparoscopic (n = 62)
Symptoms:
– Asymptomatic
– GI bleed
– Reflux/Dyspepsia
– Dysphagia
– Abdominal Pain
Neoadjuvant Imatinib
Conversion (n = 7)
Open (n = 25)
p
14 (24%) 23 (39%) 8 (14%)
0 14 (24%)
1 (14%) 2 (29%)
1 (14%) 0 3 (43%)
1 (4%) 8 (32%)
2 (8%) 1 (4%) 13 (52%)
0.01
2 (3%)
2 (29%)
6 (24%)
0.005
Preoperative Size (cm)
3.5 ± 1.8
7.7 ± 5.4
9.5 ± 7.1
<0.0001
Pathological Size (cm)
4.0 ± 2.2
7.6 ± 5.0
8.5 ± 6.2
0.0004
Operative Time (min)
145 ± 60
246 ± 84
231 ± 96
<0.0001
Estimated blood loss (mL)
35 ± 70
376 ± 422
373 ± 280
<0.0001
51 (82%) 3 (5%) 4 (7%)
1 (2%) 2 (3%) 0 1 (2%)
3 (43%) 1 (14%)
3 (43%) 0 0 0 0
9 (36%) 4 (16%) 7 (28%)
2 (8%) 1 (4%) 1 (4%) 1 (4%)
0.0003
3.5 ± 3.9
6.4 ± 1.1
8.7 ± 5.8
<0.0001
Accordian Severity Score 0 – no
complications
1 – minor (wound, foley)
2 – minor (PRBCs, Abx, TPN)
3 – Endoscopic / IR Intervention
4 – Operative Intervention
5 – MSOF 6 – Death
Hospital length of stay (days)
1008
Minimally Invasive Approach GE Junction and
Esophageal GIST
Jon Gould1, Andrew Kastenmeier1, Mario Gasparri2
1. Minimally Invasive General Surgery, Medical College of
Wisconsin, Milwaukee, WI; 2. Thoracic Surgery, Medical College
of Wisconsin, Milwaukee, WI
Gastrointestinal stromal tumors are rare neoplasms of
uncertain malignant potential. The most common site of
origin is the stomach. Approximately 5% of all GISTs originate from the esophagus. Traditional management of gastric GIST is wedge resection to grossly negative margins.
Tumors located at the GE junction are difficult to resect
without impairing esophageal emptying. Tumors in the
esophagus cannot be resected with wedge resection techniques. Rather than performing an esophagectomy, enucleation of low-risk lesions may be appropriate. We present
a video demonstrating the laparoscopic resection of two
GIST lesions in difficult anatomic locations: the GE junction and the distal esophagus.
CONCLUSIONS: Selection for laparoscopic versus open
resection appears to be influenced by factors including
tumor size, multivisceral involvement, and the need for
gastric reconstruction. Conversion to open is also more
likely with tumors in a posterior location. Laparoscopic gastric resection has decreased morbidity, operative time, and
hospital length of stay and is appropriate in well-selected
patients with gastric submucosal neoplasms.
57
Tuesday
Abstracts
RESULTS: Patients were 63 ± 14 years old, 52% male, and
had a BMI of 29.5 ± 7.3 kg/m2. Diagnostic endoscopic ultrasound use was greater in the laparoscopic group than the
open (86% vs. 64%, p < 0.05). Lesions in the laparoscopic
and open cohorts included gastrointestinal stromal tumors
(71% vs. 88%), leiomyomas (9% vs. 12%), schwannomas
(9% vs. 0), and other (11% vs. 0). There were 7 (10%) conversions to open in the laparoscopic group. Posterior location
was a predictor of conversion (71% vs. 32%, p < 0.01) and
selection for an open technique (67%, p < 0.01). There were
no other predictors of conversion by location of the mass
along the stomach. Conversions (29%) and open resections
(40%) were more likely to have multivisceral involvement
than the laparoscopically-treated patients (2%, p < 0.0001).
Combined laparoendoscopic approaches were used in 10%
of laparoscopic procedures (n = 62), which included wedge
or sleeve resection in 47 (76%), transgastric wedge resection in 5 (8%), submucosal resection in 3 (5%), midbody
gastrectomy in 2 (4%), antrectomy in 1 (2%), and other
in 4 (6%). Patients selected for open resection were more
likely to require a gastroenteric anastomosis in comparison
to patients initially selected for a laparoscopic approach
(40% vs. 4%, p < 0.0001). Significant differences in tumor
size, operative time, morbidity, and length of stay were
noted between groups (refer to Table, p < 0.001).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
1009
1010
Epigenetic Modulation of Adhesion and Proliferation
Pathways by Methionine Deficiency Attenuates
Potential for Dissemination of Gastric Cancer Cells
Adjuvant Radiation Therapy and Lymph Node Dissection
in Esophageal Cancer: A SEER Database Analysis
Ravi Shridhar2, Jill Weber1, Sarah Hoffe2, Khaldoun Almhanna1,
Richard Karl1, Ken L. Meredith1
1. Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL;
2. Radiation Oncology, H. Lee Moffitt Cancer Center, Tampa, FL
Luigina Graziosi , Andrea Mencarelli , Barbara Renga ,
Emanuel Cavazzoni2, Angela Bruno1, Chiara Santorelli2,
Emanuele Rosati2, Stefano Fiorucci1, Annibale Donini2
1. Medicina Clinica e Sperimentale, University of Perugia,
Perugia, Italy; 2. Dipartimento di Scienze Chirurgiche,
Radiologiche e Odontostomatologiche, University of Perugia,
Perugia, Italy
2
1
1
Objectives: The number of lymph nodes removed during
esophagectomy and the impact on survival remains undefined. We sought to determine the effects of post-operative
radiation therapy and lymph node dissection on survival
in esophageal cancer.
BACKGROUND: Methionine dependency is a feature
unique to cancer cells, as demonstrated by their inability
to grow in a methionine depleted environment even if the
medium is supplemented with homocysteine, the immediate precursor of methionine. Treatment of disseminated
gastric cancer is unsatisfactory and gastric tumors are frequently chemoresistant.
METHODS: We performed an analysis of patients who
underwent esophagectomy for cancer from the SEER database
between 2004–2008 to determine association of adjuvant
radiation and lymph node dissection on survival. Patients
treated with neoadjuvant radiation were excluded. Survival
curves were calculated according to the Kaplan-Meier method
with log-rank analysis. Multivariate analysis (MVA) was performed by the Cox proportional hazard model.
AIM: To investigate the effect of methionine deficiency in
rodent models of gastric cancer dissemination.
MATERIAL AND METHODS: Moderate (MKN74) and
poorly differentiated (MKN45 and KatoIII) human gastric
cancer cell lines were used for these studies. To generate
models of experimental peritoneal carcinomatosis (10 days)
and xenograft model (65 days), these cell lines were injected
intraperitoneally or subcutaneously, respectively, in NODSCID mice. For in vitro studies cells were growth in a complete medium with 10% bovine dyalized serum in a
methionine free medium containing homocysteine(MetHcy+) or a medium containing methionine but depleted of
homocytesine (Met+Hcy-).
Three-days in vitro culture In vitro of MKN45,MKN74 and
KATOIII cells in a methionine deficient medium inhibited cell proliferation by 70-% and induced cell apoptosis.
In addition, culturing cells in a methionine free medium
reduced cell adhesion and migration significantly in comparison to Met+Hcy- medium (p < 0.05). Finally, by microarray
designed to analyze the methylation of promoter CpG-islets,
we found that methionine deficiency reduced the promoter
methilation of E-Cadherin and secreted frizzled-related protein 2 (SFRP-2) by 50%, two genes involved in the gastric
cancer cell adhesion and proliferation, respectively.
RESULTS: We identified 2109 patients who met inclusion
criteria. There were 467 and 1642 patients treated with and
without radiation. Radiation was associated with increased
survival in stage III patients (HR 0.71; 95% CI: 0.56 - 0.90;
p = 0.005), no benefit in stage II (p = 0.075) and IV (p =
0.913) patients, and decreased survival in stage I patients
(HR 2.73: 95% CI: 1.76 - 4.22; p < 0.0001). Univariate analysis revealed that radiation therapy was associated with a
survival benefit in node positive (N1) patients while it was
associated with a detriment in survival for node negative
(N0) patients. The median and 3 year survival with and
without radiation is 23 months and 34%, and 20 months
and 26.7%, respectively (p = 0.0225) for N1 patients and
the 3-year survival with and without radiation is 48.8%
and 68.8%, respectively (p < 0.0001) for N0 patients. In
node negative patients, removing <12 versus >12 lymph
nodes (HR 1.316; 95% CI 1.060 - 1.634; p = 0.013) and <15
versus >15 (HR 1.313; 95% CI: 1.032 - 1.670; p = 0.027)
was associated with increased mortality. Similarly, in node
positive patients, removing <8 versus >8 (HR 1.325; 95%
CI 1.066– 1.646; p = 0.011), <10 versus >10 (HR 1.311;
95% CI 1.069–1.608; p = 0.009), <12 versus >12 (HR 1.299;
95% CI 1.066– 1.582; p = 0.009), <15 versus >15 (HR 1.258;
95% CI 1.031– 1.535; p = 0.024), and <20 versus >20 (HR
1.325; 95% CI 1.056–1.662; p = 0.015) was associated with
increased mortality. In node negative patients, age and
tumor stage, were prognostic for worse survival, while gender and number of lymph nodes removed were prognostic
for better survival. Adjuvant radiation, tumor location, and
histopathology were not prognostic for survival. In node
positive patients, age and tumor stage were associated with
increased mortality while number of lymph nodes removed
and adjuvant radiation were associated with decreased
mortality. Gender, tumor location, and histopathology
were not prognostic for survival in node positive patients.
CONCLUSIONS: Our experimental data suggest that a
deficient methionine diet might affect neoplastic tumor
growth by regulation of cell cycle, inducing apoptosis and
decreasing cellular adhesion and migration.
CONCLUSION: The number of lymph nodes removed in
esophageal cancer is associated with increased survival.
The benefit of adjuvant radiation therapy on survival in
esophageal cancer is limited to N1 patients.
RESULTS: In the xenograft models induced by subcutaneous implantation of MNK45 and MNK74 cells, two cycles of
methionine deficient diet (from day 20 to 27 and from day
34 to 41) reduced the tumor growth, measured on day 70,
by 50% (p < 0.05 versus control diet). In the model of peritoneal carcinomatosis, induced by MNK45 cells injection,
a cycle of methionine deficient diet for 10 days reduced
peritoneal nodules from 27.0 ± 3.68 to 6.7 ± 0.8 (p < 0.05).
The intraperitoneal injection of MNK74 cells precultured
for 3 days in a Met-Hcy+ medium almost abrogated peritoneal dissemination (p < 0.05 versus Met+Hcy- medium
precultured group).
58
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
1012
1011
Health-Related Quality of Life in Patients Esophageal
Cancer: Predictors Analysis at the Different Steps of
Treatment
Extent of Lymphadenectomy Does Not Predict Survival
in Patients Treated with Primary Esophagectomy
Joyce Wong, Jill Weber, Khaldoun Almhanna, Sarah Hoffe,
Ravi Shridhar, Ken L. Meredith
Surgery, H. Lee Moffitt Cancer Center, Tampa, FL
Marco Scarpa1, Luca Saadeh1, Alessandra Fasolo1, Rita Alfieri1,
Matteo Cagol1, Giovanni Zaninotto2, Ermanno Ancona2,
Carlo Castoro1
1. Oncological Surgery Unit, Venetian Oncology Institute
(IOV-IRCCS), Padova, Italy; 2. Department of Surgical and
Gastroenterological Sciences, University of Padova, Padova, Italy
BACKGROUND: The number of lymph nodes resected
and its impact on survival for patients with esophageal
cancer remains undefined. Current guidelines recommend
extended lymphadenectomy in patients not receiving neoadjuvant therapy. We reviewed our single institutional
experience with nodal harvest for esophageal cancer in a
non-neoadjuvant therapy setting.
BACKGROUND: The main outcome parameters in esophageal oncology have traditionally been morbidity and
mortality but recent improvements in the treatment of
esophageal cancer suggest to take in consideration quality
of life. Esophagectomy is associated with significant deterioration of the health related quality of life, which persists
during the follow-up period. The aim of this study was to
analyze quality of life before and after esophagectomy for
esophageal cancer and to identify possible predictors of
quality of life at the different steps of the treatment.
Patients and methods One hundred twenty six consecutive
patients presenting with esophageal cancer at the Oncological Surgery Unit of the Veneto Institute of Oncology have
been enrolled in this prospective study from 2009 to 2011.
The patients answered to three quality of life questionnaires
at diagnosis of esophageal cancer, after the neoadjuvant
therapy, after surgery and at 1, 3, 6 and 12 months after
surgery. The questionnaires were administered during the
hospitalization and outpatient visits. The questionnaires
were the Italian version of the QLQ-C30, QLQ-OES18 and
IN-PATSAT32 models, developed by the European Organization for Research and Treatment of Cancer (EORTC). Univariate and multivariate analysis were performed.
RESULTS: We identified 246 patients who underwent
esophagectomy as initial treatment. The mean age was 65
years ±10 years. The majority of patients were male (87%).
Ivor-Lewis esophagectomy was performed for 71%, minimally-invasive esophagectomy for 15%, transhiatal esophagectomy for 12%, and three-field esophagectomy for 2%.
At 60 month follow-up, there was no statistically significant difference in overall survival (OS) or disease free survival (DFS) between patients with < vs. >5 LN resected (p =
0.74 and p = 0.67, respectively) or in the < vs. >10 (p = 0.33,
p = 0.11), 12 (p = 0.82, p = 0.90), 15 (p = 0.45, p = 0.79),
or 20 (p = 0.72, p = 0.86) resected LN groups. Patients were
then sub-divided into node positive and node negative
cohorts and stratified by nodal harvest. In the subgroups
of patients with node-negative and node-positive disease,
OS and DFS also did not significantly differ between groups
with respect to number of nodes resected (p>0.05). A total
of 49 (20%) patients developed recurrent disease; however
recurrence was not statistically associated with number of
LN resected (p > 0.05).
RESULTS: Global quality of life (QL2 item) improved after
neoadjuvant therapy compared to the baseline levels, it
decreased immediately after surgery (p = 0.06) and then it
improved after 1 year (p = 0.03). At diagnosis, QL2 item correlated significantly with tumor size, gender and dysphagia
but none of these items was an independent predictor at
multivariate analysis. After neoadjuvant therapy, only age
revealed to be an independent predictor of good quality
of life (b = 0.33, p = 0.02). After surgery, gastroenterological complications of radiochemotherapy were independent
predictor of poor quality of life (b = – 0.33, p = 0.04). One
year after esophagectomy postoperative complications
were independent predictor of poor quality of life at this
stage (b = – 0.63, p = 0.01). Dysphagia (DYS item) improved
dramatically after surgery (p < 0.01). After surgery DYS was
independently predicted by the presence of skin complication of chemo radiation, hospital stay duration and the use
of jejunostomy (b = 0.33, p = 0.04, b = 0.40, p = 0.04 and
b = -0.45, p = 0.02, respectively).
CONCLUSION: We found no impact of extent of lymphadenectomy on overall or disease free survival in patients
treated with esophagectomy without neoadjuvant therapy.
In addition, the number of nodes resected at esophagectomy did not affect recurrence rates. Current recommendations for increased nodal resection during esophagectomy
in patients not receiving neoadjuvant therapy may not
improve patient outcomes, and this phenomenon warrants
further investigation.
59
Tuesday
Abstracts
METHODS: Patients who underwent esophagectomy as
primary therapy were indentified from a prospectively
maintained database consisting of 704 patients who underwent esophagectomy. Patients were stratified by number
of lymph nodes (LN) resected: >5, 10, 12, 15, or 20. Survival, clinical and pathologic parameters were analyzed
with Kaplan-Meier curves, chi-square or Fisher’s exact tests
where appropriate.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSIONS: Even if in the short-term quality of life
seems to be negatively influenced by esophagectomy after
12 months the scale returns to baseline levels. However,
the minimally invasive techniques do not seem to confer
special benefits. On the contrary, dysphagia improve significantly after esophagectomy. Older patients seem to cope
more easily with neoadjuvant therapy while complications
of chemo radiation and of surgery deeply affect quality of
life at different stage of the natural history of the disease.
chief component. Presently, there is no simple in vitro culture system of human esophageal cells that can be used
to observe the morphological and molecular effects of bile
acid and low pH on a stratified epithelium. In this study,
we showed that h-TERT-transformed primary esophageal
squamous cells (EPC1) form a 10–11 layered stratified epithelium when grown on polyester trans-well filters apically
and basally supplemented with keratinocyte serum-free
media with 0.6 mM Ca+2. This stratified epithelium shows
epithelial barrier function and expresses squamous specific
genes like GRHL-1, K10, KDAP, DSG1, and IVL. Moreover,
when exposed to bile acids at pH5 in short pulses, EPC1
cells demonstrate reduction in the stratification layers and
in the expression of squamous specific genes. The epithelium also exhibits loss of barrier function possibly due to
disruption of desmosomal junctions and phosphorylationactivation of epidermal growth factor receptor (EGFR) and
down-stream pathways. In addition, the epithelium starts
expressing columnar specific transcription factor CDX2 as
early as day 3 of treatment. These results indicate that bile
acid at low pH is responsible for skewing the differentiation status of stratified squamous esophageal epithelium
in vitro to a more columnar type possibly by initiating a
mucosal restitution response through activation of EGFR
signaling.
1013
Bile Acid at Low pH Reduces the Squamous
Differentiation and Induces Columnar Differentiation
of Primary Esophageal Cells, Possibly by Activating
EGFR Signaling
Sayak Ghatak1,2
1. Biology, University of Rochester, Rochester, NY; 2. Surgery,
University of Rochester, Rochester, NY
Esophageal Adenocarcinoma is the fastest growing cancer
in the United States and is the sixth leading cause of cancerrelated death. In its precancerous lesion, Barrett’s Esophagus, the normal squamous epithelium of the esophagus
undergoes columnar metaplasia due to long-term exposure
to reflux contents of which bile acid at acidic pH is the
60
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
POSTER SESSION DETAIL
Printed as submitted by the authors.
indicates a Poster of Distinction.
Sunday, May 20, 2012
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
Halls C-G
POSTER SESSION I
(NON-CME)
Basic: Colon-Rectal
Total purified RNA was isolated from tissue samples and
cDNA synthesized. CDH3 expression was analyzed by
quantitative PCR (QPCR) using the SYBR Green platform.
Tumor expressions levels were determined and compared
to expression levels in normal colonic tissue and PLC.
CDH3 expression in other normal organs was also assessed.
Tumors with expression levels 0.1% or more than the PLC
result were considered positive. Plasma CDH3 levels were
determined via ELISA in pts for whom PreOp blood samples were available. Plasma CDH3 levels and tumor QPCR
levels were correlated (P < 0.05). Colon and rectal tumor
expression levels were also compared (p < 0.05).
Su2020
The Tumor Associated Antigen P-Cadherin (CDH3)
in Colorectal Cancer Holds Promise as a Prognostic
Marker Rather Than as Specific Immunotherapy Target
RESULTS: A total of 77 paired CRC and normal colon
specimens (36 M/ 41 F, age 67.3 ± 14.5) were assessed
(82% colon, 18% rectal; Cancer Stage 2, 44; Stage 3, 33).
All tumors (100%) had CDH3 expression levels over 0.1%
of the PLC level and, also, a tumor to normal colon ratio
greater than 1.Expression ratios in 25 tumors were above
100 and in 19 tumors were in the 50–100 range. CDH3
expression was noted in 8/20 normal organ tissues. There
was a positive correlation between tumor CDH3 QPCR and
PreOp CDH3 blood levels (n = 57, P = 0.038). Expression
levels were significantly higher in rectal vs. colon tumors
(p = 0.019).
INTRODUCTION: Placental-Cadherin, type 1 (CDH3) is a
cell adhesion molecule that plays a role in cellular localization and tissue integrity. Because CDH3 is highly expressed
by the placenta (PLC) it holds promise as a cancer testis
antigen and, possibly, a vaccine target. Its expression profile in normal tissues has not been well studied, to date.
Up-regulation of CDH3 expression has been reported in
esophageal, pancreatic, bladder, prostate, melanoma, and
breast cancer; expression levels in colorectal cancer (CRC)
remain poorly characterized. This study’s aims were: 1) to
evaluate CDH3 expression in CRC tumors and other tissues
as well as to assess preoperative plasma CDH3 levels and
2) to determine if CDH3 holds promise as a vaccine target.
CONCLUSION: All tumors over expressed CDH3 as judged
by RT-PCR when compared to normal colon tissue; tumor
expression was also greater than 0.1% of PLC expression
levels. Unfortunately, CDH3 was expressed by other normal organs, thus, it is not a promising vaccine target or a
cancer testis antigen. Of note, appreciable plasma CDH3
levels were noted and the correlation between plasma and
tumor CDH3 levels suggests CDH3 may have value as a
prognostic marker. A larger study is needed to determine if
plasma and/or tumor expression levels correlate with T, N,
or final tumor stage.
METHODS: An IRB approved plasma and tumor bank was
utilized. CRC patients (pts) for whom tumor and normal
colon tissue samples were available were enrolled. Demographic and pathologic data were collected prospectively.
Tumor samples were OCT embedded and stored at –80C°.
61
Sunday
Poster Abstracts
C.M. Shantha Kumara H*1, Otavia L. Caballero2,
Sonali A. Herath1, Tao Su3, Aqeel Ahmed3, Linda Njoh1,
Vesna Cekic1, Richard L. Whelan1
1. Surgery, St. Luke Roosevelt Hospital, New York, NY; 2. Ludwig
Collaborative Laboratory for Cancer Biology and Therapy Department
of Neurosurgery, Johns Hopkins University School of Medicine,
Baltimore, MD; 3. Herbert Irving Comprehensive Cancer Center,
Columbia University, New York, NY
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su2021
Basic: Esophageal
The Tumor Suppressive Effects of HPP1 via STAT
Signaling in Colon Cancer Are Abrogated by
Site-Directed Mutation of Its EGF-Like Domain
Su2023
Development of a Robust Stricture Model to Assess
Therapeutic Interventions Following Circumferential
Endoscopic Esophageal Submucosal Dissection
Abul Elahi*, Whalen Clark, Jonathan M. Hernandez, Jian Wang,
Yaping Tu, Leigh Ann Humphries, David Shibata
H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL
Eric M. Pauli*1, Steve J. Schomisch1, Amitabh Chak2,
Jeffrey L. Ponsky1, Jeffrey M. Marks1
1. Surgery, University Hospitals Case Medical Center, Cleveland, OH;
2. Gastroenterology, University Hospitals Case Medical Center,
Cleveland, OH
INTRODUCTION: The novel tumor suppressor gene, HPP1
is downregulated in over 80% of colorectal cancers and
mediates its effects by alterations in STAT (Signal Transducer and Activator of Transcription) signaling. HPP1 is
a secreted transmembrane protein that contains a single
Epidermal Growth Factor (EGF)-like domain which differs from EGF by having a His instead of an Arg at what is
thought to be a critical amino acid (AA) site. We sought to
investigate the impact of targeted site-directed mutagenesis
at this AA site on HPP1’s biologic behavior.
INTRODUCTION: Circumferential endoscopic esophageal submucosal dissection (EESD) for high grade dysplasia
or early cancer provides an intact specimen for histology, offers less-invasive therapy than esophagectomy and
potentially allows one-step en bloc eradication of Barrett’s
esophagus. As such, the technique holds potential for staging, treating and preventing esophageal cancer. However,
aggressive stricture formation after EESD has limited its
clinical use. We hypothesized that an in vivo esophageal
stricture model could be developed to assess endoscopic
interventions designed to prevent stricture formation following EESD.
METHODS: Site-directed mutagenesis technology was utilized to create a mutated HPP1 construct substituting an
Arg moiety in the place of His at site 299 in its EGF-like
domain. Computed 3-D protein folding models demonstrate no alterations in the overall configuration of HPP1
as a result of this mutation. Full-length wild-type HPP1,
the mutated HPP1 (H299R) and empty vector control were
transfected into the HPP1 non-expressing HCT116 colon
cancer cell line. Biologic effects on STAT signaling were
assessed by RT-PCR and Western Blot analyses. Effects on
proliferation and anchorage-independent growth were
evaluated by MTT and soft agar assays respectively.
METHODS: Five swine were utilized in this study. Under
anesthesia, a flexible endoscope with a band ligator and
snare was used to circumferentially incise the mucosal
layer 20 cm proximal to the lower esophageal sphincter.
An approximately 10 cm circumferential segment of tissue
was dissected free from the underlying muscle and excised
using electrocautery and snare. Weekly barium esophagograms evaluated for reduction in esophageal diameter and
assessed stricture length and proximal dilation. Animals were
followed clinically and were euthanized when the stricture
exceeded 80% and they were unable to gain weight (despite
high-calorie liquid diet). A blinded pathologist evaluated
EESD and necropsy specimens.
RESULTS: We have previously demonstrated that HPP1
overexpression results in a substantial reduction in proliferation, growth in soft agar and tumorigenicity. These
effects are associated with activation of suppressive STAT1
and –2 with down regulation of oncogenic STAT3, –5 and
–6. Transfection of HPP1 H299R resulted in a reversal of
this profile with a reduction in activated STAT1 and –2 and
increased phosphorylation of STAT3, –4 and –5. Moreover,
forced expression of mutated HPP1 abrogated tumor suppressive behavior with increased cell proliferation (Optical
Density-OD: 0.78 ± 0.18 vs.; 0.33 ± 0.13 p ≤ 0.001) and
colony formation in soft agar (543 ± 20 vs 2 ± 1 colonies;
p ≤ 0.001) as compared to wild-type HPP1 transfectants.
Cell growth parameters were similar between HPP1 H299R
and EV control transfectants (OD 0.75 ± 0.07; 591 ± 176
colonies; P = NS).
RESULTS: Resected specimens ranged from 90–110 mm
in length. Histology confirmed uniform en bloc mucosal
resection down to the superficial submucosa. All five animals rapidly developed strictures following EESD. At one
week, animals demonstrated a 62.2 ± 12.9% reduction in
luminal diameter, longitudinal shortening to 77.6 ± 12.4%
of the original resected length with dilation in the proximal esophagus to 128 ± 6.2% baseline diameter. By two
weeks, animals demonstrated a 77.7 ± 12.1% reduction in
luminal diameter, longitudinal shortening to 62.7 ± 12.3%
of the original resected length with dilation in the proximal esophagus to 174.8 ± 27.3%. Based on criteria, no animal survived beyond the third week of study. There was
no correlation between resected specimen length and the
degree of luminal narrowing or survival. Stricture zone histology showed unepitheliazed submucosa with abundant
PMNs, fibrosis and neovascularization.
CONCLUSION: The EGF-like domain of HPP1 is essential
for its tumor suppressive effects with the Histidine moiety
at position 299 being critical for mediating its associated
biologic and molecular signaling effects. Therapeutic targeting of the erbB family of receptors is of great interest
and our findings may lead to a greater understanding of
the complex and sometimes contradictory nature of their
associated signaling pathways.
62
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
CONCLUSIONS: We describe the successful development
of an esophageal stricture model. EESD in the porcine
esophagus removes specimens of uniform length and depth
without damaging the underlying muscule. Circumferential EESD results in clinically significant stricture formation within weeks. Esophagograms demonstrated uniform
reduction in luminal diameter in the area of resection with
concomitant proximal esophageal dilation. Histology confirmed the presence of inflammation and fibrosis. Future
areas of investigation will focus on endoscopic methods to
alleviate or prevent stricture formation following EESD.
Su2025
Basic: Pancreas
INTRODUCTION: Severe acute pancreatitis (AP) may
lead to serious complications, with high mortality rates.
Although several clinical and radiological scores and biochemical markers can determine if an episode of AP is
severe, there is not available a precise predictor for the
severity of the pancreatitis, which could allow an early
intensive management of those patients. Our group has
focused on the study of serum ecto-nucleotidase activity
(NTPD-ases) and purine levels, and their possible role as
predictor of severity in AP. Extracellular nucleotides play
significant role in inflammation in peripheral circulation,
and their serum levels are partially controlled by NTPDases. Consequently, those enzymes act as regulatory elements in inflammation, hydrolyzing nucleotides. However,
results from our main experiments have shown an intriguing data, which could point to a possible marker of severity
in AP, with a promising clinical use.
Positive Correlation Between Serum Phosphate Levels
and Acute Pancreatitis Severity in a Rat Model of
Pancreatitis Induced by Sodium Taurocholate
Guilherme D. Mazzini*1,2, Daniel T. Jost1, Rafael Machoseki1,
Mateus A. Zeni1, Luiz V. Portela1, Maria I. Edelweiss2,
Diogo O. Souza1, Alessandro B. Osvaldt2
1. Biochemistry, Universidade Federal do Rio Grande do Sul, Porto
Alegre, Brazil; 2. Gastrointestinal Surgery, Hospital de Clinicas de
Porto Alegre, Porto Alegre, Brazil
Su2024
Aging Is Related to Increased Intestinal Damage and
Bacterial Translocation in Acute Pancreatitis in Rats
ANA Maria M. Coelho*1, 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
METHODS: The local ethics committee approved the
study. AP was induced in 20 Wistar male rats, age 90–120
days, by retrograde infusion of sodium taurocholate in
the pancreatic duct. Ten sham-operated animals were submitted to median laparotomy and closure. There were 5
absolute control animals. Blood was collected from the tail
before surgery (time 0) and after 3h and from cardiac puncture at 12h, when pancreas were excised and fixed in formalin for histopathology. AP diagnosis was made based on
amylase serum levels, determined by a colorimetric assay,
and severity was graded by histopathology, using a validated scale (from 0 to 28 points). As a control for the colorimetric assay to determine NTPD-ase activity (measured by
phosphate release), in each serum sample the basal phosphate levels were measured. These values produced interesting data, and will be presented here.
METHODS: AP was induced in male Wistar rats by intraductal 2.5% taurocholate injection and divided into 2
experimental groups: GI (n = 20): Young (3 month old rats),
and GII (n = 20): Older (18 month old rats). Two and 24
hours after AP blood were collected for determinations of
plasma ileal fatty acid binding protein (I-FABP), and biochemical markers: amylase, AST, ALT, urea, creatinine, and
glucose. Pulmonar myeloperoxidade (MPO) activity was
also performed. Bacterial translocation was evaluated by
bacterial cultures of pancreas expressed in colony-forming
units (CFU) per gram.
Results: Four animals from AP group died before 12h. Additional 2 animals from AP group were excluded from the
analysis due to invalid results. Serum amylase was diagnostic of AP in pancreatitis group, at 3h and 12h. Severity score
in AP group was 19.0 ± 4.9 (mean ± SD). Basal phosphate
levels at 12 h were significantly higher than 0h and 3 h in
AP group, and significantly higher than 0h, 3 h and 12 h, in
sham and control groups, which did not present significant
alterations in phosphate levels along the experiment (Figure 1). Additionally, in AP group, phosphate levels at 12 h
showed a positive correlation with the severity of the pancreatitis, r = 0.74 (Pearson’s coefficient, p = 0.02) (Figure 2).
RESULTS: A significant increase in serum amylase, AST,
ALT, urea, creatinine, and I-FABP levels was observed in the
older group compared to the young group (p < 0.05). Pulmonar myeloperoxidade (MPO) activity was also increased
in the older group compared to the young group (p < 0.05).
Compared to young rats, rate of positive bacterial cultures
obtained from pancreas cultures in the older rats was significantly increased.
CONCLUSION: This study demonstrated that aging is
associated to an increased distant organ damaged and bacterial translocation, and that plasma level of I-FABP is an
important marker of bacterial translocation.
63
Sunday
Poster Abstracts
BACKGROUND/AIM: Acute pancreatitis (AP) in elderly
patients in spite of similar occurrence of local complications is followed by a substantial increase in multiple organ
failure possibly due to increased bacterial translocation.
Intestinal mucosal barrier may be damage with increased
permeability promoting bacterial translocation. Intestinal
fatty acid binding protein (I-FABP), a 15-kd protein located
at the intestinal mucosa may leak out of damaged intestinal mucosal cells to the peripheral circulation. Therefore,
plasma levels of I-FABP may be an indication of bacterial
translocation. The aim of the present study was to evaluate
the effect of aging on intestinal damage, bacterial translocation, and organ failures in AP.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
extensively studied, whereas very little data exists regarding the role of IL-33 in anti-tumor immune responses. No
study has been performed to address the direct effect of
IL-33 on tumor cell proliferation or apoptosis.
METHODS: In the present study, clonogenic survival
assay, immunohistochemistry (IHC), TUNEL staining, proliferation and caspase-3 activity kits were used to evaluate
the effects of IL-33 on cell survival, proliferation and apoptosis of a pancreatic cancer cell line, MiaPaCa-2. We further
investigated the possible molecular mechanisms by using
RT-PCR, IHC, and Western blot.
RESULTS: We found that the percentage of colonies of
MiaPaCa-2 cells, PCNA+ cells and the OD value of cancer cells were all decreased after incubation with IL-33.
TUNEL+ cells and the relative caspase-3 activity in cancer
cells were increased in the presence of IL-33. The antiproliferative effect of IL-33 on cancer cells correlated with
downregulation of pro-proliferative molecule cdk2 and
cdk4 and upregulation of anti-proliferative molecule p15,
p21 and p53. The pro-apoptotic effect of IL-33 correlated
with downregulation of anti-apoptotic molecule FLIP and
upregulation of pro-apoptotic molecule TRAIL.
Figure 1: Serum phosphate levels in AP group at 12h is significantly
higher then other times and other groups. * p < 0,5 by ANOVA.
CONCLUSIONS: IL-33 inhibits proliferation and induces
of apoptosis of pancreatic cancer cells in vivo. Manipulation of the IL-33/ST2 pathway might be a promising strategy to treat pancreatic cancer.
Basic: Small Bowel
Su2027
Histone Deacetylase Inhibitors Decrease Postoperative
Adhesions with a Single Intraoperative Dose by
Targeting Early Events in Adhesiogenesis
Figure 2: Correlation between AP severity and serum phosphate levels
at 12h. (Pearson’s coefficient r = 0.74, p = 0.02)
Michael R. Cassidy*, Joseph J. Gallant, Alan C. Sherburne,
Holly K. Sheldon, Melanie L. Gainsbury, Arthur F. Stucchi,
James M. Becker
Surgery, Boston University Medical Center, Boston, MA
DISCUSSION: Our group brings preliminary experimental
results with a novel approach to the assessment of severe
AP. Although the strong correlation between pancreatitis
severity and serum phosphate levels was observed late in
the course of the experimental pancreatitis, it could be usefully evaluated in experimental and clinical studies.
INTRODUCTION: Postoperative (postop) adhesions are
a formidable source of morbidity, and previous studies in
our laboratory have shown that peritoneal inflammation
and reduced peritoneal fibrinolysis contribute to adhesiogenesis. Histone deacetylase inhibitors (HDACIs) including valproic acid (VPA), suberoylanilide hydroxamic acid
(SAHA), and MS-275 modulate protein acetylation and
gene transcription, and have anti-inflammatory and antiproliferative properties that we hypothesized could reduce
postop adhesions.
Su2026
IL-33 Inhibits Proliferation and Induces of Apoptosis of
Pancreatic Cancer Cells
Michael Nicholl*1,2, Yujiang Fang1,2, Elizabeth J. Herrick1,
Kathryn M. Cook1
1. Surgery, University of Missouri, Columbia, MO; 2. Surgical
Oncology, Ellis Fischel Cancer Center, Columbia, MO
METHODS: 42 male rats underwent laparotomy with creation of 6 peritoneal ischemic buttons to induce adhesions.
A single intraperitoneal (IP) dose of 50mg/kg VPA, 50mg/kg
SAHA, or 10 mg/kg MS-275 was administered intraoperatively (intraop). Control animals received vehicle alone. To
BACKGROUND: IL-33, a member of the IL-1 cytokine
family, acts in both an autocrine and paracrine manner by
binding its receptor, ST2. The role of IL-33 in host immune
responses to infectious pathogens and allergens has been
64
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
evaluate for a critical window of opportunity for intervention, an additional 25 rats underwent ischemic button creation with either an intraop or a delayed IP dose of VPA at
1, 3, or 6 hours postop. On postop day 7, adhesions were
quantified as percent of ischemic buttons with adhesions.
To investigate mechanism, ischemic buttons were created
in 24 rats and either VPA or saline was administered in one
intraop dose. 8 untreated rats served as non-operated controls. 3 or 24 hours later, peritoneal fluid was collected and
fibrinolytic activity was measured in a kinetic assay for tissue plasminogen activator, and peritoneal tissue was collected for RNA extraction and real-time PCR.
and increased oxidative stress are implicated in adhesiogenesis. Peritoneal fibrinolytic activity, determined by tissue plasminogen activator (tPA) activity, is modulated by
the mesothelial RAS. We hypothesized that losartan, by
blocking the angiotensin II receptor (AIIR) and modulating
the peritoneal RAS, could reduce adhesions.
METHODS: Wistar rats (n = 50) were randomized to nonoperative controls (NonOp), operative controls (Op + Saline)
or intraperitoneal (IP) administration of losartan (Op +
Losartan). Operated rats were administered either 1-ml
normal saline or losartan (100mg/kg) via IP injection 6-hrs
pre-operatively, intra-operatively, 6- and 12-hrs post-operatively. Adhesions were induced using our ischemic button
model and scored on POD7. Additional rats were sacrificed
on POD1 for peritoneal tissue analysis of 8-isoprostane (a
marker of oxidative stress) by ELISA and AIIR mRNA by
PCR. AIIR protein expression was studied by immunohistochemical staining. Peritoneal fluid was also collected on
POD1 to measure tPA activity by kinetic assay. Additionally, an in vitro study of AIIR MAP-Kinase signaling was
performed using primary rat peritoneal mesothelial cells
treated with angiotensin II (AII), losartan (Los), or angiotensin II + losartan (AII+Los) and downstream phosphoERK levels were measured via Western blot.
RESULTS: A single intraop dose of VPA significantly reduced
adhesions by 45% relative to vehicle controls (39.4 ± 4.1%
vs 71.3 ± 4.4%, p < 0.001). Similarly, single intraop doses
of SAHA and MS-275 reduced postoperative adhesions by
48% (44.4 ± 8.2% vs 86.1 ± 5.1%) and by 45% (47.2 ± 5.1%
vs 86.1 ± 5.1%), respectively (p < 0.001). Delayed doses of
VPA at 1, 3, or 6 hours postop did not reduce adhesions
(73.3 ± 4.1%, 66.7 ± 9.1%, 63.3 ± 6.2% vs 73.3 ± 4.1%). In
operated animals, peritoneal fibrinolytic activity at 3 and
at 24 hours postop was not significantly different between
animals administered saline and VPA (6.99U/ml vs 6.75U/
ml and 2.61U/ml vs 2.08U/ml). There was no differential
regulation of gene transcription for IL-6, HIF-1a, tissue factor, or PAI-1 at 3 or at 24 hours postop with administration
of VPA versus saline.
CONCLUSIONS: Three different HDACIs significantly
reduce postop adhesions with very comparable efficacy,
suggesting a similar mechanism of action. That the efficacy of VPA is limited to intraop administration only, with
delayed administration of even 1 hour postop having no
effect, suggests that HDACIs target very early events in
adhesiogenesis that are unrelated to previously described
mechanisms such as fibrinolytic activity or transcription of
inflammatory regulators. These data further indicate that
HDACIs reduce adhesions by a novel mechanism needing
further investigation.
Su2028
The Angiotensin II Receptor Blocker (ARB) Losartan
Decreases Post-Operative Intraabdominal Adhesions
by Modulating Renin-Angiotensin System (RAS) and
Oxidative Stress Pathways
CONCLUSIONS: Losartan significantly reduces intraabdominal adhesions, suggesting a novel mode-of action for
this ARB. Both regulation of peritoneal fibrinolytic activity
by RAS and attenuation of postoperative peritoneal oxidative stress are implicated.
Melanie L. Gainsbury*, Holly K. Sheldon, Michael R. Cassidy,
Daniel I. Chu, Stanley Heydrick, Somdutta Mitra,
Arthur F. Stucchi, James M. Becker
Surgery, Boston University Medical Center, Boston, MA
INTRODUCTION: Post-operative intraabdominal adhesions are a major source of morbidity and our understanding of their formation remains incomplete. Our laboratory
has previously shown that reduced peritoneal fibrinolysis
65
Sunday
Poster Abstracts
RESULTS: Losartan significantly decreased adhesion
formation by 73.3% compared to Op+Saline (16.7 ± 4.6
vs. 62.5 ± 4.2%, p < 0.001). While surgery increased tPA
activity levels by 1.7-fold compared with NonOp, Op +
Losartan further increased tPA 1.4-fold compared to Op +
Saline (0.56 ± 0.01 vs. 0.95 ± 0.18 vs. 2.24 ± 0.5 U/ml, p <
0.05). AIIR mRNA levels were upregulated 5.1-fold in Op +
Losartan compared to Op + Saline (31.9 ± 2.0 vs. 6.3 ± 0.5
fold change of NonOp, p < 0.01). Immunohistochemical
analysis also showed increased AIIR staining of peritoneal
mesothelial cells in Op + Losartan compared to Op + Saline.
While in vitro rat peritoneal mesothelial cells administered
AII showed a 95-fold increase in phospho-ERK protein levels compared to controls, the addition of losartan (AII +
Los) attenuated this response by 70% (1 vs. 95.0 ± 19.2 vs.
28.5 ± 8.2 fold change of NonOp, p < 0.05). The oxidative
stress biomarker 8-isoprostane was reduced by 45% in Op
+ Losartan versus Op + Saline (8.4 ± 0.7 vs. 4.6 ± 0.6 ng/mg
protein, p < 0.05).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Biliary
9%, or when the probability that a retained CBD stone
would eventually become symptomatic was less than 60%.
Similarly, if the sensitivity, specificity, or technical success
of an IOC fell below 78%, 54%, or 80%, LC alone was the
preferred strategy. Universal MRCP and ERCP were both
more costly and less effective than surgical strategies, even
at high probability of asymptomatic choledocholithiasis.
Within the tested range for both procedural and hospitalization related costs for any of the surgical or endoscopic
interventions, LCIOC and LC were always more cost effective than universal MRCP or ERCP, irrespective of presence
or absence of complications. Varying the cost, sensitivity,
and specificity of MRCP had no effect on this outcome.
Su1497
MRCP Is Not a Cost Effective Strategy in Management
of Common Bile Duct Stones
Irene Epelboym*, Megan Winner, John D. Allendorf
Surgery, New York Presbyterian, Columbia University, New York, NY
BACKGROUND: Few formal cost effectiveness analyses
simultaneously evaluate radiographic, endoscopic, and surgical approaches in the management of choledocholithiasis.
METHODS: Using the decision analytic software TreeAge,
we modeled the initial clinical management of a patient
presenting with symptomatic cholelithiasis without overt
signs of choledocholithiasis. In this base case we assumed a
10% probability of concurrent asymptomatic choledocholithiasis. Our model evaluated four diagnostic/therapeutic
strategies: universal MRCP, universal ERCP, laparoscopic
cholecystectomy (LC), or laparoscopic cholecystectomy
with universal intraoperative cholangiogram (LCIOC).
All probabilities were estimated from review of published
literature. Procedure and intervention costs were equated
with Medicare reimbursements. Costs of hospitalizations
were derived from median hospitalization reimbursement
for New York State using diagnosis-related groups (DRG).
Sensitivity analyses were performed on all cost and probability variables.
CONCLUSIONS: LC with routine IOC is the preferred
strategy in a cost effectiveness analysis of the management
of symptomatic cholelithiasis with asymptomatic choledocholithiasis. MRCP was both more costly and less effective
under all tested scenarios.
Su1498
The Role of Intraoperative Fluorocholangiography
During the Advance Laparoscopic Cholecystectomy Era
Harsha Jayamanne*, Jonathan Lloyd-Evans, Ashraf M. Rasheed
Department of Surgery, Royal Gwent Hospital, Newport, United
Kingdom
INTRODUCTION: Intra-operative fluorocholangiography
(IOF) allows real time demonstration of biliary anatomy
and identification of common bile duct stones irrespective
of size or site of the stones. However, routine use of IOF
for detection of unsuspected choledocholithiasis ignited a
debate during the open era that continued into the current
laparoscopic era.
Absence of conclusive preoperative predictors of choledocholithiasis, rise in the number of preoperative endoscopic
retrograde cholangiography pancreatography (ERCP)/
endoscopic sphincterotomy (ES) and availability of laparoscopic ductal stones clearance rekindled the interest and
re-ignited the debate in the clinical utility of pre-operative
magnetic resonance cholangiography (MRCP) and laparoscopic IOF.
Aims: To assess indications and utilization of IOF during
laparoscopic cholecystectomy at Aneurin Bevan Health
Board and to compare its clinical utility to MRCP in order
to evaluate -their impact on patients management.
METHODS: All the laparoscopic cholecystectomy (LC)
procedures performed during the period of January 2008
to 2010 were retrieved from computerized database. We
examined the indications and findings of IOF and MRCP
and their impact on the treatment strategy.
RESULTS: The most effective strategy in the diagnosis and
management of symptomatic cholelithiasis with a 10% risk
of asymptomatic choledocholithiasis was LCIOC. This was
followed closely by MRCP, LC alone, and ERCP; expected
values of success in each strategy did not differ in a clinically meaningful way. Varying the prevalence of asymptomatic choledocholithaisis or the probability that retained
stones would eventually cause symptomatic biliary obstruction did not affect the optimal strategy. When procedure
and hospitalization costs were taken into consideration,
LCIOC was the most cost effective approach, followed by
laparoscopic cholecystectomy. LC was preferred when the
prevalence of asymptomatic choledocholithiasis fell below
RESULTS: A total of 700 consecutive cases of LCs were
performed. Liver enzymes were elevated in 273 of 700
(39%) patients. MRCP was carried out in 139 of 700 (20%)
patients. A hundred and eighteen patients (118) had pre
operative MRCP, while 21 patients had postoperative
MRCP. Forty two (42) patients (6%) underwent ERCP, half
of these (21/42) were performed before surgery and other
half was performed after it. A total of 182 (26%) underwent
IOF during LC.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Choledocholithiasis was noted in 46 patients (6.6%), 70%
of the 46 were detected by MRCP and 30% by IOC. MRCP
reported common bile duct stones (CBDS) in 32 (27%). IOC
was performed in 21 patients who had a negative MRCP
revealing a stone in a single case.
chemotherapy, 19 (60%) underwent only chemotherapy,
while 8 (25%) received supportive care. In patients affected
by ICC, Five patients (16%) received surgical treatment, 13
(41%) chemo- or radiotherapy and 14 (43%) only supportive care. Regarding the impact of treatment on survival, the
median survivals in patients submitted to surgery, chemotherapy or supportive care were 45.5, 12.5, and 2.9 months
respectively (p < 0.05).
A hundred and three ((18.4%) of 558 patients who did not
undergo MRCP had IOF and stones were seen in 13/103
patients (2.3%). Eleven patients out of the 13 went on to
have a successful single-stage laparoscopic clearance.
CONCLUSIONS: Recurrence after liver resection with curative intent is correlated to a poor prognosis. When feasible,
aggressive treatment with radical resection of recurrence
can improve the prognosis in these patients.
CONCLUSIONS: MRCP is an accurate non-invasive diagnostic and triaging modality while IOF remains to be the
gold standard when CBD stones are suspected. IOF document site and size of known CBD stones and detect unsuspected ones in patients, who may benefit from a single stage
laparoscopic common bile duct clearance. A leaner preoperative choledocholithiasis predictability criterion is desirable
to reduce the redundancy in MRCP and IOF utilization.
Su1500
Experiences from the Use of Peroral CholangioPancreaticoscopy as a Routine Diagnostic Work Up
Tool in a Tertiary Referral Center
Lars Enochsson*1,2, Lars R. Lundell2,1, Fredrik Swahn1,2,
Matthias Loehr1,2, Urban Arnelo1,2
1. Department of Surgery, Karolinska University Hospital, Stockholm,
Sweden; 2. Karolinska Institutet, CLINTEC, Stockholm, Sweden
Su1499
Risk Factors, Pattern of Onset and Result of Treatment
of Recurrence After Liver Resection of Peri-Hilar and
Intrahepatic Cholangiocarcinoma
AIM: The aim of this study was to clarify the risk factors,
the pattern of occurrence and the results of treatment of
recurrence in patients affected by cholangiocarcinoma
submitted to surgical resection for peri-hilar (PCC) and
intrahepatic cholangiocarcinoma (ICC).
METHODS: Between 2007 and 2010, 167 SOPOC examinations have been performed using the SpyGlass system.
As we got more familair with the system there was a gradual increase in the number of examinations over the years
(19 (2007); 45 (2008); 50 (2009); 53 (2010)). In all 28% of
the patients were referred to us from other centers. In 145
(91.8%) of the examinations the complete system including the optical probe (SpyGlass) and the access and delivery catheter (SpyScope) was used. In the remaining 8.2%
the SpyGlass was introduced through a sphincterotome
catheter.
METHODS: We retrospectively analyzed the clinicopathologic data of 132 patients submitted to liver resection with curative intent from January 1990 to July 2011,
71 of whom affected by PCC and 61 withICC. Thirty-two
patients for both groups developed recurrence during the
follow-up period (45% and 52.5%, respectively). We estimated the risk factors, the onset pattern of recurrence and
the impact of treatment on survival in these patients.
RESULTS: The 3- and 5-year disease-free survival was 41%
and 21% for both groups (p = 0.35). Among the patients
affected by PCC, 11 (34%) developed intrahepatic recurrence, 5 (15%) developed peritoneal carcinomatosis, 4 (13%)
anastomotic and 4 (13%) lymph-nodal recurrence. Percutaneous transhepatic biliary drainage catheter tract recurrence occurred in 3 patients (9%). At univariate analysis,
the tumor size, the macroscopical portal involvement and
elevated serum level of Ca 19.9 were significantly associated with recurrence. In the intrahepatic cholangiocarcinoma group, 19 patients (59%) developed intrahepatic
recurrence. Five factors were significantly associated with
recurrence at univariate analysis in this group: tumor size,
serum level of Ca 19.9 and CEA, multifocal disease at resection and grading. The overall 3-year survival after recurrence was 17%. The type of treatment was different between
two groups. In patients with PCC, 5 (9%) patients were
submitted to surgical treatment of recurrence followed by
RESULTS: 167 examinations were completed in 161
patients. Among these were 56.3% males (mean age 58.4;
range 21–87) and 43.7% females (mean age 61.5; range
23–89). There were 104 (62.3%) examinations of the biliary, 45 (26.9%) of the pancreatic duct system and in 18
cases (10.8%) the ampullary tract. The optical quality of
the examination was considered to be good in 90.8%, fair
in 6.1% and inadequate in the remaining 3.1%. The overall
postoperative complication rate of the ERCP examinations
with SpyGlass was 13.3%. Postoperative complications,
however, differed significantly depending on which tract
that was investigated since postop complication rates were
12.6% in the biliary, 20.0% in the pancreatic and 0% in the
ampullary region. The diagnostic gain was in the biliary
system 82.7%, in the pancreatic duct system 68.9% and
100% in the ampullary region.
67
Sunday
Poster Abstracts
BACKGROUND: Although there are a variety of modalities
to diagnose pathology within the pancreatobiliary ductal
tract the introduction of the single-operator peroral cholangio-pancreaticoscopy (SOPOC), SpyGlass Direct Visualization
System has added a significant contribution to the diagnostic arsenal. At Karolinska University Hospital we have since
2007 used the system as an integrated part of the diagnostic
work up programme. The aim of this paper is to describe our
experiences and define its role in clinical practice.
Andrea Ruzzenente*, Alessandro Valdegamberi,
Tommaso Campagnaro, Simone Conci, Elisabeth Baldiotti,
Calogero Iacono, Alfredo Guglielmi
Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSION: The single-operator SpyGlass Direct Visualization System offers a valuable diagnostic aid with significant gains in both the biliary as well as the pancreatic
duct system. The large variation in postprocedural complication rates suggests the room for preventive measures
which requires further studies.
significantly greater OR prep, operative, emergence and
PACU time was required for patients undergoing the TVC
approach. This retrospective analysis of transvaginal cholecystectomy patients suggests that there is indeed less postoperative pain measured by the reduced opioid use after
transvaginal NOTES cholecystectomy.
Su1501
Su1502
Transvaginal NOTES Cholecystectomy: Retrospective
Analysis of Immediate Post-Operative Pain
Follow-Up of Ultrasound–Detected Gallbladder
Polypoid Lesions
Stephanie Wood*, Nalini Vadivelu, Mikhael Hosni,
Susan Dabu-Bondoc, Feng Dai, Lucian Panait, Robert Bell,
Andrew Duffy, Walter Longo, Kurt E. Roberts
Surgery, Yale School of Medicine, New Haven, CT
Amir Kambal*, Chris Brown, Ramesh Y. Kannan, Omer Jalil,
Abu Feroz, Ashraf M. Rasheed
Royal Gwent Hospital, Newport, United Kingdom
OBJECTIVES: Gallbladder polyps are reported in 5% of
screening ultrasonography (US). The majority are benign,
however some do have a malignant potential. The preoperative confirmation of the nature of these lesions is
“difficult” and the optimal management remains to be
ill-defined
INTRODUCTION: Transvaginal cholecystectomy (TVC)
is the most common Natural Orifice Transluminal Surgery
(NOTES) performed in women to date yet there is a paucity
of data on intraoperative and immediate post operative
pain management. Previous studies have demonstrated
that NOTES procedures are associated with less post-operative pain and faster recovery times. We analyzed the intraoperative and postoperative opioid use for TVC compared
to traditional 4-port laparoscopic cholecystectomies (LC)
during the last 2 years in our facility.
AIMS: To determine the nature and assess the current
clinical pathways for the ultrasound-detected gallbladder
polyps (GBP) and propose a follow -up and a therapeutic
strategy based on size and symptomatology
METHODS: A retrospective search of the US database for
“polyp” in gallbladder for the period between January 1st
2009 and Dec 31st 2010 was conducted. A database was
then constructed including demographics, clinical presentation, principal symptoms, management and pathology.
Histologic findings were analyzed in patients who underwent cholecystectomy. The electronic medical records were
searched to check the clinical outcome, pathologic data
and follow-up arrangements
METHODS: We performed a retrospective analysis of the
last 20 TVC to the last 20 LC patients at our facility. We compared demographics, intraoperative and postoperative opioid
use and times in the operating room and in the Post Anesthesia Care Unit (PACU). The opioid use is described in the
morphine equivalent (mg). We obtained data from electronically recorded anesthesia records of the perioperative period.
RESULTS: There were no significant differences between
the average age and BMI between the LC (41years, 30kg/
m2) vs. TVC (40years, 30kg/m2) groups (p = 0.9; p = 0.88).
The average time of patient in the operating room was significantly greater for the TVC (115.3 ± 20.2 min) compared
to LC (88.4 ± 21.6 min, p = 0.002). The OR preparation
time (TV: 36.2 ± 8.1min vs. LC: 22.5 ± 5.1; p < 0.001), operative time (TV: 115.3 ± 21.6 min vs. LC: 82.4 ± 19.8 min; p
< 0.001) and emergence time (TV: 17 min vs. LC: 10.5 min;
p = 0.04) were significantly greater for the TVC compared
to LC. The OR opioid use was significantly greater for the
TV group (TV: 31.8 ± 10.7mg vs. LC: 25.6 ± 6.9mg; p =
0.04), however, after adjusting for OR time the difference
in OR opioid between two groups becomes non-significant
(p = 0.09). Interestingly, while the average (PACU) time
was significantly greater for the TVC group (195.7 ± 88.9
min vs. 141.7 ± 61.6 min, p = 0.03), the average opioid use
with significantly less for the TV group (0mg, range 0–2.5)
compared to LC group (6.3mg, range 0–9.5), p = 0.01. The
overall opioid use (OR + PACU) was not significantly different between the groups (TV: 33.6 ± 10.1mg vs. LC: 31.6
± 7.3mg; p = 0.48). The average PACU pain Visual Analogue Pain Score was not statistically significantly different
between the TVC and LC groups (p = 0.51).
RESULTS: Ultrasound detected gallbladder polyps were
reported in 347 patients, 214 female and 133 males with an
age range between 14–93 yrs, (Median 5, IQR = 41–58). Polyps were found during the course of investigation for the
possibility of gallbladder disease in 125 patients (36%). The
rest were incidental finding during investigation of other
illnesses. The majority of referrals for the US came from primary care (60%), the rest came from hospital physicians in
(24%) and surgeons in (13%) of cases. Forty two percent of
the reports made no mention of polyp actual size and 39%
reported the polypoid lesion to be <10 mm without giving
the actual size. The actual size was reported in only 12%
of cases. Eighteen patients (5%) underwent laparoscopic
cholecystectomy revealing neoplastic polyps (adenoma) in
2 cases and one case turned out to be invasive adenocarcinoma. Sixty six cases (19%) were under poorly defined
surveillance and only 5 had follow up scans and more than
70% of the patients had no plans for follow up
CONCLUSION: Our preliminary data confirm that the majority of the US detected “polypoid lesions” are incidental findings and are not true epithelial polyps. The majority of patients
with symptomatic polyps who underwent cholecystectomy
had cholelithiasis on histology. The current management
strategy of asymptomatic polyps relies on its size and hence
must be included in the US report which was poorly complied
with in this series. Small (<10 mm) asymptomatic polyps need
CONCLUSION: There was significantly less use of opioids
in the PACU period for the TVC group despite no difference shown in Visual Analogue Pain scores. Additionally,
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1504
better characterisation by magnetic resonance imaging (MRI)
and/or endoluminal ultrasound (EUS), while those >10 mm
should be offered cholecystectomy. A well defined long term
follow up of patients is necessary to allow better understanding of this pathological entity and a nationwide registry or
large longitudinal observational study is warranted as these
might represent a missed opportunity for early detection of
cancer.
Biliary Stone Disease (BSD) and Its Complications in
Patients Under 25 Years
Anibal Rondan*, Rafael A. Redondo, Mauricio Ramirez, Mariano
Gimenez, Marcelo Fasano, Alberto R. Ferreres
Department of Surgery, University of Buenos Aires, Buenos Aires,
Argentina
INTRODUCTION: BSD is one of the most frequent disorders affecting the gastrointestinal tract; its incidence in the
adult population is above 25% for females and around 10%
for males. Race and ethnicity play a major role in its development, more frequent in hispanics and native descendents. In
some latinamerican countries (Chile, Bolivia, Colombia) the
incidence of gallbladder cancer is the highest in the world. A
high incidence of these conditions and its complications has
been found in the younger population.
Su1503
Incidence of Cystic Duct Stones During Laparoscopic
Cholecystectomy
Amir Kambal*, Tomos Richards, Harsha Jayamanne,
Zeyad A. Sallami, Ashraf M. Rasheed, Taha R. Lazim
Royal Gwent Hospital, Newport, United Kingdom
OBJECTIVE: With the advent of the Laparoscopic Cholecystectomy (LC) era, the loss of tactile element hindered
the detection of cystic duct stones (CDS) during surgery.
These stones are implicated in the post cholecystectomy
pain syndrome, failure of the insertion of intra-oprative
cholangiogram (IOC) catheter and the subsequent development of common bile duct (CBD) stones. The preoperative imaging rarely detects their presence. The aim of this
analysis is to quantify the frequency of the incidental finding of CDS during LC and to emphasise the importance of
the awareness of it in our routine practise.
OBJECTIVE: analyze the incidence, clinical presentation
and course and prognosis of BSD in patients under 25 years.
METHODS AND MATERIALS: After approval of our
institutional IRB a retrospective analysis of medical records
of patients who underwent admission for BSD at our single
institution between January 2005 and January 2011 was
performed. 5377 patients were admitted for BSD and/or
its complications, being 591 (10.99%) under 25 years with
a median age of 20 (range 12/24). 449 (76%) were female
and 9 patients were pregnant at the time of clinical onset
of symptoms. Our guidelines included a minimal invasive
approach for treatment of illness and complications.
RESULTS: 457 (77.33%) patients were admitted for elective surgery (laparoscopic cholecystectomy with intraoperative cholangiogram and/or CBD exploration) and the
previous medical history included: acute pancreatitis in
56 (12.25%), pancreatic pseudocysts in 3 (0.65%), acute
cholecystitis in 12 (2.62%), common bile duct stones in
32 (7.00%). Laparoscopic cholecystectomy was completed
in 433 (94.74%), intraoperative cholangiography was
achieved in 397 cases (86.66%). The remaining 24 patients
required conversión through a right subcostal incisión
due to: Mirizzi’s síndrome (3), cholecystocolonic fistula
(2), cholecystoduodenal fistula (2), CBD multiple stones,
intense adhesions, intraoperative complications (bleeding,
liver laceration). The other 134 (22.67%) were admitted
as emergency cases. The initial diagnosis was: acute cholecystitis (75), acute colangitis (55), liver abscess (4). The
treatment was the following: laparoscopic cholecystectomy
75, ERCP with papillotomy and stone removal, and percutaneous drainage. Postoperative complications were the
following:surgical site infection (5%), intraabdominal collections (2%), retained CBD stones (1%). No bile duct injuries were registered.
RESULTS: The study included 330 patients; 80 male and
250 females. Age ranged between 16 to 88 years (Median 50,
IQR: 36,62). In 266 patients no CDS were detected. However,
in 64 (19%) patients CDS were identified using the above
technique; 28 (45%) having a single stone. The remaining
36 (55%) patients had more than one stone with a maximum detected number of 7 stones in the cystic duct. Preoperative imaging failed to detect CDS in the majority of cases.
Of those 64 patients with CDS, 47 (75%) showed deranged
liver function tests at some stage of their disease prior to
surgery. In comparison, of the 266 patients with no CDS,
152 (57%) also demonstrated abnormal liver function tests.
CONCLUSIONS: the spectrum of BSD, its progress and
complications in the young population imposes a prompt
diagnosis and surgical treatment in order to correct symptoms, prevent complications and avoid sequelae and disability. Pregnant patients poises a clinical management and
challenge, mainly in the first trimester pregnancies.
DISCUSSION: The results demonstrate the fact pre-operative investigations are not helpful in diagnosing cystic duct
stones. Their occurrence is common. In order to detect CDS,
specific intra-operative vigilance is needed. Careful upward
milking of the cystic duct before applying clips is a simple,
safe and effective way of detecting and extracting these
stones. This study changed our practice as this procedure
is now included in all our Laparoscopic Cholecystectomies.
69
Sunday
Poster Abstracts
METHOD: A cohort of consecutive patients undergoing
LC during the period from November 2006 to May 2010
were included. Data was collected prospectively. Their
liver function tests were documented in the preoperative
period. The procedure entailed careful dissection of the cystic duct to the proximity of common bile duct. A clip was
then placed at the gall bladder and cystic duct junction.
If an IOC was required, the cystic duct was opened in the
routine fashion. A partially closed endoclip was then used
to milk the cystic duct towards the gallbladder; any CDS
encountered were retrieved and documented. If IOC was
not indicated, the cystic duct was milked prior to the application of gallbladder/cystic clip.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Colon-Rectal
Su1506
Su1505
Quality of Life After Surgery for Colorectal Cancer: A
Multicentric Prospective Study
Loretta Di Cristofaro1, Cesare Ruffolo2, Matteo Cortinovis2,
Alessandra Fasolo3, Maurizio Massa1, Rita Alfieri3, Matteo Cagol3,
Luca Saadeh3, Aurelio F. Costa1, Nicolò Bassi2, Carlo Castoro3,
Marco Scarpa*3
1. Department of Surgery, Montepulciano Hospital, Montepulciano,
Italy; 2. II Department of Surgery (IV unit), Regional Hospital Cà
Foncello, Treviso, Treviso, Italy; 3. Department of Surgery, Veneto
Oncological Institute (IOV-IRCCS), Padova, Italy
The Prognostic Value of Plasma TIMP-1 in Resectable
Colorectal Cancer: A Prospective Validation Study
Hans J. Nielsen*1, Nils BrüNner2, IB J. Christensen3
1. Surgical Gastroenterology, Hvidovre Hospital, Hvidovre, Denmark;
2. Faculty of Life Sciences, University of Copenhagen, Frederiksberg,
Denmark; 3. Finsen Laboratory, University of Copenhagen,
Copenhagen, Denmark
BACKGROUND: Results from retrospective studies show
that preoperative plasma TIMP-1 and CEA levels carry
independent prognostic information of patients with primary CRC. The purpose of the present, prospective study
was to validate the prognostic value of preoperative plasma
TIMP-1 and CEA in patients with primary CRC.
BACKGROUND: The aims of this multicentric prospective study were to assess the postoperative quality of life
in patients who had colonic resection for colorectal cancer
and to determine its positive and negative predictors.
PATIENTS AND METHODS: One hundred and four
patients were enrolled in this study: 68 consecutive
patients who had undergone laparoscopic assisted colonic
resection, and 31 patients who had open colonic resection.
The patients answered to three questionnaires about their
generic quality of life (EORTC QLQ-C30), their disease specific quality of life (EORTC CR29) and about their treatment satisfaction (EORTC IN-PATSAT32) at admission and
one month after surgery. Non-parametric tests and forward
stepwise multiple regression analysis were used for statistical analysis.
METHODS: Blood samples were collected before surgery
from 297 patients with stage I-IV disease. TIMP-1 and CEA
levels were determined in ETDA plasma using an automated platform (ArchitectÒ, Abbott Laboratories, Chicago,
USA). The Cox proportional hazards model was used with
TIMP-1 and CEA on a continous scale (log base 2) adjusted
for clinical covariates. The endpoints were overall survival
(OS) and disease-free survival—time from operation to any
event (DFS).
RESULTS: Of the 297 patients 118 were females and 179
males with a median age of 70 (32–79) years. Using the
TNM stage 50 had stage I, 91 stage II, 70 stage III and 86
stage IV distributed as 180 with colonic and 117 with rectal
cancer. The median observation period was 6.1 (5.2–7.3)
years and 162 deaths were recorded. In a multivariate
analysis including age, gender, stage, localization, plasma
TIMP-1 and CEA it was shown that plasma TIMP-1 had
independent, significant prognostic value: HR = 2.9; 95%
CI: 2.0–4.8; p < 0.0001, whereas the value of CEA was nonsignificant. Restricting the analysis to stages II and III and
patients not receiving adjuvant chemotherapy plasma
TIMP-1 had independent, significant prognostic value: HR
= 2.9; 95% CI: 1.3–6.8; p = 0.013, whereas the value of CEA
was non-significant. Analysis including those patients,
who received adjuvant chemotherapy, showed that neither
plasma TIMP-1 nor CEA had any prognostic value. This
indicates that adjuvant chemotherapy may be efficient to
patients with high plasma TIMP-1 levels. Similar analysis
of patients with stages II and III and focus on DFS as the
endpoint could not demonstrate significant results.
RESULTS: Generic quality of life in the first post operative month as well as patients satisfaction were similar in
patients who had minimally invasive colonic resection and
in those who had open surgery. Body image was better in
patients who had minimally invasive colonic resection (p
= 0.03). In the postoperative period the role functioning
decreased significantly (p = 0.04) while the emotional functioning improved (p < 0.01) compared to the preoperative
assessment. Anastomotic leakage and post operative psychiatric complication (i.e. depression) were the only independent negative predictors of postoperative global quality
of life (β = –0.44, p = 0.001 and ß = –30, p = 0.008, respectively). Doctors availability was the only positive predictor
of postoperative global quality of life (β = 0.33, p = 0.002)
CONCLUSIONS: Although patients who had minimally
invasive surgery reported a better body image their global
quality of life did not seem to be positively influenced by
this improved surgical technique. Postoperative quality of
life is affected by postoperative complication but can be
improved by positive relationship with the surgeons in
charge. These effects seemed help patients to accept the
burden of surgery.
CONCLUSION: The present results achieved in a prospective study confirm that preoperative plasma TIMP-1
has independent prognostic value. In addition, the results
suggest that patients with stage II or III and high plasma
TIMP-1 values have particular benefit of adjuvant chemotherapy. The results must however be confirmed in prospective studies with inclusion of sufficient numbers of
patients to confirm the results.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
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Su1508
Single-Site Laparoscopic Colorectal Surgery Provides
Similar Costs to Patients and Hospitals Compared to
Standard Laparoscopic Surgery
The Impact of a Dedicated Acute Care Surgery Clinical
Care Pathway for Suspected Appendicitis on Diagnostic
Imaging and Flow Through the Emergency Department
Evangelos Messaris*, Arthur Berg, David B. Stewart
Colon and Rectal Surgery, PennState University, Hershey, PA
Chad G. Ball*, Elijah Dixon, Anthony R. Maclean,
May Lynn Quan, Gilaad G. Kaplan, Francis R. Sutherland
Surgery, University of Calgary, Calgary, AB, Canada
BACKGROUND: Single-site laparoscopy provides an
alternative minimally invasive approach to standard laparoscopy. There is currently no published data comparing
costs for patients and hospitals accrued by these two techniques for colorectal surgery. We provide cost comparisons
between single-site and standard laparoscopic colorectal
surgeries performed at a single institution.
PURPOSE: The widespread implementation of Acute Care
Surgery (ACS) services dedicated to urgent surgical issues
has led to significant improvements in both patient flow
and care. Despite these advancements, the use of diagnostic computed tomography (CT) continues to increase across
all diagnoses. Given the high incidence of appendicitis,
the primary aim of this study was to evaluate the impact
of implementing an ACS clinical care pathway dedicated to
suspected appendicitis on the timing and use of CT, as well
as on patient flow through the emergency department (ED).
METHODS: An IRB approved, retrospective review of all
standard (SDL) and single-site laparoscopic (SSL) colon and
rectal resections performed from 2008–2011 was undertaken. Two-sided Mann-Whitney U tests and two-sided
Fisher’s exact tests were used to evaluate continuous and
discrete variables, respectively, comparing total hospital charges to patients, costs to the hospital and hospital
payments received. Charges to patients were further subcategorized by charges accrued from the operating room,
from room and board, pharmacy, radiology and emergency department visits. All monetary units were inflation
adjusted to represent 2011 US dollar value.
METHODS: All adults within a large urban health care system (Calgary, Alberta, Canada) who presented to any ED (3
hospitals) with a diagnosis of suspected, or actual, appendicitis were analyzed. Three distinct time periods (3 months
duration each) were compared (pre-implementation, post
implementation, and 12 months (follow-up) post implementation). The pathway assessment included history and
physical examination, laboratory testing, and potentially
CT or ultrasound). Standard statistical methodology was
employed (p < 0.05 = significance).
RESULTS: Among 1168 ED consultations for “appendicitis” at 3 large centers, 877 (75%) were admitted to the
Acute Care Surgery service. This included 349 (pre-implementation), 392 (post-implementation), and 427 (6 month
follow-up) patients. Overall, 83% of all patients underwent surgery in less than 6 hours (time between admission
request and procedure). There was a significant decrease in
the mean wait time from CT scan request to actual CT scan
with the implementation of the pathway at all sites (197 vs.
143 minutes; p < 0.05). This improvement was sustained at
all sites at the 12-month follow-up period (131 minutes;
p < 0.05). The percentage of CT scans performed in less
than 2 hours increased from 3% to 42% with the pathway
implementation (p < 0.05). The pathway included a short
course oral contrast load of 1–2 hours. No decrease in the
total number of CT scans (p > 0.05) or in the pattern of
ultrasonography was noted (p > 0.05). The clinical pathway
also resulted in a shorter wait time from ED triage to surgical procedure (697 vs. 642 minutes; p < 0.05).
CONCLUSIONS: Implementation of a clinical care pathway dedicated to suspected appendicitis (based on Alvarado
score and/or imaging) can decrease the time to both CT
scan and surgical intervention.
CONCLUSION: Adopting a single-site laparoscopic
approach for colon and rectal surgery provides for similar
lengths of hospital stay and similar costs to patients and
hospitals compared to standard laparoscopic surgery. Conversion from SSL to open surgery is more costly to hospitals
and patients than are conversions from SDL to open surgery,
which may suggest that patients at high risk for requiring
conversion to laparotomy should not be offered SSL.
71
Sunday
Poster Abstracts
RESULTS: A total of 167 SDL and 47 SSL cases were identified. Compared to SSL, SDL surgeries were associated with
longer median times in the operating room (SSL: 190 min
vs. SDL: 233 min; p = 0.01) as well as longer median times
for completion of surgery (SSL: 128 min vs. SDL:183 min,
p = 0.009). Despite these differences, median operating
room costs were similar (SSL: $6,110 vs. SDL: $6,460; p =
0.36). Median postoperative length of hospital stay was
similar for SSL (3.5 days) and SDL (4 day; p = 0.87), with no
significant differences with respect to patient room charges
(SSL: $3,080 vs. SDL: $3,940; p = 0.59). There was no significant difference between SSL and SDL with respect to total
patient charges (SSL: $33,700 vs. SDL: $32,100; p = 0.06),
costs to the hospital (SSL: $12,100 vs. SDL: $12,300; p =
0.48) and actual hospital payments received (SSL: $16,100
vs. SDL: $17,200; p = 0.9). There were no significant differences between the two groups with respect to radiology,
pharmacy or emergency department charges. Among laparoscopic cases requiring conversion to laparotomy, SSL and
SDL had similar median operating room costs (SSL: $6,990
vs. SDL: $6,560; p = 0.32), though SSL was found to have
approximately two-fold higher median overall patient
charges (SSL: $76,497 vs. SDL: $41,392; p = 0.006) and costs
to the hospital (SSL: $29,837 vs. SDL: $16,111; p = 0.01)
compared to SDL.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1509
ference was statistically significant (interaction p-value =
0.011). Body mass index (BMI) was an important risk factor
for wound infection after both laparoscopic and open IPAA
(p = 0.035 and p < 0.001, respectively). Surgeon, number
of surgery stages and pulmonary co-morbidities were all
associated with wound infection in open but not in laparoscopic surgery (table). Interaction analysis did not reveal
significant differences for these factors. Diabetes mellitus
was strongly associated with increased wound infection
after open (p < 0.001) but not laparoscopic IPAA (p = 0.26).
Interaction analysis suggested the presence of a difference
between laparoscopic and open IPAA for this risk factor,
although not statistically significant (interaction p = 0.1).
For functional outcomes, no differences were seen in risk
factors for pouch failure between laparoscopic and open
IPAA for both bowel frequency and incontinence after 3
years of follow-up.
Laparoscopic or Open Ileal Pouch-Anal Anastomosis
(IPAA): Which Approach to Use and When?
Usama Ahmed Ali*, Luca Stocchi, Feza H. Remzi, Pokala R. Kiran
Cleveland Clinic Foundation, Cleveland, OH
PURPOSE: To determine whether different factors determine poor pouch-related outcomes after IPAA by the laparoscopic and open approaches.
METHODS: Cohort study based on a prospectively collected database of IPAA patients operated from 1998–2010.
Primary study outcomes were pouch failure and pelvic
sepsis. Secondary outcomes were wound infection, small
bowel obstruction and functional outcomes (bowel frequency and incontinence). Regression analysis evaluating
the interaction of potential risk factors with operative technique (open vs. laparoscopic) was performed to identify
differences in risk factors between the 2 techniques.
CONCLUSION: Although risk factors for poor outcome
after laparoscopic and open IPAA are largely similar, some
differences do exist. In patients with a higher ASA grade,
the laparoscopic approach is associated with a greater risk
of pelvic sepsis after IPAA. However, patients with high risk
of wound infection, e.g. diabetes, benefit from the laparoscopic approach since this may decrease the influence of
predisposing risk factors. This novel analysis elaborating
specific benefits of the two procedures will likely additionally help guide clinicians and patients decide upon the best
approach when discussing the operative strategy prior to
IPAA.
RESULTS: Of 1962 patients, 224 (11.4%) underwent
laparoscopic and 1738 (88.6%) open IPAA. Laparoscopic
patients were younger (36 vs. 40 years, p = 0.014), had
lower BMI (25.3 vs. 26.3 kg/m2, p = 0.004) with fewer ASA
III patients (9.1% vs. 19.1%, p = 0.003). Pouch failure was
observed in 61 (3.1%) patients (laparoscopic: 2.7%, open:
3.2%, p = 0.9). On multivariate analysis, no differences
were seen in risk factors for pouch failure between laparoscopic and open IPAA. Increased ASA-classification was
associated with a higher rate of pelvic sepsis after laparoscopic (p = 0.017), but not open IPAA (p = 0.51), this dif-
Comparison of Risk Factors Between Laparoscopic and Open IPAA
Pelvic Sepsis
Wound Infection
Association with
Lap (p-value)
Association with
Open (p-value)
Interaction
P-Value*
Age at Surgery
0.103
0.294
0.25
BMI
0.863
0.967
0.88
Diagnosis
0.765
0.0603
0.36
Duration of disease
0.838
0.500
0.65
ASA classification
0.0166
0.506
0.011
Surgeon
0.784
0.130
0.36
Association with
Lap (p-value)
Association with
Open (p-Value)
Interaction
P-Value*
0.630
0.0423
0.81
0.0350
0.00098
0.19
0.166
0.419
0.25
0.178
0.498
0.29
0.952
0.287
0.72
0.300
0.00285
0.9
Number of Surgery Stages
0.638
0.281
0.87
0.796
0.0110
0.86
Immunosuppressive drugs
0.566
0.174
0.31
0.283
0.793
0.35
Diabetes
0.227
0.583
0.28
0.264
0.00098
0.1
Cardiac co-morbidities
0.843
0.243
0.61
0.937
0.140
0.65
Pulmonary co-morbidites
0.749
0.0225
0.27
0.887
0.0102
0.33
ASA: American Society of Anesthesiologists. BMI: body mass index. IPAA: ileal pouch anal anastomosis. Lap: laparoscopic. * Due to the conservative nature of
interaction analysis, the significance level used for identifying interactions was 0.10, which is warranted to achieve a prudent balance of probabilities between
type I and type II errors.
72
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
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Pre-Operative Colonoscopic Localization of Tumour
with Tattoo: A Re-Audit of Current Practice at a
District General Hospital
Right Sided Diverticulitis (RSD): Highly Successful
Non-Operative Management and Low Recurrence Rate
Juan E. Arminan*, George Roxin, Jennifer D. Stanger,
Anthony R. Maclean, William D. Buie
General Surgery, University of Calgary, Calgary, AB, Canada
Akshay Kansagra, Sofoklis Panteleimonitis*, Ugo Ihedioha,
Alison Luther, John Isherwood, John Evans, Peter Kang
General Surgery, Northampton General Hospital, Northampton,
United Kingdom
BACKGROUND: RSD, defined as diverticulitis involving
the colon proximal to the splenic flexure, is uncommon in
western countries. A low index of suspicion could affect the
diagnosis and management of these patients. The purpose of
this study was to examine presentation, treatment and outcome of patients admitted with RSD in a large urban area.
INTRODUCTION: Preoperative localisation of tumour is
an essential requirement in Laparoscopic colorectal surgery. Tattooing guidelines should be simple to follow and
consistent for all lesions irrespective of the location of the
tumour.
METHODS: The health records of all patients admitted with
diverticulitis between January 2007 and March 2010 were
reviewed and the subset of patients admitted with RSD was
identified. Records were reviewed looking at demographic,
clinical, radiologic, treatment and outcome factors.
OUR RECOMMENDATIONS WERE: To place at least
two spots of tattoo distal to each lesion, and clearly document site of tattoo with respect to tumour in the endoscopy report.
RESULTS: 715 patients presented with acute diverticulitis,
68 had RSD (9.5%). Median age was 45 years (range 19 to
92 yrs), 58.8% were female, median follow up 29.5 months
(range 12 to 50). 60 patients (88.2%) presented with uncomplicated and 8 (11.8%) with complicated diverticulitis.
METHOD: We conducted a prospective audit of endoscopic tattooing of colorectal tumours resected in our hospital from February 2010 to January 2011. It was felt that
the current guidelines were too complicated, leading to
higher rates of inaccurate tattooing. Thereafter new guidelines were developed and subsequent practice reaudited.
59 patients (86.7%) had a CT scan. 10 of these (14.7%)
required surgery due to diagnostic uncertainty (2 incidental appendectomies, 8 segmental resections). 49 patients
(83.1%) had CT diagnosis of RSD and were successfully
treated non-operatively.
RESULTS: 2010: 37 patients in total were identified. 14 were
not tattooed. 3 patients had a tattoo which was inaccurate.
13 had accurate and well documented tattoos. 7 patients
had tattoos of unknown accuracy.
Of the 55 patients whose RSD was treated without segmental resection, 1 was readmitted with recurrent diverticulitis
at 2 weeks and underwent elective resection.
Of those patients which were tattooed and seen at surgery,
78.6% were accurate and clearly documented in 2011 compared to 56.5% in 2010 (p = 0.2124).
33 patients (60%) underwent subsequent colonoscopy at a
mean of 3.5 months from admission, no alternate diagnoses
found.
Of those patients which were tattooed and seen at surgery,
14.2% had unknown accuracy (not clearly documented) in
2011, compared to 30.4% in 2010 (p = 0.3032).
CONCLUSIONS: CT scan is accurate at diagnosing RSD.
Once diagnosed, it can be successfully treated non-operatively. Risk of recurrent RSD following non operative management is very low.
Of those patients which were tattooed and seen at surgery
7.14% were deemed inaccurate (tattoo in wrong place) in
2011, compared to 13.04% in 2010 (p = 0.6043).
CONCLUSION: The simpler method of tattooing all
tumours distally has improved the accuracy of tattooing.
73
Sunday
Poster Abstracts
9 patients (13.2%) had surgery without imaging for presumed appendicitis (4 incidental appendectomies, 5 segmental resections). Post-operative morbidity was only 2.8%.
2011: 24 patients in total were identified. 6 patients were
not tattooed. 4 patients had no tattoos visible at operation.
1 patient had a tattoo which was inaccurate. 11 patients
had accurate and well documented tattoos. 2 patients had
tattoos of unknown accuracy.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1512
CONCLUSION: At a high-volume specialized colorectal
unit, proctectomy can be performed with similar longterm
oncologic outcomes and ability to restore intestinal continuity in obese patients when compared with the nonobese. The increased technical complexity expected in
obese patients likely explains the associated increased use
of NCRT and occurrence of anastomotic leak in obese when
compared with non-obese patients.
Impact of Obesity on Operation Performed,
Complications and Long Term Outcomes in Terms
of Restoration of Intestinal Continuity for Patients
with Mid and Low Rectal Cancer
Erman Aytac*, Ian C. Lavery, Matthew F. Kalady, Pokala R. Kiran
Colorectal Surgery, Cleveland Clinic Foundation Digestive Disease
Institute, Cleveland, OH
Characteristics of the Groups
PURPOSE: The impact of obesity per se on the surgical
strategy i.e. sphincter sacrifice (abdominoperineal resection,
APR) vs. restorative rectal resection (RRR), perioperative
outcomes, and long-term maintenance of intestinal continuity has been poorly studied in patients with mid and low
rectal cancer. We compare these outcomes for obese and
non-obese patients with mid and low rectal cancer undergoing surgery.
Age
Gender (male)
ASA score‡
2
Body mass index (kg/m )
METHODS: All patients undergoing curative surgery for
mid or low rectal adenocarcinoma at a single institution
from 1976–2011 were identified from a prospective cancer
database. Obese and non-obese patients were matched 1:2
for age, gender, ASA class, location (low or mid rectum) and
stage of tumor. Demographics, use of neoadjuvant chemoradiothrapy (NCRT) and adjuvant therapy, operative and
perioperative outcomes, pathology, longterm outcomes
including oncologic outcomes and whether or not restoration of intestinal continuity was performed were compared.
Tumor location (low/mid rectum)
Obese
(n = 157)
P Value
62.2 ± 10.2
61.6 ± 10.7
0.62
230
115
1
3 (1–4)
3 (1–4)
1
24.9 ± 3.6
35.7 ± 4.6
<.0001
120/194
60/97
1
Neoadjuvant chemoradiation
121 (38.5%)
76 (48.4%)
0.048
Restorative rectal resection
241 (76.8%)
121 (77.1%)
1
Postoperative hospital stay
8.2 ± 5.7
8.6 ± 5.3
0.23
Reoperation
16 (5.1%)
9 (5.7%)
0.83
3 (1%)
2 (1.3%)
1
13 (4.1%)
12 (7.6%)
0.13
Early period postoperative
mortality
Readmission
RESULTS: 157 obese patients and 314 non-obese patients,
mean age 62 years at proctectomy were included. The
groups were similar for matched characteristics. NCRT rate
was higher in obese patients (p = 0.048). A similar proportion of non-obese and obese patients underwent RRR (p =
1) while postoperative hospital stay (p = 0.23) and 30-day
postoperative reoperation (p = 0.83), mortality (p = 1)
and readmissions (p = 0. 13) was similar. Non-obese and
obese patients also had similar tumor differentiation (p =
0.92) and lymph nodes examined (p = 0.64). Anastomotic
leak was greater in obese patients (p = 0.0003). End colostomy could not been reversed in 8 cases (3 obese and 5
non-obese, p = 1) after a Hartmann’s procedure which was
performed as the initial curative intervention. During follow up, a loop ileostomy was created after an ileal pouch
anal anastomosis, because of pouch failure and two cases (1
obese and 1 nonobese, p = 1) received a permanent stoma
after secondary operations for recurrences. Cancer specific
mortality (p = 0.55) and local recurrence (p = 0.56) were
similar for non-obese and obese patients after similar mean
follow up time of 5 years for both groups (p = 0.4).
Non Obese
(n = 314)
Follow up (years)
5.3 ± 4.5
5 ± 4.2
0.4
Local recurrence
10 (3.2%)
3 (1.9%)
0.56
Cancer specific mortality
40 (12.7%)
25 (15.9%)
0.55
9 (2.9%)
7 (4.5%)
0.69
3 (1%)
1 (0.9%)
1
Wound infection
12 (3.8%)
12 (7.6%)
0.11
Stoma complication
1 (0.3%)
1 (0.6%)
1
Anastomotic leak*
5 (2.1%)
14 (8.9%)
0.0003
Complications
Bleeding
Ureteral injury
‡
median (range) *The cases, which had no anastomosis, excluded from the
leak percentage calculation
74
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1513
Su1514
Stoma Reversal in Patients Who Underwent Low
Anterior Resection and Diversion Stoma for Rectal
Cancer
Robotic Low Anterior Resection with Trans-Anal
vs.Trans-Abdominal Extraction
Christopher R. Oxner*, Julian Sanchez, Rebecca Nelson,
Joseph Kim, Julio Garcia-Aguilar
City of Hope, Duarte, CA
Wong-Hoi She*, Jensen T. Poon, Wai-Lun Law, Joe K. Fan
Department of Surgery, The University of Hong Kong, Hong Kong,
Hong Kong
BACKGROUND: Recently, there have been many studies initiated to validate robotic TME. Also, there have been
a variety of minimally invasive extraction techniques for
protocolectomy ranging from trans-abdominal to transvaginal. However, there has been little comparison of
robotic techniques combined with completely minimally
invasive approach. The goal of this study was to describe
our experience with robotic TME for very low rectal adenocarcinoma and compare trans-abdominal vs. trans-anal
extraction.
BACKGROUND: Defunctioning ileostomy or colostomy
is usually used to protect a high-risk anastomosis after low
anterior resection for rectal cancer. Although the stoma
is usually considered temporary, many a time, closure of
the stoma is not performed because of various reasons.
We aimed to review the incidence of reversal of stoma in
patients after low anterior resection (LAR) with a diversion
stoma. The factors associated with non stomal closure were
analyzed.
METHODS: Five hundred and eighty-five patients who
underwent LAR and diversion stoma from January 1999 to
December 2010 were reviewed from our prospective collected database. LAR was performed with either laparoscopic or open approach. Diversion stoma was performed
when the anastomosis was within 5 cm from the anal verge.
Contrast enema was performed to assess the integrity of
the anastomosis before closure. Patients’ characteristics,
disease status, operative details and adjuvant treatment
were reviewed. The reasons for not closing the stoma were
also studied.
Demographic and Operative Comparisons
Age
AJCC Stage
ASA
56.9 ( ± 9.1)
59.6 ( ± 12.2)
0.4468
3 (21.4%)
9 (22.5%)
0.9045
1
5 (35.7%)
11 (27.5%)
2
1 (7.1%)
4 (10%)
3
5 (35.7%)
14 (35%)
4
0 (0%)
2 (5%)
2
6 (42.9%)
21 (52.5%)
3
0.5346
8 (57.1%)
19 (47.5%)
29.7 ( ± 4.6)
27.6 ( ± 4.6)
0.1499
Conversion to Open
0 (0%)
3 (7.5%)
0.2917
Days to Regular Diet
1.5 ( ± 0.5)
2.8 ( ± 3.3)
0.1413
241.1 ( ± 146)
235.1 ( ±
179.5)
0.9117
Nodes Harvested
14.3 ( ± 4.7)
13.8 ( ± 5.6)
0.7545
Length of Stay
4.6 ( ± 2.9)
7.7 ( ± 8)
0.1678
Distance from Anal
Verge
4.8 ( ± 2.2)
6.8 ( ± 2.7)
0.0196
Operative Time
351.1 ( ± 71.6)
290.9 ( ±
83.7)
0.0200
Positive Nodes
1.1 ( ± 3.7)
1.7 ( ± 3.1)
0.6046
Complications
3 (21.4%)
15 (37.5%)
0.2723
EBL
Robotic Time
Gender
Tumor Size
75
p-Value
0
BMI
CONCLUSIONS: The temporary stoma after low anterior
resection may become permanent in some patients. Over
half of the patients who did not undergo closure of stoma
were due to reasons other than anastomotic complications. Preoperative radiation therapy is associated with
a higher chance of not closing the stoma. Thus a careful
assessment of the disease status and general condition of
the patient before deciding the use of a diversion stoma is
recommended.
Abdominal
Extraction
64.4 ( ± 26.6)
Male
12 (85.7%)
27 (67.5%)
Female
2 (14.3%)
13 (32.5%)
1.7 ( ± 2.3)
2.6 ( ± 1.4)
0.1089
Sunday
Poster Abstracts
RESULTS: Closure of stoma after initial LAR was performed in 469 patients. The median age was 67.3 months
and duration between the two operations was 6.1 months.
The remaining patients (n = 111, 19.1%) did not undergo
stoma closure. The reasons for unable underwent closure
were broadly divided into two categories, anastomoticrelated (47.7%) and non-anastomotic-related (52.3%).
Of those anastomotic-related, persistent leakage, fistula
and stricture composed 79.2% (n = 42/53); while disease
progression (n = 39/58, 67.2%) predominated in nonanastomotic related group. Pre-operative radiotherapy significantly decreased the chance of subsequent closure of
stoma (26/84, 31.0%, p = 0.001). Adjuvant chemotherapy
did not have any adverse effect to the closure of stoma nor
post-operative complications. The result of closure of ileostomy and colostomy were similar in terms of the types and
incidences of post-operative.
Anal
Extraction
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
METHODS: This is a single institution, retrospective review
comparing patients from December 2005 till August 2011
who underwent robotic TME for rectal adenocarcinoma with
coloanal anastomosis. The patients were stratified into two
groups, trans-abdominal extraction or trans-anal extraction.
Data were then collected on operative outcomes, complications, pathological specimen, etc. These groups were then
compared using chi-square and t-test.
METHODS: All patients seen in the academic practice of
two colorectal surgeons were administered the EORTC-C30
questionnaire between January 2009 and October 2011.
The EORTC-C30 is a disease specific questionnaire that was
designed to measure QOL in cancer patients but has also
been used extensively to measure QOL of patients with
benign colorectal diseases. Four hundred and ninety-four
surveys were returned (response rate 78%). One hundred
and twenty four patients were evaluated for complaints
related to HD and represented the study cohort while 61
patients who were asymptomatic as measured by the symptom scales were used as the control group (majority of these
patients had presented for screening colonoscopies). The
minimally important difference (MID) which is defined as
the smallest difference in scores of a QOL instrument that
is considered clinically significant, was estimated by calculating the Cohen’s D effect size of the mean differences.
RESULTS: Fifty four patients underwent robotic TME with
low anastomosis. 40 had a trans-abdominal extraction and
14 a trans-anal extraction. Patient demographics, BMI,
blood loss, ileus, anastomotic leak rate, hospital stay, and
days to regular diet were not significantly different. However, there was a significant difference observed in operative time and distance from the anal verge (p-value < 0.05).
Operative time for trans-anal was 350 ± 71 minutes compared to 290 ± 80 minutes for trans-abdominal. The transanal group average distance from the anal verge was 4.8 cm
while the average distance for the trans-abdominal group
6.8 cm for the with a p-value of 0.0196. Hospital stay differed from 4.6 ± 3 days vs. 7.7 ± 8 days for the trans-anal
and trans-abdominal groups respectively but did not reach
clinical significance.
RESULTS: Gender, age and marital status were similar
between the 2 groups. Mean difference in functional scales
between patients with HD and asymptomatic patients was
16 points and corresponded to a mean Cohen’s D of 0.42
(moderate effect size) and was considered the MID.
Patients with HD had significantly worse QOL on all measured functional scales compared to asymptomatic patients
(Table). Common presenting complaints for HD included
rectal bleeding (67%), pain (38%), change in bowel habits (21%) and discharge (10%). Among the patients with
HD there were no clinically significant differences in overall QOL of patients with and without symptoms of rectal
bleeding (70 vs. 70), rectal pain (65 vs. 73) and rectal discharge (59 vs. 71). However patients with change in bowel
habits had clinically significant worse overall QOL compared to patients not reporting this symptom (57 vs. 73).
CONCLUSIONS: The feasibility of robotic TME has already
been proven while its validity although early is comparable
to laparoscopic TME. Furthermore, very low tumors amenable to sphincter preservation can lend themselves to a
trans-anal extraction without compromising on operative
and short term outcomes. In light of these equivocal results,
this technique may be a more favorable option in patients
when it is more difficult to get an adequate distal margin
such as patients with a narrow pelvis (men), patient subsets
with larger body habitus, or very low tumors. While the
feasibility of trans-anal extraction is clear, larger numbers,
prospective data, and patient stratification will be required
to prove if there exists patient benefit to this technique.
Comparison of QOL of Patients with HD versus Asymptomatic
Patients
Su1516
Quality of Life of Patients Presenting with
Hemmorhoidal Disease: The Importance of Using
the Right Tool for the Right Question to Get the Right
Answer
Vriti Advani*, Margaret Boehler, Jan Rakinic, Imran Hassan
Surgery, Southern Illinois University School of Medicine, Springfield, IL
INTRODUCTION: Based on clinical experience hemmorhoidal disease (HD) is considered to have a significant
impact on patient quality of life (QOL). However there
have been only two published studies that have measured
QOL in patients with HD and both were unable to detect a
significant impact of HD on QOL using generic QOL instruments. We hypothesized that HD and its related symptoms
have a negative impact on patient QOL and that this could
be detected if the appropriate QOL instrument was used.
Patients with HD
Asymptomatic Patients
Global Health Status/ QOL
67.9 (22.2)
87.0 (15.9)
Physical Functioning
87.2 (17.4)
99.0 (4.2)
Role Functioning
80.3 (28.4)
99.4 (4.3)
Emotional Functioning
75.5 (23.2)
93.5 (11.3)
Cognitive Functioning
84.4 (20.6)
96.8 (9.5)
Social Functioning
78.8 (30.0)
94.1 (20.7)
CONCLUSION: HD and its related symptoms have a negative impact on patient QOL that is measurable with the use
of the appropriate QOL instruments. Monitoring resolution of symptoms during treatment of hemmorhoidal disease is essential to offset their impact on QOL.
76
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
resection by providing bowel rest. This mantra has been
historically scrutinized for the potential risk of retaining
a permanent stoma without reducing the need for bowel
resection. Recent data demonstrate the usefulness of antiTNFα therapy in inducing and maintaining remission in
Crohn’s disease, but its effect on pediatric colonic Crohn’s
patients is unclear. We hypothesized anti-TNFα therapy in
conjunction with temporary fecal diversion would induce
remission and reduce the need for bowel resection in medically refractory pediatric colorectal Crohn’s disease, ultimately, allowing successful restoration of bowel continuity.
Su1517
Impact of Opioid-Related Adverse Events (ORAE) on
Length of Stay (LOS) and Hospital Costs in Patients
Undergoing a Laparoscopic Colectomy
Sonia Ramamoorthy*
UCSD, La Jolla, CA
PURPOSE: Laparoscopic colectomy results in decreased
postoperative ileus, pain, and disability, and can therefore
lead to a shorter length of hospital stay (LOS) and reduced
costs of care. As opioids are often used in the treatment
of postsurgical pain, this retrospective analysis, a subset of
data from a large health economics and outcomes research
project, examined the impact of opioid-related adverse
events (ORAEs) on LOS and hospital costs for patients who
underwent laparoscopic colectomy procedures.
METHODS: Following IRB approval, records of Crohn’s
disease patients who underwent fecal diversion, between
July 2006 and April 2011, at our institution were reviewed.
Analysis focused on the clinical course and medical therapy in the perioperative periods, and long term results.
Outcomes were analyzed using Fisher’s exact test.
METHODS: Over a 2-year period, 9/1/2008 through 9/30/2010,
approximately 10 million annual hospital discharges were
reviewed from a large national database including over 450
hospitals. Data on opioid usage, ORAEs, LOS, and hospital
costs were reviewed for some of the most common surgeries in the US: open colectomy, laparoscopic colectomy, laparoscopic cholecystectomy, total abdominal hysterectomy
and hip replacement, and populations were matched at a
3:1 ratio for age, gender, and APR severity of illness. Statistical analysis was performed on 181,283 matched hospital
discharges after surgery, including 12,620 matched laparoscopic colectomies.
RESULTS: Of the 12,620 matched laparoscopic colectomies reviewed, mean unadjusted LOS for patients who had
an ORAE was 7.7 days compared to 6.2 days for patients
without an ORAE (P < 0.0001). Similarly, unadjusted mean
total costs for patients with an ORAE were significantly
higher than for patients who did not have an ORAE
($18,322 vs $15,720, respectively; P < 0.0001).
CONCLUSION: Patients who had a laparoscopic colectomy and experienced an ORAE had a longer LOS and
higher total cost than similar patients who did not experience an ORAE. As the benefits of laparoscopic surgery
include reduced LOS and cost, reducing the use of opioids
and their consequent ORAEs would be expected to result in
greater maintenance of those benefits.
CONCLUSIONS: Despite therapeutic advances, particularly the advent of anti-TNFα agents, fecal diversion in
pediatric patients with colorectal or perianal Crohn’s disease is ultimately associated with a low rate of restoration
and maintenance of intestinal continuity. Proximal diversion does not obviate the need for colonic resection in this
patient population. Counseling families regarding temporary fecal diversion in pediatric patients with Crohn’s
colitis requires tempered optimism in ultimately regaining
intestinal continuity.
Su1518
Role of Fecal Diversion in Pediatric Colorectal Crohn’s
Disease in the Era of Anti-TNF-α Therapy
Artur Chernoguz*1, Richard Falcone1, Jaimie D. Nathan1,
Shehzad A. Saeed2, Lee Denson2, Daniel Von Allmen1,
Jason Frischer1
1. Pediatric General and Thoracic Surgery, Cincinnati Children’s
Hospital Medical Center, Cincinnati, OH; 2. Gastroenterology,
Hepatology, & Nutrition, Cincinnati Children’s Hospital Medical
Center, Cincinnati, OH
PURPOSE: Colonic Crohn’s disease is a therapeutic challenge in up to 80% of pediatric patients. Temporary fecal
diversion aims to induce remission and avoid colonic
77
Sunday
Poster Abstracts
RESULTS: Eleven patients with colorectal or perianal
Crohn’s disease had undergone proximal fecal diversion with either ileostomy (81.8%) or colostomy (18.2%)
between July 2006 and April 2011. Average follow-up was
27.4 months (4.0–61.4 months) and average age at diversion was 15.1 years (7–21 years). A diversion procedure
reduced the number of patients requiring corticosteroids
from 10 (90.9%) to 7 (63.6%), but this was not statistically
significant (p = 0.3). Seven patients (63.6%) required segmental colon resections and 2 (18.2%) required proctocolectomy. Restoration of continuity was performed in 8
(72.7%) patients after an average of 9.7 months (3.0–15.1
months). Four of the 5 patients (80%) treated with an antiTNFα (Tumor Necrosis Factor) agent after diversion and 4
of the 6 patients (66.7%) off anti-TNFα therapy underwent
restoration of continuity (p = 1.0). However, three patients
(37.5%) required re-diversion (2 in the anti-TNFα group
and 1 in the non-anti-TNFα-treated patients; p = 1.0). At
the conclusion of the follow-up period only 5 (45.5%) of
the patients retained intestinal continuity. Complications
secondary to the original ostomy occurred in 9.1% of
patients and in 66.7% of the re-diverted patients.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1520
Clinical: Esophageal
Surgical Approach to Perineal Dissection Does Not
Influence Radial Margin After Abdominoperineal
Resection
Su1521
Neoadjuvant Therapy Influences Lymph Node Ratios
and Overall Survival Without Decreasing Total Node
Harvest
Sekhar Dharmarajan*, Bashar Safar, James W. Fleshman,
Matthew Mutch, ELISA H. Birnbaum, Steven R. Hunt
Surgery, Washington Univ, St. Louis, MO
Renato S. Luna*, James P. Dolan, Brian S. Diggs, Nathan W. Bronson,
Miriam Douthit, John G. Hunter
General Surgery, OHSU, Portland, OR
PURPOSE: Positive radial margins and intraoperative rectal perforation adversely affect outcome after abdominoperineal resection (APR) for low rectal cancer. Use of the
prone jackknife position during the perineal dissection
may improve exposure and therefore oncologic outcome.
Our purpose was to determine whether performing the perineal dissection of APR in prone jackknife versus lithotomy
position improves radial margin clearance and reduces
intraoperative rectal perforations.
BACKGROUND: There has been considerable debate around
the influence of neoadjuvant therapy on lymph node harvest and the prognostic value of this information following esophagectomy for esophageal adenocarcinoma. The
purpose of this study was to evaluate the effects of neoadjuvant therapy in the number of lymph node harvested,
lymph node ratio and survival after esophagectomy.
METHODS: An IRB-approved retrospective review of 130
cases of APRs over 8 years was performed after excluding patients with no radial margin reported, non-adenocarcinoma pathology, and pelvic exenterations. Primary
endpoints of radial margin and intraoperative rectal perforation were obtained from pathology reports. Data on
patient demographics, preoperative staging, preoperative
therapy, and intraoperative positioning was obtained. Statistical analysis was performed using t test or Fisher’s exact
test with significance set at p < 0.05.
METHODS: A single center retrospective analysis of 169
patients who underwent esophagectomy for esophageal
adenocarcinoma was performed. Patients were divided in
two groups: one group underwent neoadjuvant treatment
prior to surgery (NEO) and another group underwent surgery only. (SURG).
RESULTS: One hundred and three patients (61%) underwent neoadjuvant therapy (NEO) prior to resection. The
mean age was 66 years (39–89), and 83 (82%) were treated
with 2 or 3 field esophagectomy. Sixty six patients were
treated with surgery alone (SURG). The mean age was 70
years (39–89) in this group, and 28 (44%) were treated
with 2 or 3 field esophagectomy (p < 0.001). The median
number of nodes harvested in the NEO group and SURG
group was 14.0 and 11.5 respectively (p = 0.11). Looking
soley at those undergoing 2 or 3 field esophagectomy in
NEO to SURG groups, the median number of lymph nodes
harvested was 16 and 15.5 respectively. In the NEO group
the median number of lymph nodes harvested was 14.5 for
complete responders, 16 for incomplete responders, 12 for
non-responders, and 13 in those who were pathologically
upstaged (p = 0.252). The in-hospital mortality was 5% in
the NEO group and 3% in the SURG group (p = 0.56). The
median lymph node ratio was 0 for complete responders,
0 for incomplete responders, 0.055 for non-responders and
0.125 for upstaged patients (p < 0.001). Survival was influenced by the number of positive lymph nodes harvested in
both groups (p < 0.001). Survival was significantly improved
by neoadjuvant therapy in stage III patients and in patients
with N1 disease (p < 0.001 and p = 0.03, respectively).
RESULTS: Perineal dissection was performed in prone
jackknife position in 65 patients and in lithotomy position in 65 patients. There were no significant differences
between these groups in terms of patient gender, age, percent receiving preoperative therapy, distance of tumor from
dentate line, or preoperative stage. There was no significant
difference in mean radial margin between patients whose
perineal dissection was performed in the prone jackknife
versus lithotomy position (0.54 cm vs. 0.56 cm, p = 0.76).
The percent of positive radial margins in each group was
not significantly different (17% vs. 13%, p = 0.62) and the
percent of intraoperative rectal perforations in each group
also did not differ (13% vs. 24%, p = 0.35). There was a
trend toward decreased operative time in lithotomy (196
min vs. 222 min, p = 0.12).
CONCLUSIONS: APR with perineal dissection performed
in prone jackknife position is associated with longer operative times compared to lithotomy position and does not
appear to confer any oncologic advantage with respect to
radial margin clearance or intraoperative rectal perforation.
CONCLUSION: At esophagectomy, the total number of
lymph nodes harvested was not significantly influenced
by neoadjuvant treatment or by the pathologic response to
treatment. The number of positive lymph nodes was similar in both groups, but the lymph nodes ratio are inversely
related to the response to neoadjuvant therapy. The only
negative prognostic marker identified was presence of
nodal disease. Neoadjuvant therapy improved survival in
this group.
78
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1522
shock. A limitation is the inability to distinguish between
traditional versus thoracoscopic approaches; the impact of
a minimally invasive thoracic approach remains unclear.
Esophagectomies Employing Thoracic Incisions Carry
Increased Pulmonary Morbidity
Neil H. Bhayani*1, Aditya Gupta2, Ashwin A. Kurian1,
Maria A. Cassera3, Kevin M. Reavis3, Christy M. Dunst3,
Lee L. Swanstrom3
1. Providence Portland Cancer Center, Portland, OR; 2. Legacy Weight
Management Clinic, Portland, OR; 3. The Oregon Clinic, Portland, OR
Su1523
The Status of the Lower Esophageal Sphincter at
Rest and the Degree of Esophageal Acid Exposure
in Patients with Gastroesophageal Reflux Disease
Shahin Ayazi*1, Jeffrey A. Hagen1, Joerg Zehetner1,
Kimberly S. Grant1, Michael Hermansson1, Arzu Oezcelik1,
Steven R. Demeester1, John C. Lipham1, Daniel S. OH1,
Michael M. Kline2, Tom R. Demeester1
1. Surgery, University of Southern California, Los Angeles, CA;
2. Medicine/Gastroenterology, University of Southern California,
Los Angeles, CA
INTRODUCTION: A thoracic approach is not required for
all esophagectomies. Some research suggests an increased
risk of pulmonary morbidity when a thoracic incision
is used. We studied the impact of a thoracic incision on
complications after esophagectomy through a national
database. This represents the largest analysis of pulmonary
morbidity after esophagectomy.
METHODS: The National Surgical Quality Improvement
Project (NSQIP) database was queried for non-emergent
esophagectomies with reconstruction from 2005–2010.
Patients with metastatic disease were excluded. Patient
who underwent trans-hiatal esophagectomy (THE) were
compared to those who had a thoracic incision. The THORACIC group was patients with Ivor-Lewis (thoracic &
abdominal incisions) or McKeown (cervical, abdominal &
thoracic incisions) techniques. The primary outcome was
pulmonary morbidity; secondary outcomes were death,
overall morbidity, infection, and thrombo-embolic complications. Multivariable regression models controlled for age,
smoking, chronic obstructive pulmonary disease, hypertension, diabetes, American Society of Anesthesiology class
3 or higher, malignancy, and preoperative weight loss.
INTRODUCTION: A manometrically normal lower esophageal sphincter (LES) is necessary to protect the esophagus
from exposure to gastric juice. Manometric measurements
related to the competency of the LES are resting pressure,
overall length, and the length exposed to the environmental pressure of the abdomen. We hypothesized that the
magnitude of the esophageal acid exposure is related to the
degree of permanent deterioration of the LES.
RESULTS: Of 1568 patients, 717 (46%) underwent THE
and 851 (54%) were in the THORACIC group (487/31%
Ivor-Lewis & 364/23% McKeown). The overall population
was 80% male, with a mean age of 63 years. Patients undergoing THE were older (p = 0.02). Pre-operative co-morbidities were similar except for more diabetes (16% v. 11%, p =
0.02) in the THORACIC group. Malignancy was more common in THORACIC patients, 91% v. 87% (p = 0.01). Overall, morbidity was 46.5% and mortality was 3.1% without
a difference between groups. Length of stay was 1.6 days
shorter (p = 0.009) for THE patients. On multivariable analysis, the use of a thoracic incision was associated with an
increase in pneumonia (47%, p = 0.007), ventilator dependence >48 hours (34%, p = 0.04), and septic shock (86%, p
= 0.001). Mortality, surgical site infections, and thromboembolic events were similar. On subgroup analysis of the
THORACIC group, the McKeown approach increased the
odds of superficial surgical site infection by 71% (p = 0.02)
but showed similar odds of septic shock compared to the
Ivor-Lewis technique.
RESULTS: The final study group consisted of 918 patients
(58% male, median age 53 and median BMI 28.3) who
met the inclusion criteria and had an abnormal 24-hour
composite pH score as objective evidence for GERD. Of
these 406 (44%) had grade 0, 152 (17%) grade 1, 272 (30%)
grade 2 and 88 (9%) grade 3 LES. Corresponding values
for the median (IQR) composite pH score were 30.9 (20.6–
46.5), 39.5 (23.1–57.8), 42.0 (27.0–75.1) and 63.2 (31.8–
90.2) respectively (p < 0.0001, Kruskal-Wallis test). Patients
with a normal LES at rest had less esophageal acid exposure compared to those with one or more LES manometric
abnormalities (30.9 vs. 42.2, p < 0.0001, Mann-Whitney
U-test). The values for all three LES components, irrespective of the LES grade, were inversely correlated to the composite pH score: total length (r = –0.23), abdominal length
(r = –0.22) and resting pressure (r = –0.28), (p < 0.0001 for
all 3 analyses). The most common abnormal manometric
finding was a short overall length and the least common
was a hypotensive LES pressure.
CONCLUSION: Esophagectomies carry an acceptable mortality rate but have significant morbidity. We show that the
thoracic incision is associated with increased pneumonia,
ventilator dependence, and septic shock. This septic shock
is unlikely due to anastamotic leaks, given the similar
among of septic shock between McKeown and Ivor-Lewis
patients. When appropriate, avoiding a thoracic incision
may decrease pulmonary morbidity and resulting septic
79
Sunday
Poster Abstracts
METHODS: The records of 2,723 patients referred to our
esophageal function laboratory for the assessment of reflux
symptoms between 1998–2008 were reviewed. Those with
a named motility disorder or previous foregut surgery were
excluded. The study population consisted of the remaining
patients, who had a detailed assessment of their LES with
slow motorized pull-through manometry and an abnormal
24-hour pH monitoring study off acid suppression therapy. The LES was graded on a scale of 0–3, according to
the number of abnormal LES components on manometry
using previously defined normal values for resting pressure (<5.1 mmHg), overall length (<2.7 cm) and abdominal
length (<1.4 cm). Grade 0 indicated all components were
normal; 1, only one component abnormal; 2, two components abnormal; 3, all three components abnormal.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSION: Permanent manometric abnormalities of the
LES measured at rest are associated with increased esophageal acid exposure. The degree of acid exposure is related
to the extent of the manometric abnormalities. Forty four
percent of the GERD patients have a normal LES measured
at rest despite having increased esophageal acid exposure.
These patients have the lowest esophageal acid exposure
and are likely to have transient manometric abnormalities
of the LES during periods of activity.
margins (p < 0.001) and LNR >0.1 (p < 0.001) significantly
worsened prognosis. In multivariate analysis a LNR >0.1
(p < 0.001; RR 11), no response to neoT (p < 0.01; RR 1.6)
and SCC (p < 0.02; RR 1.5) were independent negative
prognostic factors. Compared to SCC patients with AC had
higher rates of positive margins (10% vs 4%) and LNR >0.1
(43% vs 16%).
CONCLUSIONS: Tumorbiological parameters (histological type, LN-ratio) influenced prognosis after resection of
esophageal cancer. Response to neoadjuvant therapy independently improved the outcome and contributed to the
clearly better outcome achieved in the later study period.
Su1524
Response to Neoadjuvant Therapy and the Lymph
Node Ratio (LNR) Are the Strongest Prognostic Factors
After Esophageal Resection for Cancer
Su1525
Frank Makowiec*1, Peter Baier1, Peter Bronsert2, Jens Hoeppner1,
Hannes P. Neeff1, Tobias Keck1, Michael Henke3, Ulrich T. Hopt1
1. Department of Surgery, University of Freiburg, Freiburg, Germany;
2. Pathological Institute, University of Freiburg, Freiburg, Germany;
3. Department of Radiation Oncology, University of Freiburg, Freiburg,
Germany
Surgical and Endoscopic Treatments for Achalasia: A
Single Institution Comparison of 190 Patients
INTRODUCTION: The exact role of neoadjuvant therapy
(neoT) including its prognostic influence in esophageal
cancer is still under debate. Pooled data (metaanalysis)
suggest a prognostic advantage of neoT but definitve data
are lacking. We analyzed our institutional experience with
resected esophageal cancer including the effect of neodjuvant therapy on long-term outcome.
BACKGROUND: Controversy still remains as to whether
an endoscopic or surgical approach should be primary
treatment for patients with achalasia. We report our experience with endoscopic and surgical treatments in patients
with achalasia over a 10-year period.
Amy K. Yetasook*1, John G. Linn1, Woody Denham1,2,
Joann Carbray1, Michael B. Ujiki1,2
1. Surgery, NorthShore University HealthSystem, Evanston, IL;
2. Surgery, University of Chicago, Chicago, IL
METHODS: Retrospective analysis of electronic medical
records was gathered from 190 patients with confirmed
achalasia between January 1, 2000 and August 9, 2011.
Demographics, data from motility studies, peri-operative
intervention data, endoscopic intervention data, the use of
a proton pump inhibitor (PPI), and presence of symptoms
(dysphagia and GERD-related symptoms) throughout their
course of treatment from clinical visits were collected.
METHODS: We evaluated overall survival in 304 patients
undergoing esophageal resection between 1988 and 2010
(patients with hospital mortality excluded). 53% had squamous cell (SCC) and 46% adenocarcinoma (AC). Indications for neoT were in general T-stage >2 and/or positively
staged lymph nodes. Tumors were in the lower third in
64%. 66% of the patients underwent neoT (60% chemoradiation 36 Gy+FU+Cisplatin; 6% chemotherapy alone).
The proportion of neoT increased from 16% in the first
third to 78% in the last third of the study period. In pathological analysis the median number of examined nodes was
17; 43% were node positive. Survival was analyzed by the
Kaplan-Meier- and Cox-models.
RESULTS: In our surgical cohort, 72 patients underwent
various types of procedures (surgical myotomy with or
without a full or partial fundoplication), with 8 (11%)
patients having more than one surgical admission for a
total of 80 surgical interventions. Thirty-two percent of the
surgical patients underwent prior endoscopic treatment.
In our endoscopic cohort, 76 patients underwent only
endoscopic treatments (balloon dilation, botulinum injection or both) with 53 (70%) patients undergoing multiple
treatments for a total of 174 endoscopic interventions. The
remaining 42 patients did not have an endoscopic or surgical intervention, or did not have adequate follow up. The
endoscopic-only managed patients underwent a mean of 3
( ± 2) and a median of 2 (range 1–8) interventions. There
was no statistically significant difference between groups
when comparing BMI, smoking status, pre-intervention
mean resting lower esophageal sphincter (LES) pressures,
pre-intervention mean lower esophageal sphincter (LES)
relaxation pressure, or use of a PPI. Patients in the surgical
cohort were significantly younger at 56.3 years versus 72.7
years (P < 0.001). Endoscopic-only managed patients had
both significantly more dysphagia (42.1% versus 16.7%,
P < 0.005) and GERD-related symptoms (72.6% versus
15.3%, P < 0.005) throughout and after their course of treatment as compared to the surgical group. The mean period
RESULTS: The proportion of patients with AC increased
from 22% (first third) to 61% (last third of the study
period). After neoT 81% of the patients showed partial or
total response. Patients without neoT had more frequently
positive margins (13% vs 4% after neoT; p < 0.01). Postoperative nodal disease was independent on neoT (40% after
neoT vs 50% without neoT) although patients in the neoT
group had more frequently positive nodes in pretherapeutical staging (71% vs 39% in patients without neoT; p < 0.01).
Overall 5-year survival (5y-Surv) was 36% and improved
clearly during the study period (5y-Surv 14% until 1994;
35% 1994–2001; 49% since 2002; p < 0.001), parallel to an
increased use of neoT. This significant improvement in survival over time was also seen in the subgroups of patients
with SCC (p < 0.01) and AC (p < 0.001). 5y-Surv in patients
with response (any/total) was 52%/60%, but only 19% in
patients without response/without neoT (p < 0.001). In further univariate analysis positive nodes (p < 0.001), positive
80
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
between the first and second endoscopic procedures was
significantly less at 2.5 ( ± 4.79) years as compared to 16.34
(± 15.9) years in between a first and second surgery for
achalasia (P < 0.05). Patients in the endoscopic cohort had
comparable average follow-up course of 7.26 (± 6.72) versus
7.35 (± 8.47) years compared to the surgical cohort. Thirtyday morbidity in the surgical cohort was 6.9% (5 patients)
versus 1.3% (1 patient) and there were no mortalities.
14 (17.5%). Manometric evidence of functional outflow
obstruction (elevated intra-bolus pressure and/or elevated
4-second integrated relaxation pressure) was present in
29/80 (36.3%) of patients. One patient met the manometric
criteria for Achalasia. Manometric evidence of the sliding
component of the PEH was present in 17/21 (81%) with a
mean length of 4.1 ± 2.1 cm. Overall LES length was short
in 14/21 (67%) patients, 19/21 (91%) had a shortened
intra-abdominal segment and 2/21 (10%) were hypertensive at rest.
CONCLUSION: Surgery may offer a more efficacious option
for patients with achalasia than endoscopic treatment
alone with less need for repeated interventions and significant relief of symptoms.
CONCLUSION: Significant abnormalities of esophageal body
function are present in a large percentage (56%) of patients
with paraesophageal hiatal hernia. Nineteen percent have
severely compromised circular muscle strength. These data
suggest that HRM should be included in the preoperative
evaluation of patients with PEH whenever possible.
Su1526
High Resolution Motility Assessment of the Esophageal
Body in Patients with Paraesophagel Hiatal Hernia
Su1527
Stefan Niebisch*, Marek Polomsky, Candice L. Wilshire,
Carolyn E. Jones, Virginia R. Litle, Christian G. Peyre,
Thomas J. Watson, Jeffrey H. Peters
Department of Surgery, University of Rochester Medical Center,
Rochester, NY
Efficacy and Safety of Self-Expanding Plastic Stent
(SEPS) in the Management of Esophageal Disorders
Yuk Law*, Daniel K. Tong, Simon Law
Surgery, The University of Hong Kong, Queen Mary Hospital, Hong
Kong, Hong Kong
INTRODUCTION: Self-expanding plastic stent (SEPS) was
introduced in recent years. Because it is easily removed
endoscopically, it can be used to treat both malignant and
benign disorders of the esophagus; including strictures,
fistulae and perforations. The present study evaluates our
experience in the use of SEPS, assessing its efficacy and
safety.
METHODS: A prospectively collected database of the use
of SEPS from 2007 to 2011 was retrospectively reviewed.
Treatment efficacy was evaluated by comparing the preand post-stenting dysphagia score in patients who had
esophageal strictures. Success of sealing of fistulae and perforations was also assessed. Short-term and long-term complications were analyzed.
METHODS: Eighty patients (mean age 64.5 ± 11.9 years;
mean BMI 30.7 ± 5.8; 65% female), with endoscopic and/
or radiographic type III hiatal hernia, who underwent
preoperative High Resolution Manometry (HRM) from
December 2006 to October 2011 formed the study population. All studies were analyzed using current esophageal
body motility classifications and current analysis software
(ManoViewTM v2.0.1). Assessment of the lower esophageal
sphincter (LES) was possible in 21 patients (26%) in which
the catheter was passed through the diaphragmatic crura
into the intra-abdominal cavity. All manometry parameters
were referenced to normal-values previously established in
our institution.
RESULTS: A total of 30 stents were inserted for 23 patients
(20 men and 3 women). The median age was 69 yrs (range
51–85). Indications included benign stricture (20%, n = 6),
malignant stricture (20%, n = 6), tracheo-esophageal fistula
(10%, n = 3), post esophagectomy anastomotic leak (16.7%,
n = 5) and benign perforation (33.3%, n = 10).
For patients with stricture (both benign and malignant,
n = 10), the median dysphagia score improved from a pretreatment score of 3 (liquid diet) to post-treatment score of
2 (semisolid diet), p < 0.001. SEPS provided satisfactory sealing in all 3 patients who had tracheo-esophageal fistulae;
none required additional intervention. Of the 5 patients
with anastomotic leak, 3 were successfully managed by
SEPS with sealing of leak after stenting. Closure was not
achieved in the other 2, who required subsequent surgical
management. In the 5 patients who had benign perforation, all had adequate sealing by SEPS and recovered. One
patient required 5 stents in total because of repeated stent
migration.
RESULTS: Esophageal body function including wave
propagation and circular muscle strength was normal in
35/80 (44%) of patients. A simultaneous/spastic contraction pattern (distal latency <4.5 sec and/or contractile
front velocity >9 cm/s) was present in 14/80 (17.5%) and
abnormal contraction strength (overall distal contractile
integral <500 mmHg•cm•s, weak peristalsis with peristaltic defects and/or frequent failed peristalsis) in another
81
Sunday
Poster Abstracts
INTRODUCTION: The clinical management of patients
with large type III paraesophageal hiatal hernia (PEH) in
both elective and urgent circumstances has become quite
common. Repair of PEH now accounts for 30–50% of fundoplications in high volume centers. Given the primary
focus on hernia repair, and not gastro-esophageal reflux
(GERD), the utility of esophageal motility in patients with
PEH is unclear. Furthermore, the availability of esophageal
motility testing, emergent presentation of patients and
complex anatomy making catheter placement difficult,
all limit the routine use of preoperative motility. The aim
of this study was to characterize preoperative esophageal
function in patients with PEH and to determine the prevalence of esophageal dysmotility which might impact surgical approach.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tracheal compression occurred in one patient under benign
perforation group immediately upon SEPS deployment.
The SEPS was removed and the lesion was successfully
managed using another SEPS of shorter length. This was
the only short-term complication identified in present
study. For delayed complications, migration was most frequently observed (40%, n = 12). Other delayed complications included food bolus obstruction (10%, n = 3), erosion
to surrounding structure (0%, n = 0) and tumor ingrowth
(3.3%, n = 1) were infrequently seen.
pathological response (pCR) to NACRT in 18 (18.9%) and
75 (64.1%) had partial response. No patient with adenocarcinoma had pCR. Overall survival in these patients who
underwent Neoadjuvant chemoradiotherapy and subsequently surgery was 65.4% at 1 yr, 28.7% at 3 yr, 19.1% in
5 yrs. 11 patients are still alive at the time of analysis of our
data. Out of 87 patients, 62 patients were on regular follow
up. Disease free survival (DFS) in these patients was 53.2%
at 1 yr, 19.4% at 3 yr, 12.9% at 5 yr (Mean 26.87months
and median was 13 months).On analyzing factors affecting
survival; only those patients who had complete pathological response to NACRT had statistically significant survival compared to patients who had no response or partial
response to NACRT (DFS median 21 months vs. 12 months,
p – 0.019). Out of 62 patients who were on regular follow
up, 51 (43.6%) had documented recurrence before death
with most common site of recurrence being lung
CONCLUSION: SEPS is a worthy alternative to metal stent
in malignant disease and has emerged as a new tool for
managing anastomotic leaks and benign perforations with
a high success rate. Migration remains a major concern.
Su1528
Impact of Neoadjuvant Chemoradiotherapy on
Survival in Carcinoma Esophagus: A Decade’s
Experience
CONCLSION: With NACRT we could achieve mean survival of 33 ± 5.39 months in carcinoma esophagus. 12% of
patients developed complications of NACRT. Patient with
complete pathological response and smaller lesions were
found to have better survival by multivariate analysis
Rajesh Gupta*1, Sunil D. Shenvi1, Rakesh Kapoor2,
Surinder S. Rana3, Deepak K. Bhasin3
1. Surgical Gastroenterology Division, Postgraduate Institute of
Medical Education and Research, Chandigarh, India; 2. Radiation
Oncology, Postgraduate Institute of Medical Education and Research,
Chandigarh, India; 3. Gastroenterology, Postgraduate Institute of
Medical Education and Research, Chandigarh, India
Su1529
Is Idiopathic Pulmonary Fibrosis Really Idiopathic?:
Patterns of Reflux Analyzed by Bi-Positional HighResolution Manometry and Hypopharyngeal
Multichannel Intraluminal Impedance
BACKGROUND: Neoadjuvant chemoradiotherapy followed
by surgery has become standard of care at most of the centres.
Toshitaka Hoppo*, Yoshihiro Komatsu, Blair A. Jobe
Cardiothoracic Surgery, University of Pittsburgh Medical Center,
Pittsburgh, PA
OBJECTIVE: To assess the impact of Neoadjuvant chemoradiotherapy on survival in patients with locally advanced
carcinoma esophagus.
MATERIALS AND 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.
BACKGROUND: Idiopathic pulmonary fibrosis (IPF) is a
diffuse fibrotic lung disease of unknown etiology. The association between IPF and gastroesophageal reflux disease
(GERD) has been suggested. The objective of this study was
to determine the prevalence of GERD and assess the proximity of reflux events in patients with histologically proven IPF.
RESULTS: 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). 15 (12.8%)
patients developed complications on CRT and 4 (3.4%)
patients died as a consequence of complications. Out of all
the patients who underwent NACRT, 22 patients did not
undergo surgery (4 deaths on CRT, two had progression of
disease, 7 patients were not willing for surgery, 9 patients
were lost to follow up). Mean interval between NACRT and
surgery was 44.36 days. 95 patients underwent surgery with
curative intent [82 underwent Transhiatal esophagectomy,
7 underwent Tran thoracic esophagectomy, 6 underwent
open assessment and closure for intrabdominal metastatic
disease. On assessing final histopathology of all patients
who underwent curative resection, we found complete
METHODS: This is a retrospective review of prospectively
collected data for patients with histologically confirmed
IPF (via lung biopsy) who underwent objective esophageal
physiology testing including bi-positional high-resolution
manometry (HRM) and hypopharyngeal multichannel
intraluminal impedance (HMII). In bi-positional HRM, 10
swallows with 5ml water each were delivered in the supine
position; this was followed by 5 additional swallows in
the upright position. Defective LES was defined as either
LES pressure of <5.0 mmHg, total length of LES of <2.4 cm
or intra-abdominal length of LES of <0.9 cm. Abnormal
esophageal motility was considered present when failed
swallows ≥30% and/or mean wave amplitude <30 mmHg
was present. HMII used a specialized impedance catheter to
measure the proximal reflux events such as laryngopharyn-
82
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
geal reflux (LPR) and full column reflux (reflux 2 cm distal
to the upper esophageal sphincter). Based on the previous
study of healthy subjects, abnormal proximal exposure
was considered present when laryngopharyngeal reflux
(≥1/day) and/or proximal esophageal reflux (≥5/day) were
present.
METHODS: The records of all patients who were diagnosed
with esophageal perforation between 2004 and 2011 were
reviewed. Patients who underwent primary surgery were
compared to patients who were treated endoscopically.
RESULTS: The study population consisted of 47 patients
with a median age of 64 years. Cervical perforation was seen
in 9 patients (19%), thoracic in 25 (53%) and abdominal
in 13 (28%). The cause of perforation was iatrogenic in 29
patients (62%) and spontaneous in 17 (38%). The median
time to diagnosis was 12 hours. The size of the perforation
was >10 mm in all cases. Surgical therapy (primary repair or
esophagectomy) was performed in 26 patients (55%); 6 cervical, 11 thoracic and 9 abdominal perforations. Definitive
endoscopic therapy (stent implantation or primary closure
with clips) was performed in 21 patients (45%); 3 cervical, 14 thoracic and 4 abdominal perforations. Of these 47
patients, 16 (36%) died after a median time of one month.
The mortality rate was significantly higher in patients with
thoracic perforation who underwent endoscopic therapy
(Table). There was no significant difference between the
groups regarding time to diagnosis, perforation size and
cause of perforation.
RESULTS: From October 2009 to June 2011, 37 patients
with IPF (male 22, female 15) including 8 patients who had
undergone lung transplant prior to objective esophageal
testing were examined. Mean age and BMI were 62 years
(range, 41–78) and 27.6 (range, 14.8–38.1), respectively.
Two patients were excluded from this study due to lack of
HMII. All patients except two were symptomatic; 26 had
predominately pulmonary symptoms such as cough and
9 had isolated typical GERD symptoms such as heartburn
and regurgitation. Abnormal proximal exposure was present in 19/35 (54%) patients. Esophageal mucosal injury
such as esophagitis and Barrett’s esophagus and/or hiatal
hernia was found in 28/32 (88%) patients. However, 29/35
(83%) patients had a negative DeMeester score. All patients
with IPF had reflux predominately in the upright position. Bi-positional HRM increased the diagnostic yield of
defective LES from 78% (supine) to 93% (upright). Sixteen
patients (50%) had abnormal esophageal motility including aperistaltic esophagus (n = 9).
Mortality of Patients who Underwent Surgical Therapy Compared to
Patients Who Underwent Endoscopically Therapy
CONCLUSION: A large number of patients with IPF have
objective evidence of GERD without typical symptoms.
Proximal reflux was common despite a frequently negative
DeMeester score. Reflux events occurred primarily in the
upright position and this was associated with a decrease in
LES integrity when examined with bi-positional HRM.
Endoscopic
Therapy
p-Value*
Cervical Perforation
1/6 patients (16%)
0/3 patients (0%)
0.3
Thoracic Perforation
3/11 patients (27%)
10/14 patients (71%)
0.04
Abdominal Perforation
2/9 patients (22%)
0/4 patients (0%)
1.0
Su1530
CONCLUSION: The results of the study suggest that thoracic perforation of the esophagus can not be managed
endoscopically and thus should be treated with early surgery, independently from the cause of perforation or time
to diagnosis. Cervical or abdominal perforation can be
treated endoscopically in a high proportion of patients.
The Multidisciplinary Management of Esophageal
Perforations
Arzu Oezcelik*1, Andreas Paul1, Renate Reinhardt1, Mark
Sandfort1, Guido Gerken2, Alexander Dechene2
1. General, Visceral and Transplantation Surgery, University of
Essen, Essen, Germany; 2. Internal Medicine, Gastroenterology and
Hepatology, University of Essen, Essen, Germany
BACKGROUND: Perforation of the esophagus is a challenging problem and can induce devastating complications. Although there are endoscopic and surgical treatment
options available, the optimal management strategy remains
unclear. The aim of this study was to evaluate the treatment
and outcome of patients with esophageal perforations in
an academic referral centre with a multidisciplinary specialist group for esophageal diseases.
83
Sunday
Poster Abstracts
Surgical
Therapy
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1531
Hybrid Ivor-Lewis Oesophagogastrectomy: Results
of the First 100 Cases and a Novel Way of Analysing
Performance
Geoffrey Roberts*, Adriana Rotundo, Priyantha Siriwardana,
Cheuk Bong Tang, Michael Harvey, Sritharan S.
Kadirkamanathan
Upper GI Surgery, MEHT, Chelmsford, United Kingdom
INTRODUCTION: The surgical management of oesophago-gastric cancer in the UK has recently been centralised
to high volume surgical cancer centres. Increasing attention has been paid to measuring surgical outcomes and
monitoring performance. The authors demonstrate results
from a UK surgical cancer centre and present a novel technique for monitoring outcomes in “real-time”.
METHODS: A prospectively collected database was used
to identify the first consecutive 100 oesophagectomies performed using a “hybrid” technique (laparoscopic abdominal approach, open thoracic approach) in the Unit. The
cumulative sum (CUSUM) technique was applied to examine the incidence of clinically relevant anastomotic leaks
and 30-day post-operative deaths.
CONCLUSIONS: The early learning curve results from a
UK surgical cancer centre show acceptable 30 day mortality
and anastomotic leak rates.
The CUSUM technique is a viable method of observing
trends in anastomotic leak rates and mortality, highlighting when the rates rise above an unacceptable level which
would then trigger internal audit. CUSUM analysis could
be further refined with the use of a risk stratification tool,
such as O-POSSUM. These tools could be implemented in
a prospective fashion, allowing “real-time” assessment of
periods of varying performance.
Cumulative sum (CUSUM) techniques, originally developed as industrial control techniques, have the potential
to provide rigorous, “real-time” monitoring of surgical outcomes. Already used in cleft surgery and burns intensive
care, CUSUM compares actual to predicted outcome rates
on a case-by-case basis. The technique described plots case
number on the x-axis versus the actual minus predicted
outcome rate on the y-axis. The graph is not allowed to
pass below the y = 0 point, preventing periods of good performance maskng a period of poor performance. A period
of performance “as predicted” would be represented by a
horizontal line, a period of worsening performance as a rising line and vice versa. The setting of “alarm points”, i.e.
the y value at which performance warrants review, means
the unit can perform that review at the time of the worsened outcomes and make immediate changes.
Su1532
Outcomes After Transhiatal and Transthoracic
Esophagectomy for Esophageal Cancer
Christopher S. Davis, Eileen Bock*, Kirstyn E. Brownson,
Cynthia Weber, P. Marco Fisichella, Margo Shoup,
Gerard V. Aranha
Surgery, Loyola University Chicago, Health Sciences Campus,
Maywood, IL
RESULTS: Ninety-seven cases were completed laparoscopically, with three converted to open procedures. Mean age
was 66.4 years (SD 9.2). Median length of inpatient stay
was 15 days. The 30-day mortality was 5%.
BACKGROUND: Controversy persists as to the preferred
operative approach to esophageal cancer. Therefore, we
investigated the peri-operative, short-term, and mid-term
outcomes between transhiatal esophagectomy (THE) and
transthoracic esophagectomy (TTE) at our institution.
The crude anastomotic leak rate was 6%. CUSUM analysis
of the incidence of leaks (Figure 1) demonstrated a peak at
case 65. This however did not breach the alarm line at two
leaks above the expected rate.
CUSUM analysis of mortality revealed two peaks, neither
of which breached the alarm line at two point five deaths
above predicted.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1533
METHODS: We conducted a retrospective review of 114
patients who had undergone esophagectomy for esophageal cancer, in our tertiary care center. Among those
patients who underwent THE or TTE we compared: a) clinical characteristics; b) pathologic findings; and c) outcomes.
Parametric and non-parametric tests of significance were
performed, and survival was determined by Kaplan-Meier
analysis.
Venous Thromboembolism in Patients Receiving
Neoadjuvant Chemotherapy for Esophagogastric
Carcinoma
David Bowrey1, Achal Khanna*1, Alex M. Reece-Smith2,
Anne Thomas3, Simon Parsons2
1. Surgery, University Hospitals of Leicester NHS Trust, Leicester,
United Kingdom; 2. Surgery, Nottingham University Hospitals
NHS Trust, Nottingham, United Kingdom; 3. Oncology, University
Hospitals of Leicester NHS Trust, Leicester, United Kingdom
RESULTS: We identified 32 patients who underwent THE,
and 82 patients who underwent TTE. Age, gender, race/ethnicity, alcohol and tobacco use, weight loss and body mass
index at the time of surgery, operative risk, chemoradiation
regimen, tumor stage, and pathologic findings were similar
between groups. Those who underwent THE had a greater
intra-operative blood loss (p = 0.003), required more intraoperative blood transfusions (p < 0.0001), spent a longer
time on the ventilator (p < 0.0001) and in the intensive
care unit (p = 0.002), and had a higher 30-day mortality (p
= 0.023). Likewise, those who underwent THE had a greater
prevalence of post-operative vocal cord dysfunction (17%
vs 3%, p = 0.027) and anastomotic leak (29% vs. 1%, p <
0.0001). Compared to THE, patients undergoing TTE had
a greater number of lymph nodes sampled (mean 13.0 vs
13.6, respectively) and frequency of lymph nodes positive
for carcinoma (29% vs 35%, respectively). Finally, survival
at 3-years was significantly less after THE than after TTE
(26% vs. 53%, p = 0.035), as was overall 5-year survival (p
= 0.039) (Figure 1).
BACKGROUND: The association between venous thromboembolism and chemotherapy for esophagogastric cancer
is well known in patients treated with palliative intent.
Whether this risk extends to the neoadjuvant and perioperative setting is unclear.
METHODS: Retrospective interrogation of databases of
patients receiving perioperative chemotherapy for potentially curative intent at the Leicester (2006–2011) and Nottingham (2004–2011) esophagogastric cancer centres.
CONCLUSIONS: Eleven percent of patients treated with
potentially curative intent will develop venous thromboembolism. This adverse event can occur at any time during the patient journey. In contrast to the commonly held
view, this did not translate into a poorer prognosis.
CONCLUSIONS: These data demonstrate a short-term survival advantage and lower morbidity of TTE as compared to
THE at our institution. We speculate that the higher morbidity after THE may account for the worse outcomes associated with this approach.
85
Sunday
Poster Abstracts
RESULTS: Thromboembolic events were diagnosed in 42 of
384 patients (11%), 16 (4%) at presentation, 14 (4%) during
neodjuvant chemotherapy and 12 (3%) in the postoperative period. By site these comprised catheter-related axillary vein thrombosis in 6 patients, deep venous thrombosis
in 16 patients and pulmonary embolism in 16 patients. All
of the pulmonary emboli were incidental findings on staging CT imaging. There was no correlation between the risk
of thromboembolism and chemotherapy regimen. Seven
of the 42 patients (17%) who developed thromboembolism did not proceed to surgery because of deterioration
in performance status. Thromboembolic disease resulted in
a non-significant increase in the interval between chemotherapy and surgery, but did not influence either length of
hospital stay or survival.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1535
Su1536
Methylene Blue (MB) Test Versus Contrast Study (CS)
in the Detection of Anastomotic Leak Following
Oesogephactomy: A Prospective Study of 58 Patients
Defining the Learning Curve for Robotic-Assisted
Esophagogastrectomy
Jonathan M. Hernandez*, Jill Weber, Khaldoun Almhanna, Sarah
Hoffe, Ravi Shridhar, Richard Karl, Ken L. Meredith
Surgery, H. Lee Moffitt Cancer Center, Tampa, FL
Adriana Rotundo*, Geoffrey Roberts, Francesco Pata,
Geoff Pratt, Michael Harvey, Cheuk Bong Tang,
Sritharan S. Kadirkamanathan
Upper GI Surgery, MEHT, Chelmsford, United Kingdom
INTRODUCTION: The expansion of robotic-assisted surgery is occurring quickly, though little is generally known
about the “learning curve” for the technology with utilization for complex esophageal procedures. The purpose of
this study is to define the learning curve for robotic-assisted
esophagogastrectomy with respect to operative time, conversion rates, and patient safety.
BACKGROUND: Anastomotic leak is a serious complication
following oesophagectomy. It is associated with considerable morbidity and mortality. The aim of our study was to
compare the accuracy of MB and CS (Gastrografin) in detecting anastomotic leaks after Ivor-Lewis oesophagectomy.
METHODS: We have prospectively followed all patients
undergoing robotic-assisted esophagogastrectomy and
compared operations performed at our institutions by a
single surgeon in successive cohorts of 10 patients. Our
measures of proficiency included: operative times, conversion rates, and complications.
METHODS: The study included 58 patients who underwent laparoscopic assisted Ivor-Lewis oesophagectomy
from September 2009 to November 2011. All patients had
intra-thoracic oesophago-gastric anastomosis, end to side
using an endoscopic circular stapler (CDH © Ethicon EndoSurgery, Inc.2010). The integrity of the anastomosis was
checked on day 5 using both MB and CS. 100ml of Gastrografin was used in the CS which was performed by an
experienced oesophageal radiologist. 10 ml of MB diluted
in 200ml of water was given orally to test the anastomosis.
The CS was performed before the MB test and was reviewed
by the radiologist who was blinded to the results of MB.
MB test was considered positive when the dye was seen in
the chest drain in less than 30 minutes. The leak was considered clinically significant if there was evidence of sepsis.
Chi square test was used to assess the difference between
the two investigations
RESULTS: Fifty-two patients (41 (78.8%) male: 11 (22.2%)
female) of mean age 66.2 ± 8.8 years underwent roboticassisted esophagogastrectomies for malignant esophageal
disease. Neoadjuvant chemoradiation was administered to
35 (67.3%) patients. A significant reduction in operative
times (p < 0.005) following completion of 20 procedures
was identified (514 ± 106 vs. 397 ± 71.9). No significant
reduction in the number of procedures requiring conversions to open operations was observed. Complication
rates were low, and not significantly different between any
10-patient cohort, although no complications occurred in
the final 10-patient cohort. However the frequency of complications decreased significantly after 28 cases: 9 (32.1%)
vs 3 (12.5%) p = 0.04. There were no in hospital mortalities.
RESULTS: There were 37 males and 21 females with median
age of 65 (range 43–78). Anastomotic leaks was diagnosed in
6 patients (10.3%). In 4 cases the leak was considered clinically significant (7%). MB detected all 4 significant leaks.
CS detected 5 leaks, 3 clinical and 2 non-clinical, but was
reported as a normal study in 1 of the clinically significant
leak. All patients recovered with conservative management.
There was no significant difference between MB and CS in
diagnosing anastomotic leaks (p = ns).
CONCLUSIONS: For surgeons proficient in performing
minimally invasive esophagogastrectomies, the learning
curve for a robotic-assisted procedure appears to begin near
proficiency after 20 cases. However this may be increased
in surgeons transitioning from an open approach. Operative complications and conversions were infrequent and
unchanged across successive 10-patient cohorts and appear
to be less then smaller previously published series. In addition, there is a decrease in frequency of complications after
28 cases.
CONCLUSION: Our study shows no difference between CS
and MB in detecting anastomtic leaks. MB might be a more
convenient investigation and could be used in a ward setting without the need for radiology. It could well form part
of the strategy of enhanced recovery after surgery (ERAS)
programme following oesophageal surgery.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Clinical: Hepatic
Su1538
Su1537
Single Hepatocellular Carcinoma Less Than 3 cm in
Cirrhotic Livers: Is Resection Better Than Ablation?
Marco Massani1, Cesare Ruffolo1, Luca Bonariol1, Ezio Caratozzolo1,
Marco Scarpa*2, Francesco Calia Di Pinto1, Francesco E. D’Amico1,
Bruno Pauletti1, Giuseppe Battistella3, Nicolò Bassi1
1. II Department of Surgery (IV unit), Regional Hospital Cà Foncello,
Treviso, Treviso, Italy; 2. Department of Surgery, Veneto Oncological
Institute, Padova, Italy; 3. Statistics and Epidemiology Service,
Regional Hospital “Cà Foncello”, Treviso, Italy
Risk Factors for Postoperative Mortality After General
Surgery in 231 Patients with Liver Cirrhosis
Frank Makowiec*1, Hans-Christian Spangenberg2, Tobias Keck1,
Ulrich T. Hopt1, Hannes P. Neeff1
1. Department of Surgery, University of Freiburg, Freiburg, Germany;
2. Department of Gastroenterology and Hepatology, University of
Freiburg, Freiburg, Germany
BACKGROUND: Hepatocellular carcinoma (HCC) is one
of the most frequent tumors and it is the predominant
primitive liver cancer and in most cases associated with cirrhosis, regardless of the etiology.
INTRODUCTION: Postoperative mortality rates after surgery in patients with liver cirrhosis are high. Risk factors
for mortality may help planning therapy in those high risk
patients. We, therefore, evaluated/updated potential risk
factors (including Child- and MELD-scores) for perioperative mortality after more than 200 operations in patients
with cirrhosis performed during the last decade.
AIM: The purpose of this study was to compare the overall survival after percutaneous ablation and resection in
patients with a single HCC lesion measuring less than 3
cm in diameter originating on liver cirrhosis. Patients and
methods From January 1999 to December 2008 556 consecutive patients were evaluated in our center for HCC.
Only patients with cirrhosis and a single nodule <3 cm
were taken into consideration: 48 underwent liver resection and 51 treated with percutaneous procedures.
RESULTS: The minimum follow up was 20 months. The
survival rate of resected patients was significantly higher
compared to the ablated patients (p = 0.0006). Child A
was a protective factor for both groups (p = 0.0001) and
HCV positive patients had worse outcomes (p = 0.005).
Moreover, age and survival were significantly associated to
resected patients (p = 0.0195). Early recurrence occurred in
3 patients after resection and in 7 after ablation.
RESULTS: Overall postoperative mortality was 17%. In
univariate analysis the CHILD classification (mortality: 6%
Child A; 11% Child B, 45% Child C; p < 0.001), higher/
increasing MELD score (p < 0.001), higher/increasing ASA
score (p < 0.001), emergency procedures (35% vs 5% elective; p < 0.001), major procedures (p < 0.02), need for transfusions (36% vs 4% in patients without transfusions; p <
0.001) and various preoperative laboratory values (anemia,
thrombocytopenia, hyponatremia; all p < 0.05) were associated with increased mortality. In multivariate risk factor
analyses blood transfusions (p < 0.001; RR 7), ASA score (p
< 0.01), Child class (p < 0.02) and a thrombocytopenia (p <
0.02) were independent predictors for mortality. The MELD
score, emergent procedures and extent of surgery showed
a trend but did not significantly predict mortality in the
multivariate model.
CONCLUSIONS: This experience confirmed that in case
of single nodule <3 cm in cirrhosis resection must be considered as the primary choice for all patients with adequate
functional reserve. Nevertheless the ablative treatment can
be considered a good second line option since it ensure
good results in terms of survival.
CONCLUSIONS: Patients requiring blood transfusions
have a very high risk for mortality. Preoperative liver function and co-morbidity also predict early mortality after surgery. In our series the CHILD score was a better predictor
for postoperative mortality than the MELD-score.
87
Sunday
Poster Abstracts
METHODS: Since 2001 231 various general surgical procedures (80% intraabdominal, 20% abdominal wall) were
performed in patients with liver cirrhosis (38% emergent).
Cirrhosis was classified according to Child (41% A; 38%
B, 21% C) and MELD-score (median 11). Procedures were
subclassified as major (laparotomy with resection) or minor
(abdominal wall, ‘minor’ laparotomy, laparoscopy). Univariate and multivariate (binary logistic regression) analysis was undertaken to identify risk factors for mortality.
Multivariate analysis was performed in different models to
exclude collinearity due to overlapping parameters (Child,
MELD, laboratory values).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1539
Clinical: Pancreas
Safety and Outcomes Following Resection of Colorectal
Cancer Liver Metastases in the Era of FOLFOX
Su1542
Ilia Gur*1, Jesse A. Wagner1, Brett C. Sheppard4, Susan L. Orloff2,
Gina M. Vaccaro3, Charles D. Lopez3, Brian S. Diggs4,
Kevin G. Billingsley1
1. Surgical Oncology, OHSU, Portland, OR; 2. Abdominal Organ
Transplantation, OHSU, Portland, OR; 3. Hematology, Oncology,
OHSU, Portland, OR; 4. General Surgery, OHSU, Portland, OR
Underuse of Surgical Therapy of Gastrointestinal
Cancer in the United States
Attila Dubecz*1, Norbert Solymosi2, Michael Schweigert1,
Rudolf J. Stadlhuber1, Jeffrey H. Peters3, Hubert J. Stein1
1. Surgery, Klinikum Nürnberg, Nuremberg, Germany; 2. Veterinary
Medicine, Szent István University, Budapest, Hungary; 3. Division of
Thoracic and Foregut Surgery, Department of Surgery, University of
Rochester School of Medicine and Dentistry, Rochester, NY
OBJECTIVE: Report the safety and outcomes following
the introduction of routine periopereative multiagent chemotherapy in the multidisciplinary treatment of patients
with colorectal liver metastases (CRLM).
BACKGROUND: Surgery is the mainstay of curative therapy for most localized gastrointestinal (GI) malignancies.
Our objective was to evaluate the utilization of surgery in
non-metastatic GI cancer and identify factors predicting
failure to undergo surgery.
BACKGROUND: Increasingly preoperative chemotherapy
is integrated into the management of patients with liver
metastases. This strategy has likely expanded the number
of surgical candidates but postoperative safety and survival
have not been clearly defined.
METHODS: Using the National Cancer Institute’s Surveillance Epidemiology and End Results-Database (1998–2008),
a total of 331,911 patients (esophagus: 20,475; stomach:
18,585; small bowel: 2,647; colon: 184,675; rectum: 45,599;
liver: 24,318; pancreas: 35,612) were identified with nonmetastatic cancer. The rate of surgical therapy in each
type was calculated. Multivariate logistic regression was
employed to identify factors predicting failure to undergo
surgical therapy. Reason for no surgery and the impact of
surgery on survival were also assessed.
METHODS: We performed a retrospective review of all
patients undergoing liver resections for metastatic colorectal cancer between 2003 and 2011 in a single academic
oncology center. Demographic data, tumor characteristics,
chemotherapy, details of surgical procedure, complications
and survival were analyzed.
RESULTS: The study population consisted of 158 patients
that underwent 169 liver operations. 11 (6.9%) patients
had repeat resections. Median length of follow up from
a first liver resection was 22.3 months. 87 (55%) patients
presented with synchronous lesions. 114 patients (72%)
underwent chemotherapy prior to the liver resection (of
them 68% FOLFOX, 12% FOLFIRI). Mean size of the lesions
3.97 cm (0.2 -18 cm) .Preoperative Portal Vein Embolization was utilized in 16 (10.1%) patients Overall survival was
89%, 57% and 17% at 1, 3 and 5 years respectively. Median
survival was 42.8 months. Perioperative mortality (30, 60
and 90 days respectively) was 1.26%, 1.89% and 2.53%.
Overall complication rate was 24% (5%–liver related) The
complication rate was not significantly different if patients
had preoperative chemotherapy (27% no chemotherapy,
24% with chemotherapy). Mean length of stay was 8.68
days. On univariate analysis negative predictors of survival included positive margins, >3 lesions, patient age >70
years. On a multivariate analysis only the presence of >3
lesions predicted poor survival.
RESULTS: Surgical resection for locoregional cancer
was surprisingly low for cancers of the liver (27%), pancreas (32%), and esophagus (56%). Cancers of the colon
(91%) rectum (72%) stomach (78%) and small intestine
(74%) had higher rates although as many as one quarter
of patients did not undergo surgical resection. The primary
reason for not undergoing surgery was classified as “not
recommended” in from 1–49% of the patients again highest in pancreas (49%), liver (47%) and esophagus (26%).
Men, non-white race, patients >80 yrs, or those undergoing surgical therapy later in the study period and living in
areas with high poverty rates were significantly less likely
to receive surgical treatment (all p < .0001). Median survival in patients who did not undergo surgical resection
was significantly better than those with metastatic disease
(9 vs 6, p < 0.0001) but far worse than patients who underwent surgery for locoregional disease (96 vs 9, p < 0.0001).
CONCLUSIONS: When viewed from a national perspective the rates of surgical resection for locoregional GI cancer vary considerably. These data suggest that operative
therapy in esophageal, liver and pancreatic cancer is particularly underutilized.
CONCLUSIONS: In recent years preoperative oxaliplatinbased chemotherapy has become commonplace in the
management of patients with resectable CRLM. Our results
suggest that even with chemotherapy and resection only
a subset of patients remain disease free after 5 years. However, even in high risk patient with multiple lesions, preoperative chemotherapy may be administered safely without
increase in postoperative complications. These results support the use of perioperative chemotherapy particularly in
patients with multifocal (>3 lesions) metastatic disease in
the liver.
88
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1543
Su1544
Serum Lipid Levels Are Associated with the Severity
of Acute Pancreatitis
Intra-Abdominal Pressure in Acute Pancreatitis: Canary
in Coal Mine? Result After a Rigorous Validation
Protocol
Jahangir Khan, Isto Nordback, Juhani Sand*
Tampere University Hospital, Tampere, Finland
Vimal Bhandar*, Sumit Budania, Jiten Jaipuria
Surgery, VMMC & Safdarjung Hospital, New Delhi, India
AIMS: Serum lipid concentrations are known to react
during acute disease. In this study, we sought to measure
changes in the serum lipid profile during acute pancreatitis
and whether these changes were associated with the severity of the disease.
INTRODUCTION: Intra-abdominal hypertension [I.A.H.]
is increasingly reported in patients with severe acute pancreatitis [S.A.P.] and is associated with significantly higher
mortality rates. Though a clear causal relationship could
not be demonstrated, some reports show excellent outcomes in pancreatitis patients undergoing abdominal
decompression suggesting that I.A.H. may be a target for
early intervention. Many studies however highlight the
issue of I.A.H. in patients with severe disease with absence
of data in those with mild disease making it confusing to
conclusively recommend whether Intra-abdominal Pressure measurement should be a routine in all patients.
METHODS: We analyzed 233 patients hospitalized for
acute pancreatitis between 1995–1995. All etiologies of acute
pancreatitis were included, as were patients with their first
acute pancreatitis or recurrencies. Serum samples were
obtained during the first days after admission and further
follow-up samples were obtained later during the course
of the disease. In most cases (n = 203, 87%), samples were
available from the first two days of hospitalization. The
serum total cholesterol, HDL-cholesterol and triglyceride
levels were measured enzymatically and the concentrations
of serum LDL-cholesterol were calculated using the Friedewald formula.
AIMS AND OBJECTIVES: The present study was undertaken to evaluate Intra-abdominal Pressure as a marker of
severity in acute pancreatitis and to ascertain the relationship between I.A.H. and development of complications in
patients with S.A.P.
MATERIAL AND METHOD: A total of 40 patients [24
male, 16 female] fulfilling the inclusion criteria were
selected in the study. Selected patients were further enrolled
into two groups [Group 1: Mild Pancreatitis, n = 24 and
Group 2: Severe pancreatitis, n = 16] based on the definitions given in the Atlanta Symposium. Group 2 patients
were further categorized into two sub-groups depending
upon the presence and absence of raised intra-abdominal
pressure [Group 2a: consistently raised I.A.P. >12 mmHg
and Group 2b: not satisfying above criteria, no elevations
in I.A.P.].
OBSERVATIONS: Development of intra-abdominal
hypertension was noted to be an early phenomenon in
patients with S.A.P. The positive and negative predictive
value of I.A.H. in developings S.A.P. were 100% and 75%
respectively. Sensitivity of I.A.H. in identifying those with
severe pancreatitis was 50% while the specificity was 100%.
Patients with S.A.P. and I.A.H. also had significantly higher
APACHE-2 Scores, a higher CT severity index and increased
incidence of persistent SIRS, organ failure, occurrence of
pleural effusions, intra-abdominal collections and overall
mortality.
CONCLUSIONS: Serum lipid concentrations react during
acute pancreatitis. The levels of serum total cholesterol,
HDL-cholesterol and LDL-cholesterol are significantly lower
in patients with severe acute pancreatitis and are associated
with in-hospital mortality and longer hospital stay. These
changes are already present during the early stages of the
disease and are similar in all etiologies of acute pancreatitis.
Furthermore, the changes observed are present even later
during the course of the disease. Further studies are needed
to study the mechanisms of this association.
89
Sunday
Poster Abstracts
RESULTS: The most common etiology for acute pancreatitis was alcohol use (n = 131, 56%), followed by biliary
(n = 48, 21%) and idiopathic (n = 36, 16%) pancreatitis.
64 (28%) patients had a severe pancreatitis, with 13 (6%)
mortalities. Serum total cholesterol, HDL-cholesterol and
LDL-cholesterol measured within 2 days of admission were
significantly lower in patients with severe pancreatitis and
associated with in-hospital mortalities and longer hospitalization (p < 0.05). In subgroup analysis, the findings
remained statistically significant in patients with alcohol
induced acute pancreatitis, though were similar with all
etiologies. Furthermore, these findings were evident even
later during the course of the disease.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Table 1
MEAN
APACHE 2
SCORE
Mean CT
Severity
index
Maximum
I.A.P.
SIRS
>48 hr
Organ
Failure
Pleural
Effusion
Length of
Hospital
Stay
Ascites/Fluid
Collections
Total
Entire population
6.6
3.5
8.05
12
8
6
7.92
6
40
Patients with mild pancreatitis:
GROUP 1
4.4
1.62
4.36
0
0
1
5.66
0
24
Patients with severe
pancreatitis: GROUP 2
10
6.31
13.81
12
8
5
11.31
6
16
Patients with severe
pancreatitis and I.A.H.
GROUP 2a
13.6
8.37
19.37
8
8
5
15.12
5
8
Patients with severe
pancreatitis and no I.A.H.
GROUP 2B
6.4
4.25
8.25
4
0
0
7.5
1
8
Patients with A.C.S.
18
10
26.66
3
3
3
6.33
3
3
Population
Table 2: Comparison of Presence of I.A.H., Presence of Pleural Effusion and A.P.A.C.H.E. 2 Score >8 [in the Initial 24 Hours] in Identifying
Patients with Severe Pancreatitis
Patients with Severe Pancreatitis
Sensitivity
Specificity
Positive Predictive Value
Negative Predictive Value
50%
100%
100%
75%
Presence of APACHE 2 SCORE >8
68.70%
83.30%
73.33%
80%
Presence of pleural effusion
31.25%
95.8%
83.33%
67.64%
Presence of I.A.H.
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CONCLUSIONS: Presence of I.A.H. in the setting of S.A.P. is
associated with a higher incidence of complications including pancreatic necrosis, persistent SIRS, organ failure, pleural effusions, intra-abdominal collections, longer duration
of hospital stay, mortality and thus intra-abdominal pressure measurement may have a definite place in being used
as a predictive marker for severe disease.
Reconsideration of Safety and Efficacy of
Pancreaticoduodenectomy for Periampullary Cancers
in Elderly Patients Aged ≥80 Years
Seiji Oguro*, Kazuaki Shimada, Yoji Kishi, Satoshi Nara, Minoru
Esaki, Tomoo Kosuge
Hepatobiliary and Pancreatic Surgery, National Cancer Center
Hospital, Tokyo, Japan
REFERENCES:
1. De Waele JJ, Hoste E, Blot SI et al Intra-abdominal hypertension in patients with severe acute pancreatitis. Crit
Care 2005;9: R452–57.
BACKGROUND: Given that the life expectancy is increasingly becoming longer, safety and efficacy of pancreaticoduodenectomy for periampullary cancers in elderly patients is
a great clinical concern. Over the last decade many reports
have described outcome of pancreaticoduodenectomy in
elderly patients, but the results are still inconsistent.
2. Adish Basu. A low cost technique for measuring the intraabdominal pressure in non-industrialized countries. Ann
R Coll Engl 2007;89:431–37.
METHODS: From a database of all the patients with periampullary cancers undergoing pancreaticoduodenectomy
between 2001 and 2009, the patients over 80 years were
identified. Perioperative characteristics, postoperative complications, mortality, and a long-term survival were retrospectively compared between the patients aged 80 and
older, and the patients younger than 80 years.
90
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: Among a total of 561 patients undergoing pancreaticoduodenectomy, 22 patients (3.9%) were over 80
years. The pathological diagnosis in the elderly patients
consisted of as follows; pancreatic cancer (n = 8), bile duct
cancer (n = 5), ampullary neoplasm (n = 5), intraductal
papillary mucinous neoplasm (n = 3), and gallbladder cancer (n = 1). The elderly patients had a higher ASA score (P
= 0.02) than the younger patients, but there was no significant difference in operative time (455 vs 520 minutes;
P = 0.08), and blood loss (654 vs 838 ml; P = 0.38). The
mortality rate was 4.5% in the elderly patients and 0.9%
in the younger patients, though the difference was not statistically significant (p = 0.106). Although the incidence of
postoperative pancreatic fistula and delayed gastric emptying were similar between the two groups, that of intraabdominal abscess, intraabdominal hemorrhage, pneumonia
and ascites in the elderly patients (22.7%, 18.2%, 9.1%
and 4.5%, respectively) were higher than in the younger
patients (6.9%, 2.2%, 0.6% and 0.2%, respectively). The
rate of grade IIIa or higher complication (Clavien-Dindo
classification) was 27.3% in the elderly patients and 6.3%
in the younger patients (P = 0.008). There was no significant difference in overall survival between the two groups.
Among the elderly patients, the median survival for those
with pancreatic cancer was significantly shorter than that
with non-pancreatic cancer. (P = 0.003)
important role in adjuvant chemotherapy for not only unresectable but also resected pancreatic carcinoma. However,
the problem is that a substantial number of patients have a
resistance to gemcitabine. The aim of this study was to clarify which is more useful as a predictive marker of adjuvant
gemcitabine-based chemotherapy for pancreatic carcinoma
after surgical resection, intratumoral human equilibrative
nucleoside transporter 1 (hENT1) or ribonucleotide reductase regulatory subunit M1 (RRM1) expression.
METHODS: Intratumoral hENT1 and RRM1 expression
were examined by immunohistochemistry in 109 pancreatic carcinoma patients who received adjuvant gemcitabine-based chemotherapy after surgical resection from
January 2002 to May 2011. Relationships between clinicopathological factors, including hENT1 and RRM1 expression, and disease free or overall survival (DFS or OS) were
evaluated by univariate and multivariate analyses. This
study was a retrospective analysis on retrospectively collected tissue and data.
CONCLUSIONS: Pancreaticoduodenectomy in patients
aged 80 and older should be indicated carefully, because of
the higher incidence of the severe postoperative complications. Pancreaticoduodenectomy for pancreatic cancer in
elderly patients could not provide a satisfactory outcome
in terms of a long-term survival compared with that for
non-pancreatic cancers.
CONCLUSIONS: Both hENT1 and RRM1 expression is useful as a predictive marker of adjuvant gemcitabine-based
chemotherapy for pancreatic carcinoma after surgical
resection. In addition, combined analysis of the two is even
more useful.
Su1546
Which Is More Useful as a Predictive Marker of
Adjuvant Gemcitabine-Based Chemotherapy for
Pancreatic Carcinoma After Surgical Resection,
Human Equilibrative Nucleoside Transporter 1 or
Ribonucleotide Reductase Regulatory Subunit M1
Expression?
Naoya Nakagawa*, Yoshiaki Murakami, Kenichiro Uemura,
Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima,
Naru Kondo, Hironori Kobayashi, Hiroki Ohge, Taijiro Sueda
Department of Surgery, Division of Clinical Medical Science,
Graduate School of Biomedical Sciences, Hiroshima University,
Hiroshima, Japan
BACKGROUND/OBJECTIVE: Although postoperative
adjuvant chemotherapy for pancreatic carcinoma improves
survival in some patients, the efficacy varies by individuals,
and the results remain unsatisfying. Gemcitabine plays an
91
Sunday
Poster Abstracts
RESULTS: High intratumoral hENT1 and RRM1 expression was observed in 78 (72%) and 44 (40%) cases, respectively. DFS rates for all 109 patients were 59% at 1 year,
42% at 2 years, and 26% at 5 years, and OS rates were 81%
at 1 year, 61% at 2 years, and 31% at 5 years, respectively.
In univariate analysis, both hENT1 and RRM1 expression
were significantly associated with DFS (hENT1: P = 0.004,
RRM1: P = 0.011) and OS (hENT1: P = 0.001, RRM1: P =
0.040). In multivariate analysis, the both were identified
as independent factors for DFS (hENT1: P = 0.001, RRM1:
P = 0.009) and OS (hENT1: P = 0.001, RRM1: P = 0.019).
The evaluation of the combination of the both was also
identified as a powerful independent predictor for DFS (P <
0.001) and OS (P < 0.001).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1547
advanced age, complications, lack of jaundice, and IPMN.
Early tumor progression was identified in seven of these
patients. Four principal reasons for unutilized therapy
were identified (Table). These segregated into two disparate
groups—Poor Clinical Outcomes (2/3rds) and Therapy Not
Elected (1/3rd), which demonstrated a marked median survival difference (6.0 mo vs. 62.6 mo respectively; p < 0.001,
Graph). The Therapy Not Elected group was characterized
by favorable tumor biology. The Poor Clinical Outcome
group contained two-thirds of all Major complications
(Clavien 3b-5) in this entire series. When scrutinized further by multivariate analysis, the only preoperative factors
associated with this group were older age and COPD, and
this cohort could not be discriminated by preoperative risk
scoring systems.
Failure to Receive Adjuvant Therapy Following
Resection for Pancreatic Cancer: Patterns and
Implications
Russell S. Lewis*1, Jeffrey A. Drebin1, Mark P. Callery2, Douglas L.
Fraker1, Tara S. Kent2, Jenna Gates1, Charles M. Vollmer1
1. Surgery, The University of Pennsylvania School of Medicine,
Philadelphia, PA; 2. Surgery, Beth Israel Deaconess Medical Center,
Harvard Medical School, Boston, MA
INTRODUCTION: Although adjuvant therapy optimizes
the prognosis for resected pancreatic ductal adenocarcinoma (PDAC), literature indicates that this approach is
not applied in up to half of patients. This has prompted
some to advocate preoperative adjuvant therapy to ensure
receipt of all elements of multidisciplinary oncologic care.
We sought to identify the frequency, reasons, and predictors of unutilized post-operative adjuvant therapy in a multidisciplinary, specialty setting.
METHODS: A database containing PDAC resections performed at two institutions over a decade (2001–2011) was
studied. Eligible patients who did not undergo adjuvant
therapy were identified and categorized based on the rationale for not receiving treatment. Demographics, perioperative features, tumor characteristics, and surgical risk scores
(ASA, POSSUM, Charlson, SOAR) were analyzed by univariate analysis and multivariate regression to assess factors
associated with these untreated patients, focusing further
on a subset that displayed poor clinical outcomes.
CONCLUSIONS: This series demonstrates that the vast
majority of PDAC patients can receive post-operative adjuvant therapy following surgical resection. There are various reasons for non-utilization, not all of which represent
inadequate care. The ability to employ adjuvant therapy
is predicated on optimal surgical outcomes. Pre-operative
prediction of the minority of patients with poor outcomes
that prevent adjuvant treatment, using current risk assessment models, remains elusive.
RESULTS: Of 412 resected PDAC patients 336 (82%)
received some form of postoperative treatment, while only
52 (including 90 d mortalities, N = 7) did not. Treated
patients had median, 1- & 5-year survivals of 23.5 mo,
80% & 25%, compared to 9.4 mo, 44% & 22% in the
Untreated group (p < .001). 24 patients whose treatment
status is unknown exhibited equivalent survival to the
treated cohort (19.3 mo, 78% & 17%; p = .296). Characteristics of the Untreated cohort by multivariate analysis were
Patients Who Did Not Receive Adjuvant Therapy after Pancreatic Resection—Categorized by Reasons
Frequency
Survival
n
%
Median (mo)
1 yr
3 yr
<P ALIGN = \“left\”>Poor Clinical Outcome
34
65.4
6.0
24%
5%
n/a
<P ALIGN = \“left\”>1. Early Death (90d)
7
13.5
1.8
0%
0%
0%
<P ALIGN = \“left\”>2. Diminished Functional Capacity (Complications/Early Recurrence)
27
51.9
6.9
31%
7%
n/a
<P ALIGN = \“left\”>Therapy Not Elected
18
34.6
62.6
82%
66%
54%
<P ALIGN = \“left\”>3. Declined Against Medical Advice—Patient’s Choice
8
15.4
10.4
57%
0%
0%
<P ALIGN = \“left\”>4. Deemed Unnecessary—Physician’s Choice
10
19.2
Not Reached
100%
100%
82%
<P ALIGN = \“left\”>Total
52
100.0
9.4
44%
27%
22%
92
5 yr
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1548
CONCLUSION: While the presence of infected necrosis
or persistent organ failure in SAP (group III) is associated
with high mortality, the combination of “infected necrosis and persistent organ failure” (group IV) is uniformly
fatal. Further research is necessary to confirm the findings
in our study and to explore ways of optimising patients in
group III to improve survival.
Retrospective Audit of Management of Patients
Admitted to Intensive Care Unit (ITU) with Severe
Acute Pancreatitis (SAP)
Omer Jalil*, Chirag Patel, Aamer F. Iqbal, Amir Kambal,
Ashraf M. Rasheed
Royal Gwent Hospital, Upper GI Surgery, Newport, United Kingdom
Su1549
INTRODUCTION: Atlanta classification stratifies acute
pancreatitis (AP) into mild and severe. Severe acute pancreatitis (SAP) is best managed in HDU or ITU setting and
associated with high mortality and morbidity despite best
efforts at attaining early diagnosis and timely intervention.
Rare Benign Cystic Lesions of the Pancreas Mimicking
Premalignant Neoplastic Cysts
Nidhi Agrawal, Nishi Dedania, Sean O’Donnell, Ross Mazo,
Jordan M. Winter, Eugene P. Kennedy, Charles J. Yeo,
Harish Lavu*
Department of Surgery, Thomas Jefferson University, Philadelphia, PA
AIM: To compare management strategies and mortality of
patients admitted to ITU with SAP against national standards and study the group who succumbed to their disease
in detail in an attempt to define the circumstances that
lead to this event and identify the most accurate prognostic
indicators in this group of patients.
INTRODUCTION: Given the increased use of crosssectional radiologic imaging in recent years, cystic lesions
of the pancreas are now being diagnosed with greater frequency. The majority of these lesions are premalignant
cystic neoplasms of the pancreas, such as intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic
neoplasms (MCNs). While pseudocysts account for most of
the remainder, there are a number of rare, benign cystic
lesions of the pancreas that can mimic neoplastic cysts. The
objective of this study was to review a single institution’s
experience with these benign cystic lesions of the pancreas.
METHODS: Retrospective audit of management and
outcome of consecutive patients admitted to ITU with
SAP during the period of 2007–2010. The development of
necrosis, infected necrosis (IN) or organ failure (OF) was
recorded. Patients were classified into group I (No necrosis
or OF), group II (sterile necrosis or transient OF), group III
(IN or persistent OF) and group IV (infected necrosis and
persistent OF). The four groups were compared regarding the clinical course, radiological/surgical intervention,
any post-intervention complications, use of antibiotics/
antifungal and nutritional support.
RESULTS: Fifty one (51) patients were admitted to ITU with
SAP (APACHE II >8, modified Glasgow score >3) during the
period of 2007–2010. All cases fulfilled the Atlanta criteria
of SAP. Median age: 66 ± 17.5. The pancreatitis was alcohol
induced in 12% and due to gallstones in 59% of patients; no
cause was found in 25% of patients. Median ITU stay was
3.23 days. The overall mortality rate during the study period
(3 years) was 38% (n-19) above national standard of 30%. All
7 patients in group IV died, 5 of them underwent necrosectomy and 1 had CT guided drainage of infected acute fluid
collection. The table shows the total number of patients
and respective mortality of SAP in all four groups. Forty one
patients (80%) received antibiotics and 35 patients (69%)
had nutritional support but neither of them seems to have
a significant impact on survival (p = 0.6 and 0.06 respectively). Outcome (death) correlated with organ dysfunction
criteria (Atlanta criteria and APACHE II score).
RESULTS: Thirteen patients (1.5%) out of a total of 170
pancreatic operations performed for cystic disease were
found to have non-neoplastic cystic lesions of the pancreas
(9 distal pancreatectomies, 4 pylorus-preserving pancreaticoduodenectomies). Preoperative imaging revealed primary
lesions in all patients, 6 of which were found incidentally.
Preoperative clinical and imaging studies suggested that
11 lesions were consistent with mucinous neoplasms and
2 with pancreatic adenocarcinoma. However, postoperative pathology revealed 5 patients with ductal retention
cysts, 4 squamoid cysts, 1 mucinous non-neoplastic cyst,
1 congenital ciliated foregut cyst, 1 endometrial cyst, and
1 lymphoepithelial cyst. Two patients had complications
postoperatively, 1 pancreatic fistula and 1 superior mesenteric vein thrombosis, both of which resolved with conservative management. All patients remain disease free with
median follow up of 2 years post resection.
The Mortaltiy of SAP in the Different Groups
Group
Total Number
Mortality
% of Mortality
0%
I
12
0
II
2
0
0%
III
30
12
40%
IV
7
7
100%
93
Sunday
Poster Abstracts
METHODS: We conducted a retrospective analysis of all
patients who underwent surgical resection for pancreatic
lesions from 2005–2011 at our institution. Out of a total
of 947 pancreatic resections, we isolated those cases performed for benign cystic disease and then examined the
clinicopathological data on these patients.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Table 1: Clinicopathological Data of 13 Patients with Non-neoplastic Cystic Lesions of the Pancreas
Patient
Age
Sex
Pre-op Symptoms
Pre-Op Imaging
EUS Results
Procedure
Pathology
1
78
F
Abdominal Pain
CT
Not Performed
PPPD
Squamoid Cyst
2
66
M
None
CT, MRI
Not Performed
DPS w/ partial Left
Hepatectomy
Squamoid Cyst, Hepatocellular Carcinoma
3
80
F
None
CT, MRI
Not Performed
DPS w/ partial Right
Hepatectomy
Ductal Retention Cyst, Cholangiocarcinoma
4
49
F
None
CT
Epithelial Cells
DP
Ductal Retention Cyst
5
56
F
Pancreatitis
CT
No cells obtained
DPS
Ductal Retention Cyst
6
37
M
Pancreatitis
CT
Epithelial Cells
PPPD
Squamoid Cyst
7
65
M
None
CT, MRI
Mucin
DPS
Congenital Ciliated Foregut Cyst
8
32
F
Abdominal Pain
CT
Amylase, Elevated
CEA
DPS
Endometrial Cyst
9
72
F
None
CT
Not Performed
Laproscopic DP
Squamoid Cyst
10
77
F
Abdominal Pain
MRI
Atypical
PPPD
Ductal Retention Cyst
11
52
F
Nausea
CT
Mucin
PPPD
Mucinous Non-neoplastic Cyst
12
46
F
Pancreatitis
CT
Not Performed
DPS
Ductal Retention Cyst
13
69
M
None
CT, MRI
Not Performed
DPS
Lymphoepithelial cyst
PPPD, Pylorus- preserving Pancreaticoduodenectomy; DPS, Distal Pancreatectomy & Splenectomy; DP, Spleen-preserving Distal Pancreatectomy
CONCLUSIONS: While pseudocysts tend to reflect inflammation and necrosis of the pancreas, there exist rare nonneoplastic cystic lesions that may not be associated with
any underlying disease process. In our institutional experience, these lesions are often indistinguishable from premalignant cystic neoplasms of the pancreas preoperatively
despite advances in diagnostic imaging and endoscopic
ultrasound fluid analysis. Although it is possible to safely
perform pancreatic resection in these patients, it is unnecessary if the patient is asymptomatic. It is important to
recognize the existence of these entities to aid in avoiding
surgical resection when not clinically indicated.
METHODS: A retrospective chart review of 40 patients
undergoing robotic distal pancreatic resections between
2006 and 2010 was performed. Data was collected for
demographics, clinical presentation, perioperative course,
histology, and survival. Comparisons were performed
between two groups of patients undergoing robotic spleen
preserving distal pancreatectomy (SPDP) and distal pancreatectomy with splenectomy (SDP). Survival analysis was
performed using the Kaplan-Meier method.
RESULTS: Twelve patients underwent SPDP compared
to 28 SDP patients. The two groups were similar in the
distribution of their clinical characteristics, including ASA
class. There were no significant differences between SPDP
and SDP groups in respect to the operative time (181 vs.
210 min, p = 0.09), blood loss (151 vs. 174 ml, p = 0.95)
and perioperative blood transfusions (n = 1, 8% vs. n = 0,
p = 0.30). The incidence of postoperative Clavien grade I
and II complications (n = 4, 33% vs. n = 10, 36% p = 0.99),
Clavien grade III and IV complications (n = 2, 17% vs. n = 0,
p = 0.09) and clinically significant pancreatic fistulas (n = 0
vs. n = 2, 7%, p = 0.99) also did not differ between the two
groups. There were no perioperative mortalities. There was
no significant difference in the incidence of malignancy (n
= 3, 25% vs. n = 10, 36% p = 0.71) and median length of
hospital stay (4.5 vs. 5 d, p = 0.49). One and two year survival rates were also similar in both groups (1 y = 86% vs.
88%, 2 y = 86% vs. 68%, p = 0.34).
Su1550
Robotic Spleen Preserving Distal Pancreatectomy Is
Safe and Feasible
Paritosh Suman*1,2, John Rutledge2, Anusak Yiengpruksawan2
1. Surgery, Harlem Hospital Center, New York, NY; 2. The Daniel and
Gloria Blumenthal Cancer Center, The Valley Hospital, Ridgewood, NJ
BACKGROUND: Robotic assisted minimal invasive
approach has the potential to overcome the limitations of
conventional laparosopic pancreatic resections. We analyzed
the outcomes of robotic distal pancreatectomies performed
at our institution to demonstrate the safety and feasibility of
spleen preservation during distal pancreas resections.
94
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1551
CONCLUSION: Robotic spleen preserving distal pancreatectomy is a safe and feasible surgery with similar perioperative and survival outcomes when compared to distal
pancreatectomy with splenic resection.
Quality Measures Have Improved Survival in
Pancreatic Cancer: A 21-Year Population-Based Study
Danielle M. Hari*1, Connie Chiu1, Anna M. Leung1, Stacey Stern1,
Anton Bilchik2,3
1. Surgical Oncology, John Wayne Cancer Institute, Santa Monica,
CA; 2. Surgery, David Geffen School of Medicine at University
of California, Los Angeles, CA; 3. Surgical Oncology, California
Oncology Research Institute, Santa Monica, CA
Perioperative and Survival Outcomes
Spleen Preserving
Distal
Pancreatectomy
(SPDP, n = 12)
Distal
Pancreatectomy
with Splenectomy
(SDP, n = 28)
P-Value
Operative time
(min)
181
210
0.09
Estimated blood
loss (ml)
151
174
0.95
Perioperative
blood transfusion
1
0
0.30
Clavien grade I or
II complications
4 (33%)
10 (36%)
0.99
Clavien
grade III or IV
complications
2 (17%)
0
0.09
0
2 (7%)
0.99
Clinically
significant
pancreatic fistula
ISGPF§ grade B
or C
4.5
5
0.49
1 year survival
86%
88%
0.34
2 year survival
86%
68%
0.34
§
DESIGN, SETTING, PATIENTS: Data from the National
Cancer Institute’s Surveillance, Epidemiology and End
Results program (1988–2008) were used to identity 12,772
patients who underwent surgical resection for adenocarcinoma of the pancreas. Patients were stratified according to
number of lymph nodes (LNs) examined over time.
MAIN OUTCOME MEASURES: Examination of LNs over
time (year stratums (YS) 1988–1993, 1994–1998, 1999–2003
and 2003–2008) and correlation with overall survival (OS).
RESULTS: Patients with at least 15 LNs (n = 2867) have
increased over time (by YS: 10%, 14%, 17% & 33%, p <
0.0001). While the LN positivity rate has increased so has
OS (Table 1, p < 0.0001). Median OS per LN stratum (1–9,
10–14 or >15) for localized (Stage I), regional (Stage II &
III) and distant (Stage IV) disease increased over time: local
(32, 33 and 54 months); regional (14, 16 & 18 months) and
distant (9, 11 and 12 months).
CONCLUSIONS: In the largest study evaluating pancreatic
resection for pancreas cancer, significant improvements in
surgical quality measures have occurred over the past two
decades. This may be contributing to a dramatic improvement in overall survival.
ISGPF: International study group definition of postoperative pancreatic fistula.
Histopathology
Distal
Spleen Preserving
Pancreatectomy
Distal Pancreatectomy with Splenectomy
(SPDP, n = 12)
(SDP, n = 28)
Pancreatic
Carcinoma
3 (25%)
Neuroendocrine
tumor
4 (33%)
IPMN
1 (8%)
5 (18%)
Other benign
neoplasms
3 (25%)
6 (21%)
0
0
Chronic Pancreatitis
10 (36%)
Node Positivity Rate and Overall Survival (*Only Includes Patients
with ≥1 LN Examined)
P-Value
% with
≥15 LN
Examined
% Node
Positive*
1-yr
OS
1988–1993
1318
131 (10%)
55%
42.9%
16.4%
12.4%
1994–1998
1799
242 (14%)
56%
51.8%
19.9%
13.8%
1999–2003
4419
770 (17%)
58%
55.0%
22.0%
15.5%
2004–2008
5236
1724 (33%)
62%
68.7%
30.4%
22.0%
0.71
Year
N=
Stratum (YS) 12,772
4 (14%)
95
3-yr OS 5-yr OS
Sunday
Poster Abstracts
Median length
of hospital stay
(days)
OBJECTIVE: To evaluate whether quality measures have
improved overall survival for pancreatic adenocarcinoma
after surgical resection over two decades.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1552
Su1553
Indicator for Proper Management of Surgical Drains
Following Pancreaticoduodenectomy
Autologous Islet Cell Transplantation After Extended/
Total Pancreatectomy for Treatment of Chronic
Pancreatitis: A Single Institution Experience
Kenichiro Uemura*, Yoshiaki Murakami, Takeshi Sudo,
Yasushi Hashimoto, Akira Nakashima, Hiroki Ohge, Taijiro Sueda
Surgery, Hiroshima Univ, Hiroshima, Japan
Avinash Agarwal*, Linda Langman, Preeti Chhabra,
Bartholomew Kane, Harry Dorn-Arias, Kenneth L. Brayman
University of Virginia, Charlottesville, VA
BACKGROUND AND OBJECTIVES: Recent reports
suggested that early removal of surgical drains following
pancreaticoduodenectomy (PD) reduce the postoperative
complications including postoperative pancreatic fistulas
(POPFs) with decreased hospital stay and costs. However,
the indicator for proper drain management still remains
unclear. The aim of this study was to identify the indicators
for proper drain management after PD.
OBJECTIVE: To describe the safety and efficacy of autologous pancreatic islet transplants following an extended/
total pancreatectomy as a treatment for chronic pancreatitis.
METHODS: Between January 2007 and October 2011, fifteen patients underwent an extended pancreatectomy for
definitive treatment of chronic pancreatitis. Pancreata were
surgically removed by the transplant division and sent to
the islet processing facility. The islets were isolated using
the Ricordi method, purified using Biocoll gradient and
loaded into a sterile infusion bag containing transplant
media for infusion. Three different enzymes were used for
transplants since 2007.
METHODS: Prospectively collected data from 200 consecutive patients who underwent PD were evaluated. (86
females and 114 males, median age 66 years; range 19–88).
The pancreatic anastomosis was reconstructed with a
two-layered duct-to-mucosa pancreaticogastrostomy with
internal stent. POPF was assessed using the criteria of
International Study Group Pancreatic Fistula (ISGPF). The
surgical complications were classified according to the Clavien-Dindo (C-D) classification. Predictive clinical factors
for clinically relevant POPFs (Grade B and C) were analyzed
by logistic regression analysis. Management of surgical
drains was also analyzed.
RESULTS: Nine patients underwent total pancreatectomy
with six cases of near-total pancreatectomy. Mean age was
38 years (range 15–62) with a male to female ratio of 6:9.
Fourteen of fifteen patients received and tolerated autologous islet cell infusion. One patient did not receive islet
infusion secondary to infectious concerns. The mean islet
equivalents were 202,903 ± 100,108 Islet equivalents (IEQs)
with mean IEQ/kg of 3,016 ± 1571 IEQ/kg. One year and
three year actuarial patient survival was 100% and 91%
(one case of bacteremia). There was low morbidity associated with pancreatectomy with autologous islet cell transplantation (no portal thrombosis, one pancreatic leak, one
SMA injury). No patients required insulin prior to surgery. At mean follow up of 23 ± 18 months, six patients
(43%) remain insulin independent (two patients require
oral hypoglycemics). Eight patients have a mean insulin
requirement of only 6 ± 5 U/day. At one month follow-up,
13 patients (93%) had detectable c-peptide (mean 1.7 ± 1.4
ng/mL). Overall, all patients reported a significant decrease
in pain and narcotic requirements.
RESULTS: Of 200 patients, 44 developed pancreatic fistulas; grade A in 29 patients, grade B in 12, and grade C
in 3. Thus, clinically relevant POPFs were occurred in 15
(8%). Severe surgical complications (over C-D classification
Grade3) were occurred in 17 (9%).
By univariate analysis, drain amylase on postoperative day
(POD) 2, 3, 4, 5, the color of surgical drain fluid (dark red)
on POD1,3,4, WBC on POD3,4, serum C-reactive protein
(CRP) on POD 3,4, and body temperature on POD3,4,5
were found to be significantly associated with clinically relevant POPFs (p < 0.05). By multivariate analysis on POD4,
the color of surgical drain fluid (dark red) [p = 0.01, Odds
ratio 9.8, 95%CI 1.7–58.3] and serum CRP [p = 0.03, Odds
ratio 1.2, 95% CI 1.1–1.4] were found to be independent
predictive factors for clinically relevant POPFs.
CONCLUSIONS: Autologous islet transplantation after
extensive pancreatic resection for chronic pancreatitis is a
safe and successful procedure. It offers definitive treatment
of their diseased pancreas without the morbidity of brittle
diabetes. The financial burden of chronic pancreatitis and
poor health associated with diabetes can be successfully
mitigated with pancreatectomy followed by isolation and
autologous transplantation of insulin producing islet clusters. Ideally, patients should be offered this therapy earlier
to decrease chronic abdominal pain and preserve endogenous endocrine function.
Based on the receiver operating characteristic curve analysis, serum CRP >15.6 mg/dl on POD 4 displayed the optimal sensitivity (80%) and specificity (87%).
In the patients with serous fluid in surgical drain, and
serum CRP levels <15.6 mg/dl on POD4 (n = 163, drains
to be removed on POD5), clinically relevant POPFs were
occurred in 2 (1%). 5 patients (3%) required additional
percutaneous drainage. Severe surgical complications were
occurred in 12 (7%). On the other hand, in the patients
with the dark red fluid in surgical drain, or serum CRP levels >15.6mg/dl on POD4 (n = 37, drains to be removed on
POD6 or longer), clinically relevant POPFs were occurred in
13 (35%). 5 patients (14%) required additional percutaneous drainage. Severe surgical complications were occurred
in 6 (16%) including one surgical mortality.
CONCLUSIONS: A combination of serum CRP levels and the
color of surgical drain fluid on POD4 may be indicators for
proper management of surgically placed drains following PD.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
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Su1555
National Trends in Resection of the Distal Pancreas
The Association Between Survival and the Pathologic
Features of Peri-Ampullary Tumors Varies Over Time
Armando Rosales-Velderrain*, Steven P. Bowers, Ross F. Goldberg,
Tatyan M. Clarke, Mauricia Buchanan, John Stauffer,
Horacio J. Asbun
General Surgery, Mayo Clinic Florida, Jacksonville, FL
Jennifer K. Plichta*1, Anjali S. Godambe2, Zachary C. Fridirici3,
Sherri Yong2, Margo Shoup1, Gerard V. Aranha1
1. Surgery, Loyola University, Maywood, IL; 2. Pathology, Loyola
University, Maywood, IL; 3. Stritch School of Medicine, Loyola
University, Maywood, IL
BACKGROUND: The authors queried three national patient
care databases evaluating what data is available to assess the
current status and trends for distal pancreatectomy (DP).
INTRODUCTION: Several pathologic features of periampullary tumors (of the pancreas, ampulla, distal common
bile duct, and duodenum) have been shown to be correlated with survival following resection. We aim to evaluate the association between survival and both perineural
invasion and the lymph node ratio at multiple time-points.
METHODS: From the National Inpatient Sample (NIS,
2003–9), the National Surgical Quality Improvement Project (NSQIP, 2005–10), and the Surveillance Epidemiology
and End Results (SEER, 2003–9) DP were identified using
appropriate diagnostic and procedural ICD-9 (NIS) and CPT
codes (NSQIP). Utilization of minimally invasive surgery
(MIS) was defined by ICD-9 procedure code (NIS) but it
could not be differentiated if done for resection or diagnosis which was followed by an open resection. We assessed
trends in patient demographics, surgical approach, outcome metrics, hospital demographics and surgical volume,
and oncologic outcomes.
METHODS: A retrospective chart review identified 147
patients with periampullary adenocarcinoma tumors who
underwent attempted curative resection (pancreaticoduodenectomy) between 1/1/2003 and 12/31/2008. The Social
Security Death Index was utilized to determine current living status. Clinical and pathologic features were assessed
from the medical record, and the data were analyzed using
univariate and multivariate analyses.
RESULTS: Of the 141 patients identified, there were 71
males and 70 females with an average age of 67 years. The
median follow-up was 1.7 years (vs. 5.4 years for survivors
alone), and the crude overall survival was 33% at the end
of the follow-up period. Most tumors were pancreatic in
origin (57% vs. 26% ampullary, 8.5% distal common bile
duct, and 8.5% duodenum). The average tumor size was 2.9
cm, and an R0 resection was achieved in 70% of patients.
On average, 20 lymph nodes were identified in a surgical
specimen, and at least one lymph node was positive in 66%
of patients. The median lymph node ratio was 18%, while
70% of tumors demonstrated perineural invasion. At 1 year
follow-up, 25% of patients had expired, which increased
to 60% by 3 years. Using univariate analyses, 1 year mortality was independently associated with age, tumor size,
margin status, lymph node status, lymph node ratio, and
perineural invasion. Multivariate analysis also revealed a
significant association between 1 year mortality and the
lymph node ratio (OR 1.4, p = 0.037), after adjusting for
age, tumor size, and margin status. Perineural invasion and
lymph node status were no longer significant in similar
analyses at 1 year. However, there was a significant association between 3 year mortality and both lymph node ratio
(OR 2.6, p < 0.001) and perineural invasion (OR 4.9, p <
0.001), after controlling for age, tumor size, and margin
status. Notably, perineural invasion had a stronger association with overall mortality (HR 2.56, p = 0.001) than the
lymph node ratio (HR 1.35, p < 0.001), after adjusting for
age, tumor size, and margin status. Stepwise selection modeling of overall mortality again revealed a stronger association with perineural invasion than the lymph node ratio
(HR 2.42 vs. 1.34), which also included age and tumor size.
CONCLUSIONS: Each database shows unique aspects of
the trends in DP, demonstrating their individual advantages and weaknesses. There appears to be an overall underutilization of laparoscopy for distal pancreatectomy across
the United States despite the benefits demonstrated on
multiple published series.
CONCLUSIONS: Survival appears to be more closely
related to lymph node ratio within the first year following surgery, while longer follow-up periods demonstrated a
stronger association between survival and perineural invasion at both 3 years follow-up and in overall survival.
97
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Poster Abstracts
RESULTS: NIS, NSQIP and SEER identified 4242, 2681 and
1259 distal pancreatectomy resections, respectively. Mean
age was 60.8 years (NIS) and 61.9 years (NSQIP). There
was a female predominance, (NIS 62%, NSQIP 59%, SEER
55%). Mean BMI was 28.0 and 13% of patients had BMI
>35 (NSQIP). There was no significant change of BMI or
frequency of BMI >35 over the course of study. MIS was utilized in 15% of operations and splenectomy was performed
in 72% (NIS). The use of MIS did not change significantly
over the course of the study. Resection was performed for
malignancy in 59% (NIS) and 66% (NSQIP). The mean
length of stay (LOS) was significantly longer in patients
with malignancy vs. benign disease (10.1 vs. 8.4 days, p
< 0.001, NIS; and 8.6 vs. 7.4 days, p < 0.001, NSQIP) and
LOS was reduced in resections for malignancy where MIS
was used (NIS). Mean hospital charges were $137,723.27
(NIS) and were not significantly different between MIS and
open resection. The majority of resections were performed
in teaching hospitals (77% NIS and 85% NSQIP), but MIS
was not more likely to be used in teaching hospitals. Mean
annual hospital volume for hospitals performing resection
was less than one case per year (NIS). Hospitals in the top
decile for volume were more likely to be teaching hospitals than lower volume deciles (88% vs 43%), and were no
more likely to utilize MIS at resection. Complication rate in
teaching and the top decile hospitals was not significantly
decreased.Over the time course of the study, there was significant increase in lymph node (LN) harvest at resection
for malignant disease but distribution of histologic type
(ductal 30%, IMPN 21%, NET 15% and islet cell tumor 7%)
was unchanged. One-year survival (mean 76.4%) was also
unchanged (SEER).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1556
Su1557
Epidural Use During Pancreaticoduodenectomy
Major Complication and Open Approach Are
Predictors of Prolonged Hospital Stay After
Pancreaticoduodenectomy
Nicolas Zea*1, William C. Conway1, Garret Owen2,
Darryl Schuitevoerder1, Adrianna C. Dornelles3, John S. Bolton1
1. General Surgery, Ochsner Clinic Foundation, New Orleans, LA;
2. Anesthesia, Ochsner Clinic Foundation, New Orleans, LA; 3. Center
for Health Research, Ochsner Clinic Foundation, New Orleans, LA
Michael J. Ferrara*, Naru Kondo, Florencia G. Que,
Michael B. Farnell, John H. Donohue, David M. Nagorney,
Kaye M. Reid Lombardo, Michael L. Kendrick
Mayo Clinic, Rochester, MN
INTRODUCTION: While multiple studies report favorable
outcomes with epidural anesthesia and analgesia (EAA)
use during major abdominal surgery, there is limited data
in regards to EAA use during pancreatic head resection. A
recent switch from EAA to narcotic PCA with OnQ pain
catheters, allowed us to critically evaluate outcomes in
patients undergoing a Whipple procedure with and without an epidural catheter.
BACKGROUND: Length of hospital stay is frequently
reported to be reduced with laparoscopic approaches. Few
studies have accounted for readmission hospital days which
may obviate any perceived benefit. The aim of this study
was to evaluate the impact of total laparoscopic approach
and other clinicopathologic factors on length of index hospital stay, readmission rates and total hospital days after
pancreaticoduodenectomy.
METHODS: After obtaining IRB approval, a retrospective chart review of 100 pancreaticoduodenectomies (PD)
was performed; this included our most recent 50 patients
without EAA use, and the last 50 patients with EAA just
before we discontinued using this device, with all cases
spanning from March of 2008 to July of 2011. Peri-operative and immediate post-operative clinical outcomes were
compared.
METHODS: A retrospective review of clinical, pathologic
and outcomes data was performed for all patients undergoing pancreaticoduodenectomy from January 2007 through
December 2010 at a single institution. Initial hospital stay,
readmission rates, and total hospital stay (initial hospital
days plus readmission days) were compared between total
laparoscopic pancreaticoduodenectomy (TLPD) and open
pancreaticoduodenectomy (OPD). The relationship between
the clinicopathological factors and total hospital stay was
investigated using univariate and multivariate analyses.
RESULTS: For obvious reasons, but not without importance, EAA patients had longer time from anesthesia start
time to surgery start time (p = 0.004). The EAA group had
significantly higher rates of intra-operative hypotension (p
= 0.001), and revealed a trend towards a higher intra-operative blood transfusion rate (56% EAA vs. 38%, p = 0.071). No
statistical significance was found between groups in terms
of length of surgery, estimated blood loss, or intra-operative fluid administration. Post-operatively, EAA patients
had a significant delay in diet initiation (8 days vs 5.6 days,
p = 0.015), and a higher requirement of post-operative fluid
administration on post-op day # 1 (3,983 ml VS. 3,088.1
ml, p = 0.001). Although the overall morbidity rate was
similar between the two groups, the EAA group had higher
rates of urinary tract infections (5/50 VS. 1/50), and intraabdominal abscess (5/50 VS. 0/50). 10 of 50 (20%) patients
in the EAA group had premature discontinuation of epidural catheter secondary to hypotension or inadequate pain
control. Length of stay was similar between the two groups
(EAA- 17 days VS. PCA- 15.1 days, p > 0.05).
RESULTS: A total of 527 patients were identified having
undergone TLPD (n = 125) or OPD (n = 402). There were
no differences in mean age, BMI or ASA Score. A malignant diagnosis was more common in patients undergoing OPD (80% vs. 68%, p = 0.004), however, there were
no differences in overall or pancreas specific postoperative
complication rates. Median length of hospital stay was
less for the laparoscopic group (7 vs. 10 days, p < 0.001).
Hospital readmission within 30 days was observed in 16%
and was not different between the TLPD and OPD groups
(14% vs. 17%, p = 0.4) Common diagnoses on readmission
included pancreatic fistula (25%), delayed gastric emptying (21%), and abdominal collection or abscess (20%). Of
patients requiring readmission, 62% had Clavien grade 3 or
4 complications diagnosed during initial hospitalization or
at subsequent readmission. Median length of readmission
hospital stay was 5 days for both TLPD and OPD groups.
When accounting for readmission days, total hospital days
were less for patients undergoing TLPD compared to OPD (8
vs.11, p < 0.001). Multivariate analysis demonstrated that
Clavien Grade ≥3) complication (HR 6.9, 95% CI 4.3–11.5,
P < 0.001) and open approach (HR 2.5, 95% CI 1.5–4.4,
P < 0.001) were independent predictors of prolonged total
hospital stay.
CONCLUSIONS: In the current study, EAA during PD was
associated with a delay in surgery start time, increased
episodes of intra-operative hypotension, a trend toward
increased intra-operative blood transfusion and a 20%
device failure rate. While pain relief may be excellent with
EAA, these issues must be considered when selecting a perioperative pain control strategy.
CONCLUSIONS: Compared with open approaches, TLDP
results in shorter hospital stay, similar readmission rates
and less total hospital days. Major complication and open
approach are independent predictors of prolonged total
hospital stay. Limitations of this study include potential
selection bias as noted by a higher incidence of malignancy
in the open group. The impact of reduced hospital stay on
cost and patient-specific advantages such as improvement
in quality of life needs to be evaluated.
98
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1558
after R1 resection (Figure). Among patients treated with
preoperative therapy, median overall survival was 26 and
15 months with negative margin width of >1 mm and ≤1
mm, respectively (p = 0.002). Width of negative margin
did not significantly affect survival among patients who did
not receive preoperative therapy.
Defining Resection Margins in Pancreatic Cancer After
Neoadjuvant Chemoradiotherapy
Alan A. Thomay*, John P. Hoffman, Yun Shin Chun
Fox Chase Cancer Center, Philadelphia, PA
BACKGROUND: Although surgical margin status is an
established prognostic factor after resection of pancreatic
adenocarcinoma, there is no consensus on what constitutes R0 versus R1 resection. R1 resection is defined in
North America as the presence of cancer cells at a resection margin and in Europe, as tumor up to 1 mm from a
resection margin. We sought to determine the association
between width of resection margin and recurrence rates
and survival.
CONCLUSIONS: Resection margin status is associated
with overall survival but not local recurrence rates. Width
of negative margin >1 mm is a significant prognostic factor
among patients treated with neoadjuvant therapy but not
among patients undergoing upfront surgery.
METHODS: Retrospective analysis was performed of 301
consecutive patients undergoing pancreaticoduodenectomy for adenocarcinoma of the pancreatic head or uncinate process at a single institution over a 20 year period
(1991–2011). Adenocarcinomas arising within IPMN or
mucinous cystadenomas were excluded. Analyzed variables included age, sex, margin status, use of neoadjuvant
therapy, recurrence, and survival. A p value <0.05 was considered significant.
Su1559
Clinical: Small Bowel
Somatostatin Analogues for the Treatment of
Enterocutaneous Fistulas: A Systematic Review and
Meta-Analysis
Shaun Coughlin*
Surgery, University of Western Ontario, London, ON, Canada
BACKGROUND: Enterocutaneous fistulas are abnormal
connections between the skin and gastrointestinal tract
that most commonly occur following surgery. Somatostatin analogues have been used in their treatment. Our objective was to determine if somatostatin analogues shorten
the time to closure of post-operative enterocutaneous fistuals compared to placebo.
RESULTS: Our initial search yielded 720 studies, of which
8 RCTs ultimately met eligibility criteria and were included
in this review. Somatostatin analogues significantly
decreased the time to closure of fistulas compared to placebo (Weighted mean difference (WMD) –6.37 days [95%
CI –8.33, –4.42]). The duration of hospital stay was also significantly decreased with somatostatin analogue treatment
(WMD –4.53 days [95% CI –8.29, –0.77]). No difference in
mortality was identified with somatostatin treatment (Relative risk 0.87 [95% CI 0.49 to 1.55]).
RESULTS: Of the 301 patients, 102 (34%) received preoperative chemoradiation, and 199 did not. The resection
margin was grossly positive (R2) in 4 patients (1%), microscopically positive (R1) in 108 (36%), negative by ≤1 mm in
54 (18%), and negative by >1 mm in 135 (45%). Resection
margin status did not correlate with rates of local or distant
recurrence (p > 0.05). Overall survival was similar among
patients with negative margin width of ≤1 mm vs. >1 mm,
with median survival rates of 19 and 21 months, respectively, contrasted with a median survival of 13 months
CONCLUSION: Somatostatin analogues appear to decrease
the duration of enterocutaneous fistuals and duration of
hospital stay while no mortality benefit was identified.
The quality of evidence for outcomes in this review ranged
from low to moderate. Future, large, blinded randomized
controlled trials would be useful in improving the confidence in the treatment effects identified in this systematic
review and meta-analysis.
99
Sunday
Poster Abstracts
METHODS: We searched Medline, EMBase, The Cochrane
Central Register of Controlled Trials, as well as reference
lists of textbooks and relevant articles for randomized controlled trials comparing somatostatin analogues to control
in the treatment of post-operative enterocutaneous fistulas.
We systematically assessed trials for eligibility and validity, and extracted data in duplicate. We pooled data across
studies using a random effects model.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
ondary outcome complication rates. The average length of
post-operative stay was similar in all groups. Use of steroids
was not associated with a difference in EPC or length of
stay in any group, removing patients on budesonide alone
had no effect. However, a greater proportion of ALLT pts
were on steroids 43.4% vs. 18.4%, p = 0.001 compared to
the IM group at the time of surgery.
Su1560
Timing of Pre-Operative Anti-Tumor Necrosis Factor
Therapy Does Not Affect Early Post-Operative
Complication Rates in Inflammatory Bowel Disease
Patients Undergoing Intestinal Resection
Parin N. Desai, Anil Sharma, Amar S. Naik, Mary F. Otterson,
Yelena Zadvornova, Lilani P. Perera, Nanda Venu, Daniel J. Stein*
Medical College of Wisconsin, Milwaukee, WI
INTRODUCTION: Patients with moderate to severe
inflammatory bowel disease (IBD) have a high likelihood of
being exposed to anti-tumor necrosis factor (TNF) therapy
as well as undergoing an operative resection. Studies looking at preoperative anti-TNF therapy effects on the early
post-operative period have shown contradictory findings.
Some physicians time operations with the nadir of the antiTNF therapy to minimize their immunosuppressive effect;
however it is unclear if this practice improves outcomes.
AIMS: 1) Determine early post-operative complication (EPC)
rates in IBD patients on anti-TNF therapy compared to
patients on immunomodulators (IM) alone and 2) assess
the effect of remote versus immediate anti-TNF pre-operative
therapy on EPC rates.
METHODS: A retrospective review of a prospectively collected database of pts with IBD who underwent resection
of small or large intestine from July 1st, 2005 to July 1st,
2010 was performed. Main outcome of interest was the
combined EPC rate, defined as any of the following secondary outcomes: infection, anastomotic leak, re-admission,
reoperation, thrombosis, acute kidney injury (AKI), ileus,
or new drain within 30 days after surgery. All pts on antiTNF therapy (ALLT) were compared to pts on IM alone. The
ALLT group was divided into remote preoperative (RP) and
immediate preoperative (IP) groups; pts receiving a TNF
dose greater than and less than ½ of their dosing interval
prior to the operation, respectively.
RESULTS: A total of 114 pts (60% F; 86.8% Crohn’s Disease) had resections, 76 ALLT pts (46 IP and 30 RP pts) and
38 IM pts. All groups were similar in terms of age, gender,
race, smoking, and disease duration; except ALLT had a
higher prevalence of penetrating CD than the IM group
(43% vs. 29.4%; p = 0.05). Comparison of the ALLT to the
IM alone group showed no difference (43.4% vs. 26.3%, p
= 0.08) in terms of the combined EPC rates, or in individual secondary outcome rates. Comparison of the IP and RP
groups showed no significant difference (21.7% vs. 30.0%
p = 0.16) in the combined EPC rate, or in individual sec-
CONCLUSION: Despite an increased likelihood of being
exposed to steroids and having more severe CD, patients
on pre-operative anti-TNF therapy had similar EPC rates
compared to IM only patients. Further investigation of
anti TNF therapy timing in the pre-operative period is warranted to recognize its contribution to EPC rates and to
optimize treatment in the peri-operative period.
Su1561
Endoscopic Ultrasound (EUS) Evaluation in the
Surgical Treatment of Duodenal and Peri-Ampullary
Adenomas
Lilian C. Azih*1, Brett L. Broussard1, Milind A. Phadnis2,4, Martin
J. Heslin1, Mohamad A. Eloubeidi3,2, Shyam Varadarajulu2, Juan
Pablo Arnoletti1
1. General Surgery, University of Alabama Birmingham, Birmingham,
AL; 2. Gastroenterology, University of Alabama Birmingham,
Birmingham, AL; 3. Gastroenterology, American University of Beirut,
Beirut, Lebanon; 4. Biostatistics, University of Alabama, Birmingham,
AL
INTRODUCTION: Precise characterization of benign
duodenal and peri-ampullary tumors, offers a diagnostic
challenge to reliably distinguish adenomas from malignant lesions and render the possibility of trans-duodenal
resection. EUS has emerged as a useful technique in assessing tumor depth of invasion and is often employed at
our institution when planning therapeutic approach. We
performed a retrospective review of patients with benign
duodenal and peri-ampullary adenomas who underwent
preoperative EUS to determine the accuracy of this technique in predicting the absence of muscular invasion and
also to analyze outcomes associated with endoscopic and
trans-duodenal surgical resection.
METHODS: Records of 111 patients seen at our institution over the last 10 years with post-operative pathological diagnosis of benign ampullary and duodenal adenomas
were identified and reviewed. We analyzed information on
patient gender, age, tumor location and size, EUS results,
type of resection performed, final pathology findings and
incidence of local tumor recurrence.
100
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: Among 111 patients with benign ampullary
and duodenal adenomas, 47 underwent preoperative EUS
for 29 periampullary lesions and 18 duodenal lesions. In
38 (81%) patients, EUS reliably identified absence of sub
mucosal and muscularis invasion. In 4 cases, EUS underestimated sub mucosal invasion that was proven by pathology.
In the other 5 patients, EUS predicted muscularis invasion
which could not be demonstrated in the resected specimen. Type of resection performed included endoscopic
resection in 25 cases, partial duodenectomy in 6 cases,
transduodenal ampullectomy with sphincteroplasty in 10
cases and pancreaticoduodenectomy in 6 cases. There were
6 local recurrences (13%; median follow-up = 20 months)
4 of which were in patients with Familial Adenomatous
Polyposis (FAP). The main post-operative final pathological results included villous adenoma (n = 5), adenoma
(n = 6), tubulovillous adenoma (n = 10), tubular adenoma
(n = 20) and hyperplastic polyp (n = 2),. Among the 47
patients who underwent resection, 8 (17%, 5 of which corresponded to surgical resection) developed post-procedural
complications which included retroperitoneal hematoma,
intraabdominal abscess, wound infection, delayed gastric
emptying and prolonged ileus.
CONCLUSION: EUS can accurately predict depth of mucosal invasion in 81% of benign ampullary and duodenal
adenomas. These patients can safely undergo endoscopic
or local resection with acceptable local control rates sparing the need for more extensive operations.
Su1562
Daniel I. Chu*, Melanie L. Gainsbury, Lauren A. Howard,
Arthur F. Stucchi, James M. Becker
Department of Surgery, Boston University Medical Center, Boston, MA
BACKGROUND: Adhesive-related intestinal obstructions
(AIOs) are a significant cause of morbidity and mortality
for the surgical patient. Classical surgical teaching advocates a watchful waiting period of 2-days before operating
on an AIO, but it remains unclear whether an early or late
DESIGN: Patients undergoing adhesiolysis for intestinal
obstruction were identified from the 2007 Nationwide
Inpatient Sample (n = 8,034,632) and stratified to early
(≤2 days from admission) vs. late (>2 days) adhesiolysis.
The primary outcome comparison was in-hospital mortality and secondary outcomes were post-operative complications (POCs), post-operative length of stay (PLOS) and
in-hospital cost. Propensity score methods were used to
balance patient characteristics before making outcome
comparisons. As a secondary analysis, different cut-off days
(from 1 and 3 to 10 days post-admission) of adhesiolysis
were used to redefine early versus late groups and reanalyzed for the above outcomes.
RESULTS: From 5,443 patients who underwent adhesiolysis for AIOs in the United States in 2007, 53% and 47%
underwent early and late adhesiolysis, respectively. Late
adhesiolysis patients were older (65.0 vs. 60.1), differed in
insurance (55.4% vs. 44.4% Medicare-covered), and had
14 co-morbidities with increased frequency compared to
the early group (p < 0.05). After adjustment by propensity score methods, no difference in mortality (odds ratio
[OR] 0.95, 95% confidence-intervals [CI] 0.67–1.36, p =
0.79) or POCs (OR 1.01, 95%CI 0.89–1.14, p = 0.91) was
observed between the two groups. Patients undergoing late
adhesiolysis, however, had increased PLOS (9.8% increase
in days, p < 0.001) and in-hospital cost (41.9% increase in
cost, p < 0.001) compared to the early group. Repeat analysis with redefined early and late adhesiolysis groups at different procedure days showed that mortality significantly
increased when adhesiolysis was performed 8 days after
admission (OR 2.06, 95% CI 1.21–3.53, p < 0.01) while no
differences in POCs were observed.
CONCLUSIONS: These data suggest that the historicallybased 2-day time limit of waiting is not associated with
increased mortality or POCs for those patients undergoing adhesiolysis for an AIO, but instead is associated with
increased PLOS and in-hospital cost. Risk of mortality was
found to increase after 8 days of admission, and future
studies will need to better understand this observation.
101
Sunday
Poster Abstracts
Early Versus Late Adhesiolysis for Adhesive-Related
Intestinal Obstruction: A Nationwide Analysis of
Inpatient Outcomes
adhesiolysis is most beneficial and cost-effective. Our aim
was to compare the clinical and cost outcomes of early versus late adhesiolysis for AIOs.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Stomach
Su1563
Evaluation and Treatment of Gastric Stimulator Failure
Nancy Salloum*1, Micah R. Walker1, Patrick A. Williams1,
Yana Nikitina1, Thomas S. Helling2, Thomas L. Abell1,
Christopher J. Lahr2, James Griffith1
1. Digestive Diseases, University of Mississippi Medical Center, Jackson,
MS; 2. Surgery, University of Mississippi Medical Center, Jackson, MS
INTRODUCTION: Some patients who undergo gastric
electrical stimulation (GES) for gastroparesis (GP) develop
recurrent symptoms i.e.: vomiting, nausea, early satiety,
bloating, and abdominal pain despite an initial good result,
replete with a functioning stimulator and unbroken leads.
This study evaluates treatment for these patients, which
includes temporary stimulation at a new gastric location
and if symptoms are relieved this is followed by implantation of new leads and stimulator. We expect symptom
scores to significantly decrease in the control group; we
hypothesize that the symptom scores will also show a significant decrease in the replacement group.
PATIENTS: 15 patients with recurrent symptoms after
placement of GES have undergone surgical insertions of a
new gastric electrical stimulation (GES) system. Of the 15
replacement surgeries, 10 (67%) were female, 5 were male
(33%) (mean age of all: 45), and 3 (20%) had diabetesinduced gastroparesis; the remainder (80%) were either
idiopathic, post-surgical, or sarcoidosis-induced.
Of 87 patients without recurrent symptoms after placement of GES who have not needed a replacement, 15 were
selected as the control arm, matched by the three variables
of investigator-derived independent outcome score (IDIOMS), baseline symptom scores before initial GES implantation, and etiology of disease (i.e. diabetic or idiopathic).
METHODS: Each patient met specific indications to receive
GES replacement surgery. All patients had a preoperative
diagnosis of either diabetic or idiopathic, drug-refractory,
or post-surgical gastroparesis, and disordered gastric emptying with significant weight change. Patients with failed
GES were evaluated over a 1–2 week period with insertion
of a temporary endoscopic gastric stimulator. Patients with
a positive response to temporary stimulation undergo GES
replacement surgery. Common gastroparesis symptoms were
evaluated before and after gastric pacemaker replacement
using the Likert score system 0–4. These symptoms include
vomiting, nausea, epigastric pain, early satiety and bloating.
RESULTS: See Tables 1 and 2. Total score of symptoms
improved for 12 out of the 15 (80%) patients that underwent the GES replacement surgery. The frequency, amplitude, freq/amplitude ratio (FAR), and gastric emptying
times (GET) are displayed to reinforce physiological similarity between the two groups.
CONCLUSION: Trial gastric mucosal electrical stimulation followed by implantation of new leads and stimulator
successfully salvages the majority of patients whose gastric
electrical stimulator is no longer relieving symptoms.
Table 1: Comparison of Mean Pre-Op and Mean Post-Op Symptom Scores
Replacement (n = 15)
Mean of Pre-Op Scores
Mean of Post-Op Scores
Difference in Symptom Scores
p-Value of Difference
Vomiting ± SD
3.2 ± 1.3
2.1 ± 1.3
1.2
0.001
Nausea ± SD
3.9 ± 0.3
3.3 ± 1.1
0.6
0.088
Early satiety ± SD
3.3 ± 0.6
2.4 ± 1.5
0.9
0.041
Bloating ± SD
3.3 ± 0.6
2.5 ± 1.5
0.8
0.057
Epigastric pain ± SD
3.6 ± 0.6
3.3 ± 1.4
0.3
0.24
Total Score ± SD
No Replacement (n = 15)
17.3 ± 1.6
13.6 ± 3.7
3.6
0.017
Mean of Pre-Op Scores
Mean of Post-Op Scores
Difference in Symptom Scores
p-value of Difference
0.019
Vomiting ± SD
3.0 ± 0.9
2.0 ± 1.5
1.0
Nausea ± SD
3.2 ± 1.2
3.0 ± 0.9
0.2
0.5
Early satiety ± SD
3.1 ± 1.0
2.4 ± 1.1
0.7
0.019
Bloating ± SD
2.8 ± 1.2
2.6 ± 1.1
0.2
0.7
Epigastric pain ± SD
3.1 ± 1.4
3.0 ± 1.2
0.1
0.88
Total Score ± SD
15.8 ± 3.6
12.3 ± 3.5
3.5
0.011
Table 2: Comparison of Mean EGG Values
Frequency ± SD
Replacement (n = 15)
No Replacement (n = 15)
p-value
Normal EGG values
5.5 ± 3.0
5.8 ± 1.5
0.73
2.7–3.3
Amplitude ± SD
0.44 ± 0.6
0.6 ± 0.6
0.54
0.5
Freq/amp ratio ± SD
31.2 ± 31.5
32.4 ± 42.3
0.94
<10
Gastric emptying time (GET), 1;2;4 hr (%)
72, 49, 25
76, 48, 22
0.61, 0.96, 0.77
Total GET (%) ± SD
146 ± 59
146 ± 60
0.99
Table is displayed to reinforce physiological similarity between the two groups.
102
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Su1564
Su1565
Thromboembolic Events After Laparoscopic Adjustable
Gastric Band: Identification of High-Risk Factors
Changes in Quality of Life Before Roux-en-Y Gastric
Bypass for Morbidity Obesity and After a Short and
Long Term Follow-Up
Chad Gonczy*, Imran Hassan, Sajida Ahad, Stephen Markwell
SIU School of Medicine, Springfield, IL
INTRODUCTION: In-hospital prophylaxis against thromboembolic events (TE) is considered routine for patients
after laparoscopic adjustable gastric band (LAGB) for morbid obesity due to the increased risk of TE in this patient
population. However, there are limited data regarding the
benefit of extending this prophylaxis beyond discharge.
Utilizing the American College of Surgeons-National Surgery Quality Improvement Project (ACS-NSQIP) database,
we analyzed patients undergoing LAGB to determine the
incidence of pre- and post-discharge TE and associated risk
factors.
METHODS: Patients undergoing LAGB between 2005–2009
were identified from the public use file of the ACS-NSQIP
database using the Current Procedural Terminology code
for LAGB. Univariate comparison and regression analysis
of demographics and comorbidities of patients with and
without TE were performed to determine independent risk
factors for the development of TE.
INTRODUCTION: Roux-en-Y gastric bypass is considered
an effective therapy for weight loss although weight regain
may be observed in a long-term follow-up. It is unclear if
quality of life is sustained in a long-term follow-up when
weight regain occurs.
METHODS: Three groups were studied: Group A—50
patients (88% females, age 51, BMI 37Kg/m2, time of follow-up 112 months) submitted to Roux-en-Y gastric bypass
more than 7 years, Group B—50 patients (82% females, age
44, BMI 31Kg/m2, time of follow-up 17 months) submitted to Roux-en-Y gastric bypass 1–2 years, Group C—50
patients (80% females, age 42, BMI 47Kg/m2) morbid obese
in the pre-operative period. We use the MOS 36-Item ShortForm Health Survey (SF-36) to analyze the quality of life
differences among the 3 groups.
RESULTS: Groups were similar for gender. Group A was
older than the other groups due to the time from operation. BMI was significantly lower for Group B compared to
Group C and higher for Group A compared to Group B. SF-36
parameters are depicted in Table 1 on next page. Physical
Functioning, Social Functioning, Emotional Problems and
Mental Health were not different when the 3 groups were
compared (p = 1). Role Functioning, Pain, General Health
Perceptions and Vitality showed an increase after the operation and a significant decrease at the 7 year follow-up (p
< 0.0001) (Figure).
Significant Independent Risk Factors After LAGB
Risk Factor
Odds Ratio
P-value
Transfusion in OR
101.24
<0.0001
Cardiac Complications Excluding PE
27.95
<0.0001
Reoperation
17.71
<0.0001
Non-caucasian
3.28
0.01
Age ≥40 years
6.27
0.02
OR Time
2.58
0.05
CONCLUSION: The 30-day incidence of thromboembolic
events after LAGB in ACS-NSQIP hospitals is exceedingly
low, although the majority of these events occur following
discharge. Certain patients are at higher risk for TE, and
may represent a cohort that could benefit from extended
post-operative prophylaxis.
CONCLUSIONS: Some Quality of Life parameters are
not changed by Roux-en-Y gastric bypass while others
are improved by the operation even though a significant
decreased is noted at a long term follow-up.
103
Sunday
Poster Abstracts
RESULTS: During the study period, 16,015 patients
underwent LGB, of whom 19 (0.12%) developed a TE (10
(0.062%) developed a pulmonary embolus, 11 (0.069%)
developed a deep-vein thrombosis, and 2 developed both)
within 30 days of surgery. Eighty percent of the pulmonary embolisms and ninety-one percent of the deep venous
thromboses were diagnosed after discharge. On regression
analysis several patient characteristics, medical comorbidities and postoperative complications were independently
associated with increased risk of TE. (Table)
Rafael M. Laurino Neto*, Fernando A. Herbella
Federal University of São Paulo, São Paulo, Brazil
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Table 1: SF-36 Concepts for the 3 Groups
Role
Functioning
Physical
Functioning
Pain
General Health
Perceptions
Vitality
Social
Functioning
Emotional
Problems
Mental
Health
Group A
77 (50–88)
75 (6–100)
51
(22–70)
72 (58–84)
55 (40–75)
68 (40–87)
66 (33–100)
66 (48–83)
Group B
95 (86–100)
100 (75–100)
84
(61–100)
92 (87–100)
85 (75–90)
100 (87–100)
100 (100–100)
90 (80–92)
Group C
50 (25–68)
37 (0–75)
41
(31–74)
54 (40–75)
40 (30–70)
56 (37–84)
33 (0–100)
58 (33–75)
Data presented as median (interquartile range 25–75).
Su1567
Laparoscopic Gastric Pacer Therapy for Medical
Refractory Diabetic and Idiopathic Gastroparesis
Poochong Timratana*1, Kevin M. El-Hayek1,2, Hideharu Shimizu1,
Matthew Kroh1,2, Bipan Chand1
1. Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH;
2. Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
BACKGROUND: Gastroparesis is a disorder of chronic
nausea and vomiting that may result in failure to thrive.
Etiologies are multifactorial, but most often are classified as
diabetic, idiopathic, post-surgical, or medication induced.
Several large series have shown efficacy of gastric pacer
implantation in certain groups with gastric dysfunction.
However, laparotomy is often employed for placement.
The aim of this study is to review outcomes of all patients
who underwent gastric pacer therapy regardless of etiology.
METHODS: Patients who underwent gastric pacer (Enterra
Therapy System; Medtronic, Minneapolis, MN) implantation with subsequent interrogation and programming
between March 2001 and November 2011 were analyzed.
Data reviewed included demographics, pre-operative
symptoms, operative technique, and post-operative symptom and nutritional improvement.
RESULTS: A total of 113 patients underwent gastric pacer
placement during the study period. Mean age was 40 years
(19–88) and 83% of patients were female. Operations were
completed laparoscopically in 110/111 cases, with one
conversion to laparotomy due to severe adhesions. Two
cases involved pacer revision for battery replacement. Gastroparesis symptoms were present for a mean duration of
4.8 years prior to surgery (1–20). Surgical intervention was
only offered for patients with medical refractory diabetic
and idiopathic gastroparesis. Prior to implantation, thirtythree patients were on supplemental nutrition (23 on jejunal feeds and 10 on total parental nutrition). There were
no operative or immediate peri-operative complications.
Battery depletion occurred in 6 patients at a mean interval
of 75 months. Pacer malfunction occurred in 4 cases. Two
of these cases required removal secondary to lead erosion,
1 underwent conversion to Roux-en Y gastric bypass, and 1
had no therapy. At a mean follow-up of 24 months, symptom improvement was achieved in 91 patients (80%) and
was similar for both the diabetic and idiopathic subgroups.
Post-operatively, 15 of 23 patients were able to discontinue supplemental nutrition. BMI increased in both the
idiopathic and diabetic cohorts (see Graph 1 and 2). Four
patients underwent conversion to laparoscopic Roux-en-Y
gastric bypass for persistent poorly controlled symptoms
and morbid obesity with associated comorbidities. Symptom control was achieved in 2 of these patients with an
overall mean excess weight loss of 22% (8–39) at 7 month
follow-up (3–12).
CONCLUSION: Gastric pacer placement is feasible using a
laparoscopic approach. Medical refractory gastroparesis in
the diabetic and idiopathic groups had significant symptom improvement with no difference between the two
groups. Gastric pacing may decrease the need for ongoing
supplemental nutrition.
Su1568
Assessment of Muscular Loss After Bariatric Surgery
Through Bioimpedancy
Wilson R. Freitas*, Paulo Kassab, Roberto D. Cordts Filho, Elias J.
Ilias, Osvaldo A. Castro, Fabio Thuler, Paulo G. Porto, Carlos A.
Malheiros
Surgery, Santa Casa São Paulo Medical School, São Paulo, Brazil
BACKGROUND: The evident weight loss observed during the first six months after bariatric surgery is due to the
reduction in body fat and muscular mass. There is, however, the need to keep track the body composition of obese
patients during this period of time in order to monitor the
different body composition fractions such as water, fat-free
mass, and fat. Bioimpedancy is a useful tool to assess body
composition and a portable and easy-to-use alternative to
determine variations of these fractions in obese patients
during their weight loss period.
METHODS: Thirty-six morbid obese patients were subjected to gastroplasty with silastic ring and Roux-en-Y distal gastric bypass, and their percentages of fat, water, and
fat-free mass were measured the day before the surgery, as
well as 2, 4, and 6 months after the surgery. A four-channel
Bioelectrical Body Composition Analyzer, which measures
the difference between upper right limb and lower right
limb was used.
104
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: The results indicated a pattern in the measurements obtained in all cases. A linear reduction of the
average fat content was observed, ranging from 50.9% at
the pre-operatory to 40.8% 6 months after the surgery.
The results also showed a linear reduction of average BMI,
which varied from 55.1 kg/m2 to 37.7 kg/m2 in 6 months,
and a linear increase of water content varying from 35.9%
to 43.4% during the same period. Although there was
a decrease in the total fat-free mass (76.9 kg to 62.7 kg),
an increase in its percentage relative to the total weight
(49.1% to 58.9%) was observed during the study.
CONCLUSIONS: Bioimpedancy measurements carried out
up to 6 months after the surgery did not reveal significant
loss in muscular mass, indicating only a minor effect of
malnutrition associated to weight loss, and an increase in
the percentage of fat-free mass relative to the total weight.
Su1569
Timing of Resolution of Comorbidities in Patients
with Laparoscopic Adjustable Gastric Banding (LAGB)
N = 698
David A. Nguyen*, Grace J. Kim, Regina M. Ramos, Carson D. Liu
Surgery, SkyLex Advanced Surgical Inc., Santa Monica, CA
INTRODUCTION: Bariatric surgery has been shown to be
an effective solution for sustainable weight loss in the morbidly obese. This study aims to investigate the impact of
LAGB on weight loss and obesity comorbidities (diabetes,
hypertension, sleep apnea, and hypercholesterolemia).
RESULTS: Analysis reveals that the first two years after
LAGB are most critical for excess weight loss. The average
percentage excess weight loss achieved was 54.2% ± 3.6%
at year one, 67.9% ± 4.5% at year two, and 74.3% ± 7.5% at
year three after band implantation. Average change in body
mass index was 11.9 kg/m2 ± 1.6 kg/m2. Resolutions of
comorbidities were analyzed each year after band implantation. Diabetes was resolved in 49% of the patients at year
one, 58% at year two, and 61% at year three. Hypertension
was resolved in 37% of the patients at year one, 45% at year
two, and 53% at three. Obstructive sleep apnea was resolved
in 63% of the patients at one, 76% at year two, and 91%
at year three. Hypercholesterolemia was resolved in 45% of
the patients at year one, 59% at year two, and 65% at year
three. Of note, many patients continued their cholesterol
medications with normal levels post-operatively. There was
no mortality in the span of four years of the study.
CONCLUSION: We are reporting a four year consecutive data with no deaths and resolution of comorbidities were observed to be long lasting in correlation with
their weight loss. We are reporting continued weight loss
Su1570
Is Laproscopic Single Stage Bilio-Pancreatic Diversion
Safe in the Super-Morbidly Obese?
Sidhbh Gallagher*, Gintaras Antanavicius, Iswanto Sucandy,
Amarita Klar, Fernando Bonanni
Department of Surgery, Abington Memorial Hospital, Abington, PA
BACKGROUND: It is hypothesized that the morbidity
and mortality of laproscopic bilio-pancreatic diversion
with duodenal switch (LBPD/DS) are likely to increase
with increasing body mass index (BMI), especially when
>50 kg/m(2). Some authors, therefore, advocate a two-stage
approach to this procedure in the super-morbidly obese. We
hypothesize that a BMI ≥50 kg/m(2) does not significantly
influence peri-operative morbidity with this procedure.
METHODS: A prospective database of all patients who
underwent laproscopic/robotic bilio-pancreatic diversion
with duodenal switch between January 2009 and September
2011 was analyzed. Two groups were identified: those with
BMI <50 kg/m(2) (Group 1) and those with BMI ≥50 kg/m(2)
(Group 2). Patient demographics, length of procedure (LOP),
intra-operative complications, conversion to open rates and
postoperative outcomes, including 30-day complication
rate, rate of re-operation at 30 days, rate of other interventions, length of stay (LOS) and readmission were compared.
T-test and Fischer’s exact test were used where appropriate.
P-values <0.05 were considered significant.
RESULTS: 226 patients underwent (LBPD/DS). Mean
patient age was 44.9 years (range: 20–72). 170 (75%) of
patients were female. Mean BMI was 50.2 kg/m(2) (range:
37.2–68.8). 127 had BMI <50 kg/m(2) (Group 1), and 99
had a BMI ≥50 kg/m(2) (Group 2). The LOP in Group 1 was
296 minutes and 287 minutes in Group 2 (p = 0.25). The
rate of conversion to open was 3% in Group 2 and 1.5% in
Group 1 (p = 0.65).
There were no mortalities. Only one intra-operative complication occurred in Group 1; none in Group 2. The rate of stenosis requiring endoscopic intervention was 0.7% in Group
1 and 1% in Group 2 (p = 1.0). Two leaks occurred in Group
1; no patient in Group 2 developed these complications.
One patient in Group 2 developed pulmonary embolism.
The rates of all other complications resulting in a longer LOS
were 11% in Group 1 and 8% in Group 2 (p = 0.50).
The 30-day re-operation rate was 3% in Group 1 and 1% in
Group 2 (p = 0.39). The rate of re-intervention (endoscopic
or percutaneous) was 1.57% in Group 1 and 1% in Group
2 (p = 1.0). The mean LOS was 3.97 days for Group 1 and
3.67 for Group 2 (p = 0.34). The 30-day readmission rate
was 11% in Group 1 and 10% in Group 2 (p = 1.00).
CONCLUSION: BMI ≥50 kg/m(2) does not increase intraoperative or postoperative complications at 30 days in (
LBPD/DS ). No significant differences were noted between
the 2 groups in any of the outcomes. A single-stage procedure can be safely offered to patients with BMI ≥50 kg/m(2).
105
Sunday
Poster Abstracts
METHODS: 698 patients with average preoperative BMI of
42.1 ± 6.5 were retrospectively analyzed through electronic
medical records from 2007–2011. Of those patients, 18.3%
were men and 81.7% were women, with a mean age of 43.
Resolution of comorbidities and weight loss were analyzed
at three different intervals after band implantation (after
year one, year two, and year three). All adjustments were
performed in clinic setting without fluoroscopy. Analysis
was performed with ANOVA. *P < 0.05 considered statistical
significance.
and improvement of co-morbid conditions are years after
implantation of the adjustable gastric band. Lifestyle changes
which include diet, exercise, and stress management in addition to follow up with the adjustable gastric band are key
components in resolution of medical co-morbidities.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Su1571
Su1572
Laparoscopic Median Arcuate Ligament Release: Are
We Improving Symptoms?
Is Weight Loss Correlated with Race in Laparoscopic
Adjustable Gastric Banding (LAGB) Patients? Yes
Grace J. Kim*, David A. Nguyen, Regina M. Ramos, Carson D. Liu
Surgery, SkyLex Advanced Surgical Inc., Santa Monica, CA
Kevin M. El-Hayek1, Jessica Titus*1, Au Bui1, Tara M. Mastracci2,
Matthew Kroh1
1. Digestive Disease Institute, Cleveland Clinic, Cleveland, OH;
2. Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
BACKGROUND: Median arcuate ligament syndrome is a
rare disorder characterized by abdominal pain, weight loss,
and isolated celiac stenosis. Though the diagnosis is often
difficult to determine, it can be made with vascular ultrasound, axial imaging with angiography, or formal angiography. Several reports have shown that surgical release
of the median arcuate ligament is a durable and effective
treatment option for symptomatic patients. We present our
experience using a laparoscopic approach for this particularly uncommon problem.
METHODS: This is a prospectively collected, retrospective
analysis of 14 patients at our institution. Between March
2007 and June 2011, patients treated with laparoscopic
median arcuate ligament release were analyzed. Data collected included patient demographics, pre-operative symptoms, operative approach, and post-operative outcomes.
Pre-operative evaluation included vascular ultrasound or
axial imaging (CT or MR angiography) in all cases. Minimally invasive surgical options included laparoscopy and
robotic assisted laparoscopy. Endovascular management
was used in select cases. Using an IRB approved database,
patients were then contacted to complete a post-operative
survey aimed at assessing resolution of symptoms and
overall satisfaction.
RESULTS: The mean age was 34 years (17–68) and 92%
of patients were female. Mean pre-operative BMI was 24.1
kg/m2 (19–32) and 64% of patients had prior abdominal
surgery. Mean celiac velocity was 374 cm/s (210–600). Preoperative CT angiogram was performed on 10 patients with
7 patients demonstrating celiac stenosis. Thirteen patients
had laparoscopic median arcuate ligament release while
1 patient had robotic assisted laparoscopic release. Mean
operating time was 184 minutes (79–473) and average
estimated blood loss was 229 cc (5–2000). There were two
intra-operative complications. One was an aortic injury
and another was an ulnar artery occlusion from endovascular stenting. The aortic injury occurred with the robotic
assisted approach and required a laparotomy for vascular
repair. All other cases were completed laparoscopically.
Eleven patients had post-operative vascular ultrasounds
with a mean velocity of 215 cm/s (135–306). Mean postoperative BMI was 24.7 (18–32). Response rate for the
post-operative survey was 79% at a mean follow-up of 16.5
months (5–32.6). All but one patient experienced complete
resolution of symptoms with no persistent pain.
CONCLUSION: Laparoscopic release of the median arcuate ligament is a safe, feasible and effective means of managing median arcuate ligament syndrome. Post-operative
symptomatic relief is seen in the vast majority of patients
undergoing this procedure.
INTRODUCTION: Variability of percentage excess weight
loss (%EWL) in LAGB patients can be influenced by many
preoperative factors, such as gender, race/ethnicity, and
age. We hypothesize that race/ethnicity plays an important
predictor in the post-operative weight loss.
METHODS: A retrospective analysis of 428 patients using
electronic medical record was performed to assess differential %EWL for patients across a period of three years
post-band implantation, with an average of 1.53 years for
all groups and no significant differences between ethnic
groups. Average initial BMI is 42 ± 5. ANOVA was used to
analyze data and P < 0.05 considered significant.
RESULTS: Percent excess weight loss (EWL) are reported
for the following racial groups. Asians lost the most, followed by Caucasians, the Hispanics and finally African
Americans. The Caucasian group lost 66.33% ± 2.4%%EWL
(N = 209); the Asian group lost 88.6% ± 7.7 %EWL (N = 23);
the Hispanic group (50.2% ± 2.3%; P = 1.5E-05, N = 123),
and African American group lost 44.4% ± 3.3%; P = 9.96E06, (N = 73). Furthermore, the average number of adjustments was 6 for the Caucasian group, 5 for the Asian group,
and 4 for the Hispanic and African American groups.
CONCLUSION: Our findings suggest that weight loss outcome for LAGB may be related to a patient’s race/ethnicity.
Patients in the Caucasian group have significantly more
adjustments than any other group. Excess weight loss is
correlated with race and number of adjustments as well
as willingness to diet and exercise. Cultural differences in
types of food and exercise is also important in weight loss
outcome.
Translational Science: Colon-Rectal
Su2094
Surgeon Leadership Enables Development of a
Colorectal Cancer Biorepository
Miriam Douthit, Vassiliki L. Tsikitis, Kim C. Lu, Daniel O. Herzig*
Department of Surgery, Oregon Health and Science University,
Portland, OR
BACKGROUND: A cancer biorepository that links a
patient’s demographic, clinico-pathologic and tissue molecular profile data is critical for translational research to
develop personalized cancer treatment. We hypothesize that
a surgeon-directed biorepository optimizes the collection of
all necessary elements needed to build a complete, robust
research resource.
106
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
METHODS: All colorectal cancer patients treated at a
university medical center and its affiliates were eligible
for inclusion in the biorepository. All patients signed an
Institutional Review Board-approved genetic consent form
and medical release authorization. Data was collected
from: an 18-page personal and family health questionnaire completed by the patient; a prospectively maintained
clinical database which included oncologic outcomes; and
molecular testing. Specimen collection for the biorepository included: serum, plasma and peripheral blood mononuclear cells as well as tumor and normal tissue maintained
as snap frozen samples, cryovials and paraffin blocks. The
patient cohort was divided into a surgeon-referred group
and a clinician-referred group. The groups were analyzed
with the primary outcome variable as complete collection
of data (clinical data, blood samples and tissue collection).
Statistical analysis was performed using Student’s t-test.
CONCLUSION: Surgeon-directed enrollment in a biorepository improves the ability to collect blood and tissue
samples in conjunction with demographic and clinicpathologic data. Surgeons should take a leadership role in
the development of tumor biorepositories.
Su2095
Bacterial Genomic Sequences Within Submucosal
Tissues Suggest Distinct Populations Within the
Crohn’s Disease Spectrum
Brian R. Davis*1, Rod Chiodini2, William Chamberlin2,
Jerzy Sarosiek2, Richard Mccallum2
1. Surgery, Texas Tech University Health Sciences Center, El Paso, TX;
2. Internal Medicine, Texas Tech University Health Sciences Center,
El Paso, TX
Bacteria have been suspected in the etiopathogenesis of
Crohn’s disease (CD). Over 80% of intestinal microbial flora
represent unidentified species for which plasmid-mediated
107
Sunday
Poster Abstracts
RESULTS: Since inception of the program in 2006, 452
patients were approached to join the registry and 430
(95%) patients have been enrolled. Of these, 124 patients
were referred by their surgeon and consented at the time
of surgery, and 306 patients were consented in a clinical
setting or over the telephone. Of patients referred by their
surgeon, tumor tissue, blood samples and clinical data were
obtained in 119 patients; conversely, in patients referred by
oncologists or other clinicians the combination of tumor
tissue, blood samples and clinical data were obtained in
133 patients (96% vs. 43.5%, p < 0.05). A total of 257 tissue
samples were obtained from all patients. Additional testing
has been performed on 228 specimens including immunohistochemistry, microsatellite testing, and genotype mutational analysis.
virulence factors exist. Molecular biology allows detection of virulence-associated genes independent of species.
Because of transmural inflammation in CD, we hypothesize
that submucosal bacterial populations are more relevant to
chronic inflammatory disease as opposed to mucosal or
luminal populations. The purpose is to determine prevalence of virulent genes and/or infectious agents in submucosal tissues from patients with disease and controls
using genomic markers in a comparative assay. Submucosal tissues were obtained from fresh surgical specimens
by manual excision and digestion of mucosal layers. DNA
was extracted by a modification of the Human Microbiome Project protocol and assayed for 30 virulence genes
and/or unique genomic sequences representing 16 distinct
bacterial species using quantitative real-time PCR (qPCR).
All positive results were repeated, and all qPCR products
were verified by gel electrophoresis and sequencing of the
PCR amplicon product. Non-Inflammatory Bowel Disease
(nIBD) controls represented negative margins of colon cancer patients. A positive result was assigned only if results
were reproducible and the PCR product was at least 97%
homologous to the known sequence. Tissues from 11
patients with Crohn’s disease and 7 controls have been
examined. The intestinal intimin (eaeA) invasion gene of
enteropathogenic E. coli and the InvA invasion gene of Salmonella were detected predominately in Crohn’s disease
(6/11–55%). The absence of other sequences suggests these
plasmid-mediated invasion genes may not be associated
with either E. coli or Salmonella. In the absence of eaeA
and InvA invasion genes, M. paratuberculosis associated
sequences were detected in 4/11 (36%) of CD submucosal
tissues. Virulence-associated genes were not identified in
one suspected Crohn’s patient (1/11, 9%). The eaeA invasion gene was detected in only 1/7 nIBD controls (14%).
Other virulence-associated genes and/or infectious agents
sought in our assay system were randomly detected in both
study populations. This study examines and reports on the
bacterial populations within submucosal tissues as opposed
to the mucosal and/or luminal microbiome. Preliminary
data suggests the existence of a submucosal microbiome
in both normal and diseased intestinal tissue. CD may be
divided into 2 distinct populations based on presence/
absence of adhesion/invasion genes or the presence of M.
paratuberculosis-associated sequences. Future efforts focus
on confirming these findings in populations from various
geographical locations. Confirmation of these findings
could have ramifications to the care of CD by the implementation of targeted therapy based on the submucosal
microbiome-type.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Translational Science: Esophageal
Translational Science: Small Bowel
Su2096
Su2097
Evaluation of Clinical Predictors of Epcam
Over-Expression in Patients with Esophageal
Adenocarcinoma
Evidence for the Hindgut Hypothesis After Ileal
Interposition Associated with Sleeve Gastrectomy:
Increased Number of GLP-1-Producing Cells in
Interposed Ileum and Pancreatic Islets in Rats
Erik M. Dunki-Jacobs*, Yan LI, Charles R. Scoggins,
Kelly M. Mcmasters, Glenda Callender, Robert C. Martin
Department of Surgery, Division of Surgical Oncology, University of
Louisville, Louisville, KY
INTRODUCTION: Epithelial Cell Adhesion Molecule
(EpCAM) is a transmembrane glycoprotein expressed by
human epithelial cells. EpCAM is known to be involved in
cell-cell adhesion, proliferation, differentiation and apoptosis. The aim of this study was to evaluate the clinical predictors of EpCAM over-expression in patients with resected
esophageal adenocarcinoma (EAC).
METHODS: EpCAM expression was assessed using immunohistochemical (IHC) staining in patients undergoing
esophagogastrectomy for EAC. EpCAM expression was
classified as low (<10%), intermediate (11–60%), or high
(>60%). EpCAM expression in malignant tissue was compared to expression in benign esophageal tissue harvested
approximately 1–2 cm from the margin of the tumor. Age,
gender, TNM stage at diagnosis, and presence of neoadjuvant therapy were evaluated as possible clinical predictors
of increased EpCAM expression. Disease-free survival (DFS)
and overall survival (OS) were evaluated.
RESULTS: The median age of the patient population was
61 years. Pre-operative TNM stage distribution was n = 3,
n = 4, and n = 6, for stages 1, 2, and 3 respectively. 62%
of patients underwent neoadjuvant therapy. Low, intermediate, and high EpCAM expression in malignant tissue
occurred in 61%, 31%, and 8% of patients respectively and
in 77%, 23%, and 0% of benign adjacent tissue respectively. EpCAM expression in malignant tissue was not
shown to be significantly higher than EpCAM expression
in benign adjacent tissue (p = 0.3). Clinical variables of age,
TNM stage at diagnosis, and neoadjuvant therapy did not
predict level of EpCAM expression (p = 0.9, p = 0.4, and p
= 0.6 respectively). Median DFS and OS were 12 months
and 28 months respectively. DFS and OS did not correlate
with EpCAM expression (p = 0.6 and p = 0.6 respectively).
Median survival after recurrence was 1 month and did
not correlate with EpCAM expression (p = 0.6). Complete
response to neoadjuvant therapy based on postoperative
pathologic stage was associated with an increased level of
EpCAM expression (p = .02).
CONCLUSION: EpCAM expression is significantly
increased in patients who have complete response to neoadjuvant therapy. Further evaluation is needed to better
characterize the relationship between EpCAM over-expression and pathologic response to neoadjuvant therapy for
EAC.
Helene Johannessen*1, Yosuke Kodama1, Chun-Mei Zhao1,
Gjermund Johnsen2, Ronald MåRvik2, Baard Kulseng2,1, Duan
Chen1
1. Department of Cancer Research and Molecular Medicine, Norwegian
University of Science and Technology, Trondheim, Norway;
2. Department of Surgery, St. Olav’s Hospital, Trondheim University
Hospital, Trondheim, Norway
BACKGROUND/AIM: Based on the hindgut hypothesis,
ileal interposition with sleeve gastrectomy (II-SG) has been
proposed as a procedure in metabolic surgery. The aim of
the present study was to study the underlying mechanism
of II-SG in rats.
METHODS: Male Sprague-Dawley rats were subjected
to laparotomy, ileal interposition (II), sleeve gastrectomy
(SG), or II-SG. Metabolic parameters were monitored by
an open-circuit indirect calorimeter composed in comprehensive laboratory animal monitoring system. The number of GLP-1-producing cells was examined by quantitative
immunohistochemistry
RESULTS: After II alone, satiety ratio i.e., intermeal interval/meal size, was reduced while calorie intake was increased
at two weeks postoperatively. Respiratory exchange ratio,
i.e., VCO2/VO2, was increased to above 1.0 (i.e., carbohydrate metabolism) during both daytime and nighttime
two and six weeks postoperatively. After SG alone, satiety
ratio and respiratory exchange ratio were unchanged, and
the number of GLP-1-producing cells was not increased in
the ileum (in terms of volume density), but increased in
the pancreatic islets (number of cells per islet). After II-SG,
rate of eating was reduced, while meal duration (minutes/
gram) was increased during both daytime and nighttime
at two and six weeks postoperatively. The number of GLP1-producing cells increased by about 2.5-fold in the interposed ileum, and also increased to the same extent in the
pancreatic islets as seen after SG alone. The increased GLP1-producing cells in the pancreas were distributed around
the insulin-producing cells.
CONCLUSION: The present study provides evidence that
II-SG stimulates GLP-1 production not only in the interposed ileum (to act by endocrine mechanism) but also
in the pancreatic islets (to act on the cells by paracrine
mechanism), leading to the metabolic beneficial effects and
the altered eating behavior as manifested by eating slowly.
ACKNOWLEDGMENTS: The research leading to these
results has received funding from the European Union Seventh Framework Programme (FP7/2007–2013) under grant
agreement n°266408, the Faculty of Medicine, Norwegian
University of Science and Technology, and the Central Norway Regional Health Authority.
108
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Translational Science: Stomach
Su2098
Overexpression of ADP-Ribosylation Factor 1 (ARF1)
in Human Gastric Cancer and Its Clinicopathological
Significance
Chia-Siu Wang*1, Kwang-Huei Lin2
1. Department of General Surgery, Chang Gung Memorial Hospital,
Chiayi, Putz City, Taiwan; 2. Department of Biochemisty, Chang
Gung University, Taoyuen, Taiwan
BACKGROUND: Gastric cancer is the second most common cancer worldwide and the sixth leading cause of cancer-related death in Taiwan. Biomarkers are investigated to
improve early detection and patient survival. Previously,
ARF1 was identified as one of the strongest upregulated
proteins by using proteomic technique: two-dimensional
(2D) gel electrophoresis combined with matrix-assisted
laser desorption/ionization time-of-flight mass spectrometry. ARF1 belongs to the Ras superfamily or GTP-binding protein family and has been shown to enhance cell
proliferation.
DISCUSSION & CONCLUSION: ARF, a family of small
GTP-binding proteins, play important roles in intracellular trafficking in animal and yeast cells. Over-expression of
ARF1 in cancer cells has been reported in human breast
cancer cells. ARF1 regulates breast cancer cell growth and
invasion during cancer progression. Our data demonstrated
that expression of ARF1 is associated with tumor progression and survival outcome. And, it might be a potential
prognostic marker for gastric cancer. These findings collectively support the utility of ARF1 as a potential prognostic
marker for gastric cancer and its role in cell invasion.
109
Sunday
Poster Abstracts
SUBJECTS & METHODS: A total of 110 patients (69
males, 41 females; median age: 66 years, range 28–86
years) with gastric cancer undergoing gastrectomy were
enrolled into this study. Real-time quantitative RT-PCR,
western blot analysis and immunohistochemistry (IHC) on
resected specimens were used to confirm the ARF1 overexpression in surgical patients. The clinical significance of
ARF1 expression was evaluated by clinicopathological correlations and patient’s suruvial outcome. To establish the
specific function of ARF1 in human gastric cancer, isogenic
ARF1-overexpressing cell lines were prepared.
RESULTS: Expression of ARF1 mRNA was significantly
upregulated in 67.2% of gastric cancer patients by using
Real-time quantitative RT-PCR test. Paired comparison of
IHC study for ARF1 revealed that the IHC scores of cancerous tissues were higher than those of the nontumorous
counterparts in 76.5% of patients. Elevated ARF1 expression was strongly correlated with lymph node metastasis
(p = 0.008), serosal invasion (p = 0.046), lymphatic invasion (p = 0.035) and pathological staging (p = 0.010). Moreover, the 5-year survival rate for the lower ARF1 expression
group (n = 50; IHC score <90) was higher than that of the
higher expression group (n = 60; IHC score ≥90) (log rank
p = 0.0228). Our functional studies also demonstrate that
ARF1-overexpressing clones display enhanced cell proliferation, migration and invasion.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Monday, May 21, 2012
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
Halls C-G
POSTER SESSION I
(NON-CME)
Basic: Biliary
CONCLUSION: A significant number of patients continue
to experience symptoms following laparoscopic cholecystectomy. In patients were pain was the most troublesome symptom pre-operatively, significant symptomatic
improvement was noted. Similarly, those patients that
experienced symptoms more dyspeptic in nature pre-operatively were less likely to be symptom free following LC.
A careful biliary history, a focused physical examination
and a thorough pre-operative assessment must be carried
out prior to LC to rule out conditions that masquerade as
gallbladder disease.
Mo1874
Persistent Symptoms Following Cholecystectomy Is
Unacceptably High and in Need of Further Evaluation
Rami Radwan*, Chris Brown, Jonathan Lloyd-Evans,
Chirag Patel, Omer Jalil, Ashraf M. Rasheed
Minimal Access Surgery, Royal Gwent Hospital, Newport,
United Kingdom
INTRODUCTION: Up to 20% of patients undergoing cholecystectomy continue to experience symptoms. We consider such results unacceptably high and in need of further
evaluation.
Objectives: To identify the biliary symptoms for which the
cholecystectomy was carried out and then determine the
prevalence and the nature of persistent symptoms following cholecystectomy in a cohort of 500 consecutive cases.
METHODS: A validated pre-operative symptoms survey
was completed at the time of listing of 500 consecutive
laparoscopic cholecystectomies (LC) followed by a follow
up phone survey 12 weeks after the procedure to record the
nature, severity and frequency of symptoms experienced
pre- and post-operatively. A detailed clinical profiling was
carried out on all patients with persistent biliary symptoms.
RESULTS: All patients had at least 2 symptoms pre-operatively and 337 (67.4%) had 3 or more. The most common
symptoms pre-operatively were abdominal pain (93.8%),
nausea (65.8%), pain related to food (54.4%) and bloating
(48.6%).
A total of 90 patients were symptomatic post-operatively.
Eighty one patients (16.2%) complained of abdominal
pain, while 63 (12.6%) patients also experienced associated
dyspeptic symptoms. Seventy three patients (14.6%) developed 1 or more new symptoms post-operatively, the most
common being heartburn found in 34 (6.8%) and abdominal bloating in 29 (5.8%).
Sixty patients underwent further investigation following LC; 36 patients went on to have a secondary diagnosis made, the most common (13/36) being hiatus hernia,
seven patients were found to have a retained common bile
duct stone. Overall, there was no significant difference in
histology among patients post-operatively.
Basic: Colon-Rectal
Mo1875
Human Growth Hormone (hGH) Abolishes the
Negative Effects of Everolimus on Intestinal
Anastomotic Healing
Markus A. KüPer*, JüRgen Weinreich, Frank Traub,
Alfred KöNigsrainer, Stefan Beckert
Department for General, Visceral and Transplant Surgery, University
of Tübingen, Tübingen, Germany
INTRODUCTION: The mTOR-inhibitor everolimus inhibits healing of intestinal anastomoses by interfering with
the inflammatory phase of healing and reducing collagen
deposition. Aim of this study was to investigate whether
the simultaneous administration of everolimus and hGH
abolishes the negative effects of everolimus on anastomotic
healing.
METHODS: 48 male Sprague-Dawley-rats were randomized to three groups of 16 animals each (I: vehicle; II:
everolimus 3mg/kg p.o.; III: everolimus 3mg/kg p.o. + hGH
2,5mg/kg s.c.). Animals were pre-treated with hGH and/or
everolimus daily for seven days. Then a standard anastomosis was created in the descending colon and treatment
was continued for another seven days. The anastomosis
was resected in toto and mechanical, biochemical and histological parameters of intestinal healing were assessed.
RESULTS: Anastomotic bursting pressure was significantly
reduced by everolimus and a simultaneous treatment with
hGH resulted in considerably higher values (I: 134 ± 19,
II: 85 ± 25, III: 114 ± 25 mmHg; p < 0,05 I vs. II; p = 0,09
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
I vs. III and II vs. III) Hydroxyproline concentration was
significantly increased by hGH compared to everolimus
alone (I: 14,9 ± 2,5, II: 8,9 ± 3,6, III: 11,9 ± 2,8 μg/mg; p <
0,05 I vs. II/III and II vs. III). The number of MPO-positive
cells was reduced significantly by hGH compared to everolimus alone (I: 10 ± 1, II: 15 ± 3, III: 9 ± 2 n/sqmm; p < 0,05
I vs II und II vs. III), while the number of PCNA-positive
cells were increased by hGH (I: 28 ± 3, II: 12 ± 3, III: 26 ±
12 /sqmm; p < 0,05 I vs. II und II vs. III). Corresponding
to these biochemical findings, HE-histology revealed significantly increased amount of granulation tissue in hGHtreated animals.
CONCLUSION: The inhibitory effects of everolimus on
intestinal wound healing can be partially neutralized by
simultaneous treatment with human growth hormone.
hGH-treatment addresses both the inflammatory phase as
well as collagen deposition.
Mo1876
Mo1877
Intra-Abdominal Adipose Tissue as a Major Source of
IL-6 During Acute Experimental Colitis
W.C. Mustain*1,2, Marlene E. Starr1,2, Daiki Okamura1,2,
B. Mark Evers1,2, Hiroshi Saito1,2
1. Markey Cancer Center, University of Kentucky, Lexington, KY;
2. Department of Surgery, University of Kentucky, Lexington, KY
INTRODUCTION: Adipose tissue has been shown to produce a number of inflammatory cytokines and may play a
role in the development and progression of several inflammatory diseases. Accumulation of intra-abdominal fat correlates more strongly with inflammatory disease states than
does total body fat, suggesting depot-specific differences in
the inflammatory potential of adipose tissue. In inflammatory bowel disease specifically, recent clinical studies suggest that patients with increased intra-abdominal fat may
suffer a more aggressive clinical course.
OBJECTIVE: The purpose of the present study was to evaluate the significance of inflammatory cytokine production
by various adipose tissue depots during acute experimental
colitis.
Intestinal Permeability for Macromolecules Following
Mechanical Ileus in Mice
Xue Zhao, Till Macheroux, Michael S. Kasparek, Mario H. Mueller,
Martin E. Kreis*
Surgery, University of Munich, Munich, Germany
INTRODUCTION: Acute mechanical ileus is a frequent
disorder seen in general surgery which—if untreated—terminates in peritonitis secondary bacterial translocation.
We aimed to investigate the time course of changes in gut
permeability during acute mechanical ileus for molecules
of different molecular weight.
RESULTS: At 3 hours after the beginning of mechanical
ileus, the FITC-dextrane concentration was 187 ± 7.6 ng/ml
in ileus animals and 147 ± 8.1 ng/ml in sham controls (p
< 0.05), while it was 86 ± 8.9 and 62 ± 0.8 ng/ml at the
9 hour time point (p < 0.05). For the bigger molecule, HRP,
concentrations at 3 hours were 5.6 ± 3.6 ng/ml in ileus animals and 4.1 ± 1.6 ng/ml in sham controls which was not
different. At 9 hours the serum concentrations were 23.0 ±
4.3 ng/ml in ileus animals which was higher compared to
9.0 ± 3.1 ng/ml in sham controls (p < 0.05).
CONCLUSIONS: Intestinal permeability for macromolecules increases a few hours after acute mechanical ileus.
It seems that soon after the beginning of mechanical
ileus, intestinal permeability is increased for small-sized
molecules, while it takes a few hours more until it is also
increased for bigger sized molecules.
RESULTS: Histologic evidence of colitis and significantly
increased plasma IL-6 levels were evident by Day 7 and
peaked at Day 14. Changes in cytokine expression within
the colon occurred earlier, with significant increases in
TNF-a, IL-1b, and IL-6 mRNA all evident by Day 3 (P =
0.016). Of the cytokines analyzed, IL-6 in the colon exhibited the most profound increase with colitis, with levels at
Day 7 increased 230-fold from baseline (P = 0.002). Analysis of adipose tissues from this time point revealed that
while IL-6 mRNA expression in mesenteric and epididymal adipose tissue was significantly increased compared
to controls, 8.6-fold (P = 0.016) and 3.8-fold (P = 0.004)
respectively, no increase in subcutaneous adipose tissue
IL-6 mRNA was observed. Multi-tissue analysis at this time
point revealed that mesenteric and epididymal adipose
tissue expressed significantly more IL-6 mRNA than the
kidney or the liver, whose levels of IL-6 did not increase
significantly from baseline.
CONCLUSIONS: This study demonstrates that intraabdominal adipose tissue is a major source of IL-6 during
acute experimental colitis. The time course analysis suggests
that intra-abdominal fat may have a significant impact on
plasma IL-6 levels. Unlike the mesentery, the epididymal
fat pad is not contiguous with the inflamed bowel and
does not contain the venous or lymphatic drainage of the
affected bowel. This suggests a tissue-specific response by
the intra-abdominal adipose tissue, rather than merely a
local lymphoid reaction to tissue damage in the colon.
111
Monday
Poster Abstracts
METHODS: C57Bl6 mice were anesthetized by isoflurane
inhalation and gavaged with flourescein isothiocyanate
conjugated dextrane (FITC-dextrane, 4.4 kDa) and horseradish peroxidase (HRP, 40 kDa). After a mini- laparotomy,
the small intestine was ligated approximately 5 cm distal
to the ligament of Treitz, while controls received a minilaparotomy only. Intestinal permeability was assessed in
ileus animals or controls 3 and 9 hours later in different
subgroups (each n = 4). 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.
METHODS: Colitis was induced in C57BL mice by addition of 2% dextran sulfate sodium (DSS) to drinking water
for 5 days. Mice were sacrificed at Day 3, 7, 14, and 21
following initiation of DSS treatment. Control mice were
sacrificed prior to initiation of treatment. Plasma cytokine
levels at time of sacrifice were analyzed by multiplex assays.
Colonic tissue damage was evaluated histologically by H&E
staining. Tissue levels of cytokine mRNA were compared
between the colon, 3 adipose tissue depots (mesenteric, epididymal, and subcutaneous), kidney, and liver by qRT-PCR.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Basic: Esophageal
Mo1879
EGFR in Gastroesophageal Reflux Disease, Barrett’s
Esophagus, and Esophageal Adenocarcinoma
Guilherme Pretto*1,2, Richard R. Gurski1,2, Daniel Navarini1,
Marcelo Binato1, Luise Meurer2, Laura Z. Costamilan2,
Guilherme D. Mazzini2, Gabriela G. Costa1
1. Programa de Pós-Graduação em Cirurgia, Universidade Federal do
Rio Grande do Sul, Porto Alegre, Brazil; 2. Digestive Surgery, Hospital
de Clínicas de Porto Alegre, Porto Alegre, Brazil
INTRODUCTION: Gastroesophageal reflux disease (GERD)
is a common pathology with a wide range clinical and
endoscopic manifestations whose underlying mechanisms
are not well understood. Epidermal growth factor receptor
(EGFR), found in the epithelium of the digestive tract, plays
an important role in epithelial repair and shows increased
expression in a number of different neoplasms, including
esophageal tumors.
OBJECTIVES: To evaluate EGFR expression using immunohistochemistry in esophageal biopsies obtained from
patients with GERD, Barrett’s esophagus, and adenocarcinoma of the esophagus.
METHODS: EGFR expression was immunohistochemically
determined in biopsies from 194 patients with symptoms
suggestive of GERD or adenocarcinoma of the esophagus
seen at two Brazilian university hospitals between January 2003 and December 2008. Based on histopathological
analysis, patients were divided into three groups: GERD,
Barrett’s esophagus and adenocarcinoma of the esophagus.
EGFR expression was considered positive when staining
was detected in the membrane.
Figure 1: Esophageal biopsy from a patient with Barrett’s esophagus,
positive for EGFR expression
RESULTS: Mean age was 55.25 years (30–90). Patients
with GERD (n = 127) accounted for 65.5% of the sample,
compared with 12.4% (n = 24) of patients with Barrett’s
esophagus and 22.2% (n = 43) of patients with esophageal
adenocarcinoma. Immunohistochemical analysis was positive for EGFR in 19.1% of the patients (37/194), divided
as follows: 8.7% (11/127) in the GERD group, 25% (6/24)
in the Barrett’s esophagus group, and 46.5% (20/43) in
the esophageal adenocarcinoma group. Statistical analysis
revealed significant differences between the three groups
(p = 0.0001).
Figure 2: Immunohistochemical expression of EGFR in the three
groups assessed.
CONCLUSIONS: GERD patients showed lower levels of
EGFR expression than patients with Barrett’s esophagus or
patients with adenocarcinoma of the esophagus, suggesting a direct relationship between EGFR expression and disease progression.
KEYWORDS: EGFR, GERD, adenocarcinoma, esophagus,
Barrett’s esophagus.
Basic: Pancreas
Mo1880
Effects of Intravenous Administration of Pentoxifylline
in Pancreatic Ischemia/Reperfusion Injury
Edmond R. Campion, ANA Maria M. Coelho*, Marcel C.
Machado, Sandra N. Sampietre, Nilza A. Molan, José Jukemura,
Luiz C. D’Albuquerque
Gastroenterology, University of São Paulo, São Paulo, Brazil
BACKGROUND/AIM: Therapeutics strategies to reduce
pancreatic ischemic/reperfusion injury (I/R) might improve
the outcome of human pancreatic-kidney transplantation.
Pentoxifylline (PTX) beside its hemorrheologic effects has
an anti-inflammatory effect by inhibiting NF-kappaB activation. We have previously demonstrated that PTX had
anti-inflammatory response in acute pancreatitis and liver
ischemia/reperfusion models. We have hypothesized that
PTX could reduce pancreatic, renal lesions and the systemic
inflammatory response in pancreatic I/R injury. The aim of
this study was to evaluate the effect of PTX administration
in a rat model of pancreatic I/R injury
METHODS: Pancreatic ischemia was performed in Wistar
rats during one hour by clamping the splenic vessels under
mechanical ventilation. The vascular clamp was removed
1 hour after ischemia and pancreatic revascularization was
achieved, followed by 4h or 24h of reperfusion. The animals submitted to ischemic/reperfusion were randomly
divided into 2 groups: Group C (n = 20): control, rats
received saline solution IV, 45 minutes after ischemia, and
Group P (n = 20): rats received PTX (25mg/Kg) IV, 45 minutes after ischemia. Four and twenty four hours after reperfusion blood were collected for determinations of amylase,
creatinine, TNF-α, IL-6, and IL-10. Pancreatic malondialdehyde (MDA) content was also performed. After 24 hours of
reperfusion pulmonary tissues were assembled for myeloperoxidade (MPO) analyses.
112
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: A significant reduction in serum TNF-α, IL-6,
IL-10, and creatinine levels was observed in PTX group
compared to control group (p < 0.05). No differences in
pancreatic MDA content and in serum amylase levels were
observed between two groups. Twenty-four hours after
ischemia it was not observed any significant difference in
the results of lung myeloperoxidase activity (MPO).
CONCLUSION: Pentoxifylline administration reduced the
systemic inflammatory response and renal dysfunction in
pancreatic I/R injury and could be a useful tool in pancreaskidney transplantation
Mo1881
The Expression of Putative Pancreatic Stem Cell
Marker DCAMKL-1 Is Elevated in Early Stage
Pancreatic Adenocarcinoma Patients
that DCAMKL-1 mRNA levels in adjacent tissues are significantly higher than the respective tumor tissues. DCAMKL-1
mRNA levels were higher in the adjacent tissues compared
to the respective tumor tissues of stage II (7-fold) and stage
III (2.7-fold) patients. Furthermore, we observed increased
DCAMKL-1 immunostaining in all stages of cancer compared to controls. Although there were no significant differences between the stages, we observed increased stromal
staining compared to the epithelium within the specimens.
CONCLUSION: These data suggest that DCAMKL-1 is
increased in all stages of pancreatic cancer tissues. Additionally, the higher DCAMKL-1 level in the tissue adjacent to the
tumor may suggest a premalignant condition in this tissue.
Furthermore, DCAMKL-1 is elevated in plasma of stage I and
II patients, suggesting that it may potentially be used as a
biomarker for the early detection of pancreatic cancer.
Mo1882
Jeremy J. Johnson*1, Dongfeng Qu2, Sripathi M. Sureban2,3,
Randal May2,3, Stanley Lightfoot5, Lewis A. Hassell5,
Shubham Pant4, Russell G. Postier1,3, Courtney W. Houchen2,3
1. Surgery, The University of Oklahoma Health Sciences Center,
Oklahoma City, OK; 2. Medicine/Gastroenterology, OUHSC, Oklahoma
City, OK; 3. Veterans Affairs Medical Center, Oklahoma City, OK;
4. Medicine/Hematology and Oncology, The University of Oklahoma
Health Sciences Center, Oklahoma City, OK; 5. Pathology, The
University of Oklahoma Health Sciences Center, Oklahoma City, OK
DNA Methylation as a Biomarker System for Pancreatic
Adenocarcinoma
Qi Huang*2, ADAM A. Golas2, Zhongmin Guo2, Kenneth P. Nephew2,
Michael G. House1,2
1. Surgery, Indiana University School of Medicine, Indianapolis, IN;
2. Biology, Indiana University, Bloomington, IN
BACKGROUND: Pancreatic ductal adenocarcinoma carries a grave prognosis with the majority of patients presenting with locally advanced or metastatic disease. Patients
diagnosed with early stage pancreatic cancer are often
candidates for surgical resection and have improved overall 5 year survival. Doublecortin and CaM kinase-like-1
(DCAMKL-1), a microtubule-associated kinase, is a putative
intestinal and pancreatic stem cell marker. We have previously demonstrated that DCAMKL-1 is upregulated in multiple cancers. The aims of this study are to determine the
plasma expression level of DCAMKL-1 in pancreatic cancer patients by stage, and to measure the tissue expression
level of DCAMKL-1 in this patient population.
RESULTS: We observed greater than a 2.5-fold increase
in plasma DCAMKL-1 in patients with stage I pancreatic
cancer compared to controls by Western blot analysis (p <
0.05). We also observed increased DCAMKL-1 expression
by ELISA: stage I (3.42-fold, p = 0.07); II (4.1-fold, p < 0.05);
III (2.06-fold, p > 0.05) and IV (1.15-fold, p > 0.05). There
were similar DCAMKL-1 mRNA expression levels in both
stage II and III tumor tissues (n = 8). Interestingly, we found
METHODS: Isolated DNA samples from primary PDAC
and individually matched adjacent normal tissue from 37
patients who underwent operative resection were analyzed.
The methylation status of 6 gene promoters (RASSF1A,
MGMT, GSTP1, APC, P16/CDKN2A, and NEFL) was determined by quantitative methylation-specific PCR (QMSP).
Promoter site methylation levels were calculated and correlated with clinical, pathologic, and outcome factors.
RESULTS: Hypermethylation of the neurofilament light
chain (NEFL) gene was significantly higher in PDAC compared to matched adjacent normal tissue (p < 0.01). Promoter methylation levels of APC in PDAC correlated with
overall survival, HR = 1.004 (95% CI, 1.001–1.007), and
APC gene hypermethylation in matched normal tissue was
associated with death within one year after resection (OR
0.073; 95% CI, 0.007–0.724). Promoter methylation of APC
in host normal tissue along with APC methylation levels of
primary tumors and surgical resection margin status can
be used to evaluate the risk of death within one year after
resection with a predictive accuracy of 87%.
CONCLUSION: Hypermethylation of the promoter region
of candidate tumor suppressor genes in patients with pancreatic adenocarcinoma treated by operative resection is
associated with early recurrence and death. Larger scale
studies will be necessary to validate patterns of gene methylation as a potential cancer-specific molecular marker system related to outcomes for pancreatic cancer.
113
Monday
Poster Abstracts
METHODS: Purified plasma samples from controls (n =
10) and stage I (n = 9), II (n = 15), III (n = 14) and IV (n
= 11) pancreatic cancer patients were subjected to Western blot and ELISA analysis. Surgical cancer specimens and
normal pancreas (commercial tissue array) were immunostained for DCAMKL-1. An independent pathologist scored
the immunohistochemical staining based on intensity and
tissue involvement. Samples of tumor and adjacent normal
tissue from pancreatic surgical specimens were homogenized. Total RNA isolated from these samples was subjected
to real-time PCR to measure mRNA expression levels.
BACKGROUND: Reliable biomarkers to predict prognosis
are lacking for patients with pancreatic ductal adenocarcinoma (PDAC) who are being considered for appropriate
multimodality treatment. The aim of this study was to
investigate aberrant hypermethylation of a candidate set
of tumor suppressor genes as a potential cancer-specific
molecular marker system related to outcomes for patients
with resected PDAC.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Basic: Small Bowel
were observed, these changes appear not to be specific for
POI, as they occurred also in SC, without delayed intestinal transit or inflammation. However, these postoperative
changes in α-adrenergic neurotransmission might still participate in disturbances of postoperative bowel function.
DFG KA2329/5–1
Mo1884
Changes in Neurotransmission via α1- and
α2-Receptors During Postoperative Ileus in Rat
Bernhard Stoklas*, Brigitte Goetz, Petra Benhaqi, Martin E. Kreis,
Michael S. Kasparek
Department of Surgery, Ludwig-Maximilians-University Munich,
Munich, Germany
Basic: Stomach
BACKGROUND: The role of α-receptors in control of
intestinal motility is poorly understood. We aimed to
study the mechanism of action of α1- and α2-agonists and
to investigate changes in α-adrenergic neurotransmission
potentially participating in pathophysiology of POI.
METHODS: Circular, jejunal muscle strips (n = 8/rat) were
obtained from male Sprague Dawley rats (n = 6/group).
Groups: Naïve controls (NC), sham controls 12h and 3d
after laparotomy to study combined effects of anesthesia
and laparotomy (SC12h, SC3d), and rats 12h and 3d after
laparotomy and small bowel manipulation (P12h, P3d) to
induce POI. Dose-dependent effects of α1-agonist phenylephrine (10–8–10–5M) and α2-agonist clonidine (3 × 10–8–3
× 10–5M) without and with TTX (blocking enteric nerves;
10–6M), L-NIL (blocking inducible nitric oxide-synthase;
3 × 10–5M) and nimesulide (blocking cyclooxygenase-2;
10–5M), or α-receptor antagonist phentolamine (10–5M)
were studied. Intestinal transit was studied by charcoal
gavage ([%] small bowel passed by marker). Histology in
whole mounts was performed for myeloperoxidase positive
cells (MPO), macrophages, and mastcells (cells/mm2). Data:
mean ± SEM.
RESULTS: Phenylephrine and clonidine caused dosedependent inhibition in all groups (p < 0.05). Phenylephrine-induced inhibition was increased only in SC3d (p <
0.05 vs NC). TTX reduced phenylephrine-induced inhibition in NC, P3d, and SC3d (all p < 0.05 vs without TTX),
while L-NIL and nimesulide had no effect on phenylephrine-induced inhibition (p = NS vs without L-NIL and
nimesulide). Clonidine-induced inhibition was reduced in
P3d and SC12h (p < 0.05 vs NC). TTX reduced clonidineinduced inhibition in NC while it increased the clonidineeffect in P3d (both p < 0.05 vs without TTX). L-NIL and
nimesulide reduced clonidine-induced inhibition in P12h,
SC12h, and SC3d (all p < 0.05 vs without L-NIL and nimesulide). Phentolamine prevented phenylephrine- and
clonidine-induced inhibition in all groups (all p < 0.05).
Intestinal transit was delayed only in P12h (P12h 28 ± 3;
NC 54 ± 2%; p < 0.05 vs NC). MPO positive cells and mast
cells were increased in P12h and P3d, but not in sham controls (MPO: NC 12 ± 2; P12h 908 ± 125; P3d 828 ± 84; mastcells: NC 19 ± 4; P12h 639 ± 174; P3d 1137 ± 225; all p <
0.05 vs NC). Macrophages were elevated in only P3d (NC
369 ± 30; P3d 1274 ± 237; p < 0.05 vs NC).
CONCLUSION: We demonstrated that contractile activity
can be inhibited via α1- and α2-receptors and that this effect
is in parted mediated via enteric nerves. Although postoperative changes in α1- and α2-adrenergic neurotransmission
Mo1885
Intratumoral Epcam Expression in Gastric Cancer: A
Potential Prognostic Marker and Therapeutic Target
Daniel Vallbohmer*1, Agnieszka Dulian1, Feride KröPil1,
Andreas Krieg1, Stephan E. Baldus2, Wolfram T. Knoefel1,
Nikolas H. Stoecklein1
1. Department of General, Visceral and Paediatric Surgery, University
of Dusseldorf, Dusseldorf, Germany; 2. Department of Pathology,
University of Dusseldorf, Dusseldorf, Germany
INTRODUCTION: Intratumoral expression of the epithelial cellular adhesion molecule (EpCAM) is of great prognostic impact in various malignant tumors. However, less
data about its role in gastric cancer is available. Therefore,
we investigated the expression patterns of EpCAM in this
malignancy and its prognostic impact on gastric cancer
patients undergoing primary surgical therapy.
PATIENTS AND METHODS: The intratumoral protein
expression of EpCAM was assessed in 163 gastric cancer
patients undergoing primary surgical therapy (61 diffuse-,
62 intestinal-, 32 mixed-type and 8 unclassified tumors) by
immunohistochemistry, using the monoclonal antibody
Ber-EP4. Intensity of staining was classified according the
HercepTest-Score as a standardized scoring system. Afterwards intratumoral EpCAM expression patterns were correlated with clinicopathologic parameters including overall
survival.
RESULTS: EpCAM expression was observed in 77% of the
tumors. Of these, 58% (n = 74) presented a homogeneous
intratumoral EpCAM expression while 42% presented a difference between the centre and invasion front of the tumor.
Interestingly, tumors with high EpCAM expression in the
invasion front were associated with a significantly higher
proportion of lymph node metastases and lower median
overall survival (p = 0.03; p = 0.001). This observation was
significantly (p = 0.04) higher in diffuse type of gastric cancers compared to the intestinal type. Multivariate survival
analysis identified high EpCAM expression in the invasion
front as an independent prognostic factor (Cox-Regression
analysis).
CONCLUSION: Intratumoral EpCAM expression in the
invasion front was associated with a significant decrease in
overall survival of patients with gastric cancer. Considering
the discontenting results of the current neoadjuvant/adjuvant concepts for gastric cancer patients, EpCAM might
provide a promising target for a neoadjuvant/adjuvant
immunotherapy.
114
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Clinical: Biliary
Mo1455
Extended Left Hepatic Trisectionectomy as a
Feasible Surgical Procedure for Advanced Perihilar
Cholangiocarcinoma
Minoru Esaki*1, Kazuaki Shimada1, Seiji Oguro1, Yoji Kishi1,
Satoshi Nara1, Tomoo Kosuge1, Yoshihiro Sakamoto2,
Tsuyoshi Sano3
1. Hepato-biliary pancreatic surgery, National Cancer Center Hospital,
Tokyo, Japan; 2. Hepato-Biliary-Pancreatic Surgery Division, Graduate
School of Medicine, University of Tokyo, Tokyo, Japan; 3. Department
of Gastroenterological Surgery, Aichi Cancer Center, Nagoya, Japan
OBJECTIVES: The aim of this study was to clarify the
short and long term outcome of extended left hepatic trisectionectomy (LT) for perihilar cholangiocarcinoma.
METHODS: Patients with perihilar cholangiocarcinoma who
underwent LT between January 2000 and October 2010 for
perihilar cholangiocarcinoma were analyzed retrospectively.
Operative variables, mortality, morbidity, recurrence sites and
survival of three groups were compared among LT, right hemihepatectomy (RH) and left hemihepatectomy (LH).
RESULTS: A total 203 patients underwent surgical resection for perihilar cholangiocarcinoma, 22 (11%) of whom
underwent LT, 79 (39%) underwent RH, and 84 (41%)
underwent LH. No mortality occurred, but 17 patients had
morbidity. Operative time and blood loss were 655 ± 142
minutes and 2100 ± 1080 ml, respectively.
Blood loss in patients with LT was significantly more than
in those with LH (2100ml versus 1300ml; P = 0.017). The
incidence of Grade IIIa complication in patients with LT was
significant higher than RH and LH (P = 0.044 and P = 0.014),
but Grade IIIb and IV complication did not occur in patients
with LT. Overall 5-year survival rate was 40% with median
survival of 45.8 years. There was no significant difference in
survival in patients between LT and other two procedures.
CONCLUSIONS: LT for perihilar cholangiocarcinoma
is feasible and can provide a comparable prognosis for
advanced perihilar cholangiocarcinoma originating from
left hepatic duct or segment 4 especially extending to the
root of the right anterior portal pedicle or confluence of the
anterior and posterior branch of the bile duct.
Mo1456
Audit of the Use of Critical View of Safety and
Infundibular Cystic Technique in Cystic Duct
Identification in Laparoscopic Cholecystectomy
Anokha Oomman*1,2, Ashraf M. Rasheed2, Karthic Rajaram2,
Krithika Murugan2
1. Withybush General Hospital, Haverfordwest, United Kingdom;
2. Gwent Institute of Minimal Access Surgery, Royal Gwent Hospital,
Newport, United Kingdom
INTRODUCTION: The commonest cause of bile duct
injury (BDI) during laparoscopic cholecystectomy (LC) is
the confusion of bile duct with cystic duct. Operation notes
must include the anatomical rationale by which the cystic
duct was conclusively identified.
AIM: To examine the quality of documentation and the
terms used to describe the method/methods utilised to identify the cystic duct during laparoscopic cholecystectomy.
115
Monday
Poster Abstracts
METHOD: The documentation of the method/s used for
cystic duct identification was examined in 322 consecutive non-converted LCs that were carried out between
the months of August 2010 and January 2011. Non-protocolised operation notes were studied and stratified into
different groups according to the descriptive terms used.
The strata included: 1). No documentation of the method
used, 2). Calot’s triangle was dissected or demonstrated, 3)
Infundibular or infundibulo-cystic technique used, 4). Critical view of safety (CVS) demonstrated, 5) Intra-operative
cholangiogram used, or 6) Other methods.
RESULTS: Demonstration of the critical view of safety was
documented in (4/310) 1.3% of the cases. Infundibular or
infundibulo-cystic technique was used to define the cystic
duct in (9/310) 3.4% of the notes. Calot’s triangle was mentioned in (255/310) 82.3% of the notes. In (43/310) 13.9%
of cases, the cystic artery and duct were mentioned without any reference to critical view of safety, infundibular/
infundibulo-cystic technique or Calot’s triangle.
CONCLUSION: Written documentation of the method
of cystic duct identification in the operation notes during
LC is sub-optimal. We, hence recommend standardization
of the cholecystectomy operative report, inclusion of a
video clip and/or photo image using digital information
and communication in medicine (DICOM) to complement
the textual operation notes and move towards structured
computerised input that links to the picture archiving and
communication system (PACS).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1457
CONCLUSION: Complications, particularly stent occlusion, occur frequently after PBD in patients scheduled to
undergo PD for malignancy. Compared to PS, SEMS do not
impact on the incidence of major postoperative complications and may be cost-effective as first-line endobiliary
drainage given the high incidence of early stent occlusion
with PS.
Self-Expandable Metallic Stents Do Not Impact
on the Frequency of Complications Related to
Preoperative Biliary Drainage or Subsequent
Pancreatoduodenectomy
Wesley D. Leung*1, Gregory A. Cote1, Damien M. Tan1,
Joshua A. Waters2, C. Max Schmidt2, Stuart Sherman1, Glen
A. Lehman1, Evan L. Fogel1, James L. Watkins1, Lee Mchenry1,
Michael G. House2
1. Gastroenterology, Indiana University, Indianapolis, IN; 2. Surgery,
Indiana University School of Medicine, Indianapolis, IN
Mo1458
The Influence of Analgesia, Antiemetics and Operative
Factors on Admission Following Cholecystectomy: A
Retrospective Review
BACKGROUND: Preoperative endobiliary drainage (PBD)
is commonly performed in patients with malignant
obstruction for whom operative resection is eventually
planned. The aim of this study was to compare the safety
of pancreatoduodenectomy (PD) following PBD with selfexpandable metallic stents (SEMS) versus standard plastic
stents (PS).
METHODS: We conducted a single center, retrospective
cohort study of patients undergoing PBD followed by PD for
periampullary cancer between January 1998 and December
2009. Patients were excluded if PBD was solely performed
at a different facility because details regarding PBD complications and stent type were unavailable. To determine
the potential impact of SEMS on PBD and postoperative
outcomes, we compare patient characteristics as well as
PBD and postoperative complications between groups. If
patients had more than one PBD procedure, we present
complications during 1) any PBD and 2) the last PBD procedure. SEMS were routine placed at least 1 cm from the
hepatic bifurcation. Variables are presented as simple proportions or medians, with two-way statistical comparisons
(Fisher’s exact or Mann-Whitney-U test).
RESULTS: We identified 147 patients who underwent PBD
and then PD at our center, 17 (12%) of who underwent
placement of a fully covered (10) or uncovered (7) SEMS.
Among PS patients, 74% had a 10Fr PS placed during their
final PBD. In all patients, 29% had previously undergone
1 (25%) or 2 (4%) PBDs with PS. Neoadjuvant therapy
was used in 8.0% of PBD and 17.6% of SEMS patients (p
= 0.20). Including previous PBD attempts, patients had at
least one failed PBD (17%) or other complication (18%)
including early stent occlusion (n = 22), pancreatitis (n = 1)
and perforation (n = 1). Complications specific to the last
PBD were similar (5.9% v. 7.1%, p = 0.85) in SEMS and PS
patients, with no cases of early stent occlusion in the SEMS
group. The median number of PBD procedures was significantly greater in SEMS v. PS, 2 v. 1, p < 0.001; no SEMS cases
required repeat PBD.
The median time from last PBD to surgery was longer in
SEMS v. PS patients, 31 v. 18 days, p = 0.004. Postoperative
complications Clavien grade ≥3 occurred in 22% of SEMS
versus 11% of PS patients, p = 0.37. Infection-specific complications after PD were similar in the SEMS (11.1%) and PS
groups, 26.8%, p = 0.31. Perioperative cholangitis occurred
in one SEMS patient while one postoperative bile leak was
recorded in the PS group. Median postoperative length of
stay was similar in SEMS and PS patients, 8.5 v. 8.0 days;
p = 0.87.
Mark Bignell*, Anna Bayston, David Nunn, Michael P. Lewis
General Surgery, Norfolk and Norwich university Hospital, Norwich,
United Kingdom
INTRODUCTION: Laparoscopic cholecystectomy is the
most commonly performed elective abdominal operation
and can be performed as a day case procedure. However
day case rates in the UK vary widely between hospitals with
figures ranging from 6.4% to 50% with higher performing
centres feeling rates up to 70% are achievable. The reasons
for such disparity between hospitals is multifactorial and
therefore a retrospective review was undertaken to determine if any perioperative factors influenced length of stay.
METHODS: 100 patients (50 day case and 50 overnight
stay) who underwent elective laparoscopic cholecystectomy were subjected to a medical note review. Information
on operative time, duration, surgeon, anaesthetist, patient
demographics and perioperative medication such as the
use of opiates and antiemetics were collected. Statistical
analysis was undertaken using a Fishers’ exact test.
RESULTS: The mean age in the day case group was 48
years compared to 55 years in the overnight group (NS).
There were 12 males in the day case group compared to 13
in the overnight group. The mean ASA was 2 in both groups
(range 1–2 in each group). 80% (n = 40) of day case patients
had an anaesthetic start time before 12pm compared to
48% (n = 24) in the overnight group (p = 0.0016). Intraoperative morphine was used in 40% (n = 20) of day case
patients compared to 68% (n = 34) of overnight patients (p
= 0.0088) whilst this use changed to 6% (n = 3) and 26%
(n = 13) respectively in recovery (p = 0.0122). The use of
fentanyl was not statistically significant between the two
groups intraoperatively or in recovery (88% versus 86%
intraoperatively and 52% versus 60% in recovery). Dexamethasone was used in 92% (n = 46) of day case patients
intraoperatively compared to 70% (n = 35) in the overnight
group (p = 0.0095). The use of ondansetron was not significantly different between the two groups.
CONCLUSION: Anaesthetic start time and the use of fentanyl and dexamethasone are associated with a shorter stay
in hospital whilst the use of morphine either intraoperatively or in recovery leads to a longer length of stay following elective laparoscopic cholecystectomy.
116
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1459
Perioperative Outcomes of Patients Undergoing
Laparoscopic Cholecystectomy: The Critical Impact
of Age and Operative Status
Sajida Ahad, Ibrahim B. Cetindag, Stephen Markwell,
Imran Hassan*
SIU School of Medicine, Springfield, IL
INTRODUCTION: We evaluated the perioperative outcomes of patients undergoing elective and emergency laparoscopic cholecystectomy (LC) who were <80 and >80 years
of age.
PATIENTS AND METHODS: Patients undergoing LC
for benign disease between 2005 and 2010 were identified
from the ACS-NSQIP participant use file (PUF) utilizing the
current procedural terminology (CPT) codes for LC with
and without intraoperative cholangiogram. Patients undergoing any other procedure except a LC as identified by the
CPT codes were excluded. A procedure was considered an
emergency if so designated by the surgeon or anesthesiologist or if surgery was performed no later than 12 hours after
the patient was admitted to the hospital or after the onset
of related preoperative symptoms. Outcome measures analyzed included 30-day mortality, return to operating room,
serious morbidity and overall morbidity. Serious morbidity
was defined as having documentation of one of the following complications: organ space surgical site infection (SSI),
wound dehiscence, neurologic event (cerebrovascular accident or coma lasting more than 24 hours) cardiac arrest,
myocardial infarction, bleeding requiring transfusion
of more than 4 units of packed red cells or whole blood,
pulmonary embolism, ventilator dependence more than
48 hours, progressive or acute renal insufficiency, and sepsis or septic shock. Overall morbidity was defined as having documentation of a serious morbidity or at least one
of the following complications: superficial SSI, deep SSI,
pneumonia, unplanned intubation (without preoperative
ventilator dependence), urinary tract infection, peripheral
neurological deficit and deep vein thrombosis. Preoperative variables including patient characteristics and co-morbidities and postoperative outcomes were compared by age
groups (<80 vs. >80 years) and operation status (elective vs.
emergency). Multiple logistic regression was used to assess
the influence of age and operation status on outcomes after
accounting for available covariates.
RESULTS: During the study period 91,034 patients underwent LC, which represented 90% of patients undergoing a
LC in the database. Patients older than 80 years were likely
to have more preoperative comorbidities and worse perioperative outcomes, however the outcomes were much worse
when they underwent emergency surgery. These unadjusted comparisons persisted in the multivariable analysis.
Male gender and presence of medical comorbidities were
also independently associated with worse perioperative
outcomes. (Table)
CONCLUSIONS: Patients older than 80 years of age have
more medical comorbidities and worse perioperative outcomes, particularly if they undergo emergency LC. These
patients represent a high risk group and therefore in emergency situations, a non operative approach should be initially considered if feasible.
Elective LC
Emergency LC
≤80 Years (n = 79,641)
>80 Years (n = 3,277)
≤80 Years (n = 7,679)
>80 Years (n = 437)
30-day mortality
0.1
1.7
0.4
5.3
Serious morbidity
0.9
4
2
10
Overall morbidity
2.5
7
4
14
Return to OR
1
1.6
1.2
2.8
Male Gender
25
40
31
45
Diabetic
10
18
10
19
Pulmonary disease
7
20
5
19
Bivariate Comparisions*
98
85
96
75
30-Day Mortality
Serious Morbidity
Overall Morbidity
Return to OR
Emergency vs. elective
2.3 (1.6–3.2)
2 (1.6–2.2)
1.6 (1.4–1.7)
1.3 (1.0–1.6)
>80 vs.≤80
Logistic regression**
2.7 (2.0–3.7)
1.3 (1.1–1.6)
1.3 (1.2–1.5)
NS
Male vs. female
NS
1.5 (1.4–1.7)
1.1 (1.0–1.2)
1.3 (1.1–1.5)
Diabetes vs. No diabetes
NS
1.3 (1.2–1.5)
1.3 (1.2–1.5)
1.2 (1–1.5)
Pulmonary disease vs. No pulmonary disease
2.3 (1.7–1.9)
1.6 (1.4–1.9)
1.5 (1.3–1.6)
NS
Cardiac disease vs. No cardiac disease
1.4 (1.0–1.9)
NS
NS
1.3 (1.1–1.6)
* All values are expressed in percentage. ** Odds ratio (95% confidence interval) NS = Not Significant
117
Monday
Poster Abstracts
Independent functional status
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1460
results and the importance of early surgical intervention
for improved outcomes in patients with cholecystitis, especially when focusing on efficient resource utilization, it
would be advisable to proceed to cholecystectomy immediately following positive ultrasound findings without the
delay or expense of a confirmatory HIDA scan.
Is HIDA Scan Necessary for Sonographically Suspicious
Cholecystitis?
Irina Bernescu*, Tomer Davidov
Surgery, Robert Wood Johnson UMDNJ, New Brunswick, NJ
INTRODUCTION: Gallbladder disease is a common and
escalating problem, particularly in the United States and
other developed countries, where a variety of modifiable
factors (including diet, alcohol consumption, and activity
level) come into play. It is estimated that 20–25 million
Americans have gallstones, representing 10–15% of the
adult population. Of these, approximately 20% become
symptomatic at some point, causing cholecystitis to account
for 3–9% of hospital admissions for acute abdominal pain,
with 1–3% requiring removal of the gallbladder. The progressively increasing prevalence of gallbladder disease represents a major health burden, with direct plus indirect
costs of approximately $6.2 billion annually in the United
States. In this context, the timely and efficient diagnosis
of cholecystitis is of paramount importance, as length of
hospital stay and multiple diagnostic tests for each patient
are major contributors to the cost of treating gallbladder
disease. Currently, abdominal ultrasound is the study of
choice for diagnosing cholelithiasis, while HIDA scan is the
study of choice for diagnosing cholecystitis. However, our
study had the goal of determining whether patients with
suspected cholecystitis on ultrasound benefitted from subsequently having a HIDA scan to clarify diagnosis.
METHODS: We retrospectively reviewed patients evaluated for presumed cholecystitis between 2007 and 2010,
through the Emergency Department of our 600-bed academic medical center. We identified 154 patients who
underwent abdominal ultrasound and HIDA scan, and proceeded to cholecystectomy on the same admission. Ultrasound results were compared to those of HIDA scan. The
pathology findings of the cholecystectomy were used as
the gold standard for the diagnosis of cholecystitis.
RESULTS: Statistical analysis revealed that abdominal
ultrasound had 47% sensitivity for cholecystitis, with a
positive predictive value of 96%. HIDA scan had a sensitivity of 62% for cholecystitis, with a positive predictive value
of 96%.
CONCLUSIONS: Our study confirmed previous findings
related to the superior sensitivity of HIDA scan in diagnosing cholecystitis. However, we also showed that both
ultrasound and HIDA scan have a positive predictive value
of 96%, suggesting that a HIDA scan would not provide
additional diagnostic benefit in a patient with sonographic
findings consistent with cholecystitis. Based on these
Mo1461
Costs Associated with Delayed Cholecystectomy After a
Biliary Migration
Charles MéNard*, René-Paul Beauchamp
Gastro-Enterology, Sherbrooke, Sherbrooke, QC, Canada
Biliary migration treated with ERCP alone carries an
increased risk ok recurrent biliary event compared to cholecystectomy. It is our impression that delayed gallbladder
removal also imposes additionnal costs to healthcare.
Charts from1600 patients with a primary diagnosis of
biliary migration, cholangitis, biliary pancreatitis or gallstone-related obstructive jaundice event between 1994 and
2008 in a single community-based teaching hospital were
reviewed. Minor aged patients, one-day elective surgery at
the first diagnosis of a biliary event and excessive lenght of
stay were excluded.The costs of hospital care was calculated
using consultation fees, procedure costs, hospital stay and
clinical support related costs. Totals costs related to the biliary event when the cholecystectomy was performed at the
initial event were compared to the total health care costs of
postponed cholecystectomy.
Surprisingly, biliary event-related costs of initial cholecystectomy ($CAN 15 531.53) was slightly higher (but
non-significantly) than later cholecystectomy ($CAN 14
822,70), even when readmission and ERCP occured inbetween for recurrent biliary complication. This unsuspected
twist may be driven by the longer lenght of stay during
the initial event caused by delays related to imaging, ERCP
and other tests done before the surgery. It is possible that
in a different health care setting where procedural costs are
much higher, the economic weight of late cholecystectomy
would have leaned if favor of faster access to surgery.
Readmission for new biliary complication occured significantly more often during the lenght of the study when
cholecystectomy was delayed (17%) compared with initial
cholecystectomy (7.5%), imposing unnecessary inconvenience to patients and increased technical and human
burden to the health care system. Late cholecystectomy
does not seem to impose additionnal costs over first episode cholecystectomy in Quebec health care system but is
associated with increased admission for relapsing biliary
events.
118
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Clinical: Colon-Rectal
Mo1464
Mo1462
Impact of Operative Duration on Postoperative
Pulmonary Complications Among Patients Undergoing
Complex Gastrointestinal Procedures
Colostomy vs. Ileostomy: An ACS-NSQIP Evaluation
of Complications from Diverting Stoma Reversal
Rachel M. Owen*, Sebastian D. Perez, John F. Sweeney
Surgery, Emory University, Atlanta, GA
Dhruvil R. Shah*1, Yueju LI2, Laurel Beckett2, David Wisner1,
Steve R. Martinez1, Vijay P. Khatri1
1. Surgery, University of California Davis, Sacramento, CA;
2. Public Health Sciences, University of California, Davis, CA
BACKGROUND: The optimal method of fecal diversion
remains controversial as either colostomy or ileostomy may
be sufficient. Perioperative outcomes associated with subsequent stoma reversal may inform the decision of which
diversion method to use. Our aim was to evaluate perioperative morbidity and mortality associated with colostomy
and ileostomy reversal.
METHODS: The American College of Surgeons National
Surgical Quality Improvement Program database was queried for all patients who underwent diverting stoma reversal between 2005 and 2008. Patients were excluded if the
type of stoma reversal could not be ascertained via CPT or
ICD-9 code. Outcomes evaluated included overall morbidity (≥1 serious complication), mortality, wound infections,
and total surgical length of stay. Multivariate analysis identified patient- and procedure-related risk factors associated
with each outcome. We reported adjusted odds ratios (aOR)
and 95% confidence intervals (95% CI).
CONCLUSION: Colostomy reversal is associated with
increased overall morbidity, wound infections, and nearly
twice the operative time compared to ileostomy reversal.
These factors should be considered when deciding which
type of diverting stoma to perform.
METHODS: We queried American College of Surgeons
National Surgical Quality Improvement Program 2009 Participant User File for patients who underwent elective open
colectomy, hepatectomy, or pancreatectomy. For this study,
PPC was defined as pneumonia, prolonged mechanical
ventilation greater than 48 hours, and unplanned reintubation. Patients both with and without PPCs were evaluated for operative duration, length of hospital stay, and
30-day mortality. The impact of operative duration on the
risk of PPC was evaluated using logistic regression models
with PPC occurrence as an outcome and operative time (in
hours) as the predictor. A model was also run controlling
for preoperative functional status and American Society of
Anesthesiologist (ASA) class to account for differences in
preoperative patient acuity.
RESULTS: 8620 cases (5523 colectomies, 915 hepatectomies, and 2182 pancreatectomies) were reviewed. 456
patients (5.3%) experienced at least one PPC. For operations
less than 480 minutes, each 60-minute increase in operative time was associated with a 13% increased risk of PPC
(OR 1.133; 95% CI, 1.077–1.192). For operations exceeding 480 minutes, each additional 60 minutes of operative
time beyond 8 hours was associated with a 30% increased
risk of PPC (OR 1.296; 95% CI, 1.143–1.470). Controlling
for differences in operative procedures did not affect regression modeling. Thirty-day mortality occurred in 54 (0.7%)
patients without PPC, whereas 72 patients (15.7%) with
one or more PPC died postoperatively. Overall, patients
with one or more PPC were 28 times more likely to die than
those who did not have a PPC (OR 28.3, p < 0.0001). The
average length of stay for patients with at least one PPC was
nearly three times as long as those without PPCs (20.08 vs.
7.43 days, respectively; p < 0.0001).
CONCLUSIONS: Operative duration is independently
associated with increased risk of PPC in patients undergoing complex gastrointestinal procedures, thus indirectly
leading to increased postoperative mortality and longer
hospital stays.
119
Monday
Poster Abstracts
RESULTS: A total of 5190 patients met inclusion criteria.
There were 2188 colostomy reversals and 3002 ileostomy
reversals. The colostomy reversal group had a significantly
higher median operative time (151 min vs. 75 min, p <
0.01). The number of contaminated and dirty wounds was
similar between both types of stoma reversal (49% vs. 49).
There was no significant difference in mortality, median
surgical length of stay, or re-operation rates. On multivariate analysis, the following preoperative factors were significant predictors of postoperative morbidity: Cr >2.0 (aOR
1.99, 95% CI :1.33–2.93), WBC between 10–20 (aOR 1.44,
95% CI:1.13–1.81), moderate exertional dyspnea (aOR
1.94, 95% CI: 1.47–2.53), and ASA status greater than 3
(aOR 1.79, 95% CI:1.53–2.10). Colostomy reversal was also
associated with higher odds of overall morbidity (aOR 1.28,
95% CI:1.08–1.50) and wound infections (aOR 1.70, 95%
CI :1.39–2.07).
BACKGROUND: Postoperative pulmonary complications
(PPC) are associated with higher healthcare costs, prolonged hospital stays, and increased morbidity and mortality than that of other postoperative complications. Many
studies have demonstrated that prolonged operative duration is associated with increased postoperative morbidity
and mortality. To our knowledge, the direct impact of operative duration on PPCs has not been specifically analyzed.
We hypothesize that longer operative times are independently associated with an increased risk of PPCs in patients
undergoing complex gastrointestinal procedures.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1465
Mo1466
Microlaparoscopic Colectomy: Initial Experience
Longer LOS Yet Similar Return of BM for Hand-Assisted
(vs. Laparoscopic) Colorectal Resection Patients Who
Had a Higher BMI and Risk Profile
Christopher Foglia*, Stuart L. Blackwood, Pierre F. Saldinger
Surgery, Danbury Hospital, Danbury, CT
INTRODUCTION: There has been a recent trend toward
decreasing surgical invasiveness by minimizing incision
size using single incision laparoscopic surgery. The technique and tools for performing this type of surgery are
completely different from conventional laparoscopic surgery thus generating a steep learning curve and increased
operative time. We have explored the use of microlaparoscopy in colon surgery to minimize the trauma of surgery
without the need for learning an entirely new skill set.
METHODS: A retrospective review of all microlaparoscopic segmental colectomies performed by a single surgeon over a 28 month period at a teaching hospital was
conducted. Microlaparoscopic surgery was defined as the
use of 3 mm trocars in addition to a 12 mm Hasson umbilical incision, which was later widened for specimen extraction. Cases were excluded if the decision to use either a
GelPort, or standard laparoscopic instruments was made at
the outset of the case.
RESULTS: 38 patients underwent microlaparoscopic colectomy for cancer (n = 14), polyps (n = 7), diverticulitis
(n = 14), Crohn’s disease (n = 2) and volvulus (n = 1). Six
patients (16%) required conversion: 2 to limited laparotomy, 3 to a hand assisted approach through an 8 cm pfannenstiel incision, and 1 where a 3 mm port was upsized to
12 mm. Reasons for conversion included: difficult visualization, inadvertent colotomy, excessive visceral fat, adhesions, inadequate reach of 3 mm instruments, need for
use of a right lower quadrant GIA stapler, and one positive
intra-op leak test. In patients who had resection for cancer,
average lymph node harvest was 25 (range 14–70 nodes).
Patients who were completed with microlaparoscopic technique had an average extraction incision length of 3.8 cm
(range 3.0–6.5 cm) and on average two additional 3 mm
port sites. Right colon resections had on average a shorter
operative time (181 minutes) when compared to left colon
resections (253 minutes). Median length of stay was 4 days
(range 3–13 days). 5 patients experienced a total of 10 post
operative complications. These included CDiff, AFib, CHF,
pneumonia, acute renal insufficiency, respiratory failure,
DVT, wound infection, GI bleed, recurrence of colovesical
fistula, and one anastomotic leak 2 weeks postoperatively
that was managed non-operatively. Thirty day mortality
rate was 0/38
CONCLUSION: Microlaparoscopic colectomy is safe and
feasible. It offers a minimally invasive technique that
reduces incision length while using similar techniques as
standard laparoscopic colectomy. Future advances may
continue the trend toward reducing instrument size, thus
reducing trauma to the patient while preserving a technique that has already taken years to infiltrate common
practice for colon surgery.
Samer Naffouje*1, Sonali A. Herath1, M.C. Shantha Kumara H1,
Xiaohong Yan1, Joon Ho Jang1, Linda Njoh1, Elizabeth Myers1,
Tromp Wouter1, Vesna Cekic1, Daniel L. Feingold2,
Richard L. Whelan1,2
1. Department of Surgery, St. Luke’s Roosevelt Hospital Center, New
York, NY; 2. Department of Surgery, Columbia University College of
Physicians and Surgeons, New York, NY
INTRODUCTION: Most minimally invasive surgery
(MIS) surgeons utilize Laparoscopic Assisted (LA) or HandAssisted (HA) colorectal resection methods; the majority do
not use both methods. This review of the experience of a
group of MIS surgeons who embrace both methods selectively for sigmoid resection (SR) was begun in an attempt
to identify factor(s) that influence the choice of surgical
method. It was believed that the selective use of LA and
HA methods would allow more cases to be done using MIS
methods.
METHODS: A retrospective review of SR data from 2 institutions over a 10 year period was carried out. Demographic
data as well as comorbidities, indications, operative data,
and short term results were reviewed.
RESULTS: A total of 536 SR patients (pts) were identified, the methods used were: LA, 286 pts (53.4%); HA, 172
(32.1%); and Open (OP), 78 (14.5%). SR indications were
cancer in 206 pts (38.4%) and benign problems (diverticulitis, polyps, IBD, etc) in 330 pts (61.6%). The HA group’s
mean BMI (29.04 ± 6.18) was significantly greater than the
mean BMI of the LA (25.85 ± 5.35) and OP (25.88 ± 5.53)
groups (p < 0.0001 for both comparisons). In regards to
benign SR’s, the HA group had significantly more high risk
patients (HRP) than the LA group but significantly fewer
HRP’s than the OP group (Charlson Comorbidity Index).
In the cancer pts there was a trend toward more HRP’s in
the HA vs. the LA group (p = 0.074). Notably more OP pts
required transfusions (34.6%) than LA (8.3%) or HA (7%)
pts (p < 0.0001 for both). The mean incision lengths (IL)
were: LA, 6.59 ± 4.18 cm; HA, 9.82 ± 3.57 cm; and OP, 19.35
± 5.94 cm (p < 0.05 for all). The mean time to first flatus (FL)
and mean time to first bowel movement (BM) were significantly shorter for the LA (FL, 2.60 days; BM, 3.09 days) and
HA groups (FL, 2.70 days; BM, 3.30 days) when compared
to the OP group’s results (FL, 3.76 days; BM, 4.11 days). The
HA mean length of stay (LOS) of 7.12 ± 5.0 days was longer
than for the LA pts (6.14 ± 3.8 days; p = 0.03) yet shorter
than the OP LOS (11.5 ± 10.6 days; p < 0.0001). The overall
morbidity rate for the three methods was: LA, 24.5%; HA,
38.4%, and OP, 48.7% (LA vs. OP; p = 0.002, LA vs. HA; p
= 0.0021). The leak/abscess rates were: LA, 2.1%; HA, 2.9%;
and OP, 3.8% (p = ns for all). There was no difference in the
wound infection, bleeding, or cardiac complication rates.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
CONCLUSIONS: The majority of SR’s were done using LA
methods whereas HA methods were used for about 1/3 of
cases. HA methods were used for higher BMI and higher
risk pts (vs. LA patients). The HA LOS was 1 day longer than
the LA group yet the HA and LA return of bowel function
was similar. Except for BMI, the OP pts were the most challenging. Utilization of both HA and LA methods allows the
great majority of SR cases to be done using MIS methods.
Mo1467
Predictors of Successful Pelvic Reoperations in
Colorectal Surgery: A Multivariate Analysis
Emanuela Silva*, Marylise Boutros, Ricardo Aliendre,
Fabio Potenti, Giovanna Dasilva, Steven Wexner
Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
Predictors of successful outcomes following reoperative
pelvic surgery are poorly defined. We aim to identify predictors of successful pelvic colorectal reoperations.
After IRB approval, we identified all patients from our prospective database who underwent re-operative pelvic surgery from 01/02–07/11. Patient demographics and clinical
variables were confirmed by chart review. Primary outcome
was the overall complication rate; including early (≤30
day) and late (>30 day) complications, and the secondary
outcome was diverting stoma closure [SC]. Chi-square and
student’s t test were performed. All variables with p < 0.1
on univariate analysis were included in multivariate cox
regression analysis.
Mo1468
Ethnicity Defines the Risk of Crohn’s Disease of the
Ileoanal Pouch
Saurabh Mukewar*1, Xianrui Wu3, Rocio Lopez4, Pokala R. Kiran2,
Feza H. Remzi2, Bo Shen3
1. Cleveland Clinic Foundation, Ohio, Cleveland, OH; 2. Colorectal
Surgery, Cleveland Clinic Foundation, Ohio, Cleveland, OH; 3.
Gastroenterology and Hepatology, Cleveland Clinic Foundation, Ohio,
Cleveland, OH; 4. Quantitative Health Sciences, Cleveland Clinic
Foundation, Ohio, Cleveland, OH
BACKGROUND: A few previous paired studies (including
ours) showed that African-American (AA) and HispanicAmerican (HA) had similar pouch related outcomes after
ileal pouch-anal anastomosis (IPAA). There is no previous
data on pouch outcomes for Indian-American (IA) patients.
Further, whether ethinicity differentially influences pouch
related outcomes after IPAA has not been investigated.
AIM: To compare differences in outcomes after IPAA for
ulcerative colitis (UC) for AA, HA, IA and Caucasian-American patients.
METHODS: From a prospectively maintained Pouchitis
Database, this historical cohort study identified and compared UC patients with different racial background (AA, HA,
IA or Caucasian-american) who underwent IPAA. Pouch
patients with familial adenomatous polyposis, and those
with unknown or mixed racial background were excluded.
CD of the pouch was diagnosed based on a combined
assessment of endoscopic, histologic, and radiographic features. A total of 25 demographic and clinical variables were
evaluated with both univariate and multivariable analyses.
RESULTS: There were 22 IA, 26 AA, 37 HA and 822
Caucasian-American patients. Results of unvariable and
multivariable analyses associated with characteristics and
outcomes for the various groups are shown in the following Tables 1 and 2, respectively.
CONCLUSION: Significant differences in the disease
course of UC before colectomy such as disease extent, use of
immunomodulator or biologics, and duration of UC exist
between the various ethnic groups. Racial background is
independently associated with the risk for developing CD
of pouch with AA patients having a 11-fold and CaucasianAmericans an 8-fold higher risk of developing CD of pouch
compared to IA UC patients undergoing IPAA surgery.
121
Monday
Poster Abstracts
254 pelvic reoperations (mean age 52 years, 47% male) were
performed, including 104 with establishment of intestinal
continuity. The most common diagnoses were: mucosal
ulcerative colitis (35%), rectal cancer (24%), diverticulitis
(18%), Crohn’s disease (6%) and familial adenomatous
polyposis (6%). The most common initial operations performed were: total proctocolectomy with ileoanal pouch
anastomosis [IPAA] (41%), resection with colorectal anastomosis (27%) and resection with coloanal anastomosis
(17%). Indications for reoperation included: anastomotic
leak (53%), fistula (14%), anastomotic stricture (10%), IPAA
dysfunction (11%) and recurrent cancer (8%). The overall
complication rate after reoperation was 20%; 8% early and
12% late. On multivariate regression, BMI ≥ 25 kg/m2 (p <
0.03) and anastomotic complications (leak, fistula or stricture) as the indication for reoperation (p < 0.0001) were
independent predictors of complications. Intraoperative
complications during initial operation (p < 0.002) and steroids at the time of reoperation (p < 0.01) were independent
predictors of early and late complications, respectively. 104
patients underwent reoperation with re-establishment of
intestinal continuity with an overall complication rate of
19% (8% early and 11% late). 88% had an ileostomy at
time of reoperation, of whom 71% underwent SC. Complications after reoperation delayed time to SC (380 vs.
196 days, p < 0.05). On multivariate regression, IPAA (p <
0.0001) and ASA class I (p < 0.03) were independent predictors of SC; while rectal cancer (p < 0.005) and diverticulitis
(p < 0.02) as the initial indication for operation, and coloanal anastomosis at initial operation (p < 0.03) were independent negative predictors of SC.
Despite the complexity of pelvic colorectal reoperations,
in experienced hands, the overall complication rate is low.
Whenever possible, patients should be counseled to taper
steroids and reach ideal BMI prior to undergoing pelvic
reoperative surgery.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Table 1: Risk Factors for Post-Op Development of CD of the Pouch: Multivariable Logistic Regression Analysis
Odds Ratio (95% Confidence Interval)
p-Value
African-American vs. Indian-American
Factor
11.2 (1.1, 1507.3
0.012
Caucasian-American vs. Indian-American
8.1 (1.10, 1040.0)
0.008
Hispanic-American vs. Indian-American
4.2 (0.40, 572.0)
0.091
Age at time of pouch creation (5 yr. increase)
0.87 (0.81, 0.93)
<0.0001
Pouch duration (5 yr. increase)
1.2 (1.08, 1.4)
0.002
Pre-operative diagnosis: CD vs. UC
6.6 (2.2, 21.5)
0.001
Family history of CD
2.0 (1.06, 3.6)
0.035
Table 2: Descriptive Characteristics of IPAA Patients Based on Racial Background
Caucasian-American
(N = 822)
African-American
(N = 26)
Indian-American
(N = 22)
Hispanic-American
(N = 37)
p-Value
Male
458 (55.7)
13 (50.0)
10 (45.5)
23 (62.2)
0.59
Age at time of diagnosis (yrs.)
27.6 ± 12.4
28.0 ± 11.1
28.7 ± 10.3
24.4 ± 13.2
0.45
Age at time of IPAA surgery (yrs.)
36.2 ± 13.9
33.3 ± 11.6
36.7 ± 11.9
32.9 ± 13.5
0.39
Factor
Current age (yrs.)
46.2 ± 14.2
39.5 ± 9.3
43.7 ± 13.5
41.9 ± 15.0
0.027
Duration of UC from diagnosis to IPAA
surgery (yrs.)
6.0[2.0,12.0]
5.0[2.0,7.0]
5.5[4.0,12.0]
8.0[2.0,11.0]
0.56
. Never
630 (76.6)
24 (92.3)
22 (100.0)
27 (73.0)
. Ex-smoker
9 (24.3)
Smoking
0.026
122 (14.8)
2 (7.7)
0
. Current smoker
70 (8.5)
0
0
1 (2.7)
Chronic NSAID use
50 (6.1)
5 (19.2)
1 (4.5)
2 (5.4)
0.058
179 (21.8)
1 (3.8)
1 (4.5)
10 (27.0)
0.026
Family history
IBD
CD
53 (6.4)
0
0
1 (2.7)
0.25
UC
132 (16.1)
1 (3.8)
1 (4.5)
9 (24.3)
0.073
. Refractory to medical therapy
716 (87.1)
26 (100.0)
20 (90.9)
29 (78.4)
. Dysplasia
106 (12.9)
0
2 (9.1)
8 (21.6)
Indication for colectomy
0.083
Pre-operative diagnosis
0.53
. UC
744 (90.5)
26 (100.0)
21 (95.5)
35 (94.6)
. IC
66 (8.0)
0
1 (4.5)
1 (2.7)
. CD
12 (1.5)
0
0
1 (2.7)
777 (94.5) 3
22 (84.6)
15 (71.4)1
35 (94.6)
. Left-sided colitis/Proctitis
45 (5.5)
4 (15.4)
6 (28.6)
2 (5.4)
Fulminant colitis
88 (10.7)
0
3 (13.6)
4 (10.8)
Extent of ulcerative colitis
. Pancolitis
<0.001
122
0.34
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Caucasian-American
(N = 822)
African-American
(N = 26)
Indian-American
(N = 22)
Hispanic-American
(N = 37)
Pre-operative use of biologics
70 (8.5)
4 (15.4)
5 (22.7) 4
03
0.015
Number of visits to pouch clinic
2.0 [1.00,3.0] 3,4
1.00 [1.00,2.0]
1.00 [1.00,2.0] 1
1.00 [0.00,2.0] 1
<0.001
.J
767 (93.4)
26 (100.0)
21 (95.5)
36 (97.3)
.S
25 (3.0)
0
0
0
. Other
29 (3.5)
0
1 (4.5)
1 (2.7)
.1
28 (3.4)
0
0
0
.2
626 (76.2)
22 (84.6)
16 (84.2)
30 (81.1)
.3
120 (14.6)
3 (11.5)
3 (15.8)
5 (13.5)
Factor
Pouch type
p-Value
0.7
Stage of pouch surgery
0.85
. 4 or redo pouch
48 (5.8)
1 (3.8)
0
0
Post-operative use of immunomodulator
88 (10.7)
2 (7.7)
1 (4.5)
2 (5.4)
0.55
Post-operative use of biologics
75 (9.1)
2 (7.7)
1 (4.5)
1 (2.7)
0.5
Autoimmune disease
115 (14.0)
4 (15.4)
0
3 (8.1)
0.2
Primary sclerosing cholangitis
43 (5.2)
1 (3.8)
1 (4.5)
1 (2.7)
0.9
Liver transplantation
8 (0.97)
1 (3.8)
0
1 (2.7)
0.39
Significant comorbidities
65 (7.9)
3 (11.5)
0
2 (5.4)
0.44
. Normal pouch
82 (10.0)4
5 (19.2)
7 (31.8)
13 (35.1) 1
. Irritable pouch syndrome
142 (17.3)
4 (15.4)
1 (4.5)
5 (13.5)
. Active pouchitis
164 (20.0)
5 (19.2)
7 (31.8)
6 (16.2)
Final diagnosis
0.003
. Refractory pouchitis
107 (13.0)
1 (3.8)
3 (15.8)
5 (13.5)
. Crohn’s pouch
164 (20.0)
5 (19.2)
0
4 (10.8)
. Cuffitis
83 (10.1)
2 (7.7)
1 (4.5)
2 (5.4)
. Surgical complications
78 (9.5)
4 (15.4)
3 (15.8)
2 (5.4)
. Anismus
2 (0.24)
0
0
0
Extra-intestinal manifestations
314 (38.2)
7 (26.9)
6 (27.3)
9 (24.3)
0.16
Post-op hospitalization
133 (16.2)
4 (15.4)
6 (27.3)
8 (21.6)
0.46
Pouch failure
62 (7.5)
3 (11.5)
4 (18.2)
2 (5.4)
0.24
9.0 [5.0,14.0] 2,3
4.5 [2.0,10.0] 1
4.0 [2.0,10.0] 1
9.0 [4.0,13.0]
<0.001
Values presented as Mean ± SD with ANOVA; Median [P25, P75] or Median (min, max) with Kruskal-Wallis test, or N (%) with Pearson’s chi-square test unless
otherwise stated.
1
Significantly different from Caucasian
Significantly different from African-Am
3
Significantly different from Indian
4
Significantly different from Hispanic
2
123
Monday
Poster Abstracts
Follow up of Pouch Failure (yrs.)
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1469
Intestinal Surgery for Crohn’s Disease: Role of
Preoperative Therapy in Postoperative Outcome
Marco Scarpa*1, Matteo Martinato2, Anna Pozza2, Cesare Ruffolo3,
Giorgia Maran2, Renata D’Incà2, Romeo Bardini2, Imerio
Angriman2
1. Oncological Surgery Unit, Venetian Oncology Institute (IOV-IRCCS),
Padova, Italy; 2. Department of Surgical and Gastroenterological
Sciences, University of Padova, Padova, Italy; 3. IV Unit of Surgery,
Ospedale Regionale “Ca’ Foncello”, Treviso, Italy
INTRODUCTION: During their life, 80% of patients
affected by Crohn’s disease (CD) require at least one surgical procedure. All CD patients assume lifelong medical
therapy and this therapy may have several severe side
effects that can affect the outcome after surgery. The aim of
this study was to evaluate the role of preoperative medical
therapy in the outcome of intestinal surgery for CD.
PATIENTS AND METHODS: In our department, 453
surgical procedures for intestinal CD were performed from
1982 to 2011. Adequate data about preoperative therapy
(6 months before the operation) were available for 100
patients that were thus enrolled in this retrospective study.
They were 40 women and their median age was 35 (IQR:
18–44). The median CD duration was 92 (IQR: 33–160)
months and 26 patients presented a fistulizing phenotype.
Medical therapy before the operation (use and dose of sulphasalazine, mesalazine, azathioprine, prednisone, beclometasone, budesonide, anti-TNFalpha) was used as possible
predictor of postoperative outcome. Surgical predictors
(video assisted intestinal surgery, strictureplasty, stoma
creation, ileal resection and colonic resection) as well as
clinical predictors (age, gender, CD duration, activity and
localization, recurrent CD) were also evaluated. Outcome
measures were medical and surgical complication, reoperation, day of first bowel movement, postoperative hospital
stay. Univariate and multivariate analysis were performed.
RESULTS: Preoperative rectal administration of beclometasone was the only independent predictor of the anastomotic leak (beta = 0.36, p < 0.001) in a model that also
included minimally invasive surgery, colonic resection,
obstructing phenotype, type of suture and end-to-end
anastomosis (R2 = 0.29, p < 0.001). Preoperative therapy
with budesonide was the only independent predictor of the
delayed canalization after surgery (beta = 0.44, p < 0.001)
in a model that also included minimally invasive surgery,
patients gender, disease activity, ileocolonic resection, stricturoplasty, and therapy with mesalazine and beclometasone (R2 = 0.29, p = 0.003). Postoperative rectal bleeding
was independently predicted by azathioprine dose (beta =
0.29, p = 0.012) while reoperation in the first month was
independently predicted by the use of budesonide (beta
= 0.25, p = 0.044). No adverse effect on surgical outcome
were observed after the use of anti TNFalpha therapies.
CONCLUSIONS: Severe CD require adequate and important medical therapy thus this is an almost unavoidable
variable affecting the surgical outcome of these patients.
Curiously enough, “topic” steroids seemed to be associated
to poor outcome after intestinal surgery while oral steroid
seemed to not affect it. Azathioprine association to postoperative rectal bleeding may be due to a decreased platelets
count that sometimes occurs during the use of this immunomodulator .
Mo1470
Factors Associated with Long-Term Quality of Life (QL)
After Ileocolic Resection (ICR) for Crohn’s Disease
Felipe Bellolio*1,4, Zane Cohen1,4, Helen M. Macrae1,4, J. Charles
Victor2, Brenda I. O’Connor4, Harden Huang4, Robin S. Mcleod1,3
1. Surgery, University of Toronto, Toronto, ON, Canada; 2. Dalla
Lana School of Public Health, University of Toronto, Toronto, ON,
Canada; 3. Health Policy, Managment and Evaluation, University of
Toronto, Toronto, ON, Canada; 4. Zane Cohen Centre for Digestive
Diseases, Samuel Lunenfeld Research Institute, Mount Sinai Hospital,
Toronto, ON, Canada
INTRODUCTION: ICR is the most commonly performed
procedure in patients with Crohn’s disease yet there are few
reports regarding long term QL and factors associated with it.
PATIENTS AND METHODS: All patients who had ICR
between 1990 and 2010 were identified from a prospectively maintained IBD database. A12 item questionnaire
which included questions regarding current status, use of
postoperative medications, tobacco history, need for further surgery, fertility (in females) as well as the short version
of the IBDQ [scores ranging from 1 (poorest) to 7 (best)]
were mailed to all patients. Uni and multivariate analyses
were performed to determine factors associated with QL.
RESULTS: Of 434 patients surveyed, 206 (47.5%) (mean
age 33.9 ± 12.3 years at the time of surgery; 122 women)
responded. Eighty-six (41.7%) received postoperative
maintenance therapy and 25 (12.1%) are current smokers. Overall, 88 (42.7%) patients reported having recurrent disease of which 71 (80.6%) were clinical recurrences
and 17 (19.8%) required surgery, 15 of them resection of
the previous ileocolic anastomosis. Eighteen (15%) of the
119 females who responded stated they had fertility problems (at least one episode longer than 12 months trying
to get pregnant) although 17 were ultimately successful in
becoming pregnant. The mean SIBQ score was 5.2 ± 1.3
with scores ranging from 1.4 to 7.0 in the four domains.
On multivariate analysis only recurrence of Crohn’s disease
(p < 0.001) and the absence of penetrating disease at the
original surgery (p = 0.039) were associated with decreased
SIBD scores.
CONCLUSIONS: Most patients have a good QL following
ICR. However non-penetrating disease at surgery and disease recurrence appear to negatively impact on QL.
124
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1471
Mo1472
Is Laparoscopic Resection for Recurrent Disease
Beneficial in Patients with Previous Intestinal
Resection for Crohn’s Disease Through Midline
Laparotomy? A Case-Matched Study
Nervosa Anorexia Leads to Defaecatory Disorders
Compared to General Population
Erman Aytac*, Luca Stocchi, Feza H. Remzi, Pokala R. Kiran
Colorectal Surgery, Cleveland Clinic Foundation Digestive Disease
Institute, Cleveland, OH
BACKGROUND: Patients undergoing abdominal surgery
for Crohn’s disease are predisposed to recurrence requiring reoperation. The effectiveness of laparoscopic vs. open
resection in patients with previous intestinal resection for
Crohn’s through a midline laparotomy is controversial.
METHODS: Patients with previous open resection for
intestinal Crohn’s disease undergoing elective laparoscopic
surgery for recurrent bowel disease from 1997–2011 were
case-matched with open counterparts based on age (±5
years), gender, body mass index (±2 kg/m2), ASA score, surgical procedure and year of surgery (±3 years).Groups were
compared using chi-square or Fisher exact tests for categorical and the Wilcoxon rank sum test for quantitative data.
CONCLUSIONS: Bowel resection for recurrent Crohn’s disease in patients with previous primary resection through
laparotomy can be frequently and safely completed laparoscopically. Wound infection rates are reduced but there are
no clear recovery advantages when compared with open
surgery. The decision to operate laparoscopically should
therefore be carefully calibrated.
BACKGROUND: We have previously shown that Defaecatory Disorders (DDs) can be as high as 60% in obese
patients and are reversed after bariatric surgery. Conversely,
similar data on DDs in patients with nervosa anorexia have
been overlooked. In this case-control study we evaluated
the prevalence and type of DDs in patients with nervosa
anorexia.
PATIENTS AND METHODS: A questionnaire-based study
was proposed to patients with nervosa anorexia. Data
included mean body mass index (BMI), demographics, past
medical, surgical and obstetrics histories, as well as eating
disorders duration. Wexner Constipation Score (WCS) and
the Faecal Incontinence Severity Index (FISI) questionnaires
were used to evaluate constipation and incontinence. For
the purpose of this study, we considered clinically relevant
a WCS ≥5 and a FISI score ≥10. Data were compared to a
matched control group with 18 < BMI >28.
RESULTS: a total of 32 anorexia patients (group A) accepted
the study and 30 patients filled the questionnaires as
matched control-group (group B). Overall, in group A
mean BMI was 17 ± 3 Kg/mq(2)(range 12–23); mean illness
duration 5 ± 3 (range 1–13); mean WCS was 10 ± 5 (range
2–22), while mean FISI score was 6 ± 8 (range 0–38). Overall, 90% of these patients reported DDs according to the
above-mentioned scores. Thirty patients (94%) had WCS
≥5. Eleven patients (34%) had FISI score ≥10. While eleven
patients (34%) reported combined abnormal scores. In
Group B, mean BMI 21 ± 3 (range 18–28); mean WCS was
3.8 ± 3 (range 0–10), while FISI score was 0. Overall, 53% of
these patients reported DDs according to the above-mentioned scores. Sixteen patients (53%) had WCS ≥5. None
had FISI score ≥10. In group A, according to the illness
duration (<5 years/>5 years) we found a statistical significance in terms of WCS ≥5 and FISI score ≥10 (p < 0.0001,
p < 0.02). According to the WCS ≥5, we found a statistical
significance between the two groups (p < 0.0001).
CONCLUSION: Defaecatory Disorders are common in
anorexia nervosa patients compared to general population.
The risk of DDs increases with anorexia nervosa duration.
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Monday
Poster Abstracts
RESULTS: 26 patients undergoing laparoscopic ileocolectomy (n = 14), proctocolectomy (n = 5), small bowel resection (n = 4), abdominoperineal resection (1), extended
right colectomy (1) and stricturoplasty (n = 1) were wellmatched to 26 patients undergoing open surgery. The
number of previous operations, steroid use, and incidence
of hypertension, diabetes, cardiopulmonary, neurological,
renal and hepatic comorbidities were comparable in the 2
groups. There were no deaths and 3 patients (12%) required
conversion because of adhesions. Laparoscopic and open
groups had statistically similar operating times (169 ± 83
vs. 158 ± 42 minutes, p = 0.94), estimated blood loss (222
± 181 vs. 427 ± 589 ml, p = 0.32), overall morbidity (39%
vs. 69%, p = 0.051), reoperation rates (8% vs. 0, p = 0.5),
postoperative return to bowel function (3.5 ± 1.4 vs. 3.9 ±
1.7 days, p = 0.3), mean length of hospital stay (6.4 ± 6.2
vs. 6.9 ± 3.5 days, p = 0.12) and readmission rates (8% vs.
12%, p = 0.64). Wound infection rate was decreased after
laparoscopic surgery (0 vs. 27%, p = 0.01).
Pierpaolo Sileri1, Iacoangeli Fabrizio2, Federica Starr2,
Luana Franceschilli*1, Elisabetta De Luca1, Alessandra Di Giorgio1,
Marilena Raniolo1, Maria Irene Bellini1, Stefano D’ Ugo1,
Achille Gaspari1
1. Surgery, University of Rome Tor Vergata, Rome, Italy; 2. Internal
Medicine, University of Rome, Tor Vergata, Rome, Italy
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1473
Mo1475
Role of Metastatic Lymph Node Ratio as a Prognostic
Index in Colorectal Cancer Surgery
Does Laparoscopic Colectomy Have Reduced PostOperative Morbidity and Mortality in Octogenarians
Compared to Open?
Pierpaolo Sileri1, Stefano D’ Ugo*1, Giulio P. Angelucci1,
Luana Franceschilli1, Marco D’Eletto1, Mara Capperucci1,
Vincenzo Formica2, Giampiero Palmieri3, Nicola Di Lorenzo1,
Achille Gaspari1
1. Surgery, University of Rome Tor Vergata, Rome, Italy; 2. Oncology,
University of Rome, Tor Vergata, Rome, Italy; 3. Pathology, University
of Rome, Tor Vergata, Rome, Italy
Roman Grinberg, Muhammad Asad Khan*, John Afthinos,
Karen E. Gibbs
Surgery, Staten Island University Hospital, Staten Island, NY
BACKGROUND: The ratio of metastatic to total retrieved
nodes, defined Lymph Node Ratio (LNR), has shown a better prognostic significance in several gastrointestinal cancers compared to the absolute number of positive lymph
nodes. The aim of this study was to assess the value of LNR
on long-term outcome of patients submitted to colorectal
surgery for malignancies.
METHODS: Clinical and pathologic data of patients
underwent colorectal surgery for resectable cancer at our
Department of Surgical Sciences were routinely and prospectively inserted in a database between January 2003
and August 2011 . We reviewed the total number of lymph
nodes retrieved in the surgical specimen and the number of
lymphatic metastasis. The value of the LNR was compared
with the long term outcome for each patients, and the
prognostic significance of LNR evaluated using the KaplanMeier survival curve and the log-rank test.
RESULTS: From an overall database of 1004 patients we
selected two hundred and thirty patients
(51.3% male, 48.6% female) that fulfilled the study criteria.
The mean age of the study group was 68.4 ± 10.5 years.
The type of surgery performed were right colectomy in 72
patients (31.3%), left colectomy in 73 patients (31.7%),
anterior resection or miles procedure in 79 patients (34.3%)
and other procedures in 6 patients ( 2.6%). Ten patients
(4.3%) were T1 staged, 30 (13.1%) were T2, 167 (72.6%)
were T3 and 23 (10%) were T4. The mean number of lymph
node retrieved were 13.6 ± 6.9 and 89 patients (38.7%) were
node positive with a mean metastatic lymph node number
of 1,4 ± 2.7. Since LNR increase as a function of metastatic
lymph node number we found that a LNR between 0.1
and 0.2 compared to LNR major than 0.2 has a significant
difference in predicting the long term outcome of these
patients ( p = 0.04).
CONCLUSION: After colorectal cancer surgery the LNR is
an accurate prognostic factor in node-positive patients in
long term overall survival and disease free survival.
OBJECTIVES: The benefits of laparoscopic colectomy are
well described in the literature and its use has been continually increasing. Given the sharp rise in the octogenarian
population from longer life expectancy, they will make up
a larger proportion of patients which are cared for by surgeons. We wished to compare the outcomes of laparoscopic
and open colon resections in this distinct and challenging
age group.
METHODS: Using the ACS-NSQIP database, we identified
all elective laparoscopic colectomies performed between
2007 and 2009 in patients ≥80 years of age. Preoperative
co-morbidities, operative time, length of hospitalization
and perioperative mortality and morbidity were compared
between the two groups using chi-square and independent
t-test as appropriate.
RESULTS: A total of 3,898 patients ≥80 years old were
identified who underwent a colectomy with primary
anastomosis. Of these, 1,123 (28.8%) patients underwent
laparoscopic colectomy while 2775 (71.2%) patients underwent open colectomy. There were no statistically significant differences between the laparoscopic and open groups
in terms of comorbidities. The only statistically significant
complications were cardiac arrest, superficial wound complication and sepsis, all of which were higher in the open
group.
There was otherwise no statistically significant difference
in surgical wound complications between open and laparoscopic group. There was no difference in operative times
between the two groups. Length of stay (7.9 ± 7 days vs.
10.8 ± 8.1 days, p < 0.001) and rate of major complications
was significantly less in the laparoscopic group (12.9% vs.
17.9%, p < 0.001). The post-operative mortality rate was
similar in both groups (3.2% vs. 3.3% for laparoscopic vs.
open, respectively, p = 0.05).
CONCLUSION: Minimally invasive colectomy in patients
≥80 years old reduces length of stay and major postoperative complications when compared to the open
approach. However, mortality is not different. This suggests that laparoscopic colectomy has potential benefits for
octogenarians and should be considered as the approach of
choice when feasible.
126
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1476
Mo1477
Does the Laparoscopic Approach to Colectomy Lessen
the Post-Operative Complications in Octogenarians?
Endoscopic Resection of Rectal NETs: Establishing
Guidelines for Oncologic Endpoints
Muhammad Asad Khan*, Roman Grinberg, John Afthinos,
Karen E. Gibbs
Surgery, Staten Island University Hospital, Staten Island, NY
Thomas Curran*1, Vitaliy Y. Poylin1, Robert M. Najarian2,
Deborah Nagle1
1. Surgery, Beth Israel Deaconess Medical Center, Boston, MA;
2. Pathology, Beth Israel Deaconess Medical Center, Boston, MA
OBJECTIVES: The percentage of octogenarians in the
population is increasing and these patients are now more
commonly seen in surgical practice. Colonic pathology is
a major disease entity for which surgical therapy is sought
by this age group. Octogenarians are more susceptible to
complications and mortality after colectomy given their
high incidence of comorbid factors and decreased physiologic reserve. There have been conflicting reports in the
literature regarding the outcomes of this population with
respect to laparoscopic colectomy. We sought to evaluate
this using a national database sample.
METHODS: Using the ACS-NSQIP database, we identified
all elective laparoscopic colectomies performed between
2007 and 2009 in patients ≥80 years of age. Preoperative
co-morbidities, operative time, length of hospitalization
and perioperative mortality and morbidity were compared
between the two groups using chi-square and independent
t-test as appropriate. A multivariate logistic regression analysis was used to analyze potential factors contributing to
post-operative morbidity and mortality.
CONCLUSION: Despite the potential benefits derived from
a laparoscopic approach, octogenarians had a higher morbidity and mortality rate. Independent risk factors which
increased the probability of complications post-operatively
were defined. These must be weighed carefully in the riskbenefit analysis of an octogenarian about to undergo an
elective colectomy. Interestingly, the presence of ascites
was the strongest predictor of mortality in this analysis.
METHODS: All pathologically confirmed, endoscopically
diagnosed rectal NETs at a tertiary care center from 2000
to 2010 were retrospectively reviewed. Clinical data from
were evaluated. Pathologic criteria including tumor size,
margin status, mitotic rate, depth of invasion, lymphovascular invasion and other factors were considered.
RESULTS: 40 patients (21 male) with rectal NETs were
identified. Mean age was 55 years (range: 31.8–73.9 years).
Mean follow up was 44 months (range: 1–122 months). A
majority (68%) were asymptomatic, undergoing colonoscopy for general screening. 27 (68%) underwent whole
endoscopic resection while the remainder underwent
piecemeal resection (N = 9) or biopsy (N = 4). Mitotic rate
was <2 mitoses per high-powered field in 29 (97%). Mean
tumor size was 0.9 cm (range 0.2–2.5 cm). Margin positive
patients (N = 18) showed no residual disease on re-resection
in 11 cases (2 TEM, 9 endoscopic); 3 had remaining disease
managed endoscopically and 3 went to OR for resection
of large or deeply invasive tumors. Indeterminate margin
patients (N = 11) showed no residual disease in 6 cases; 2
had remaining disease managed endoscopically, 3 went to
OR for resection of large/deeply invasive tumors, 1 died of
other causes before follow up. Negative margin patients
(N = 7) had no further interventions or no residual disease
in 5 cases; 1 had residual disease managed endoscopically
and 1 went to the OR for resection for large size. Tumor size
was not significantly different between groups. Overall, 31
patients with mean tumor size 0.8 cm (max 2.0 cm) were
managed with endoscopy alone; 23 required 2 procedures
while 8 required single procedure. None of these had recurrent disease. 9 patients required surgery (3 proctectomy, 3
transanal excision, 3 TEM) with most common indication
being size 2 cm or greater. 1 node positive patient developed distant metastasis.
CONCLUSIONS: This retrospective study suggests that
patients with rectal NETs less than 2 cm and without evidence of nodal disease on imaging may safely undergo
endoscopic management alone if subsequent surveillance
biopsy demonstrates no residual disease. Positive margin
status in endoscopically resected rectal NETs may not reflect
residual disease and should not be used alone as an indication for surgery. Larger, prospective trials will be needed to
further investigate these findings.
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Monday
Poster Abstracts
RESULTS: We identified 16,536 patients, of which 2,155
patients (13%) were ≥80 years and 14,381 patients (87%)
were <80 years old. Elective laparoscopic colectomy of
any type with primary anastomosis was accomplished in
each case. Independent predictors associated with a significantly increased rate of mortality were male gender (AOR
2.12), age above 80 years (AOR 2.92), dyspnea on exertion
and rest (AOR 1.75 and 5.85 respectively), partially and
completely dependent functional status (AOR 3.4 and 3
respectively), COPD (AOR 2.08), HTN (AOR 2.68), previous
cardiac surgery (AOR 2.07), >10% weight loss (AOR 2.3),
ASA III/IV (AOR 2.9), ascites (AOR 23.3). In the immediate
postoperative period the group of patients ≥80 years had
a higher incidence of PE (1.1% vs. 0.3%), failure to wean
and subsequent reintubation (2.2% vs. 0.9% and 2.9% vs.
1.1% respectively), cardiac arrest (0.6% vs. 0.2%) and septic
shock (2.4% vs. 0.8%). There was no difference in terms
of wound-related complications in both groups. Operative
time was found to be shorter for patients ≥80 years (141 vs.
161 min), but reoperation rate within 30 days was higher
(AOR 3). The rate of major complications and death were
also higher (AOR 1.73 and 6 respectively).
BACKGROUND: Neuroendocrine tumors (NETs) of the rectum are often indolent in nature with metastatic potential
related to grade and size of the primary tumor. Endoscopic
management of small NETs may be appropriate though
uncertain oncologic adequacy of resection frequently leads
to more invasive procedures. This study aims to delineate
adequate oncologic endpoints for management of rectal
NETs by endoscopic means alone.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Esophageal
CONCLUSION: This study demonstrates that delirium is
a risk factor for complicated post-operative recovery and
increased treatment costs following esophagectomy, and
furthermore that age is independently predictive of its
development. Focused screening will allow targeted preventative strategies to be employed in the peri-operative
period to reduce complications and cost associated with
delirium.
Mo1478
The Clinical and Economic Cost of Delirium Following
Surgical Resection for Esophageal Malignancy
Sheraz Markar*1, Alan Karthikesalingam2, Donald Low1
1. Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA;
2. Department of Outcome Research, St George’s Hospital, London,
United Kingdom
Mo1479
BACKGROUND: Delirium is an under-estimated and serious complication following major surgery, particularly in
the elderly population. The aim of this study was to identify pre-operative risk factors for delirium following esophagectomy for malignancy, and investigate its impact upon
short and long-term outcome.
METHODS: All patients undergoing esophagectomy for
cancer between 1991 and 2011 had information prospectively entered in an IRB-approved database. Patients were
divided into two groups based upon the presence or absence
of clinically-significant post-operative delirium, and were
compared with respect to use of neoadjuvant therapy,
medical co-morbidities, operative outcomes, post-operative
complications, overall cost and survival. For the purposes
of this study delirium was defined as an acute fluctuating
confusional state that required intervention.
RESULTS: 500 patients were included in this analysis;
46 (9.2%) patients with post-operative delirium and 454
patients without. Age was significantly increased (71 ± 8.12
yrs vs. 63 ± 10.86 yrs) and BMI was reduced (25 ± 4.24 vs.
27 ± 4.82 kg/m2) in the delirium group. There were no significant differences in cardiac, pulmonary or renal co-morbidities, however ASA grade was significantly increased in
the delirium group (2.83 ± 0.44 vs. 2.62 ± 0.54). There were
no significant differences between the groups in the use of
neoadjuvant therapy.
Analysis demonstrated that delirium was associated with
a significantly longer hospital (13.98 ± 7.54 vs. 10.88
± 5.67 days) and ICU stay (3.59 ± 3.82 vs. 2.68 ± 16.92
days). Furthermore post-operative delirium was associated
with a significantly increased incidence of post-operative
pneumonia (21.74% vs. 7.93%), pneumothorax (10.87%
vs. 2.64%), re-intubation (10.87% vs. 1.76%) and increased
overall treatment costs ($28223 ± 13018 vs. $22702 ± 9689;
P < 0.05).
Age was the only pre-operative predictor of post-operative
delirium in multivariate modeling (Odds ratio = 1.08; 95%
C.I. = 1.04–1.12, P < 0.05). Patients were followed up for an
average of approximately 4 years. There was no significant
difference between the groups in overall survival (1105 ±
910 days vs. 1273 ± 1428; P = 0.28) and there was no difference in Kaplan Meier curve distribution between the
groups.
The Incidence of Hiatal Hernia After Minimally
Invasive Esophagectomy
Nathan W. Bronson*, James P. Dolan, Renato A. Luna,
Brian S. Diggs, John G. Hunter
Department of General Surgery, Oregon Health and Science University,
Portland, OR
INTRODUCTION: Minimally invasive esophagectomy
(MIE) has evolved as a means to minimize the morbidity
of an operation which is traditionally associated with significant morbidity and mortality. Given recent reports of
increased hiatal herniation after robot assisted esophagectomy, we intended to describe the incidence and outcomes
of hiatal hernia in a large cohort of post-MIE patients.
METHODS: Clinical follow up data on one hundred and
fourteen patients who had undergone minimally invasive
esophagectomy between 2000 and 2011 was retrospectively
reviewed. Imaging findings derived from routine computed
tomography (CT) scans of the chest and abdomen were
used to establish the diagnosis of hiatal herniation after
minimally invasive esophagectomy. Age, gender, comorbid
conditions, clinical tumor stage, specimen size, length and
cost of hospital admissions, presenting complaint for hiatal
hernia, operation performed to correct hiatal herniation,
and mortality were all recorded for analysis.
RESULTS: Of the 114 patients identified in the database
who underwent MIE, a total of 8 were identified with postoperative hiatal herniation (7% incidence). Five of these
patients were asymptomatic. One of the three symptomatic patients presented with a perforated colon in the chest.
One patient complained of abdominal pain, nausea and
vomiting, and a final patient complained of gastric outlet obstruction with chest and neck fullness. All patients
except the one who presented emergently were repaired
laparoscopically on an elective basis. The average length of
stay associated with hiatal hernia repair in this setting was
5 days at an average expense of $40,785 (range $25,264–
$83,953). At follow-up only 1 patient complained of symptoms associated with reflux.
CONCLUSION: Hiatal herniation is not a rare event after
MIE. It is also associated with a large health care cost and
may be lethal. Most occurrences appear to be asymptomatic and if detected, can be repaired with good resolution of
symptoms and minimal associated morbidity.
128
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1480
Mo1481
The Utility of Esophageal Stents as an Adjunct in the
Perioperative Management of Cancer of the Esophagus
The Impact of Impedance (MII) Testing on Patient
Selection for Anti-Reflux Surgery in the Setting of a
Normal 24-Hour pH Test
Nicolas Zea*1, John Bolton1,2, Lisa L. Wang2, Abbas Abbas1,2
1. Department of Surgery, Ochsner Health Systems, New Orleans, LA;
2. Department of Surgery, The University of Queensland, Australia
School of Medicine, Brisbane, QLD, Australia
INTRODUCTION: Esophageal stents (ES) may be used as
an adjunct in the management of patients with resectable
cancer of the esophagus (EC) to improve nutritional status
during neoadjuvant therapy, or to manage postoperative
anastomotic leaks or strictures. We describe our experience
with the use of ES in a consecutive series of 97 patients
undergoing resection of EC between September of 2007
and March of 2011.
METHODS: This is a retrospective record review with IRB
approval. All patients receiving ES at our institution for
whom follow up is available are included. The indication
for ES placement was noted and the clinical effectiveness
was determined: did the ES successfully resolve the clinical
problem for which it was placed?
CONCLUSIONS: The effectiveness of ES placement for
preop nutritional stabilization (20%) and resolution of
postop leak (31%) is low. ES for postop anastomotic stricture is moderately effective (57%). The high proportion of
patients with cervical anastomoses in our patient population predisposes to ES migration; in addition, the prevalence of foregut symptoms with neoadjuvant therapy limits
the effectiveness of preop ES.
BACKGROUND: Gastroesophageal reflux (GER) has been
defined as abnormal acid exposure in the distal esophagus as
measured by 24 hr pH testing. However, there is a subset of
patients who present with classic reflux symptoms but have a
normal pH test. These patients present a treatment dilemma
for the esophageal surgeon as anti-reflux surgery (ARS) based
on symptoms alone has often been associated with unpredictable outcomes. Non-acid reflux has been suggested as
a valid indication for ARS in certain subsets of patients as
identified by multi-channel intraluminal impedance (MII)
testing . However, there is a paucity of data regarding the
incorporation of this modality in routine surgical decision
making. The aim of this study is to evaluate the impact of
MII-pH testing in a high volume ARS practice.
METHODS: Routine pH-MII testing was incorporated in
our esophageal testing laboratory in 2010. Prospectively
collected data for all patients who underwent standard
laparoscopic Nissen fundoplication from 2004–2010 was
reviewed. Patients with partial fundoplication, gastroparesis,
paraesophageal hernia, redo ARS or Collis gastroplasty were
excluded. Patients were divided into 2 groups (pH-ONLY,
pH-MII) based on the type of testing they had before surgery.
Standardized symptom assessment scores (pre and postoperative), indication for operation and pH and pH-MII results
were analyzed. Total number of referrals for ARS with normal preoperative pH testing was recorded for comparison.
RESULTS: Three hundred five ARS patients were analyzed
(250 pH-ONLY, 55 pH-MII). In the pH ONLY group, 17/250
(6.8%) underwent ARS despite a normal preoperative pH
test compared to 13/55 (23.6%) in the pH-MII group (p =
0.0004). The average number of referrals for ARS with normal preoperative pH testing was 50/yr and did not change
with the introduction of pH-MII testing but annual rate of
ARS in patients with a normal preoperative pH increased
from 4/50 (8%) to 12/50 (24%) (p = 0.03). Primary symptoms for patients with normal pH were similar for both
groups. The most common surgical indications were similar between groups: esophagitis, large-volume regurgitation, and symptom correlation (pH-ONLY) or positive
symptom index (pH-MII). The MII testing influenced the
decision to operate in seventy-seven percent of patients
in the pH-MII group (6/13 abnormal reflux events, 4 positive symptom index) and the remainder (3/13) had biopsy
proven esophagitis. The symptom scores for heartburn,
regurgitation, and chest pain were improved after surgery
in both groups (p < 0.05).
CONCLUSIONS: Conventional pH testing has been the
gold standard for selecting patients for ARS. In patients
with normal 24-hour pH testing, the addition of impedance
resulted in a 3-fold increase in patients identified as appropriate surgical candidates.
129
Monday
Poster Abstracts
RESULTS: Among 97 consecutive patient undergoing
resection of EC, 46 patients received ES for the following
indications: to improve preoperative nutritional status (25
patients), for postoperative anastomotic leak (13 patients),
and for postoperative anastomotic stricture (14 patients).
9 patients had multiple ES placed at different time points
for multiple indications. ES deployment was technically
successful in all patients. Preop ES: Swallowing symptoms
improved in 52% of patients; however, nutritional status deteriorated in 80%, with a median weight loss of 15
lbs and median decrease in serum albumin of .4gms/dl.
ES migration, which occurred in 64%, and upper gastrointestinal symptoms, which occurred in 72% of patients
receiving neoadjuvant therapy, limited the effectiveness
of preop ES. ES for postop leak: Postop leak occurred in
the neck in 10 patients and in the chest in 3 patients. ES
effectively sealed the leak and allowed prompt (within 48
hrs) resolution of oral intake in only 4/13 patients (31%).
Early ES migration (7 patients) and the presence of limited
conduit necrosis (2 patients) was associated with ES failure.
ES for postop stricture: 12 of the 14 strictures for which
stents were deployed were in the neck and 2 were in the thorax. 57% of patients had sustained relief of dysphagia and
required a median of only one subsequent intervention for
stricture. Stent failure occurred in 43%, due to early migration (4 patients), pharyngeal or mediastinal pain (1 patient
each), or bilious vomiting (2 patients). ES migrated prematurely in 11/14 patients, including 6/8 successfully treated
patients and 5/6 unsuccessfully treated patients.
Ashwin A. Kurian*1, Ahmed Sharata2, Neil H. Bhayani1,
Kevin M. Reavis2, Christy M. Dunst2, Lee L. Swanstrom2
1. Providence Portland, Portland, OR; 2. GMIS, Oregon Clinic,
Portland, OR
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1482
Table 1: The Prediction Accuracies of the Proposed Automatic
Cancer Staging Model for Esophageal Cancer Based on Different
Editions of AJCC Cancer Staging Ssystem
Automatic Cancer Staging for Esophageal Pathological
Reports by Text Mining and Data Mining: Comparison
Between AJCC 6th and 7th Editions
Yung-Han Sun*1,2, Chih-Cheng Hsieh1,3, Chun-Hsien Chen1,2,
Shih-Wei Lin1,2
1. Department of Surgery, Taipei-Veterans General Hospital, Taipei,
Taiwan; 2. Department of Information Management, Chang Gung
University, Taoyuan, Taiwan; 3. School of Medicine, National
Yang-Ming University, Taipei, Taiwan
Cell type
BACKGROUNDS: Cancer staging by manual interpretation of pathological report is very time-consuming. In our
previous research, text mining and data mining techniques
were applied to automatic staging of esophageal cancer for
pathological reports according to the 6th edition American
Joint Committee on Cancer (AJCC) cancer staging system.
Since the staging system is updated every several years,
how to quickly and accurately transform the old stages into
new stages becomes an important issue. The nodal status
for esophageal cancer staging in the 6th edition was just
grouped into positive (N1) and negative (N0), but it was
different in the 7th edition. The aim of this study was to
compare the results of the automatic cancer staging model
using new staging edition with those based on the old staging edition.
METHODS: Pathological reports of 234 patients undergone esophagectomy were collected in this study. All the
pathological reports were collected and entered into Access
database as text file. The reports were compuationally converted into weighted frequency vectors of keywords by
using text mining techniques to analyze cancer staging
related keywords in the reports. Lymph node metastasis
status N of a pathology report were derived from the total
number of positive lymph nodes and the distal metastasis status (M) were also modified by analyzing the text
keywords of the pathology report computationally. J48
decision tree learning algorithm was used to train the classification model for cancer staging. One third of the data
was used for training and two thirds of the data was used
for testing in evaluating the prediction performance of the
model.
RESULTS: The results were shown in Table 1. The prediction accuracies for cell type and T status nearly did not
change, and the prediction accuracies for N and M status
reached 91.9% and 95.3% respectively. Comparison with
the accuracies for predicting N and M status based on the
6th edition of AJCC cancer staging guideline, those based
on the new edition decreased just a little.
Based on
7th Edition
Based on
6th Edition
97.5%
97.5%
Tumor Depth status (T)
88.5%
88.5%
Lymph node metastasis status (N)
91.9%
95.0%
Distant metastasis status (M)
95.3%
96.3%
CONCLUSIONS: This study provides a computational
model for automatic cancer staging of esophageal pathological reports according to the 7th edition American Joint
Committee on Cancer (AJCC) cancer staging system. In
the future, we hope to apply this automatic cancer staging
model to pathological reports of other cancers and collect
clinical data for other text file reports.
Mo1483
pH-Symptom Indices Do Not Predict Symptom
Improvement After Antireflux Surgery
Stefan Niebisch*, Candice L. Wilshire, Carolyn E. Jones,
Virginia R. Litle, Christian G. Peyre, Thomas J. Watson,
Jeffrey H. Peters
Department of Surgery, University of Rochester Medical Center,
Rochester, NY
INTRODUCTION: Prospective randomized trials document long term relief of gastro-esophageal reflux (GERD)
symptoms in 85% of patients following antireflux surgery.
One of the key challenges, in the decision to pursue antireflux surgery, is assuring that the patients symptoms are
actually caused by GERD. Mathematical calculations of the
relationship of reflux events to the occurrence of symptoms have been proposed as a mechanism to support GERD
as the underlying cause of both typical and atypical reflux
symptoms. The symptom index (SI) and Symptom Association Probability (SAP) are the most commonly calculated
measures in clinical use. The clinical utility of these measures is unclear and unexplored with respect to antireflux
surgery.
METHODS: The study population included 66 patients
(mean age 52.6 years; 58% female) undergoing laparoscopic fundoplication from November 2006 to October
2011. All were pH-positive (DeMeester Score >14.72) with
either cough, heartburn and/or regurgitation, in which SI
(positive ≥50%) and SAP (positive ≥95%) were calculated
pre-op. Symptom outcome after surgery was categorized as
‘improvement’, ‘no change’ and ‘worsening’ in their symptoms. All available data were logged into SPSS (version 18)
for statistical analyses.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: At the time of pH testing heartburn was
recorded in 51 (84%), regurgitation in 22 (33%) and cough
in 21 (32%) patients. One or both symptom indices were
positive in 85% (56/66) and both negative in 15% (10/66)
of the patients. Cough was significantly less associated
with positive SI and/or SAP when compared to heartburn
and regurgitation (SI 19% vs. 72.5% and 81.8%; p < 0.0001;
SAP 33.3% vs. 78.4% and 68.2%; p = 0.0007 and p = 0.0337
respectively). Overall, 93% (62/66) of patients reported
improvement in their symptoms which was independent
of a positive or negative SI or SAP. Eighty percent of patients
(8/10) with negative SI and SAP pre-op improved compared
to 87% (54/62) with positive SI and/or SAP (p = 0.6217).
There was no significant difference in symptom improvement between atypical and typical symptoms; patients
with heartburn improved in 98%, regurgitation in 95.5%
and cough in 85.7% (p = 0.072).
CONCLUSION: These data show that symptom improvement following antireflux surgery is independent of the
commonly used 24hour pH symptom indices SI and SAP.
Atypical symptoms such as cough are less likely associated
with a positive symptom index, particularly when compared
to typical symptoms such as heartburn and regurgitation.
duration was 302 min (150–465min). The operative procedures and route of reconstruction of these 57 patients were
listed in Table 1 and 2 respectively. The reasons of using
colonic interposition included: stomach was involved
by tumor (n = 18 (31.6%)), prior gastrectomy (n = 34
(59.6%)), presence of peptic ulcer (n = 3 (5.3%)) and other
(n = 2 (3.5%)). There were 6 (10.5%) had conduit gangrene
required re-exploration. Nine (15.8%) patients had either
clinical or subclinical anastomotic leakage. The median
survival was 34.8 months (17–52 months). The 30-day
mortality rate was 3.5% (n = 2) and the hospital mortality
rate was 15.8% (n = 9). Presence of major post-operative
medical complications such as stroke or myocardial infarction (p = 0.026, HR 2.114, 95%CI 1.094–4.084) was identified to be predictive factor for poor survival.
Table 1. Operative Procedures of 57 Patients had Colonic
Interposition in Esophagectomy for Esophageal Cancer with
Curative Intent
Procedures
Pharyngolaryngoesophagectomy
5 (8.8)
Transhiatal
9 (15.8)
Minimally invasive esophagectomy
Mo1484
Operative Outcomes of Colonic Interposition in the
Treatment of Esophageal Cancer: A Three Decades
Experience
Daniel K. Tong , Simon Law, Fion S. Chan
Surgery, The University of Hong Kong, Hong Kong, Hong Kong
*
BACKGROUND: Colonic interposition is the treatment of
choice when the stomach cannot be used as a substitute for
reconstruction after esophagectomy for esophageal cancer.
The aim of present study was to review our experience on
colonic interposition.
N = 57 (100%)
2 (3.5)
3 phase esophagectomy
13 (22.8)
Lewis Tanner esophagectomy
18 (31.6)
Staged
5 (8.8)
Other
5 (8.8)
Table 2. Route of Reconstruction of 57 Patients who had Colonic
Interposition in Esophagectomy for Esophageal Cancer with
Curative Intent
PATIENT AND METHODS: A prospectively collected
database on patients with esophageal cancer from 1982–
2010 was reviewed. Outcomes of these patients were analyzed. The indications, morbidity, mortality, long-term
survival and potential predictive factors were evaluated.
Route of Reconstruction
Right chest
6 (10.5)
RESULTS: A total of 119 patients were found to have colon
harvested for management of esophageal cancer. Of whom,
62 had palliative bypass surgery and 46 (74.2%) were performed in 80s, 16 (25.8%) in 90s, and none in 00s. The role
of bypass surgery become less popular was probably due to
the availability of less invasive palliative modalities such
as stenting. For the remaining 57 patients, the median age
was 64 (28–82) and 49 (86%) were male. The median blood
loss was 850ml (150–2500ml), and the median operative
Orthotopic
29 (50.9)
Subcutaneous
Retrosternal
N = 57 (100%)
3 (5.3)
19 (33.3)
131
Monday
Poster Abstracts
CONCLUSIONS: The role of bypass surgery using colon for
esophageal cancer management is fading. Colonic interposition remained an important treatment option in patients
with prior gastrectomy or when the stomach was invaded
by the tumor. The operative procedure was complex and
could associated with high morbidity rate.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1485
Mo1486
Short-Term Outcome of Antireflux Surgery on Patients
with Chronic Cough and Abnormal Proximal Exposure
as Measured by Hypopharyngeal Multichannel
Intraluminal Impedance
PET-CT for Response Assessment of Neoadjuvant
Chemoradiation in Locally Advanced Squamous Cell
Carcinoma Esophagus: Initial Experience from Tertiary
Referral Center in North India
Toshitaka Hoppo*, Yoshihiro Komatsu, Blair A. Jobe
Cardiothoracic Surgery, University of Pittsburgh Medical Center,
Pittsburgh, PA
Saurabh Kalia*, Prasanna Chandrasekaran, Rajesh Gupta,
Ganga R. Verma, Rakesh Kapoor, Bhagwant Rai Mittal,
Rakesh K. Vasishta, Rajinder Singh
PGIMER, Chandigarh, India, Chandigarh, India
BACKGROUND: Chronic cough can be caused by direct
exposure of gastric refluxates to the aerodigestive tract. The
treatment outcome has been conflicting due to the lack of
objective testing to directly measure the proximal extent of
gastric refluxates. The objective of this study was to evaluate the proximity of reflux events in patients with chronic
cough and to assess the outcome of antireflux surgery (ARS)
on patients, who were selected based on the presence of
abnormal proximal exposure as measured by hypopharyngeal multichannel intraluminal impedance (HMII).
METHODS: This is a retrospective review of symptomatic
patients who were referred for the evaluation of gastroesophageal reflux disease (GERD) and subsequently underwent HMII with a specialized catheter to measure proximal
reflux events such as laryngopharyngeal reflux (LPR) and
full column reflux (reflux 2 cm distal to the upper esophageal sphincter) at our institution. Chronic cough was
defined as persistent cough with unknown etiology, which
lasted for more than 6 months. Patients with positive Tb
test and a history of seasonal allergy or pulmonary diseases
such as asthma and pulmonary fibrosis were excluded.
Based on HMII, abnormal proximal exposure was defined
as LPR ≥1/day and/or full column reflux ≥5/day. Patients
with abnormal proximal exposure subsequently underwent ARS. The outcomes were reviewed.
RESULTS: From October 2009 to June 2011, 314 symptomatic patients underwent HMII at our institution. Of
314, 55 patients were identified as having chronic cough
with unknown etiology (male 16, female 39). Mean age
and BMI were 57 years and 30.3, respectively. Six patients
were excluded because of inadequate information available. Of the remaining 49 patients, 36 patients were found
to have LPR ≥1/day (n = 10, range 1–12/day) and/or full
column reflux ≥5/day (n = 35, range 5–32/day). Of these
36 patients with abnormal proximal exposure, 33 (92%)
patients were found to have either endoscopic evidence of
esophageal mucosal injury such as esophagitis or Barrett’s
esophagus, radiographic evidence of hiatal hernia or PPI
dependence. However, 67% (24/36) of patients had a negative DeMeester score. Of these 33 patients with abnormal
proximal exposure and objective evidence of GERD, 14
patients subsequently underwent ARS including Nissen (n
= 8), Dor (n = 2), Toupet (n = 1) and esophagojejunostomy
(n = 3), and 12 patients (86%) had a complete resolution
of cough and 2 (14%) had a significant improvement at a
mean follow-up of 4 months (range, 0.5–12 months).
CONCLUSIONS: Abnormal proximal exposure as measured by HMII is likely to be associated with objective evidence of GERD in patients with chronic cough regardless
of whether there is a positive DeMeester score. Presence of
abnormal proximal exposure could be an indicator of successful ARS for patients with chronic cough.
INTRODUCTION: Neoadjuvant chemoradiation is a part
of multimodality management of locally advanced carcinoma esophagus. 18F FDG PET-CT (PET-CT) has been
evaluated for assessing the response to neoadjuvant therapy and correlated with the prognosis in various studies
with inconsistent results. We report our experience from
prospectively collected data at tertiary referral center from
North India.
METHODS: We reviewed prospective data of 34 patients
of potentially resectable squamous cell carcinoma esophagus from Feb 2010 to Nov 2011 at our institute. All patients
(M:F 1.6:1, mean age 51 years) had locally advanced squamous cell carcinoma of middle and lower 1/3rd esophagus
(Stage T2–4NxM0) on initial staging with CECT thorax and
abdomen ± PET-CT. Patients with good performance score
underwent Neoadjuvant chemoradiation (NACRT) protocol including Cisplatin (30 mg/m2) + 5FU (500mg/m2)from
Day1 to Day4 and EBRT 30 Gy/10#/over 2 weeks. Restaging was done with PET-CT after >4 weeks after completion
of NACRT. All resectable patients underwent transhiatal/
transthoracic esophagectomy without formal lymphadenectomy. Histomorphological regression was graded as
per four tiered scheme described by CAP Cancer Protocol
for Esophageal carcinoma (TRG 0 and 1 as complete and
moderate response respectively and TRG 2 and 3 as minimal and poor response respectively)by single experienced
pathologist blinded to clinical data. Post NACRT PET-CT
Standard uptake value (SUVmax) and percentage change
of SUVmax was correlated with tumor regression (TRG 0
and 1).
RESULTS: Transhiatal esophagectomy was done in 30
patients and Transthoracic esophagectomy in 2 patients.
Two patients had metastatic disease at surgery. Mean SUVmax was 13.6 and 6.45 for Pre NACRT and Post NACRT
respectively suggesting metabolic response to therapy.
Tumor regression (TRG 0 and 1) was seen in 12 (35.3%)
patients. The percentage decrease in SUVmax >80% correlated with tumor regression with sensitivity, specificity,
PPV, NPV and accuracy of 71.4%, 92.8%, 83.3%, 80% and
85.7% respectively. Post NACRT SUVmax <4.0 correlated
with tumor regression with sensitivity, specificity, PPV,
NPV and accuracy of 83.3%, 86.3%, 76.9%, 90.4% and 85%
respectively
132
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
METHODS: All patients (pts) undergoing esophagectomy
from 2005–11 for malignant disease at a North American
university hospital were identified from a prospectively
collected database. All patients were subject to BE within
the first week postoperatively. Patients were dichotomized
according to whether they had an AL or not and the sensitivity and specificity of barium swallow was determined.
In pts who had an AL, the relationship between barium
swallow results and time to AL, hospital length of stay, and
start of enteral feeding was determined. Furthermore, the
effect of BE results on postoperative management, defined
as cessation of enteral feeding, additional interventions,
or delay in discharge was recorded. Data are expressed as
median (range). Mann Whitney U and Fischer’s exact test
determined significance (*p < 0.05).
Figure 1: PET-CT images with complete metabolic response in a
72 year old male
Figure 2: Gross and Microscopic tumor regression (Complete
pathological response) CAP TRG 0 in the same patient.
CONCLUSIONS: 18F FDG PET/CT is 85% accurate in
response assessment of Neoadjuvant Chemoradiation for
squamous cell carcinoma esophagus.
Mo1487
Routine Barium Esophagram Has Minimal Impact
on the Post-Operative Management of Patients
Undergoing Esophagectomy for Esophageal Cancer
Maxime Noreau-Nguyen*, Jonathan Cools-Lartigue, David S.
Mulder, Lorenzo E. Ferri
Surgery, McGill University, Montreal, QC, Canada
CONCLUSIONS: Barium esophagram has a poor sensitivity in the detection of anstamotic leak and has minimal impact in the postoperative management of patients
undergoing esophagectomy for malignant disease. The
routine use of contrast esophagograms after esophageal
resection should be abandoned.
133
Monday
Poster Abstracts
INTRODUCTION: Esophagectomy is currently the treatment modality of choice in patients with esophageal carcinoma. Post-operatively, routine fluoroscopic imaging
with barium sulfate is employed in order to detect occult
anastamotic leaks (AL) prior to resumption of enteral feeding. This modality is plagued by a low sensitivity, and its
routine use has been called into question. Accordingly, we
sought to demonstrate the clinical impact of routine barium esophagography (BE) in the post-operative management of patients undergoing esophagectomy for malignant
disease.
RESULTS: Two-hundred and twenty-seven pts underwent esophagectomy over the study period. Twenty-nine
pts (12.8%) developed an AL, of which 12 (41.4%) had a
positive BE, 11 (37.9%)had a negative BE and the remaining 6 (20.7%) were not subject to BE and were diagnosed
either clinically (1/6), by CT (4/6), or endoscopically (1/6).
AL in pts with a negative BE was confirmed either clinically
(4/11 pts), by CT (5/11 pts), endoscopically (1/11 pts), or
at reoperation (1/11 pts). In pts who had an AL, those with
a positive BE leaked earlier than those with a negative BE
(POD 7 (2–8) vs POD 10.5 (6–22)* respectively). The sensitivity and specificity of barium BE in this series was 36.3%
and 99.7% respectively. Result of BE in pts with an AL did
not correlate with hospital length of stay or date of commencement of enteral feeding. Overall, BE altered postoperative management in 6/227 (2.6%) pts with 4/227 (1.7%)
pts undergoing further testing which went on to confirm a
leak. Conversely 2/227 (0.9%) pts demonstrated clinically
insignificant AL, having their discharge delayed without
additional intervention.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1488
CONCLUSIONS: This study shows for the first time an
effective endoscopic treatment for GERD patients. The new
developed Medigus stapling device can endoscopically create an anterior fundoplication. The procedure under general anesthesia showed acceptable complications (6%),
high efficacy rates (74%) and can be recommended for
patients with small hernias.
Effective Endoscopic Treatment of Gastroesophageal
Reflux Disease Using a New Endoscopic Stapling
System Results of a Prospective Controlled Multicenter
Tria
Aviel Roy-Shapira*1,2, Amol Bapaye1, Ralf Kiesslich1, Santiago
Horgan1, Sebastian F. Schoppmann1, Johannes Zacherl1, Luigi
Bonavina1, Glen A. Lehman1
1. Surgery A, Soroka Univesity Hospital, Beer Sheva, Israel; 2. Critical
Care Medicine, Soroka University Hospital, Beer Sheva, Israel
Mo1489
Resolution of Anemia Following Repair of Giant
Paraesophageal Hernias
INTRODUCTION: A new system which is designed for
transoral endoscopic treatment of Gastro Esophageal Reflux
Disease (GERD) was tested in a multicenter study. The
device is a flexible video endoscope coupled with a surgical stapler and an ultrasonic range finder. The device can
endoscopically create an anterior fundoplication. Aim of
the current prospective controlled multicenter trial was to
evaluate safety and efficiency of the newly developed endoscopic stapling device in GERD patients with small hernias.
METHODS: Inclusion criteria moderate to severe GERD
with response to PPI treatment, abnormal 24h esophageal
acid exposure and Hill gastro-esophageal valve grade ≥II.
Patients with significant comorbidities, esophageal motility disorders and hiatal hernia >3 cm were excluded. Procedures were performed under general anesthesia at 5 centers
using positive end expiratory pressure (PEEP) to optimum
reduction of the hernia. Anterior fundoplication was performed with two or three stapling sites between the esophagus and the stomach under control of the ultrasonic range
finder. Patients were followed at 1, 2 and 4 weeks for safety
and at 6 months for efficacy. The primary outcome of the
study was safety and reduction of the off PPI GERD Health
Related Quality of Life scores (GERD-HRQL) score by at
least 50%. Secondary outcome criteria were elimination or
reduction of PPI use, improvement in 24h acid exposure
and Hill valve grade.
RESULTS: 67 patients were finally treated as per protocol.
Primary outcome—Safety: There were 2 occult perforations
(pneumomediastinum—asymptomatic and empyema—
chest tube drainage) and one case of bleeding (treated
endoscopically). Hospital stay was prolonged in another
patient due to signs of infection. Additional adverse events
occurred in 12 patients, were mostly related to elevated
inflammatory markers in the first 24–48h post procedure
and did not appear to carry any clinical significance. They
were more common when only two rather than three staplings had been placed.
PRIMARY OUTCOME—EFFICACY: 74% patients (50/67)
met the primary success criterion—50% reduction in GERDHRQL scores. The median scores drooped from baseline of
29 to 6 at six months post-procedure (p < 0.001). Acid exposure normalized in 49% (33/67) subjects and improved in
additional 18% (12/67). PPI usage reduced by ≥50% in 85%
(57/67) patients (p < 0.001,. 73% patients (46/63) demonstrated an improved flap valve angle at 6 months.
Michael Hermansson*, Steven R. Demeester, Joerg Zehetner,
Kimberly S. Grant, Daniel S. OH, Tom R. Demeester, Jeffrey A.
Hagen
Surgery, Keck medical center of USC, University of Southern
California, Los Angeles, CA
BACKGROUND AND AIM: The association between anemia and paraesophageal hernia (PEH) was reported in 1931.
Nonetheless, extensive evaluation for a source of bleeding
in patients with anemia and PEH is common. The aim of
this study was to evaluate the prevalence of anemia in
patients with PEH and the impact of surgical PEH repair
on anemia.
METHODS: A retrospective chart review was performed of
all patients who underwent primary repair of a PEH with
50% or more of the stomach in the chest between May
1998 and January 2010. Patients with incomplete or missing records were excluded. Patients with a history of anemia were contacted postoperatively and the status of their
anemia was determined.
RESULTS: There were 118 patients that met the inclusion
criteria. A history of anemia was present in 41 patients
(35%), and these patients formed the study group. There
were 14 males (34%) and 27 females (66%). The mean age
was 64 years. The median duration of anemia prior to PEH
repair was 4 years. Treatment for anemia consisted of oral
iron supplements (n = 17), intravenous iron infusions (n =
2) and blood transfusions (n = 11). Evaluations for anemia
consisted of upper endoscopy (n = 41), colonoscopy (n =
20), capsule enteroscopy (n = 3), push enteroscopy (n = 1),
and tagged red blood scan (n = 2). In the 41 patients with
preoperative anemia detailed postoperative follow-up was
available in 23 patients (56%). The median follow-up for
these 23 patients was 59 months (range 25–133). Resolution of anemia occurred in 18 patients (78%). In 5 patients
anemia has persisted and they remain on oral iron supplements. The median follow-up in these patients did not differ from those with resolution of their anemia. No patient
has required a blood transfusion or intravenous iron infusion after PEH repair. A recurrent hernia was found in 2 of
those 5 patients
CONCLUSION: Anemia is common in patients with a
giant PEH, and surgical PEH repair resolved the anemia in
78% of patients. Therefore, repair of a giant PEH is indicated in patients with anemia. Extensive evaluations for an
alternative explanation for the anemia in patients with a
giant PEH are unlikely to be useful.
134
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1490
Mo1491
Annual CT Scans Do Not Improve Survival Following
Oesphagectomy for Cancer: A Follow Up Study of
126 Patients
Influence of Postoperative Morbidity on Longterm
Cancer Survival After Esophagogastric Surgery
David Bowrey, Steve Satheesan*, Sukhbir Ubhi, Amar Eltweri
Surgery, University Hospitals of Leicester NHS Trust, Leicester, United
Kingdom
Stefan S. Antonowicz*, Bruno Lorenzi, Adriana Rotundo,
Cheuk Bong Tang, Michael Harvey, Sritharan S.
Kadirkamanathan
Upper GI Surgery, MEHT, Chelmsford, United Kingdom
BACKGROUND: Evidence for the best approach to followup after oesophagectomy for cancer is scant and conflicting. Routine computer tomography scanning (CT) remains
an integral part of oesophageal cancer follow up, despite
recurrences often being signposted by symptoms and other
mechanisms first. Additionally, there is wide variation in
the frequency of CT scanning schedule owing to resource
pressures and anecdotally perceived benefit.
AIMS: We sought to determine how useful routine CT
scanning was in detecting treatable stages of recurrence in
an Upper Gastrointestinal cancer centre.
METHODS: We performed a retrospective review of 126
consecutive patients who have undergone oesophagectomy between 2001 and 2009. Annual CT-scan was part of
the routine follow-up in all patients. Two patients were lost
to follow-up. Outcome data was focused on recurrence and
mortality. Data was analysed using chi squared for binomial comparisons, the method of Kaplan-Meier for survival
estimates, and the log-rank statistic to compare survival
between cohorts.
METHODS: Retrospective review of patients undergoing
esophagogastric resection for carcinoma during the years
2006–2010 at our institution. Minimum follow-up of 12
months was required.
RESULTS: The study population was 164 patients (110
male) of median age 64 years (range 32–84). 84 underwent
esophagectomy, 80 gastrectomy. Ninety-nine received neoadjuvant chemotherapy. The 90-day, 1-year and 3-year
survivals were 92%, 84% and 49% respectively. Sixty-nine
patients (42%) developed postoperative complications
(commonest: pneumonia 19%, anastomotic leak 7%,
wound infection 6%). None of tumor site (esophagus vs.
stomach, p = 0.73), length of ITU stay (<3 days vs. >3 days,
p = 0.50) or development of postoperative complications
(p = 0.70) influenced longterm prognosis. The only two
factors that influenced longterm outcome were UICC stage
(p < 0.001) and circumferential resection margin (positive vs.
negative, p < 0.001).
CONCLUSIONS: Patients experiencing postoperative morbidity can expect the same longterm oncologic outcome as
those not suffering these early setbacks.
CONCLUSION: Routine CT appeared to detect preclinical
recurrences only in a handful of patients who had undergone oesophagectomy. The majority of recurrences were
diagnosed when patients presented with symptoms. Our
data suggests that routine CT scanning in asymptomatic
patients may not add any survival benefit. A well-designed
prospective study may give a definitive answer.
135
Monday
Poster Abstracts
RESULTS: Recurrence was detected in 46 cases (37%).
Median time to recurrence was 9 months (range 1–108
months). Median time to death from radiological confirmation of recurrence was 4 months (range 1–18 months),
increasing to 13 months (range 6–18 months) if the patient
subsequently underwent an interventional therapy (2 =
25.63, log-rank p < 0.001). In nine cases, the recurrences
were loco-regional; the remainder had a systemic component. In 12 cases CT detected recurrence in asymptomatic patients; in the remaining 34, suspicious symptoms
or tumour marker rise prompted further investigation.
Routine-detected recurrences were not more likely to have
further interventional treatment for their cancer (Fisher, p
= 0.519), nor did it confer survival benefit (log-rank, p =
0.532). Subgroup analysis by neo-adjuvant therapy, preoperative stage and resection status further confirmed this.
BACKGROUND: Previous studies have shown that postoperative adverse events after colorectal resection predict
a poor prognosis with early cancer relapse. The aim of this
study was to report the outcome of patients undergoing
esophagogastric resection to assess the influence of in-hospital factors on longterm cancer survival.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Hepatic
Mo1492
Symptomatic and Radiographic Evaluation of
Hiatal Hernia Recurrence Following Laparoscopic
Paraesophageal Hernia Repair with Polyester
Composite Mesh Reinforcement
Mo1493
Safety of a Multimodal Enhanced Recovery Pathway in
Liver Resection Surgery
Jeffrey Eakin, Mark Wendling*, Dean J. Mikami,
Bradley Needleman, W.S. Melvin, Kyle A. Perry
Division of General and Gastrointestinal Surgery, The Ohio State
University Medical Center, Columbus, OH
INTRODUCTION: Laparoscopic paraesophageal hernia
repair (LPEHR) is the preferred treatment for symptomatic
paraesophageal hiatal hernia in specialized centers. LPEHR
has yielded excellent perioperative outcomes and symptom
control; however, it has been associated with high radiographic recurrence rates. Hiatal reinforcement with PTFE
mesh prevents hernia recurrence, but is associated with
unacceptable mesh related complications. Conversely, bioabsorbable mesh placement has proven safe, but failed to
produce long term reductions in hiatal hernia recurrence.
The primary objective of this study was to review a single
institution experience to evaluate the initial safety and efficacy of LPEHR with crural reinforcement using a polyester
composite mesh.
METHODS: A retrospective review of patients undergoing
LPEHR from 2006–2011 was conducted under an institutional review board approved protocol. All patients who
underwent LPEHR with placement of polyester composite mesh were contacted for study enrollment. Long-term
follow-up evaluation was performed in person or by telephone questionnaire. Outcomes included barium esophagram, GERD health related quality of life (GERD-HRQL)
assessment, and patient satisfaction with their operation.
Significant reflux was defined as a GERD-HRQL score >12.
RESULTS: Between 2006 and 2011, 175 patients underwent LPEHR, and polyester composite mesh was used for
hiatal reinforcement in 29 cases. Twenty (70%) patients
completed the questionnaires, and 12 (41%) patients
returned for a post-operative barium esophagram to assess
for hernia recurrence. The median follow-up interval was
29.5 (6–66) months, and esophagrams were performed at a
median of 34 (9–66) months following LPEHR. There were
no mesh related complications within the study group.
Eight of the twelve patients (75%) who underwent a radiographic evaluation with barium had evidence of recurrence. The incidence of significant reflux was 15%. There
was no significant difference between the median GERDHRQL scores between those with radiographic recurrence
and those without (p = 0.732). Fifteen percent (n = 3) of
patients reported moderate to severe dysphasia, and esophagram demonstrated a recurrent hiatal hernia in each case.
Eighty-one percent of patients polled reported being satisfied with their surgery, and 86% reported that they would,
with the benefit of hindsight, have their surgery again.
CONCLUSIONS: LPEHR with polyester composite mesh
reinforcement provides durable symptomatic relief with
high levels of patient satisfaction at intermediate followup. No mesh related complications or side effects occurred
in this series. While anatomic hiatal hernia recurrence
detected by routine post-operative imaging is common,
most of these are asymptomatic and do not correlate with
patient symptoms or dissatisfaction with the operation.
Clancy J. Clark*1, Shahzad M. Ali1,3, ADAM K. Jacob2, David M.
Nagorney1
1. Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN;
2. Anesthesiology, Mayo Clinic, Rochester, MN; 3. 2nd Department
of Medicine, University Hospital and Faculty of Medicine, Hradec
Kralove, Czech Republic
BACKGROUND: Implementation of enhanced recovery
and fast-tract care pathways in colorectal surgery have
demonstrated decreased overall cost and length of stay
(LOS) while resulting in no significant increase in perioperative morbidity and readmission rate. Similar pathways
are yet established for liver surgery due to concern for perioperative coagulopathy, hepatic dysfunction, and perioperative volume management. The aim of this study was to
evaluate the safety of an enhanced recovery pathway (ERP)
for patients undergoing open liver resection.
METHODS: A single-institution, observational cohort
study was performed by comparing the clinical outcomes
of patients treated before and after implementation of an
ERP. The ERP included pre-operative oral celecoxib and
gabapentin, standardized anesthetic including general
anesthesia, intrathecal analgesia, and postoperative nausea prophylaxis, and a standardized post-operative care
regimen. Clinical outcomes including morbidity, mortality, reoperation, LOS, and readmission rate were compared
between ERP and non-ERP cohorts on an intention-to-treat
basis.
RESULTS: A total of 126 patients (ERP = 53, non-ERP =
73) were included in the study. Patient characteristics and
operative details including ASA (p = 0.71), diagnosis (p
= 0.32), type of liver resection (p = 0.86), and estimated
blood loss (p = 0.81) were similar between groups. Overall complication rate was slightly lower in the ERP cohort,
but not statistically significant (28.3% vs. 37.0%, p = 0.86).
Before and after pathway implementation, the median LOS
remained identical (5 days vs. 5 days, p = 0.71). No differences were identified for reoperation rate (2.7% vs 3.8%,
p = 1.00), complication requiring ICU transfer (13.7% vs.
7.6%, p = 0.40), or readmission (2.7% vs 3.8%, p = 1.00).
After adjusting for age, type of resection, and ASA, ERP and
non-ERP patients had no increased risk of major complication (OR 0.38, 95% CI 0.14–1.02, p = 0.06) or LOS greater
than 5 days (OR 1.21, 95% CI 0.18–2.62, p = 0.62).
CONCLUSIONS: Routine use of a multimodal ERP is safe
and is not associated with increased the post-operative morbidity after major open liver resection. However, the current
study found that LOS was unchanged for patients treated
with an ERP compared to conventional management.
136
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1494
Mo1495
Prediction of Survival After Surgery in Patients with
Liver Cirrhosis
Patterns and Prognostic Significance of Lymph-Node
Dissection for Surgical Treatment of Peri-Hilar and
Intrahepatic Cholangiocarcinoma
Hannes P. Neeff*1, Hans-Christian Spangenberg2, Tobias Keck1,
Ulrich T. Hopt1, Frank Makowiec1
1. Department of Surgery, University of Freiburg, Freiburg, Germany;
2. Department of Gastroenterology and Hepatology, University of
Freiburg, Freiburg, Germany
Andrea Ruzzenente*, Tommaso Campagnaro,
Alessandro Valdegamberi, Francesca Bertuzzo,
Fabio Bagante, Calogero Iacono, Alfredo Guglielmi
Chirurgia Generale A, Policlinico GB Rossi, Verona, Italy
INTRODUCTION: Patients with cirrhosis have an
increased risk of postoperative mortality. In addition,
patients with cirrhosis per se have a reduced life expectancy.
Little is known about the combined effect of these reduced
outcomes after surgery. We thus evaluated early and longterm survival after surgery in patients with cirrhosis.
BACKGROUND: Lymph node (LN) metastasis is a major
negative prognostic factor for intrahepatic (ICC) and perihilar (PCC) cholangiocarcinoma. Prognostic significance
of LN dissection (LND), number of metastatic LN, LN stations and lymph-node ratio (LNR) are still under debate for
cholangiocarcinoma.
METHODS: For prediction of long-term outcome we evaluated survival after general surgical procedures performed
during the last decade by two different approaches: I) Actuarial survival was estimated in 180 patients after surgery
(thus including postoperative deaths) and II) Survival was
analyzed separately in 143 patients who were discharged
after postoperative treatment (i.e. patients without in-hospital mortality) and with survival information available.
Survival was analyzed by actuarial methods, risk factors
were assessed univariately (log rank) and multivariately
(Cox regression, multiple models).
AIMS: The aims of this study are to evaluate the prognostic
value of LND, of the number of LNs harvested, of number
of positive LNs, of LN stations and of LNR in ICC and PCC.
CONCLUSIONS: Long-term survival in patients with liver
cirrhosis requiring general surgery is poor. In the entire
patient group poor liver function and, in part, factors
influencing postoperative mortality like comorbidity (ASA)
or thrombocytopenia are prognostic factors. In patients
surviving the early postoperative period the long-term
outcome is determined mainly by the natural course and
severity of liver disease (MELD better than Child).
RESULTS: One hundrend and thirty patients were submitted to surgical resection with curative intent; 61 were ICC
and 69 PCC. Lymph-node dissection (LND) was performed
in 71% of patients with ICC and in 96% with PCC. Median
survival of patients with 0, 1 to 3 and more than 3 LNs
retrieved was respectively 31, 37 and 36 months for ICC
(p = 0.53) and 3, 18 and 34 for PCC (p < 0.01), respectively.
Median survival of patients with negative LN (N0) and
with LN metastasis (N+) was 43 and 19 months in ICC (p =
0.03) and 42 and 20 months in PCC (p = 0.01), respectively.
Median survival of patients with up to 3 N+ and more than
3 N+ was 52 and 7 months in ICC (p < 0.01), and 26 and
11 months in PCC (p < 0.01). Median survival of patients
with LNR up to 0.25 and greater than 0.25 was 42 and 14
months in ICC (p = 0.01), and 37 and 11 months in PCC,
respectively (p < 0.01). At multivariate survival analysis
LNR and macroscopic vascular invasion were significantly
related to survival with hazard ratios of 3.00 (95% CI 1.69–
5.34; p < 0.001) and of 1.90 (95% CI 1.17–3.07; p = 0.009)
respectively.
CONCLUSIONS: LN metastasis is a major prognostic factor for survival after surgical resection of ICC and PCC.
Lymphadenectomy should be performed because number
of LN retrieved and LNR showed high prognostic value.
LNR can stratify patients with positive LNs and identify
patients with not favourable prognosis that might be feasible of adiuvant therapy.
137
Monday
Poster Abstracts
RESULTS: I) Survival in all 180 operated patients was
54% after one and 25% after 5 years (median survival 1.24
years). In univariate analysis the CHILD-score (p < 0.001),
MELD-score (p < 0.001), ASA-score (p = 0.05), emergency
procedures (p < 0.001), viral hepatitis (p < 0.01 vs alcoholic/
other origin), hyponatremia (p < 0.01) and major procedures (p < 0.03 vs minor) were associated with decreased
survival. In multivariate analysis CHILD- (p < 0.02) and
MELD-score (p < 0.001), ASA-class (p < 0.01), preoperative hyponatremia and thrombocytopenia were independently associated with poor prognosis. II) Survival in 143
patients discharged after surgery was 68% after one and
32% after 5 years (median survival 2.8 years). Long-term
survival (univariately) correlated with CHILD- and MELDscores (p < 0.01/ < 0.001), (preoperative) hyponatremia (p
< 0.01) and ASA class (p < 0.05). In multivariate analysis
the MELD-score (p < 0.001) and hyponatremia (p < 0.01)
but not significantly the CHILD-score (p = 0.06) or ASAclass independently predicted the outcome after hospital
discharge. Neither an underlying malignant disease nor age
nor emergency operations independently correlated with
long-term survival.
METHODS: Extension of LND, according with Japanese
Society of Biliary Surgery (JSBS), number and status of
harvested LNs were retrospectively evaluated in patients
cholangiocarcinoma submitted to surgical resection with
curative intent between 1990 and December 2010.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1496
Serum Markers for Predicting Surgical Outcomes
in Patients with Cirrhosis
Edward Chu, Andrew N. Harrington, Malika Garg*,
Celia M. Divino
Surgery, The Mount Sinai School of Medicine, New York, NY
INTRODUCTION: Predictors of post-operative outcomes
for patients with liver disease who undergo general surgical
procedures have not been adequately assessed. Coagulation
status consisting of a complete blood count (CBC), prothrombin time (PT), partial thromboplastin time (PTT) and
international normalized ratio (INR) is the only routinely
measured preoperative screening tool. Child-Pugh and
Model for End-Stage Liver Disease (MELD) scores have also
been used to estimate perioperative risk but with inconsistent results. The aim of this study is to identify if certain
serum assays of the liver function panel and hematological parameters are associated with increased morbidity and
mortality in cirrhotic patients who undergo abdominal
surgery.
METHODS: After receiving IRB approval, a retrospective
chart review was performed which identified 83 cirrhotic
patients who underwent 89 abdominal surgical procedures
between 2001 and 2008 at Mount Sinai Medical Center.
Pre-operative demographic information, comorbidities,
etiology of cirrhosis, and serum test results consisting of
PT, PTT, INR, CBC, liver function panel, blood urea nitrogen (BUN), and creatinine (Cr) were collected. The primary
endpoint was 30-day post-operative mortality. The secondary endpoint was development of post-operative complication prior to discharge, 30-day readmission or 30-day
re-operation. Univariate analysis was performed using chi
square test and Student’s t test. Associations with p values
less than 0.05 were considered significant.
Table 1. Mortality and Complication Rate
RESULTS: The primary endpoint occurred in 6.7% (n = 6)
of operations and was significantly associated with platelet
count <80, hemoglobin (Hb) <10, total protein (TP) <6,
lactate dehydrogenase >220, albumin <2.8, INR >1.4, and
Cr >1.2, and total bilirubin (TB) >2. The secondary endpoint occurred in 42.7% (n = 38) of operations and was
significantly associated with Hg <10, TP <6, albumin <2.8,
INR >1.4, and TB >2. Transaminases (AST and ALT), alkaline phosphatase, white blood count and gamma-glutamyltransferase showed no significant association with the
primary or secondary endpoint.
CONCLUSION: The current classification systems utilized
for risk stratification in cirrhotic patients undergoing general surgery are not optimal. Preliminary analysis shows
candidate serum markers for predicting 30 day complication and mortality rate. These additional indicators can be
used to supplement the Child-Pugh and MELD scores in
assessing surgical outcomes.
Clinical: Pancreas
Mo1498
Quality of Life in Patients After Total Pancreatectomy
Is Comparable to Quality of Life in Patients After a
Partial Pancreatic Resection
Irene Epelboym*, Megan Winner, Joseph Dinorcia,
Minna K. Lee, James A. Lee, Beth Schrope, John A. Chabot,
John D. Allendorf
Surgery, New York Presbyterian, Columbia University, New York, NY
BACKGROUND: Quality of life after total pancreatectomy
is perceived to be poor secondary to insulin-dependent
diabetes and pancreatic insufficiency. As a result, surgeons
may be reluctant to offer this treatment for benign and
premalignant diseases.
METHODS: We retrospectively reviewed a prospectively
maintained database of pancreatic operations and identified patients who underwent a total pancreatectomy
between 1994 and 2011 at our institution. Presenting
features, operative characteristics, and postoperative outcomes were evaluated. Quality of life was assessed using
institutional questionnaires and validated general, pancreatic disease-related, and diabetes-related instruments
(EORTC QLQ-C30, EORTC-PAN26, ADD-QOL) in patients
alive at the time of analysis, and compared with frequency-matched controls, patients after a pancreaticoduodenectomy. Continuous variables were compared using
Student’s t-test or ANOVA. Categorical variables were compared using chi-square or Fisher’s exact test.
RESULTS: Between 1994 and 2011, 77 total pancreatectomies were performed, 39 for benign or premalignant,
and 38 for malignant disease. Overall morbidity after total
pancreatectomy was 49%, but only 12 (16%) patients
experienced a major complication. Perioperative mortality was 2.6%. At the time of this study, 33 (43%) patients
were alive and 25 agreed to participate in the survey; final
138
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
results represent aggregate responses of 15 (10 benign
and premalignant, 5 malignant). Mean time between surgery and survey administration was 3.2 years. Scores were
compared with 14 matched patients who underwent pancreaticoduodenectomy (10 benign and premalignant, 4
malignant; 8 with postoperative diabetes). There were no
statistically significant differences in quality of life in the
global health, functional status, or symptom domains of
the EORTC QLQ-C30 or in the pancreatic disease-specific
EORTC-PAN26 between total and partial pancreatectomy
patients, regardless of final pathology. Total pancreatectomy patients had slightly but not significantly higher
incidence of hypoglycemic events as compared to partial
pancreatectomy patients with postoperative diabetes. The
negative impact of diabetes as assessed by the ADD-QOL
did not differ between total and partial pancreatectomy
patients. Life domains most negatively impacted by diabetes involved travel and physical activity, while self-confidence, friendships and personal relationships, motivation,
and feelings about the future remained unaffected.
Defining Quality for Distal Pancreatectomy: Does the
Laparoscopic Approach Protect Patients from Poor
Quality Outcomes?
Marshall Baker*1,2, Karen L. Sherman3, Amanda V. Hayman3,
Richard Prinz1,2, David J. Bentrem3, Mark Talamonti1,2
1. Surgery, NorthShore University Health System, Evanston, IL;
2. Surgery, University of Chicago, Pritzker School of Medicine,
Chicago, IL; 3Surgery, Northwestern University, Feinberg School of
Medicine, Chicago, IL
OBJECTIVES: Established systems for grading postoperative complications do not change the assigned grade when
multiple interventions or readmissions are required to manage the complication. We seek to define a quality outcome
for distal pancreatectomy (DP) and determine if laparoscopic distal pancreatectomy (LDP) affords an improvement
in quality relative to open distal pancreatectomy (ODP).
METHODS: Inpatient and office charts for patients undergoing either ODP or LDP between January 2006 and December 2009 were reviewed to capture all complications and
90-day readmission events. Clavien-Dindo grade IIIb, IV and
V complications were classified as severe adverse postoperative outcomes (SAPO). II and IIIa complications requiring
either prolonged overall lengths of stay (>2 standard deviations beyond the mean for patients undergoing ODP without complication) including readmissions or more than one
interventional procedure were also classified as SAPOs. All
others were considered minor adverse outcomes (MAPO).
RESULTS: 127 patients underwent DP. 63 (49%) had a complication. 91% of DP patients had a complication of low/
moderate Clavien-Dindo grade (I, II, IIIa) or no complication. Using our re-classification, however, 24.8% had what
was considered to be a poor quality outcome (SAPO) while
75.2% had a high quality outcome (MAPO or no complication). Of the patients undergoing DP, 77 underwent ODP
and 50 underwent LDP. Compared to patients undergoing
ODP, patients undergoing LDP were statistically less likely
to have ductal adenocarcinoma (4% vs. 26%, p < 0.01) and
tended to have smaller tumors (3.1 + 0.36 cm vs. 3.9 +
0.26 cm, p = 0.05). Those undergoing LDP did also demonstrate, however, lower volumes of intraoperative blood loss
(234+30.1 mLs vs 752 + 152.7 mLs, p < 0.01), lower rates of
postoperative transfusion (2% vs 20%, p < 0.01), lower rates
of postoperative morbidity (35% vs 58%, p < 0.01), shorter
initial postoperative lengths of stay (4.1 + 0.23 vs 8.3 + 0.7
days, p < 0.01), shorter overall lengths of stay including
90-day readmissions (6.1 + 0.9 days vs. 10.51 + 0.9 days,
p < 0.01), and were less likely to have a poor quality (SAPO)
outcome (15% vs 31%, p = 0.02)than those undergoing
ODP. There were no statistical differences between the two
groups in regard to age, presenting symptoms, incidence
of diabetes, chronic pancreatitis or comorbid cardiopulmonary disease, preoperative albumin, operative time, the rate
of readmission or of pancreatic fistula.
CONCLUSIONS: Generic grading systems underestimate
the severity of some complications following distal pancreatectomy. Using a procedure specific metric for quality following distal pancreatectomy, LDP affords a higher quality
postoperative outcome than ODP resulting in shorter initial and overall lengths of stay, a lower incidence of postoperative transfusion and a lower incidence of severe adverse
postoperative outcomes.
139
Monday
Poster Abstracts
CONCLUSIONS: While total pancreatectomy-induced
diabetes negatively impacts select activities and functions,
overall quality of life is comparable to that of patients after
a partial pancreatic resection.
Mo1499
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1500
Mo1501
Clinical Pathway for Pancreaticoduodenectomy
Improves Short Term Outcomes at a Rural Tertiary
Care Center
Postoperative Systemic Inflammatory Response
Syndrome Is a Predictor of Major Complication
After Pancreatoduodenectomy
Halle Beitollahi*, Erica L. Case, Nicole L. Woll,
Mohsen M. Shabahang, Angela Huttenstine,
Kathy J. Gorton, Marie A. Hunsinger, Joseph A. Blansfield
General Surgery, Geisinger Medical Center, Danville, PA
Naru Kondo*, Clancy J. Clark, Florencia G. Que, Kaye M. Reid
Lombardo, David M. Nagorney, John H. Donohue,
Michael B. Farnell, Michael L. Kendrick
Mayo Clinic, Rochester, MN
INTRODUCTION: Pancreaticoduodenectomy (PD) is a
complex procedure with historically high rates of morbidity but can be performed efficiently at high volume centers. Clinical pathways increase efficiency for multiple
operations including PD and have been shown to decrease
length of stay and cost of PD at academic institutions. Our
goal was to study implementation of a clinical pathway for
PD at a rural tertiary care center to determine if length of
stay decreased post implementation.
BACKGROUND: Pancreatoduodenectomy (PD) has long
been associated with high rates of morbidity and mortality.
Identification of early predictors of postoperative complications is important to minimize the morbidity of PD.
METHODS: Patient outcomes prior to and following
implementation of a PD clinical pathway were studied
between January 2006 and February 2011. Thirty five
patients underwent PD prior to implementation of the clinical pathway and twenty two underwent PD after implementation. Primary outcomes included hospital length of
stay and intensive care unit length of stay; operative time
and estimated blood loss were analyzed as well. The pathway consists of pre-established daily goals; implementation
began at the pre-operative visit and goals were set for the
operative and the post-operative course.
RESULTS: The two groups were well matched in terms of
age, gender, BMI, and histology. The primary outcome was
length of stay, determined to be 14 days prior to pathway
implementation and 7 days following pathway implementation (p < 0.0001). Operative time was also statistically
shorter in the pathway group. There was no statistically
significant difference in length of intensive care unit stay
between the two groups.
CONCLUSION: Implementation of a clinical pathway for
PD is possible at a rural tertiary care center. Following our
pathway led to more reproducible post operative care. At
our institution this pathway led to a decrease in length of
stay and thereby improved short term patient outcomes.
OBJECTIVE: To assess the usefulness of systemic inflammatory response syndrome (SIRS) as a predictor of major
complications after PD.
HYPOTHESES: 1) Early SIRS (postoperative day [POD]
≤3) can predict major complications after PD. 2) Late SIRS
(POD 4–7) can predict late major complications (≥POD 8)
after PD.
METHODS: A retrospective cohort study of 527 consecutive patients who underwent PD between 2007 and 2010
was performed. Incidence of SIRS was investigated three
times a day (at the nearest point of 8, 16 and 24 o’clock)
from POD 1 to POD 7. SIRS was diagnosed based on the
standard criteria including body temperature, heart rate,
respiratory rate and white blood cell count. A day of SIRS
was defined by meeting the criteria of SIRS at two or more
points during the same day. Postoperative incidence of SIRS
was classified into two groups: Early SIRS (at least one day
of SIRS between POD 1 and 3), and Late SIRS (at least one
SIRS positive day between POD 4 and 7). The relationship
between clinicopathological factors, Early and Late SIRS,
and major complications was evaluated by univariate and
multivariate analyses.
RESULTS: Early and Late SIRS presented in 193 (37%)
and 121 (23%) patients, respectively. Major complications
were observed in 149 patients (28%) with72 (13%) patients
developing late. Sixty-day mortality was 1.3%. Total number of days with SIRS was associated with severity of complication (P < 0.001). Incidence of Early SIRS was associated
with postoperative major complication (P < 0.001) with a
sensitivity and specificity of 57% and 71%, respectively.
Multivariate analysis demonstrated that the incidence of
Early SIRS (HR 2.5, 95% CI, 1.6–3.9, P < 0.001), soft pancreatic texture (HR 2.4, 95% CI 1.4–3.8, P < 0.001), and prolonged operative time (>360 min) (HR1.6, 95% CI 1.1–2.5,
P = 0.02) were independent risk factors for major complications after PD. For late complications, multivariate analysis
demonstrated that Late SIRS (HR 3.6, 95% CI 1.8–7.1, P <
0.001), soft pancreatic texture (HR 2.1, 95% CI 1.1–4.1, P =
0.01), and male patients (HR, 1.9, 95% CI 1.1–3.6, P = 0.02)
were identified as independent risk factors.
CONCLUSION: In a large cohort of pancreaticoduodenectomy patients, early postoperative SIRS (POD ≤ 3) was an
independent predictor of major complications after PD;
and, similarly, Late SIRS (POD 4–7) independently predicted late major complications (≥POD 8).
140
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1502
Bioabsorbable Staple Line Reinforcement Reduces Risk
of Fistula Following Pancreatic Resection
Eric H. Jensen*1, Ming Teng2, Jessica Chowaniec2
1. Surgery, University of Minnesota Medical Center, Minneapolis, MN;
2. Covidien, New Haven, CT
BACKGROUND: Pancreatic fistula remains a common
post-surgical complication following stapled pancreatic
transection. Surgical staple line reinforcement with bioabsorbable materials has grown in popularity in recent
years with hopes that they may reduce pancreatic leaks.
We sought to determine whether staple line reinforcement
reduces risk of pancreatic fistula compared to bare metal
staples.
to REINF. Heterogeneity was calculated for prospective,
retrospective and combined data. Prospective data had a
Q-statistic of 0.44 with I2 of 0, consistent with low heterogeneity. In contrast, retrospective data had Q-statistic of
11.62 (p-value 0.02) with I2 of 66, indicative of moderate
to severe heterogeneity. This is consistent with our observation that prospective studies all identified similar increased
RR of leak with STPL technique, while there was conflicting
data in the retrospective group. A forest plot summarizing
the relative risk of pancreatic fistula for the 5 prospective
studies is shown in Figure 1.
METHODS: We performed a meta-analysis of existing
data regarding pancreatic fistula following stapled pancreatic transection, comparing bare metal staples to reinforced
staple loads.
RESULTS: We identified 10 manuscripts between 2007 and
2009 reporting outcomes following stapled division of the
pancreas, comparing bare staples (STPL) to reinforced staples (REINF). Five retrospective reviews and 5 prospective
case series were included (Table 1). A total of 483 stapled
pancreatic resections are included in this meta-analysis. Of
these, 234 (48%) were REINF and 249 (52%) were STPL.
Out of 483 cases, there were a total of 100 documented
pancreatic leaks (21%). Sixty-one leaks were reported out
of 249 STPL divisions (24%), while 39 leaks were reported
following REINF division (17%). The overall relative risk
of developing a pancreatic fistula following distal pancreatectomy was not significantly different comparing STPL
to REINF when all studies were combined (RR 1.00 95%CI
0.65–1.53). We further evaluated the data stratifying by
study design (prospective or retrospective). In doing this,
we found that prospective studies reported a significantly
higher risk of pancreatic fistula with STPL compared to
REINF technique (RR 14.45, 95% CI 3.15–66.21). Both
fixed and random effects models for the retrospective data
revealed similar RR for pancreatic fistula comparing STPL
Figure 1: Forest Plot summarizing prospective studies to date. Metaanalysis indicates significantly increased risk of pancreatic leak with bare
staples (STPL) compared to reinforced staple loads (REINF).
CONCLUSION: We have identified a significant reduction in risk of pancreatic fistula comparing reinforced to
bare staples. Ideally, a randomized clinical trial should be
performed to validate our observations. In the absence of
that, however, reinforced staples should be the preferred
method of pancreatic stump closure following distal
pancreatectomy.
Study Type
Study (Year)
Prospective
Rotellar (2008)
Retrospective
STPL Total
STPL Leaks
REINF Total
REINF Leaks
2
2 (100%)
7
0 (0%)
Pugliese (2008)
6
4 (67%)
7
0 (0%)
Melotti (2007)
51
16 (31%)
7
0 (0%)
Thaker (2007)
11
4 (36%)
29
1 (3%)
Jiminez (2007)
18
7 (39%)
13
0 (0%)
Yamamoto (2009)
25
5 (20%)
47
2 (4%)
Johnson (2009)
44
7 (16%)
70
7 (10%)
Ferrone (2008)
41
10 (24%)
45
15 (33%)
Guzman (2009)
15
3 (20%)
15
11 (73%)
Laxa (2008)
21
3 (14%)
9
3 (33%)
141
Monday
Poster Abstracts
Table 1: Summary of Studies Included in this Meta-Analysis with Total Number of Pancreatic Surgeries and Pancreatic Leaks Identified
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1503
The results are summarized in the following Table.
Indications for Total Pancreatectomy and Islet
Auto-Infusion Beyond Chronic Pancreatitis with
Intractable Pain
TP + IAI for Indications Other Than Intractable Pain in Chronic
Pancreatitis
Luis F. Lara1, Marlon F. Levy*2,4, Morihito Takita4,5,
Shinichi Matsumoto4,5, Daniel C. Demarco3,4
1. Department of Gastroenterology, Cleveland Clinic Florida, Weston,
FL; 2. Division of Gastroenterology, Baylor All Saints Medical Center,
Fort Worth, TX; 3. Division of Gastroenterology, Baylor University
Medical Center at Dallas, Dallas, TX; 4. Baylor Regional Transplant
Institute, Dallas, TX; 5Baylor Research Institute, Dallas, TX
BACKGROUND/AIMS: Total pancreatectomy with islet
auto-infusion (TP + IAI) is effective in selected patients
with chronic pancreatitis (CP) who have intractable pain
unresponsive to medical and interventional therapies. IAI
can maintain adequate glycemic control, possibly insulin
independence, and has been used in selected cases following total pancreatectomy for IPMN, pancreas trauma
or pancreas necrosis with persistent leak. We report our
experience with TP + IAI for indications beyond chronic
pancreatitis.
METHODS: TP + IAI has been performed since 2006 at
BUMC. Pancreata are preserved using chilled ET-Kyoto
solution and using the oxygen-charged static two layer
method. Digestion is by the modified Ricordi method, and
purified when over 10 ml of tissue is obtained and then
injected into the portal vein. A SUITO index of >10 and
islet yield of 500,000 correlates with increased insulin independence. Patients who had the procedure for a diagnosis
other than chronic pancreatitis and intractable pain were
selected from the IRB approved database.
RESULTS: Thirty seven patients had a TP + IAI since 2006;
34 patients had CP confirmed by CT/MRI and/or EUS/
ERCP, endoscopic secretin stimulated pancreas function
testing (ePFT) and histology. Three patients had the procedure for other indications and are reported.
Patient 1: 32 y/o F with idiopathic recurrent acute pancreatitis (IRAP)resulting in multiorgan failure (MOF), ARDS
and ventilator dependency with each attack. EUS/ERCP
were not diagnostic of CP, ePFT was normal. No evidence
of endocrine/exocrine failure. No genetic mutations found.
Decision to perform TP + IAI after last admission with 2
month hospitalization with MOF.
Patient 2: 31 y/o M with hereditary chronic pancreatitis
(HP) with PRSS1 (R122H) mutation, mother with CP and
PRSS1, 2 family members with CP, 2 family members with
pancreas cancer (<55 y/o). Intermittent pain exacerbations
treated mostly at home. Decision to perform procedure due
to known mutation and family history of cancer.
Patient 3: 62 y/o F with ampullary adenoma, recurrent high
grade dysplasia despite repeated ampullectomies complicated by pancreas necrosis, and distal pancreatectomy with
persistent leak. Decision to perform procedure as a completion pancreatectomy was expected.
Patient 1
Patient 2
Patient 3
basal c-peptide
1.8 ng/ml
0.9 ng/ml
0.5 ng/ml
basal SUITO index
73
46.6
6.6
Total islet yield (IE)
500,351
212,463
Impossible to remove
head of pancreas
IE/kg
4313
3708
post IAI c-peptide
0.7 ng/ml
0.5 ng/ml
post IAI SUITO index
10.5
5.8
Insulin need
*Partial
*Partial
TP = total pancreatectomy; IAI = islet auto-infusion; *Partial = c-peptide
measurable but insulin needed for glycemic control
CONCLUSIONS: The pt with IRAP had a higher c-peptide,
SUITO index and islet yield compared to the patient with
HP, but post-procedure c-peptide and glycemic control
were similar. Despite purity of the pancreas extract ductal
cells could have been injected into the portal vein, which
was explained to the patient with HP and who consented.
As TP + IAI becomes more routine studies are needed to
understand its application beyond treatment of intractable
pain and glycemic control in CP.
Mo1504
Does Pancreatic Stump Closure Method Influence
Fistula Rate After Distal Pancreatectomy
Eugene P. Ceppa*, Robert M. Mccurdy, Molly Kilbane,
Attila Nakeeb, C. Max Schmidt, Nicholas J. Zyromski,
Keith D. Lillemoe, Henry A. Pitt, Michael G. House
Surgery, Indiana University Medical Center, Indianapolis, IN
INTRODUCTION: Pancreatic fistula (PF) remains the
primary morbidity following distal pancreatectomy (DP).
Previous studies have reported specific methods of parenchymal transection and sealing in an effort to decrease the
PF rate with highly variable results. The aim of this study
was to determine the pancreatic fistula rate following various sealing methods.
METHODS: All cases of DP were reviewed at a single highvolume institution between January 2008 and June 2011.
Sealing method of the pancreatic stump was used to create
operation groups (suture, staple, or saline linked radiofrequency (SLRF)). All cases were monitored with complete
30-day outcomes through the American College of Surgeons-National Surgical Quality Improvement Program
(ACS-NSQIP). Two and three-way statistical analyses were
performed among the operation groups.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: Two hundred and three patients underwent DP
over the 42-month period. The most common diagnoses
included pancreatitis (32%), adenocarcinoma (19%), and
IPMN (13%) which did not differ significantly among the
3 operation groups. The suture, staple, and SLRF groups
included 90 (44%), 61 (30%), and 52 (26%) patients,
respectively. Operative technique included open (68%) and
minimally invasive (32%) approaches and did not differ
among the stump sealing groups. Thirty-six patients (59%)
within the staple group received staple line reinforcement
with bioabsorbable material. Postoperative outcomes for
the three groups of patients are summarized in the table.
Overall complications and PFs were similar in each group.
Operative technique was not associated with the need for
carryover outpatient drainage, postoperative interventional drain placement, or hospital readmission.
SLRF,
N = 52
Staple,
N = 61
Suture,
N = 90
p-Value*
Overall complications
16 (31%)
23 (38%)
35 (39%)
0.61
Pancreatic fistula
13 (25%)
16 (26%)
23 (26%)
0.95
Panc fistula grade B/C
6 (11%)
11 (18%)
15 (17%)
0.60
Home drain
4 (8%)
10 (16%)
15 (17%)
0.29
IR drainage procedure
6 (11%)
6 (10%)
13 (14%)
0.71
30d hosp readmission
7 (14%)
14 (23%)
17 (19%)
0.44
*Chi-square correlations among all three groups
CONCLUSIONS: Postoperative outcomes after distal pancreatectomy are unaffected by the use of SLRF sealing of the
pancreatic stump when compared to traditional suture or
reinforced stapling techniques. A randomized clinical trial
comparing these three operative techniques may not demonstrate a difference that is clinically significant.
Mo1505
Reduction in Delayed Gastric Emptying Following
Non-Pylorus Preserving Pancreaticoduodenectomy by
Addition of Braun Enteroenterostomy
Mehrdad Nikfarjam*
Surgery, University of Melbourne, Melbourne, VIC, Australia
BACKGROUND: Delayed gastric emptying (DGE) is a
major cause of morbidity following pancreaticoduodenectomy (PD), with various factors implicated in its development. The influence of operative technique on the
occurrence of DGE is controversial. The impact of a Braun
enteroenterostomy (BE) in reconstruction following classic
PD was assessed.
METHODS: Forty-four consecutive patients undergoing
non-pylorus preserving PD from August 2009 to November
2011 by a single surgeon were included in this study. The
first twenty patients had a standard antecolic gastrojejunal
anastomosis. The subsequent twenty-four patients had an
antecolic gastrojejunal anastomosis with the addition of a
BE. The groups were compared and complications assessed
according to criteria set by the International Study Group
of Pancreatic Surgery (ISGPS).
RESULTS: Patient characteristics between the groups were
similar as was the extent of surgery and tumour and pancreatic characteristics. The median estimated blood loss
was greater in the standard reconstruction group (450 ml
(100–1500) vs 325 (100–1500 ml) p = 0.04). All other operative factors, including intra-operative blood transfusions
were similar between the two groups. The DGE rate in the
BE was significantly lower than the standard reconstruction group (1 (4%)versus 7 (35%); p = 0.015). In the standard group, 6 of 7 cases of DGE were Class C in nature. The
pancreatic fistula rate in the BE group was similar to the
standard reconstruction group (4 (21% versus 5 (29%); p =
0.706) as was the median length of hospital stay (10 days
(7–38) vs 15 (7–45); p = 0.291). On assessing factors associated with DGE, the BE technique was the only significant
factor in this study.
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Monday
Poster Abstracts
CONCLUSION: The use of BE following non-pylorus preserving PD appears to results in a significant reduction in
DGE.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1506
Mo1507
Duct-to-Mucosa Pancreaticogastrostomy Reduces
Postoperative Pancreatic Stump Leak Rates After
Distal Pancreatectomy
Risk Factors, Hospital Cost, and Complications
Associated with Transfusion in Elective
Pancreatectomy
Yasushi Hashimoto*, Yoshiaki Murakami, Kenichiro Uemura,
Takeshi Sudo, Akira Nakashima, Taijiro Sueda
Department of Surgery, Division of Clinical Medical Science, Graduate
School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
Raphael C. Sun*1, Anna M. Button2, Brian J. Smith2,
Hisakazu Hoshi1, Richard F. Leblond3, Howe R. James1,
James J. Mezhir1
1. Surgery, University of Iowa, Iowa City, IA; 2. Biostatistics,
University of Iowa, Iowa City, IA; 3. Internal Medicine, University
of Iowa, Iowa City, IA
BACKGROUND: Pancreatic stump leak is the major source
of morbidity after distal pancreatectomy. We hypothesized
that a duct-to-mucosa pancreaticogastrostomy after distal
pancreatectomy (DP-PG) can decrease pancreatic fistula
(PF) rates when compared to hand-sewn or staple closure.
Since 2008, we conducted the nonrandomized cohort study
with a prospective DP-PG group, forming our experimental
group, and a retrospective control group undergoing handsewn closure. The aim of this study is to analyze the safety
and efficacy of this method.
METHODS: DP-PG was intended to prevent PF after DP
in 30 patients between April 2008 and November 2011. A
historical control group was composed of 30 consecutive
patients undergoing hand-sewn closure between January
2005 and March 2008. Main outcome measure was incidence of PF which was defined and graded according to the
International Study Group on Pancreatic Surgery (ISGPS)
classification. Secondary measures were complications
which were assessed by the Clavien classification and postoperative hospital length of stay. Two groups were compared using Kruskal-Wallis test or chi-square tests.
RESULTS: Overall, a cohort of 60 patients underwent
DP between 2005 and 2011. In the DP-PG group (n = 30),
none PF was observed in 19 patients (63%), Grade A was
10 (33%), Grade B was 1 (3%), and Grade C was none. In
the control group (n = 30), none PF was observed in 17
patients (57%), Grade A was 7 (23%), Grade B was 5 (17%),
and Grade C was 1 (3%). Therefore the clinically-relevant
PF (ISGPS Grade B/C) rate was significantly lower in the
DP-PG group (3%) comparing to the control group (20%; P
= 0.01). Re-operation was required for one patient in both
groups, but no one was due to PF. The mortality was zero in
both groups. The operative time was slightly longer in the
DP-PG group (median, 237 min) comparing to the control
group (198min, P = 0.05). The Clavien III-V severe complications were observed in 2 patients (7%; none for PF) in the
DP-PG group, but in 4 patients (13%) in the control group.
Development of a pancreatic leak resulted in prolonged
hospital stays: 20 days in the DP-PG group vs. 29 days in
the control group (P = 0.03). The advantage of this technique is that pancreatic juice leaking from smaller branches
on the cut surface which cannot be drained through the
remnant main duct directly passes into the stomach and
also allows decompress the intraductal pressure through
the anastomosis.
CONCLUSIONS: Drainage through the pancreatic stump
provided by duct-to-mucosa pancreaticogastrostomy after
distal pancreatectomy (DP-PG) appears to have abruptly
reduced clinically-relevant PF (ISPGS Grade B/C) rate and
hospital stay. The economic impact of lower leak rates is
reflected in lower morbidity rate and significantly shorter
hospital stays. The results of our study should be validated
in a randomized controlled trial.
BACKGROUND: There is now increased awareness of the
detrimental effects of transfusion in elective general surgical procedures. Our objectives are to determine 1) which
preoperative clinical variables can predict the need for
intraoperative transfusion and 2) the impact of transfusion
on hospital costs and complications in pancreatectomy.
METHODS: Using our prospective institutional and ACSNSQIP database, we identified 173 patients who had elective pancreatectomy from 9/2007 to 9/2011. Univariate
and multivariate analyses were performed using 24 preoperative clinical variables to identify risk factors associated
with transfusion. Preoperative severity of illness (SOI) and
mortality risk were determined using the Agency for Health
Research and Quality (AHRQ) Risk Adjustment Score, a
standardized metric used by the University Health System
Consortium. Hospital costs and operative complications
were also evaluated.
RESULTS: Patients had left pancreatectomy (n = 60) or
pancreaticoduodenectomy (n = 113) to treat malignant
(n = 134) or benign (n = 39) disease. Median OR time was
7.4 hours (2.4–12.3). Median LOS was 10 days (4–77) and
51 patients (29%) spent at least one night in the ICU. 98
patients (56.6%) had a complication and 90-day mortality
was 2.9% (n = 5). SOI at admission was minor in 21 patients
(12.1%), moderate in 59 (34.1%), and major/extreme in 43
(24.8%). Risk of mortality at admission was: minor (n = 91,
53%), moderate (n = 58, 34%), and major (n = 24, 14%).
There were 78 patients (45%) who received at least 1 unit
of blood and the median number of intraoperative transfusions was 3.0 units (1–55); 11 of these patients (6.4%) also
received plasma. Mean total hospital costs observed was
$39,434 ($13,285-$251,157). Compared to patients who
did not receive a transfusion, those who received at least
one blood product had a higher mean hospital cost and
hospital charges (Table 1). Among transfused patients, 65%
(n = 51) experienced at least one complication vs. 49% (n =
47) of patients not transfused (p = 0.036), including infectious complications and pancreatic fistula/leak/abscess
(Table). In multivariate analysis, independent predictors
of increased transfusion likelihood included lower hematocrit, increased BMI, and worse AHRQ SOI and mortality
risk scores. Age, gender, comorbidities, diagnosis, ASA class,
procedure, OR time, and ICU stay were not independent
predictors of transfusion risk.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Table 1: Cost and Complications Associated with Transfusion in Pancreatectomy
Transfusion
Hospital Cost
p-Value (a)
Hospital Charges
p-value (a)
Infectious
Complication
p-Value (b)
Grade III Pancreatic
Fistula/Leak/Abscess
p-Value (b)
Yes No
$53,239
$28,099
<0.0001
$123,978 $66,023
<0.0001
46% 18%
<0.0001
22% 3%
0.001
*p-values determined using (a) two-sample t-tests and (b) chi-square tests.
CONCLUSIONS: Blood transfusion is associated with
increased hospital cost and morbidity in pancreatectomy.
Factors associated with increased risk for transfusion such
as preoperative hematocrit, BMI and AHRQ scores can be
utilized to stratify patients in clinical trials and inform
patients of their risk for transfusion. Further research is
needed to determine the extent to which transfusion contributes to morbidity and cost independently of SOI.
Mo1508
Laparoscopic Distal Pancreatectomy for Benign and
Malignant Lesions: A Nationwide Analysis of Patient
Outcomes
Hop S. Tran Cao*, David Chang, Andrew M. Lowy,
Michael Bouvet, Mark A. Talamini, Jason K. Sicklick
Department of Surgery, University of California, San Diego,
La Jolla, CA
BACKGROUND: Laparoscopic distal pancreatectomy
(LDP) was first reported in 1996. Since then, all publications evaluating LDP have consisted of single center or
multi-institutional case series. We hypothesized that a
national database inquiry could offer insight into the indications and outcomes of LDP.
METHODS: The Nationwide Inpatient Sample was queried for patients undergoing LDP for benign and malignant pancreatic lesions from 1998 to 2009. Univariate
and multivariate analyses were performed using logistic
regression models, adjusting for age, gender, ethnicity, and
comorbidities.
CONCLUSIONS: The reported experiences of single or
multiple institutions with LDP for cancerous lesions of the
pancreas remain limited. We now report the nationwide
experience and outcomes of LDP for patients with benign
and malignant pancreatic diseases utilizing a national database. We show that patients undergoing LDP for pancreatic
cancer tend to be older, have more comorbities, and are
more likely to undergo concurrent splenectomy. However,
on multivariate analyses, this does not result in increased
in-hospital morbidity or mortality rates. In summary, the
application of laparoscopic distal pancreatic resections for
malignancies has emerged as a feasible and safe approach
with comparable outcomes to resections performed for
benign pancreatic lesions. However, long-term oncological
outcomes need to be better studied before this technique
can be widely accepted as standard of care.
145
Monday
Poster Abstracts
RESULTS: 1,908 LDPs were performed between 1998 and
2009. 506 cases were excluded due to unclearly coded
ICD-9 diagnoses. The remaining 1,402 LDPs were coded
for benign (57.8%) or malignant (42.2%) diseases of the
pancreas. The groups were similar for gender, ethnicity,
and in-hospital mortality rates but cancer patients were on
average 6.9 years older (P = 0.0001) and had higher Charlson comorbidity indices (scores ≥2: 75.5% vs. 50.8%, P =
0.0001). On univariate analyses, patients undergoing LDPs
for malignancies had longer lengths of stay (8.95 vs. 6.89
days, P = 0.02), higher overall complication rates (34.4% vs.
22.0%, P = 0.045), more inadvertent organ injuries (5.5%
vs. 1.1%, P = 0.03), higher splenectomy rates (93.8% vs.
71.4%, P < 0.0001) and increased requirements for blood
transfusions (15.8 vs. 6.6%, P = 0.019). On multivariate
analyses, LDPs performed for cancer were associated with a
statistically significant increase in the incidence of splenectomy (OR 5.92, 95% CI 2.32–15.1). In contrast, there were
no differences in individual complication rates, including
fistulae, infections/abscesses, hemorrhage/hematomas,
inadvertent organ injuries, wound complications, organ
dysfunction, thromboembolic events, or in-hospital mortality based upon disease indication for LDP.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1509
Contemporary Treatment and Outcomes of
Periampullary Adenocarcinomas at a Single Institution
Vei Shaun Siow*, Zhi Ven Fong, Harish Lavu, Eugene P. Kennedy,
Patricia K. Sauter, Leonidas Koniaris, Ernest L. Rosato,
Charles J. Yeo, Jordan M. Winter
Thomas Jefferson University Hospital, Philadelphia, PA
INTRODUCTION: Periampullary adenocarcinoma (PA)
is the most common indication for pancreaticoduodenectomy (PD). The four cancers that comprise the PAs include
pancreatic ductal (PDA), ampullary (AA), distal common
bile duct (CBDA), and duodenal adenocarcinoma (DA).
While PDA has been studied extensively, it is unclear
whether these data are applicable to the rarer PAs.
METHODS: We queried our institutional PD database for
patients treated for PA from November 2005 to October
2011. Out of 650 resections, 390 (60%) patients had PA.
Clinicopathologic data were analyzed, and statistical comparisons between PA subtypes were made with respect to
PDA, unless otherwise indicated. We aimed to identify the
differences in the biology, natural history, and treatment
patterns between PAs.
RESULTS: The 390 resected PAs included 293 (75%) PDAs,
48 (12%) AAs, 28 (7%) distal CBDAs, and 21 (5%) DAs. Preoperative CA 19–9 levels were elevated in 76% of patients
with PDA, 56% with distal CBDs (p = 0.04), 62% with AA (p
= 0.071), and 55% with DA (p = 0.06). In general, resected
PDAs and CBDAs had the more aggressive pathologic features. Specifically, perineural invasion was identified in
92% of PDAs, 93% of distal CBDAs (p = 1.0), 51% of AAs (p
< 0.0001) and 34% of DAs (p < 0.0001). Lymph node metastases were identified in 74% of PDAs, 50% of distal CBDAs
(p = 0.013) 60% of AAs (p = 0.05) and 57% of DAs (p = 0.1).
Documented recurrence patterns were available in a subset of patients (22%) followed at our own institution. Due
to the small number of patients, non-pancreatic PAs were
analyzed together. The site of first recurrence was the surgical bed in 24% of PDAs and 20% of non-pancreatic PAs. A
distant metastasis was identified in 76% of PDAs and 80%
of non-pancreatic PAs (p = 1.0). With regards to treatment
patterns at our institution (N = 158 with treatment data),
patients with PDA and distal CBDAs are virtually always
treated with adjuvant gemcitabine (91%), as compared to
the other two subtypes (55%, p < 0.0001) which are frequently treated with a 5-FU based regimen. The median
and 2-year survivals associated with each PA were (Figure):
PDA, 19 months and 39%; CBDA, 18 months and 37% (p =
0.8); AA, 43 months and 65% (p = 0.002); and DA, median
not reached and 67% (p = 0.04). After adjusting for lymph
node metastases, AA was still more favorable than PDA
(hazard ratio = 0.73, p = 0.01) while DA showed a trend
but was not significantly more favorable (hazard ratio, 0.8,
p = 0.1).
Kaplan-Meier survival curves for patients with periampullary
adenocarcinoma.
CONCLUSIONS: These findings support the notion that
PAs are a heterogeneous group. As compared to AAs and
DAs, PDAs had more aggressive pathologic features and
worse long-term survival. In addition, CA19–9 was a more
sensitive test for PDAs than the non-pancreatic PAs. Our
practice patterns approach pancreatobiliary cancers primarily with gemcitabine-based treatment, which differs
from the approach with the other subtypes.
Mo1511
Predictive Factors of Pancreatic Fistula and
Postoperative Complications After Pancreatic
Resections in Two High Volume Centers: Comparison
Between Posterior Invagination and Duct-to-Mucosa
Pancreaticogastrostomy
Filippo Scopelliti*1, Giovanni Butturini1, Carlo Frola2,
Mohammad Abu Hilal2, Claudio Bassi1
1. Department of Surgery, Verona University, Verona, Italy; 2. Hepato
Pancreatico Biliary Surgery Unit, Southampton General Hospital,
Southampton, United Kingdom
INTRODUCTION: Pancreatic fistula (PF) is a major complication after pancreatic resections. Well known risk factors are soft pancreatic remnant and small duct. The most
widely used techniques to reconstruct the pancreo-digestive continuity are pancreojejunostomy (PJ) and pancreogastrostomy (PG), either executable by invagination or
duct-to-mucosa. Unlike PJ, there are no studies evaluating
short term outcome and PF rate comparing invagination
versus duct-to-mucosa PG.
METHODS: In this dual-institution retrospective study,
345 patients, reconstructed by invagination or duct-tomucosa PG after pancreatic resections, were stratified in
two groups by the type of PG performed. The invagination
group consists of 173 patients from 2000 and 2010 at the
same institution, selected for having soft pancreatic remnant. The duct-to-mucosa group consists of 172 consecutive patients from 2007 and 2010 at the other institution.
Primary end point was to compare the two groups in terms
of postoperative complications, including PF rate and grad-
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
ing, as defined by the International Study Group of Pancreatic Fistula. Secondary end point was the assessment of
possible predictive risk factors of PF, unrelated to the type
of anastomosis.
RESULTS: No differences in demographic data between
the two groups were found except of the median age, significantly higher in duct-to-mucosa group (67 vs 62 years;
P = 0,001). In invagination group 90,1% of patients had a
soft pancreatic remnant vs 48,2% in the duct-to-mucosa
group (P = 0,0001). There were 47 PFs (27,2%) in the invagination group and 44 (25,6%) in the duct-to-mucosa group
(P = NS). Furthermore no differences in PF grading were
found. The patient in duct-to-mucosa group experienced
abdominal collections in 42 cases (24,2%) respect of the
18 patients (10,4%) in the invagination group (P = 0,001).
Also delayed gastric emptying rate was significantly higher
in duct-to-mucosa group, 44 cases (25,6%) respect of the
10 (5,8%) in the invagination group (P = 0,0001). Mortality
was 0% in invagination group and 4,1% (7 cases) in ductto-mucosa group, but this difference may be due to the
higher median age of this population respect of the invagination group. In multivariate analysis for PF, independent
risk factors, unrelated to the type of anastomosis, included
sex male (P = 0,0001), soft pancreatic remnant (P = 0,0001)
and small pancreatic duct (P = 0,005).
CONCLUSIONS: The type of pancreogastrostomy does
not significantly influence the overall postoperative complication rate or incidence of PF. However, abdominal
collections and delayed gastric emptying are significantly
reduced in patients treated by invagination PG. Furthermore invagination seems to be safer than duct-to-mucosa
in case of soft pancreatic remnant. In addition, soft pancreatic remnant and small duct can be confirmed as independent risk factors for PF.
Mo1512
Pancreaticoduodenectomy at High Volume Centers:
Surgeon Volume Goes Beyond the Leapfrog Criteria
Abhishek Mathur*1, Kenneth Luberice2, Edward Choung2,
Sharona B. Ross1, Alexander S. Rosemurgy2
1. Surgery, University of South Florida, Tampa, FL; 2. Surgery,
Tampa General Medical Group Tampa General Hospital, Tampa, FL
INTRODUCTION: The Leapfrog Group has stated that outcomes after high-risk procedures, like pancreaticoduodenectomy, are superior at high-volume hospitals. High-volume
hospitals are inexorably intertwined to high-volume surgeons; however, high-volume hospitals also have low-volume
surgeons. This study was undertaken to determine if outcomes after pancreaticoduodenectomy are different for highvolume vs. low-volume surgeons at high-volume hospitals.
METHODS: High-volume hospitals for pancreaticoduodenectomy (defined by the Leapfrog Group as ≥12/year) were
identified from the State of Florida Agency for Health Care
Administration database for a 33-month period ending in
October 2010. In these centers, outcomes for high-volume
surgeons (undertaking ≥12 pancraetoduodenectomies per
year) were compared to those of low-volume surgeons
(undertaking <12 pancraetoduodenectomies per year).
Median data are presented.
Figure 1: Invagination PG
# of
Surgeons
# of
PD’s
LOS
(days)
In-Hospital
Mortality
Hospital
Charge ($)
High-Volume
Hospitals
55
928
11 (15 ± 14)
4.09%
99,409
( $142,578 ±
153,064)
High-Volume
Surgeons
10
705
10 (15 ± 14)
2.83%
98,848
( $133,218 ±
136,379)
Low-Volume
Surgeons
45
223
12 (17 ± 14)*
8.07%*
100,289
( $172,166 ±
194,142)*
*p < 0.01 vs. High-Volume Surgeons
Figure 2: Duct-to-mucosa PG
147
Monday
Poster Abstracts
RESULTS: 55 surgeons undertook 928 pancreaticoduodenectomies at 6 high-volume hospitals; 10 surgeons were
high-volume surgeons. High-volume surgeons in these
high-volume hospitals had shorter lengths of stay (LOS),
lower in-hospital mortality, and lower hospital costs (p <
0.001) than low-volume surgeons (Table).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSIONS: Within high-volume hospitals, high-volume surgeons have superior outcomes (including decreased
lengths of stay, in-hospital mortality, and cost of care) relative to low-volume surgeons. Outcomes after pancreatecticoduodenectomy at high-volume hospitals are dependent
upon surgeon volume; any “hospital affect” is limited and
does not benefit low-volume surgeons.
complications were identified after any DBE procedure in
mean follow-up period of 6 months. Mean procedure time
was 89.6 (38–180) minutes and average fluoroscopy time
was 173 (15–466) seconds.
Clinical: Small Bowel
Mo1513
Double Balloon Enteroscopy in Patients with
Surgically Altered Bowel Anatomy: Analysis of Large
Prospectively Collected Database
Mihir K. Patel*1, Victoria Gomez1, Ali Lankarani1, John Stauffer2,
Mark E. Stark1, Frank Lukens1
1. Gastroenterology, Mayo Clinic, Jacksonville, FL; 2. Surgery,
Mayo Clinic, Jacksonville, FL
BACKGROUND: The referral of patients with surgically
altered bowel anatomy such as Bariatric surgery, Billroth
II surgery, and Roux en Y anastomosis during liver transplants etc. for endoscopic evaluation is rising. The Double
Balloon Enteroscopy (DBE) procedure has both diagnostic
and therapeutic value in small bowel evaluation in these
patients. Reported data on DBE in the patients with surgically altered bowel anatomy is limited.
AIM: To evaluate the success rate, diagnostic yield, and
safety of DBE procedure in patients with surgically altered
bowel anatomy.
METHODS: We reviewed our large prospectively collected
DBE database from 2006 to 2011. The patients with history
of surgically altered bowel anatomy who underwent DBE
were included in our study analysis. Patients’ Demographics
along with DBE procedure indication, findings and complications were recorded. We used the frequency statistics to
calculate the diagnostic yield of the DBE in these patients.
RESULTS: A total of 1218 DBE procedures were performed
from 2006 to 2011 at our tertiary referral center. Out of
these, 64 DBEs (11 DBE-ERCP) performed in 62 patients
(73% Female) with surgically altered bowel anatomy were
included in our study analysis. Their mean age was 51
(26–77) years and mean BMI was 28.2 (20.3–53.6) kg/m2.
Bariatric surgery was the most common 83% (n = 53) type
of the surgery for altered bowel anatomy. The most common indication of DBE was abdominal pain and DBE-ERCP
was acute cholangitis (see table). The overall procedure
success rate for adequate examination of roux limb was
92.2% (59/64). The success rate of DBE–ERCP with adequate examination of pancreato-biliary tree and required
therapeutic intervention was 63.3% (n = 7/11). The overall
diagnostic yield (pertinent positive findings) of DBE procedure was found to be 64% (n = 41). The diagnostic yield in
patients with prior negative imaging and/or capsule endoscopy was found to be 47% (n = 30). The diagnostic yield
of small bowel biopsy (targeted or random) was 9.4% (n =
3/32), while the diagnostic yield of small bowel aspirate for
bacterial overgrowth was found to be 100% (n = 5/5). No
Indications of DBE without ERCP (n = 53 pts)
n (%)
Persistent abdominal pain Bleeding—Overt
Bleeding—Obscure Other
17 (32) 10 (19) 8 (16)
18 (33)
Indications of DBE-ERCP (n = 11 pts)
n (%)
Acute cholangitis Recurrent pancreatitis Biliary
Stricture Other
3 (27.3) 2 (18.2) 2
(18.2) 4 (36.3)
CONCLUSION: The DBE is a safe procedure and carries
very high diagnostic yield in the patients with surgically
altered bowel anatomy for various indications. The diagnostic yield remains high even if there are negative radiology tests and/or capsule endoscopy prior to DBE procedure.
The diagnostic yield of small bowel aspirate was very high
while diagnostic yield of gastrointestinal biopsies were low.
In our study, we found fair success rate of DBE with ERCP
procedure in terms of adequate examination with required
therapeutic intervention.
Mo1514
Fifteen Cases of Superior Mesenteric Artery Syndrome:
Diagnosis and Surgical Strategies
Romeo Bardini1,2, Angelica Ganss1,2, Marinella Menegazzo1,2,
Marco Tonello1,2, Imerio Angriman*1,2
1. University of Padova, Padova, Italy; 2. Surgical & Gastroenterologic
Science, University of Padova, Padova, Italy
INTRODUCTION: Superior mesenteric artery syndrome
(SMAS) is a condition caused by duodenal compression
between aorta and superior mesenteric artery (SMA).
SMAS’s symptoms are nausea, vomiting, post-prandial epigastric pain and weight loss. Computed tomography (CT)
angiography and magnetic resonance (MR) angiography
are at present the most informative diagnostic technique.
Diagnostic criteria are a narrowing in the aorto-mesenteric
angle lesser than 22° (normal 28°–65°) and a reduction
of the aorto-mesenteric distance to 8 mm or less (normal
10–28 mm). Usually SMAS is not recognized and mistreated. Medical treatment includes pro-motility agents,
but surgical approach is advocate in case of conservative
treatment failure.
METHODS & AIM: Fifteen consecutive patients (11F, 4 M,
mean age 45 ± 9 years) who underwent surgical correction
of SMAS between 2008 and 2010 have been enrolled in this
prospective study. Before operation all patients have been
investigated with CT and/or MR angiography with multiplanar three-dimensional reconstructions, EGDS, barium
contrast radiography. In patients previously operated for
GERD, also pH-metry and esophageal manometry were
performed. Postoperative outcome was evaluated considering the following clinical variables: weight, BMI, medical
therapy, serum albumine, amylase and lipase. Aim of the
study is to evaluate safety, efficacy and outcome of surgical
correction of SMAS.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: All the patients enrolled were symptomatic
for abdominal pain, nausea and anorexia. In addition 11
patients reported GERD, 3 had recurrent episodes of acute
pancreatitis and 7 cases presented symptoms of upper GI
obstruction. 5 patients had previously undergone fundoplication without symptoms relief. Mean aorto-mesenteric angle was 18° ± 1.8 and distance 4.6 ± 2.1 mm. A
duodenojejunostomy was performed in 7 patients, in the
remainders the duodenojejunostomy was done after distal
duodenum resection. There were no mortality, we observed
2 post operative complications: an abdominal bleeding and
a mild acute pancreatitis. At mean follow period of 10 ±
6.3 months, all patients are well and alive, 2 of them are
still complaining mild epigastric pain. There is a significant
improvement in patient weight (pre-operatory mean 50 ± 1
kg, post-operatory mean 55 ± 9 kg p = 0.003) and BMI (preoperatory mean 18.1 ± 3.4 kg, post-operatory mean 20.0
± 3.4 kg p = 0.004) and there is a significant decreased in
need of PPI therapy (p = 0.004). We didn’t observed significant differences, in the outcome, between the two surgical
procedures.
CONCLUSIONS: Duodenojejunostomy can be recommended as a safe and appropriate option for SMAS. In our
series there is no significant difference between distal duodenal resection with duodenojejunostomy and duodenojejunostomy bypass.
Mo1515
Impact of Abdominal Insufflation for Laparoscopy on
Intracranial Pressure
Tovy H. Kamine*1, Efstathios Papavassiliou2, Benjamin E. Schneider1
1. Surgery, BIDMC, Boston, MA; 2. Neurosurgery, BIDMC, Boston, MA
INTRODUCTION: Diagnostic laparoscopy has recently
emerged as an alternative to laparotomy in trauma patients.
However, the impact of abdominal insufflation on intracranial pressure is not well described outside animal models.
We present a retrospective review of patients who underwent a laparoscopic assisted ventriculoperitoneal shunt
placement (lap VPS) at our single institution with intraoperative intracranial pressure (ICP) measurements.
RESULTS: Nine patients had ICP measurements noted.
The mean increase in ICP with insufflation was 7.22 cm
H2O (95%CI:5.38–9.07; p < 0.001). The maximum ICP difference was 12.5 cm H2O. The maximum ICP measured in
this population with insufflation was 25 cm H2O. None
of the baseline data measured had a significant effect on
increase in ICP with insufflation.
Mo1516
Effects of Preoperative Enteral Glutamine and Arginine
in Patients Submitted to Surgical Treatment of
Enterocutaneous Fistulas
Jose L. Martinez, Enrique Luque-De-LEóN*, Eduardo A. Ferat-Osorio
Gastrocirugía, UMAE Hospital Especialidades Centro Médico Nacional
SXXI, Mexico DF, Mexico
INTRODUCTION: Sepsis remains the main cause of morbidity and mortality in patients with enterocutaneous fistulas (ECF). Although preoperative immunonutrition has
shown less infectious complications (IC) in patients with
gastrointestinal malignancies submitted to operative treatment, no studies have been done regarding use of these
agents in patients with ECF. Our aim was to assess the
effects of preoperative enteral glutamine and arginine in
patients with ECF who require surgical attempts for its
closure.
PATIENTS AND METHODS: During a 24 month study
period, 38 patients with ECF were operated upon. All had
at least 100 cm of proximal small bowel. They were divided
in 2 groups: patients in group A (control, n = 20) were managed with our standard preoperative protocol; patients in
group B (experimental, n = 18) received oral glutamine (4.5
g/day) and arginine (10 g/day) preoperatively for 7 days.
Patient, disease, and operative variables were prospectively
collected. Our primary endpoint was IC. Secondary endpoints included ECF recurrence, definitive ECF healing and
mortality. Comparisons were made using Students T test
for continuous variables and chi-square or Fischers exact
test for categorical variables.
RESULTS: All patient, disease and operative variables were
similar for both groups. IC developed in 8 and 2 patients
(groups A and B respectively, p = 0.06). Some patients in
group A had more than one IC and thus this difference
became more evident when total number of complications
per group were calculated (15 vs 2 respectively, p < 0.05).
Comparing secondary endpoints for patients in group A
vs B, ECF recurred in 8 and 2, respectively (p = 0.06), and
definitive ECF closure was achieved in 12 and 16, respectively (p = 0.06). Three patients died in group A, and 1 in
group B (from an unrelated non-septic cause), p = 0.60.
CONCLUSIONS: Use of preoperative enteral glutamine
and arginine seems to provide beneficial effects for patients
with ECF submitted to operative treatment. There were
less number of total IC and a clear tendency towards less
number of patients with IC, less ECF recurrence and more
definitive ECF closures and healing.
149
Monday
Poster Abstracts
METHODS: Retrospective chart review was performed for
sequential patients who underwent laparoscopic-assisted
VPS placement since 2008. Abdominal insufflation was performed using CO2 to 15 mmHg. ICP was measured through
the ventricular catheter with insufflation and desufflation,
using a manometer. Baseline data were obtained as well
including: age, sex, HTN, CHF, cancer, cirrhosis, renal failure, BMI, and prior abdominal or cranial surgery. Paired
t-tests were performed to determine differences between
ICP on insufflation and desufflation. Baseline data analyzed using linear regression to the ICP difference.
DISCUSSION: ICP was significantly elevated with the
insufflation associated with laparoscopy up to a maximum
12.5 cm H2O above the desufflated baseline. These data suggest that laparoscopy should be used cautiously in patients
with a baseline elevated ICP or head trauma.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Stomach
Mo1518
Mo1517
Correlation Between Gastric Emptying Time and
Weight Loss After Silastic Ring Roux-en-y Gastric
Bypass
Revisional Bariatric Surgery for Weight Regain and
Complications
Jorge M. Junior1, Fernando Herbella*2, Antonio C. Valezi1,
Silvia Brito3
1. Surgery, Uel, Londrina, Brazil; 2. Digestive Surgery, Unifesp,
São Paulo, Brazil; 3. Nutrition, Uel, Londrina, Brazil
Hideharu Shimizu*, Matthew Kroh, Tomasz Rogula,
Bipan Chand, Philip R. Schauer, Stacy A. Brethauer
Bariatric and Metabolic Institute, Cleveland Clinic, Cleveland, OH
INTRODUCTION: With the increase in the number of
bariatric surgery performed every year, there are growing
numbers of patients who require revisional surgery due to
undesirable results from their primary procedures. Anatomic complications and weight regain are the two most
common reasons for pursuing revisional bariatric surgery.
METHODS: We conducted a retrospective analysis from
a single institution to evaluate medium-term weight loss
and complication rates after revisional bariatric procedures.
RESULTS: From 01/04 to 01/11, 2918 patients underwent
bariatric surgery at our institution. 155 (5%) had revisional
surgery. 81% were female. The mean age at revision was
49 and the mean BMI at time of revision was 44. The most
common primary procedures were Roux-en-Y gastric bypass
(RYGB) (n = 55, 36%), vertical banded gastroplasty (n = 37,
24%), sleeve gastrectomy (SG) (n = 26, 17%), and adjustable gastric banding (AGB) (n = 23, 15). Two groups were
defined according to the indication for revision. Group A
included patients with unsatisfactory weight loss or regain
of co-morbidities (n = 108) and Group B included complications from their primary procedures (n = 47). In group
A, majority of the patients (69%) were revised to standard
or distal RYGB. Others underwent redo gastrojejunostomy,
placement of AGB over a large gastric pouch or stoma, or
SG. Mean excess weight loss at 1 year follow up was 56%
after revision of primary restrictive procedures and 40%
after primary bypass procedures (p < 0.01). At mean follow up of 3 years, EWL was 48% and 37%, respectively (p
= 0.08). In group B, 77% of the patients were revised to
RYGB. The complications prompting revision (recalcitrant
gastrojejunal stricture, refractory marginal ulcer, severe
gastroesophageal reflux disease, and malnutrition) were
effectively treated by revisional surgery. The mean BMI in
Group B was 30 at the time of revision and was 32 at 3
years. Revisional surgery was performed laparoscopically
in 121 patients (78%). Major and minor complications
were observed in 13 and 17%, respectively, of those who
had laparoscopic surgery and 29 and 35%, respectively, of
those who had open surgery (p < 0.05). Open revisions had
greater blood loss (p < 0.01), and longer length of hospital stay (p < 0.01) compared with laparoscopic revisions.
Mortality was seen in 1 patient (0.6%) 5 months after open
surgery.
CONCLUSION: Revisional bariatric surgery was performed
effectively to manage undesirable results from primary bariatric surgery. Laparoscopic revisional surgery can be performed safely in the majority of these patients. Carefully
selected patients undergoing revision for weight regain
have satisfactory additional weight loss.
PURPOSE: The real importance of gastric pouch emptying
time to determine weight loss is still unclear. This study
aims to evaluate the association between excess weight loss
(EWL) and gastric pouch emptying time of obese subjects
who underwent silastic ring Roux-en-Y gastric bypass.
METHODS: 159 morbid obesity patients (mean age 41 ± 11
years, 112 females) underwent silastic ring Roux-en-Y gastric bypass and were followed for two years. Gastric pouch
emptying time was studied by scintigraphy at 1 and 2 years
after the operation. Individuals with diabetes or inability to
ingest the test meal in 10 min were excluded. Pearson and
Spearman correlation test, analysis of variance, and Bonferroni tests were used in the statistical analysis.
RESULTS: Gastric pouch emptying time ranged from 58
to 83 min (mean = 71 min) and 58 to 81 min (mean =
70min) during first and second year, respectively. A positive correlation between weight loss and gastric emptying
time at the first year (r = 0.584, p < 0.001) and at the second
year of follow-up (r = 0.660, p < 0.001) was found.
CONCLUSION: Gastric pouch emptying time was associated with weight loss after silastic ring Roux-en-Y gastric
bypass, during the two years follow-up.
KEY WORDS: Gastric pouch emptying; weight loss;
gastric bypass.
Mo1519
Change in National Trends Adversely Impact Survival
in Stage IV Gastric Cancer
Anna M. Leung*1, Danielle M. Hari1, Connie Chiu1, Anton
Bilchik1,2
1. Department of Surgery, John Wayne Cancer Institute, Santa
Monica, CA; 2. Surgery, California Oncology Research Institute, Santa
Monica, CA
BACKGROUND: With more effective systemic chemotherapy, the role for palliative gastrectomy in patients with
Stage IV gastric cancer has been questioned.
METHODS: Using the National Cancer Data Base we identified 29,655 patients with Stage IV gastric cancer over a
14 year period (1994–2008). Patient demographics, tumor
related features, and treatments were analyzed. Overall
survival rates were examined using log-rank test power
analysis.
150
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Observed Survival for Stage IV Gastric CA OverTime (1994–1997) vs. (1998–2002)
Year of
Diagnosis
Total Patients
1 Year
(% Survival)
2 Year
(% Survival)
3 Year
(% Survival)
4 Year
(% Survival)
5 Year
(% Survival)
95% Confidence
Interval
P-Value
(1994–1997)
12,132
23.8
12.1
9.1
7.8
6.0
5.6–6.4
p < 0.05
(1998–2002)
17,523
22.6
8.4
5.0
3.6
2.9
2.7–3.2
p < 0.05
RESULTS: There was a decrease in surgical resection from
31.2% in 2000 to 22% in 2008 (p < 0.0001), a decrease in
radiation from 20% in 2000 to 18.5% in 2008 (p = 0.0009),
and an increase in systemic therapy from 45.5% in 2000
to 55.1% in 2008 (p < 0.001). There were no differences
in gender, age, or histology, but there was a decreasing
trend of Caucasians diagnosed (p < 0.0001). Survival rates
decreased significantly over time p < 0.05 (see Table below).
CONCLUSIONS: RYGBP determined profound changes
in urinary composition which predisposed to a lithogenic
profile. The prevalence of urinary lithiasis increased almost
70% in the postoperative period. A metabolic evaluation
for nephrolithiasis is suggested for obese patients following
RYGBP.
CONCLUSIONS: Over the past 14 years there has been an
increase in the use of systemic chemotherapy and a reduction in palliative gastrectomy for stage IV gastric cancer.
The negative impact on survival suggests that treatment
pathways be reevaluated.
Gastric Electrical Stimulation for Symptom Control of
Patients with Diabetic, Idiopathic, and Post Surgical
Gastroparesis
Mo1520
Urinary Evaluation After RYGBP: A Lithogenic Profile
with Early Postoperative Increase in the Incidence of
Urolithiasis
Mo1521
Samira Hasan1, Chad J. Davis*1, Joel C. Hammond1,
Thomas V. Nowak2, Lisa Ruehr2, Curtis Ramsey1
1. St. Vincent Hospital, Indianapolis, IN; 2. St. John’s Hospital,
Anderson, IN
INTRODUCTION: Gastric electrical stimulation has been
used for over a decade for symptom control of gastroparesis
refractory to medical treatment.
Antonio C. Valezi1, Fernando Herbella*2,1, Jorge M. Junior1, Paulo
Fuganti1
1. Surgery, Universty of Londrina, Londrina, Brazil; 2. Paulista School
of Medicine, São Paulo, Brazil
OBJECTIVE: To evaluate long-term symptom control with
gastric pacemaker therapy and the relationship to improvement in gastric emptying.
PURPOSE: Bariatric surgery is followed by multiple
changes of urinary composition with a propensity toward
a lithogenic profile. We prospectively studied patients who
underwent Roux-en-Y gastric bypass (RYGBP) to assess urinary composition and lithiasis incidence.
RESULTS: Median BMI decreased from 44.1kg/m2 to
27.0kg/m2 (p = 0.0001) in the postoperative period. Urinary oxalate (24mg versus 41mg; p = 0.000) and urinary
uric acid (545mg versus 645mg; p = 0.000) increased significantly postoperatively (preoperative versus postoperative, respectively). Urinary volume (1310ml versus 930ml;
p = 0.000), pH (6.3 versus 6.2; p = 0.019), citrate (268mg
versus 170mg; p = 0.000), calcium (195mg versus 105mg; p
= 0.000) and magnesium (130mg versus 95mg; p = 0.004)
decreased significantly postoperatively (preoperative versus
postoperative, respectively). Stone formers increased from
16 (10.6%) to 27 (17.8%) patients in the postoperative
analysis (p = 0.001). Predictors for new stone formers after
RYGBP were postoperative urinary oxalate (p = 0.015) and
uric acid (p = 0.044).
RESULTS: Symptom scores for all patients were significantly improved at all follow-up intervals compared to
pre-op (P < 0.0001). Patients with idiopathic gastroparesis
achieved the same degree of symptom control as diabetic
patients. There was no significant change in gastric emptying from pre-op to 6 months or at 1 year post-op.
CONCLUSIONS: Symptoms for all patients significantly
improved after initiation of gastric electrical stimulator
therapy. The improvement continued for up to 5 years
postoperatively. Patients with idiopathic gastroparesis had
similar symptom improvement as those with diabetic gastroparesis. Despite symptom improvement, gastric emptying, as measured by nuclear scanning, was not significantly
changed with gastric electrical stimulation. This observation suggests that gastric stimulation improves symptoms via a mechanism independent of the rate of gastric
emptying.
151
Monday
Poster Abstracts
MATERIALS AND METHODS: One hundred and fifty
one obese patients underwent RYGBP and were followed
for one year. The analysis comprised two study time points:
preoperative (T0) and one year after surgery (T1). They were
analyzed for urinary stones, blood tests and 24h-urinary
evaluation. Nonparametric tests, logistic regression and
multivariate analysis were conducted using SPSS 17.
METHODS: A retrospective review of symptom scores
and gastric emptying nuclear scans of 117 patients at a
single center from 2000 to 2011. The patients included
in the study were 55 with diabetic gastroparesis, 55 with
idiopathic gastroparesis, and 7 with post-surgical gastroparesis. Symptoms scores were compared for severity and
frequency of nausea, vomiting, early satiety, and epigastric
pain at pre-op, 6 months, 1 year, 3 years, and 5 years. Gastric emptying scan results from pre-op, 6 months, and 1
year were compared.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Mo1522
Mo1523
GLP-1 Analogues Do Not Improve Remission of
Diabetes After Gastric Bypass
Newly-Devised Method for Totally Laparoscopic Total
Gastrectomy (TLTG), Application Easiness and Cost
Effectiveness: The Experience of Over 140 Cases in
Single-Institution
Andrew A. Taitano*1, Tejinder P. Singh2,1
1. General Surgery, Albany Medical Center, Albany, NY; 2. AMC
Bariatric Surgery Group, Albany Medical Center, Albany, NY
INTRODUCTION: Surgical treatment for morbid obesity
via Laparoscopic Roux-en-Y Gastric Bypass (LRNYGB) leads
to weight loss and remission of diabetes in most patients
with type 2 diabetes mellitus (T2DM). The outcomes in
patients taking GLP-1 analogues for glycemic control are
not well understood. We analyzed the rate of remission of
T2DM in patients after gastric bypass surgery with respect
to the diabetic medications taken preoperatively.
METHODS: 157 patients with T2DM were studied. Baseline demographics, hemoglobin A1C levels, and medication lists were evaluated for patients undergoing LRNYGBP
between January 2005 and December 2009.
RESULTS: The mean age was 50 years, 73.9% were female,
mean BMI at surgery was 47.6. Mean follow-up was 2.34
years. 79.0% of patients were off medications for T2DM at
last follow-up. 19.1% of patients were on a GLP-1 analogue
at the time of surgery. The average preoperative hemoglobin A1c level was higher in this group (6.92 vs 6.80), but no
other significant differences were found. The rate of remission of diabetes was not significantly different between
patients on a GLP-1 analogue and others (80.0% vs 78.7%).
Remission rates did not vary according to the number of
anti-diabetic agents taken at the time of surgery (91.1% for
1, 89.6% for 2, 90.0% for 3 or 4). Multivariate regression
analysis revealed preoperative insulin use to be the only
significant predictor of postoperative T2DM status (RR
5.48, 95% CI 2.91 to 10.30).
CONCLUSIONS: The use of GLP-1 analogues in patients
who undergo LRNYGBP surgery is not associated with
improved glycemic control, lower BMI at the time of surgery, or improved long term outcomes. Preoperative insulin
use is a risk-factor for non-remission of T2DM postoperatively. Surgical intervention prior to insulin dependence is
needed to maximize long term remission rates. Early surgical intervention for morbidly obese patients with T2DM
should be considered instead of escalation of medical
management.
Hitoshi Satodate*, Haruhiro Inoue, Shin-Ei Kudo
Digestive Disease Center, Showa University Northern Yokohama
Hospital, Yokohama, Japan
INTRODUCTION: Although laparoscopy-assisted distal
gastrectomy for gastric cancer is becoming popular procedure especially in Japan and Korea, laparoscopy-assisted
total gastrectomy is less common operative procedure. One
of the major problems is difficulty of intracorporeal reconstruction, and another problem is cost. We developed TLTG
procedures that requirement of disposable instruments is
minimal, within the coverage of Japanese insurance system.
METHOD: A 12-mm trocar is placed through umbilical
incision, and four additional trocars are placed. Only two
12-mm trocar incisions and three 5-mm trocar incisions,
including for the camera, are created for this procedure.
After thorough mobilization of the abdominal esophagus,
the esophagus is divided with stapler, and Orvil is inserted
per orally, and the anvil is loaded into the esophageal stump.
Then the handpiece of EEA stapler is introduced from the
umbilical port incision, and the jejunojejunal anastomosis
is also created from the umbilical port incision.
RESULTS: We have performed 142 cases of the TLTG with
this procedure, and have experienced only one minor anastomotic leakage. No other major problems had occurred.
Mean operation time is 231 min. And the mean time for
the whole procedures for reconstruction including creation
of Roux-en-Y jejunojejunal anastomosis is 53 min.
CONCLUSION: Two clear advantages can be mentioned
with this method, compare with other techniques. First,
this technique can be relatively easily applied for the cancer of the cardia. Second, minimize the use of disposable
instruments. Only three linear staplers and one circular stapler are needed, and these are completely covered by insurance. This technique could become the standard methods
for reconstruction after TLTG, and facilitate the acceptance
of TLTG. And also lead to the hospital benefit. We will
show our clinical practice.
152
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Mo1524
of potentially curative cancer resections of the foregut, including esophagus, stomach, liver, and pancreas.
Preoperative Chemotherapy in High Risk Gastric
Cancer: No Guarantee of Downstaging But Remains
Our Best Magic Bullet
Veeraiah Siripurapu*, Ashley Mekala, Elizabeth T. Liu,
Dhiresh R. Jeyarajah
Surgery, Methodist Dallas Medical Center, Dallas, TX
INTRODUCTION: With the advent of the MAGIC trial,
preoperative chemotherapy is utilized for high risk tumors
in gastric cancer (T3 and higher/Node positive tumors).
The regimen is often toxic and often necessitates nutritional support with the hope of downstaging these aggressive tumors. We aim to see if our population of high risk
tumors receiving preoperative therapy experienced any
downstaging in comparison to those who did not.
METHODS: The Nationwide Inpatient Sample was queried to identify all esophageal, gastric, liver and pancreas
resections performed for cancer during 1998–2009. Annual
incidence, major in-hospital postoperative complications,
length of stay and in-hospital mortality were evaluated.
Univariate and multivariate analysis performed by chi
square and logistic regression. For all comparisons, p-values
<0.05 were considered statistically significant.
AIM: All gastric cancer cases operated on by a single surgeon in the last five years were queried. Of these, only those
who had strict clinical staging with radiological imaging/
EUS and who were deemed high risk were included for
analysis. Clinical stage was correlated to pathologic stage
with a view to see if any tumors were upstaged, downstaged
or had complete pathologic response.
RESULTS: A total of 27 patients met all criteria. Twelve
patients (44%) had tumors designated as Siewert 3 and 1
patient as Siewert 2. Of the 27 patients, 15 (55%) were node
positive. Twenty patients (74%) were staged T3 or higher.
Ten patients received no preoperative therapy. The major
preoperative regimen used was Epirubicin, Cisplatin &
5FU (ECF) or a combination similar such as EOX (78%).
Of those who received preoperative therapy, ten patients
(58%) were downstaged. There were 4 complete pathologic
responses (cPR). All these patients received either ECF or
EOX. Tumor location was varied for those with cPR
CONCLUSIONS: Complete pathologic response is obtainable in high risk gastric cancer. Downstaging of these
tumors happens in 58% of the high risk gastric populace. For those who can tolerate the regimens, this should
remain the standard of care until further trials establish different treatment approaches.
Foregut Surgery in the Modern Era: A National Survey
Zeling Chau*1, Jillian K. Smith1, Elan R. Witkowski1, Elizaveta
Ragulin-Coyne1, Sing Chau NG1, Tara S. Kent3, Shimul A. Shah1,
Jennifer F. Tseng2,1
1. Surgical Outcomes Analysis & Research, University of Massachusetts
Medical School, Worcester, MA; 2. Division of Surgical Oncology, Beth
Israel Deaconess Medical Center, Harvard Medical School, Boston,
MA; 3. Department of General Surgery, Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, MA
BACKGROUND: Foregut surgery is technically complex. In
recent years, increasing attention has been paid to high-stakes
surgery outcomes, including mortality and complications. In
addition, the use of advanced technology including minimally
invasive approaches has been introduced. The current study
aims to determine national trends in utilization and outcomes
153
Monday
Poster Abstracts
Mo1525
RESULTS: 298,871 patients (nationally-weighted) underwent cancer directed foregut surgery 1998–2009. Of those
19,002 (6%) were esophagectomies, 123,198 (41%) were
gastrectomies, 62,313 (21%) were hepatectomies and 94,358
(32%) were pancreatectomies. From early years (1998–2000)
to late years (2007–2009) use of laparoscopy in foregut surgery increased from 3% to 5%. Laparoscopy in esophagectomy increased the most from 1% to 5%, while its use in
hepatectomy remained unchanged at 4%. Gastrectomy and
pancreatectomy involving minimally invasive techniques
increased from 2% to 5% and 5% to 6%, respectively. For all
four foregut surgery types, patient comorbidities increased
over time; patients with ≥2 major comorbidities increased
from 53% to 64%. Conversely, patient mortality and length
of stay (LOS) decreased over time. However, we observed an
increase in complications for all sites combined from 22.8%
to 24.4%. Laparoscopy was not significantly associated with
decreased complications, but was associated with lower mortality when compared to open resection alone 3.1% vs. 5%.
Independent predictors of increased complications included
older age, gender, higher comorbidity, hospital volume.
Older age, male sex, higher comorbidity, low volume center
and non-use of laparoscopy were independent predictors of
in-hospital mortality.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSION: Foregut surgery in the modern era is being
increasingly deployed on sicker patients. While decreased
in-hospital mortality and LOS are commendable, complication rates remain substantial and nondecreasing. Minimally
invasive techniques have minor but increasing penetrance
in foregut surgery. Our results suggest comparable advances
and potential pitfalls among major types of foregut surgery
in the current era.
Translational Science: Colon-Rectal
Mo2071
Thromboelastography Delineates Hypercoagulation in
an Immunocompentent Murine Model of Metastatic
Colon Cancer
Karen K. Lo*1,2, Theresa Chin1, Marguerite Kelher3, Martin
Mccarter1, Ernest E. Moore2, Christopher Silliman1,3, Carlton C.
Barnett2
1. Surgery, University of Colorado, Denver, Aurora, CO; 2. Surgery,
Denver Health, Denver, CO; 3. Bonfils Blood Center, Denver, CO
Mo1526
What Motivates Weight Loss Surgery Patients?
Nayna A. Lodhia*, Jaffer M. Kattan, Dylan Gwaltney, Kate E.
Kiely, Shushmita Ahmed, Homero Rivas, John M. Morton
Surgery, Stanford University, Stanford, CA
BACKGROUND: By better understanding patient motivations, patient education can be individualized for the most
effective healthcare possible. The purpose of this study was
to evaluate patient motivations for bariatric surgery.
METHODS: Preoperative, three, six and twelve month
postoperative data were prospectively obtained for 169
consecutive laparoscopic Roux-en Y gastric bypass surgery patients at a single academic institution. All patients
were given a standardized multiple choice questionnaire
which asked them about their primary motivations for
bariatric surgery preoperatively, then 6 and 12 months
postoperatively.
RESULTS: Better health was the primary motivator preoperatively and at 12 months postoperatively (87, 89%, respectively). A better appearance was a primary motivation for
only 15% of patients preoperatively and 20% of patients 12
months postoperative. Within health-related motivations
for bariatric surgery, 29% of patients expressed a primary
desire to live longer preoperative and, by 12 months postoperatively, this number increased to 38.7% of patients postoperatively. The primary motivation for bariatric surgery from
a family perspective was to have more energy with children preoperatively and remained so at 12 months postoperatively (44 to 46%). The second most common familial
motivation was to be a healthy role model which did not
change from pre- to post-operatively (29.8 to 29.5%). Preoperatively, 65% of patients thought that diet and exercise
would be the most important factor to maintain long-term
weight loss; however, by 12 months postoperatively, only
56% of patients thought that diet and exercise would be the
most important factor. Patients gave an increasingly greater
role to surgery as an important factor for weight loss raising
its importance from 45% preop to 58% at one year postoperatively. Observed to patient-expected (O:E) ratios of 12
month percent excess weight loss became more accurate as
patients progressed from preop to 6 and 12 months postop
(0.60, 0.70, 0.78). Pre-operative O:E Ratios of percent excess
weight loss were strongly correlated with 12 postoperative
excess weight loss (p < 0.001).
INTRODUCTION: The association between malignancy
and venous thrombosis (VTE) has been well documented
since the 1860s. Moreover, it has been demonstrated that
perioperative blood transfusions increase the risk of VTE in
colon cancer patients. Despite efforts to prevent VTE, current diagnostic tests (INR, PTT, PT, platelet count) are often
unreliable. Recently, our lab has demonstrated that Thromboelastography (TEG) is able to better assess coagulation
kinetics and direct patient therapy than conventional
testing. We hypothesize TEG will delineate coagulation
abnormalities in a murine model of transfusion mediated
metastatic colon cancer.
METHODS: C57/BL6 male mice, age 7–9 weeks, underwent splenic inoculation with 2.5 × 104 MC38 murine
colon adenocarcinoma cells. Control mice underwent the
same surgery with splenic injection of normal saline. One
week after inoculation, all mice were randomized to receive
blood transfusion via tail vein injection in the amount of
1 mg/kg or the equivalent dose of normal saline. N ≥ 4
in all groups. Three weeks after cancer inoculation, cardiac
puncture was performed and blood was collected with
citrate in a 1:10 ratio. TEG was performed on TEG® 5000
Thrombelastograph® Hemostasis Analyzer. Necropsies
were then performed: tumors were harvested and metastases were determined. TEG was compared between mice
with metastatic cancer with and without transfusion and
control mice, who received sham cancer surgery, with and
without transfusion. Data were analyzed using ANOVA
with p ≤ 0.05 used to determine significance.
RESULTS: Mice with cancer that received blood transfusions were found by TEG to have significantly lower R times
(4.4 minutes versus 8.5 minutes p = 0.018), K times (1.6
minutes versus 3.3 minutes p = 0.0004), and significantly
higher angles (67° versus 52° p = 0.0005), MA (68 mm versus 62 mm p = 0.019), and G (10.7 versus 8.05 dynes/cm2
p = 0.04) when compared to mice who received a sham
operation and blood transfusions. TEG value interpretation shown (Table 1); R times demonstrate that mice with
metastatic colon cancer form clot significantly faster than
mice without cancer (Figure 1). Surprisingly, blood product
transfusion did not affect hypercoagulabilty.
CONCLUSIONS: Patients had increasingly, more realistic
expectations for surgery’s role and ideal weight. Preoperatively, accurate patient expectation of surgical weight loss
resulted in better observed post-op weight loss. Patient
motivation may be a prime factor for weight loss and
should be harnessed for improved outcomes.
154
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
MATERIALS AND METHODS: After obtaining approval
from our Animal Ethics Committee, ten pigs were anesthetized using a standard protocol. A midline laparotomy
was performed and the terminal ileum identified. Subsequently the intestine was completely sectioned 30 cm
proximal to the ileocecal valve. All hand-sewn end-to-end
anastomoses were performed by the same surgeon, using
interrupted absorbable (3-0 polyglactine 910) sutures and
leaving an orifice of 18French in the suture line (as shown
in Figure 1). Animal were randomized to the application of
a synthetic sealant (polyethylene glycol, group I) or fibrin
sealant (group II) on the defect and the suture line. Animal
were postoperatively followed for 7 days and prematurely
sacrificed if sepsis developed. Otherwise, they underwent
a second surgery for revision and the anastomosis was isolated and removed for subsequent histological examination. Fischer’s and Student’s t test was used for statistical
analysis. P < 0.05 was considered significant.
Table 1: TEG Value Interpretation
Value Meaning
Decrease
Indicates
Increase
Indicates
R
Clotting Time, i.e. time
(minutes) until the first
detectable levels of fibrin
clot formation. Generally
reflects coagulation factor
levels
Hypercoagulable
Hypocoagulable
Factor deficiency,
anticoagulant,
hypofibrinoginemia
K
Clot Kinetics. Measures the Hypercoagulable
speed to reach clot strength
of 20 mm amplitude. Looks
at intrinsic clotting factors,
fibrinogen, platelet function
Hypocoagulable
Angle Clot strengthening, rapidity Hypocoagulable
Hypercoagulable
of fibrin-buildup and clot
Hypofibrinogenemia
formation, angle of tracing or thrombocytopenia
from r to K value.
MA, G Overall Clot strength,
represents maximum
dynamics of fibrin and
platelet bonding
Hypocoagulable
Hypercoagulable
Figure 1
RESULTS: Preoperative data was comparable between
groups, with no statistical difference.
Figure 1: * p = 0.05% p = 0.003 # p = 0.02
Mo2072
Reinforcing the High Risk Intestinal Anastomosis:
Experimental Pilot Study
Jana Dziaková*1,2, Iris Sanchez Egido1,2, Diego Sierra Barbosa1,2,
Julio Mayol1,2
1. Servicio de Cirugia I, Hospital Clinico San Carlos, Madrid, Spain;
2. Universidad Complutense, Madrid, Spain
INTRODUCTION: Anastomotic leakage is one of the
causes of increased morbidity and mortality in gastrointestinal and colorectal surgery and it is also associated with
elevated costs. The aim of this study was to investigate the
effect of synthetic hydrogel sealant and a fibrin sealant on
incompetent anastomosis in animal experimental model.
DISCUSSION: We present a preliminary study describing a
new model of incompetent anastomosis in a large animal,
designed to study the effect of sealants and glues on intestinal healing. Our findings show that this is a viable model
and that both synthetic and fibrin sealant may be useful in
reinforcing incompetent anastomoses. Further studies are
needed to understand the role of these products in the prevention of anastomotic leaks.
155
Monday
Poster Abstracts
CONCLUSION: TEG is able to delineate hypercoagulabilty
associated with metastatic colon cancer in an immunocompetent murine model. Receipt of packed red blood cell
product did not affect hypercoaguability in this model. As
thrombotic events are morbid and potentially mortal, additional investigation of this modality in perioperative management of cancer patients appears warranted.
No septic complications developed in any of the study
subjects. Only one animal presented a contained wound
dehiscence. On the second surgery, macroscopic findings
showed no difference between the 2 groups: There was no
evidence of diffuse purulent peritonitis or bowel obstruction. One contained anastomotic leak was found in each
group (1/5 vs. 1/5, NS). Adhesions between intestinal loops
were found 4 animals: 2 in group I and 2 in group II (2/5
vs. 2/5, NS). An inflammatory mass, containing the leak
appeared in 1 case (0/5 vs. 1/5, NS). Microscopically, the
local inflammatory response, with granulation tissue and
local peritonitis was similar in both groups. Continuity of
the mucosal layer was observed in 4 of 10 samples, similar
in both groups (2/5 vs. 2/5, NS). Epithelial inclusions in the
anastomotic line was found in 1 case in group I and in 3
cases in group II (1/5 vs. 3/5, p = 0,26).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Translational Science: Esophageal
adverse consequences, hence appropriate training is essential for the safe adoption of this procedure. The objective of
this study was to compare swine and fresh human cadavers
(FHC) as training models for POEM.
Mo2073
Impact of Blood Biomarker of Neoadjuvant Treated
Patients with Esophageal Carcinoma
Peter P. Grimminger*1, Juliane Bergenthal1, Hakan Alakus1,
Martin K. Maus1, Till Herbold1, Elfriede Bollschweiler1,
Ralf Metzger1, Arnulf H. HöLscher1, Jan Brabender2
1. Department of General-, Visceral- and Tumor Surgery, University
Clinic Cologne, Cologne, Germany; 2. General- and Visceral Surgery,
St. Antonius Hospital, Cologne, Germany
The prognostic value of ERCC-1 (excision repair cross Complementing genes), TS (thymidylate synthase) and DPD
(dihydropyrimidine dehydrogenase) RNA expression in the
blood of patients with esophageal cancer is not known. The
aim of this study was to evaluate the significance of these
molecular alterations in the blood as a prognostic marker
for patients with neoadjuvant treated esophageal cancer.
A total of 29 patients with locally advanced esophageal
cancer (cT3-T4, Nx, M0) were enrolled in this prospective
study. All patients received neoadjuvant radio-chemotherapy followed by a transthoracic resection (curative transthoracic en bloc esophagectomy, RO). Peripheral blood
samples were drawn before initiation of therapy. The analysis was performed using quantitative real-time RT-PCR
(TaqMan ©). The histomorphological regressionsgrading
after neoadjuvant therapy was defined as follows: major
response (MaR) = less than 10% vital tumor tissue, minor
response (MiR) = more than 10% vital tumor tissue.
19 out of 29 patients (65.5%) had a MiR and 10 (34.5%)
had a MaR. The median survival of patients was 2.08 years
(0.15–4.53). Among the tested genes, the RNA expression of
TS was significantly associated with prognosis of patients.
Patients with TS expression above 0.78 had a median survival of 1.1 years (0.21 -3.16) compared to 3.36 years (0.15
to 4.53) in patients with TS expression lower than 0.78 (p =
0.031, log rank test). There was no association between
clinical variables (eg, tumor stage, gender, age, etc.) and the
RNA expression of TS in the serum.
The RNA expression of TS in the blood is a potential prognostic marker in patients with neoadjuvant treated esophageal cancer. The significance of these molecular alterations
as non-invasive prognostic marker for esophageal cancer
should be evaluated in prospective studies.
Mo2074
Training for Per-Oral Endoscopic Myotomy (POEM):
Cadavers or Swine?
METHODS: Healthy Yorkshire male pigs (40–46 kg) were
used for POEM training. Procedures were also performed in
male and female FHC during the same time period. A standardized procedure was used in both models. Following submucosal injection of methylene blue dye to mark the distal
extent of the dissection, a mucosotomy was made in the
mid-esohagus. The endoscope was then inserted into the
mucosotomy and a submucosal tunnel bluntly dissected.
Endoscopic myotomy of the circular muscle layer from
the mid-esophagus to the gastroesophageal junction was
performed using a triangular tip knife. The mucosotomy
was subsequently closed with endoscopic clips. Following POEM in swine, the animals were sacrificed and necropsy performed to assess for organ injury and myotomy
adequacy. In FHC, thoracoscopic and laparoscopic evaluation was performed to assess for pleural violation,organ
injury and myotomy adequacy. Adequacy of myotomy was
determined by endoscopic transillumination at distal most
myotomy site.
RESULTS: POEM was performed in 7 acute swine and 6
FHC. In swine, POEM was successfully completed in 5 animals (72%). Two animals (29%) expired during the procedure from cardiopulmonary collapse. In the remaining 5
animals, POEM was uncomplicated with no evidence of
complication on necropsy. The average procedure time was
90 minutes (range70–120 minutes). The primary limitation of the swine model related to the attenuated circular
muscle of the porcine esophagus which made myotomy
technically difficult and pleural violation a frequent complication. No problems closing the myotomy were encountered. In contrast, POEM was successfully performed in all
FHC. The average procedure time was 85 minutes (70–120
minutes). Pleural violation was noted in one cadaver. In
4 cadavers, the mucosotomy was inadvertently extended
during creation of the submucosal tunnel. The technical
limitations of the cadaver model were difficulties with the
mucosotomy and submucosal tunnel dissection due to
decreased tissue pliability and poor tissue distension.
CONCLUSION: Although cadavers are more anatomically relevant as a training model for POEM, creation of
the mucosotomy and submucosal tunnel is limited by poor
tissue pliability. Conversely, mucosotomy and submucosal
tunnel dissection is more easily achieved in an acute swine
model, but the myotomy limited by attenuated circular
muscle. A hybrid teaching paradigm using both porcine
and human cadaver model may be necessary for comprehensive POEM training.
Dana A. Telem*1, Ozanan R. Meireles1, Denise W. Gee1,
Patricia Sylla1, William R. Brugge2, David W. Rattner1
1. Surgery, Massachusetts General Hospital, Boston, MA; 2.
Gastroenterology, Massachusetts General Hospital, Boston, MA
BACKGROUND: POEM is a promising totally endoscopic
method for treating achalasia. Esophageal perforation
and incomplete myotomy are technical errors with severe
156
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Translational Science: Hepatic
Mo2075
Triptolide Demonstrates Novel Chemotherapeutic
Potential as Single-Agent or Combination Therapy
with Sorafenib for Treatment of Hepatocellular
Carcinoma
Tara C. Krosch*, Veena Sangwan, Sulagna Banerjee, Ashok Saluja,
Eric H. Jensen, Selwyn M. Vickers
Department of Surgery, University of Minnesota, Minneapolis, MN
BACKGROUND: Hepatocellular carcinoma (HCC) is the
most common malignant primary liver tumor worldwide.
Systemic treatment in advanced disease has been limited to
sorafenib, a broad spectrum tyrosine kinase inhibitor, with
many adverse side effects and suboptimal outcomes. Our
lab has investigated triptolide, a diterpene triepoxide, as a
potential chemotherapeutic option. This study evaluates
the response of HuH-7 and Hep3B HCC cells to triptolide,
with or without combination therapy with sorafenib.
METHODS: HuH-7 and Hep3B HCC cell lines were treated
in vitro with triptolide and/or sorafenib at varying concentrations. Cell viability (MTT assay), caspase activation
(Promega), and Annexin V positivity (Guava Nexin) were
then assessed. Real-time PCR was utilized to determine the
changes in mRNA levels, and Western blots were used for
evaluation of protein expression.
Cell death with both treatments resulted in increased caspase-3
activation and Annexin V positivity in both cell lines, confirming apoptosis. Evaluation of mRNA and protein levels in
response to triptolide showed significant downregulation of the
heat shock protein cascade, with levels of HSF-1 decreased in
both cell lines. Downstream expression of HSP70 and HSP27,
known upregulated proteins in metastatic HCC disease, were
also significantly decreased.
Figure 2: HuH-7 HCC cell viability to triptolide and sorafenib combination
therapy. HuH-7 HCC cells were treated with low doses of triptolide,
sorafenib or combined doses, and viabilty was assessed at 2h-hour
intervals. Notably, the combination of 100 nM triptolide and 0.625 uM
sorafenib was found to have increased efficacy in comparison to either
treatment alone. (N = 2-3, Bars = + SEM).
CONCLUSIONS: Treatment of advanced HCC is currently
limited to sorafenib therapy, with many adverse side effects
and suboptimal outcomes. We have shown that triptolide
treatment in vitro induces HCC cell death by apoptosis,
with decreased expression of proteins found to be normally
upregulated in metastatic disease. While triptolide therapy
alone results in significant cell death in Hep3B cells, combination therapy with sorafenib, both at low concentrations,
results in notably superior cell death to either treatment
alone in the more resistant HuH-7 cells. Our study suggests
triptolide may serve as a therapeutic option for advanced
HCC. Orthotopic mouse model studies are underway.
157
Monday
Poster Abstracts
RESULTS: Triptolide and sorafenib were equally effective
at reducing cell viability in Hep3B cells, at low concentrations (FIGURE 1). Within 72 hours of 25 nM triptolide treatment, 80% cell death was noted, and similar a reduction
in cell viability was seen with 2.5 uM sorafenib. Increased
concentrations of either drug achieved minimal increases
in cell death. In distinction to the Hep3B cell line, the
HuH-7 cells were more resistant to single agent treatment.
Sorafenib treatment (2.5 uM) resulted in 70% cell death at
72 hours, whereas triptolide (100 nM) resulted in 40% cell
death (Figure 1). Combination therapy was attempted in
this cell line. Notably, a significant reduction in cell viability was found using lower concentrations of each drug, in
comparison to either drug concentration alone, with less
than 20% cell viability at 72 hours (Figure 2).
Figure 1: Hep3B and HuH-7 HCC cell viability to triptolide and sorafenib.
Hep3B and HuH-7 HCC cells were treated in vitro with varying concentrations of
triptolide or sorafenib and viability was assessed at various time points. A
concentration of 2.5 uM sorafenib has been equated to a therapeutic plasma
concentration in treated patients, with 5 uM used as a supra-therapeutic and
likely toxic dose in this experiment. Hep3B HCC cells were susceptible to low
doses of triptolide or sorafenib, with significant cell death at 72 hours. HuH-7
cells were less susceptible to treatment. (N = 4, * = p<0.05, Bars = + SEM).
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Translational Science: Stomach
gastric cancer pts with non-response to chemotherapy were
performed. The Affymetrix assay was done by the guidelines provided by Affymetrix. For statistical evaluation a
pathway analysis approach using the KEGG BIOCARTA
REACTOM and AMBION database, including 1266 pathways, was performed.
Mo2076
SNP Array 6.0 Analysis in Advanced Gastric Cancer
Patients Treated with 5-FU and Platinum or Irinotecan
Based Chemoradiation
Peter P. Grimminger*1, Martin K. Maus1, Frederick Schumacher2,
Ralf Metzger1, Jan Brabender3, Arnulf H. HöLscher1, Heinz-Joseph
Lenz2
1. Department of General-, Visceral- and Tumor surgery, University
Clinic Cologne, Cologne, Germany; 2. Division of Medical Oncology,
University of Southern California/Norris Comprehensive Cancer
Center, Los Angeles, CA; 3. General- and Visceral Surgery, St.
Antonius Hospital, Cologne, Germany
BACKGROUND: Biochemical pathway SNP’s as possible
molecular markers for response prediction in adjuvant chemotherapy in gastric cancer have already been reported.
In our study we performed a systematic Single Nucleotide Polymorphism genotyping analysis by Affymetrix
SNP 6.0 arrays that interrogates 906,600 single nucleotide
polymorphisms.
MATERIALS/METHODS: Affymetrix SNP Array 6.0 analysis of 16 gastric cancer pts with response to chemotherapy
(5FU + platinum or irinotecan and/or Radiation) and 30
RESULTS: Several hundred SNP were identified with a possible association with response to chemotherapy. However,
focusing on biochemical pathways with possible involvement in the efficiency of the chemotherapy treatment 6
pathways of the KEGG database were identified with an
association to response to adjuvant treatment. The six identified pathways were: KEGG Colorectal Cancer Pathway (p
= 0.0001, FDR = 0.343), Ambion Epithelial Tight Junctions
(p = 0.001, FDR = 0.357), Reactome Muscle Contraction (p
= 0.001, FDR = 0.331), KEGG Chronic Myeloid Leukemia (p
= 0.001, FDR = 0.463), Ambion Transcritptional Regulatory
Network in Embryonal Stem Cell (p = 0.006, FDR = 0.553 )
and Biocarta ALK Pathway (p = 0.004, FDR = 0.646).
CONCLUSION: The SNP’s of the six identified pathways
have a possible impact on response to 5-FU and platinum/
irinotecan based chemoradiation. Our future aim is to
identify the key SNP in the pathways which may play the
crucial role for treatment response. Future SNP array studies are in process to validate the identified pathways and
also the single involved SNPs.
Tuesday, May 22, 2012
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
Halls C-G
POSTER SESSION I
(NON-CME)
Basic: Colon-Rectal
of action of these receptors remains unclear. We studied the
role of 5-HT3 and 5-HT4 receptors in colonic transit and
peristalsis in guinea pigs in vivo and in vitro.
Tu2052
5-HT3 and 5-HT4 Receptors Promote Colonic Peristalsis
via Different Mechanisms in Guinea Pigs
Irena Gribovskaja-Rupp*, Jung-Myun Kwak, Toku Takahashi, Kirk
A. Ludwig
Surgery, Medical College of Wisconsin, Milwaukee, WI
BACKGROUND: Pelvic surgery may damage extrinsic
nerves, resulting in colonic dysmotility and constipation.
Adaptation restores motility after extrinsic denervation.
We showed that intrinsic 5-HT3 and 5-HT4 receptors are
upregulated to compensate for the loss of extrinsic 5-HT3
receptors after parasympathetic denervation in rats (J Surg
Res. 2011, 171:510–516). However, the specific mechanism
METHODS: For in vivo colonic transit study, 51Cr was
infused into the proximal colon after saline, ondansetron
(a 5-HT3 receptor antagonist; 1 mg/kg), or GR 125487 (a
5-HT4 receptor antagonist; 1 mg/kg) injection. Three hours
later, geometric center (GC) of the 51Cr distribution in
the entire colon was calculated. For in vitro studies, distal
colonic segments were laid flat in an organ bath with KrebsHenseleit buffer. Oral ends of segments were connected to
an infusion syringe, and anal ends to a pressure transducer.
Pressure changes in response to luminal infusion (0.2 ml)
were recorded in the presence of ondansetron (3 × 10–6 M)
or GR 125487 (3 × 10–6 M). In another setting, oral and anal
ends were opened and the peristaltic reflex in response to
pellet insertion or luminal balloon inflation was studied.
158
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
reduced oral contractions and increased anal contractions.
As a result, the ratio of anal/oral contractions was increased
to 1.4 ± 0.2 by GR 125487, compared to controls (0.6 ± 0.1;
n = 9, p < 0.01). Similarly, L-NAME (a nitric oxide inhibitor,
10–4 M) significantly increased anal contractions (Figure 2).
CONCLUSION: Ondansetron impairs colonic transit by
lowering the magnitude of peristaltic contractions. GR
125487 impairs colonic transit by generating potent contractions on the anal side. Because L-NAME has a similar
effect with GR 125487, it is suggested that 5-HT4 receptors
stimulate nitric oxide release distally. In contrast, 5-HT3
receptors stimulate excitatory neurotransmission proximally. Our study offers new insight into the function of
5-HT3 and 5-HT4 receptors in regulating colonic peristalsis.
Tu2054
Figure 1: Luminal infusion-induced pressure increase in the presence of
ondansetron and GR 125487 of the guinea pig distal colon. Ondansetron
reduced, while GR 125487 increased motor responses to luminal
infusion (**p < 0.01, n = 4–7).
Tumor Growth Is Stimulated After Sham Laparotomy
and Is Associated with Enhanced Tumor Angiogenesis
and Elevated Serum PDG-BB Levels in Mice
Xiaohong Yan*, Joon Ho Jang, Daniel D. Kirchoff, Sonali A.
Herath, Linda Njoh, C.M. Shantha Kumara H, Samer Naffouje,
Richard L. Whelan
St. Luke’s Roosevelt Hospital, New York, NY
INTRODUCTION: Surgical trauma-related increased rates
of metastasis formation and tumor growth have been noted
in murine models. In humans, major abdominal surgery
has been associated with persistent proangiogenic plasma
protein changes and postoperative plasma been shown to
promote Endothelial cell (EC) proliferation, migration, and
invasion. The current murine study was done to determine:
1) if tumor angiogenesis and growth was increased after
sham laparotomy (SL) vs. anesthesia alone (control, AC)
and 2) to assess postoperative (postop) serum levels of four
proangiogenic proteins.
Figure 2: Magnitude of oral and anal contractions in response
to balloon distention of the guinea pig distal colon. Ondansetron
significantly reduced both anal and oral contractions. In contrast, GR
125487 or L-NAME significantly decreased the magnitude of oral
contraction and increased anal contractions, compared to controls (*p <
0.05, **p < 0.01, n = 4–7).
RESULTS: The median tumor volume of the SL group
(625.9 mm3) was significantly larger than the AC group
result (510.2 mm3, p = 0.01). Also, the SL group’s median
tumor mass (0.55g) was greater than that of the AC group
(0.35g, p = 0.04). Lastly, a higher microvessel density was
found in the SL group tumors (8.5/field) than in the AC
group (6.7/field, p = 0.001). Elevated serum PDGF-BB levels
were observed in the SL group on POD5 (SL, median level
15.40 ng/ml, vs AC, 8.90 ng/ml, p = 0.002) and POD7 (SL,
median 10.85 ng/ml, vs AC, 7.59 ng/ml, p = 0.02).
159
Tuesday
Poster Abstracts
RESULTS: Colonic transit was impaired by ondansetron
(GC = 4.5 ± 0.3, n = 6, p < 0.01) and GR 125487 (GC = 5.3 ±
0.3, n = 7, p < 0.01) compared to controls (GC = 6.8 ± 0.3, n
= 10). Ondansetron reduced intraluminal pressure increase
by 40 ± 9% (n = 4, p < 0.01), whereas GR 125487 increased
it by 76 ± 28% (n = 7, p < 0.01) (Figure 1). Pellet transit
time was 46 ± 9 sec (n = 5) in controls, which was completely abolished by ondansetron (n = 4) and prolonged by
GR 125487 to 137 ± 41 sec (n = 8, p < 0.05). In response to
balloon distention, contractions observed at the anal side
were smaller than those at the oral side (n = 8). Ondansetron reduced the magnitude of oral and anal contractions
in response to balloon distention. In contrast, GR 125487
METHODS: Fifty BALB/cJ mice were subcutaneously inoculated with syngeneic CT26 colon adenocarcinoma cells
on Day 1. On Day-15 the mice were randomized into 2
groups (n = 25/group), one underwent SL and the other
anesthesia alone (AC). Tumor Study: On Day-29 the mice
were sacrificed and the tumors excised, measured, and
weighed. The tumor microvessel density was determined
via IHC CD34 staining. Serum Study: Blood samples were
taken and serum harvested from a second group of mice
that underwent SL or anesthesia alone (total n = 84). The
sampling points were: preoperative (Preop), POD1, 3, 5, 7,
10, and 14. Serum levels of FGF, VEGF, sVCAM and PDGFBB were determined via ELISA.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSION: Tumor growth was increased after SL as
was tumor angiogenesis and serum PDGF-BB levels. These
results support the hypothesis that increased tumor growth
after SL may, at least in part, be due to proangiogenic plasma
protein alterations that promote tumor angiogenesis.
Basic: Esophageal
CONCLUSION: Chromosal aberration patterns in lymph
node metastases and disseminated tumor cells of patients
with esophageal cancer undergoing multimodality therapy are very similar while primary tumors show a different genomic aberration pattern. These individual genetic
tumor characteristics might guide future multimodality
treatment options in esophageal cancer.
Basic: Hepatic
Tu2055
Evaluation of Chromosal Aberrations in the Primary
Tumor, Lymph Node Metastases and Disseminated
Tumor Cells of Patients with Esophageal Cancer:
Implications for Anti-Tumoral Therapy?
Tu2056
Sevofluorane Reduces Liver Damage Secondary to
Ischemic/Reperfusion Injury by a Mechanism Not
Related to a Preconditioning Effect
Daniel Vallbohmer*1, Sarah Schumacher1, Stephan E. Baldus2,
Christian Vay1, Andreas Krieg1, Jan Schulte Am Esch1,
Wolfram T. Knoefel1, Nikolas H. Stoecklein1
1. Department of General, Visceral and Paediatric Surgery, University
of Dusseldorf, Dusseldorf, Germany; 2. Department of Pathology,
University of Dusseldorf, Dusseldorf, Germany
Fernanda P. Cavalcante, ANA Maria M. Coelho*, Marcel C.
Machado, Sandra N. Sampietre, Nilza A. Molan, Eleazar Chaib,
Luiz C. D’Albuquerque
Gastroenterology, University of São Paulo, São Paulo, Brazil
INTRODUCTION: Recent analyses uncovered genetic
variations between paired samples from primary gastrointestinal tumors, lymph node metastases and disseminated
tumor cells (DTCs). These findings might help to explain
individually variable responses to standard (neo-)adjuvant
therapies and further suggest that multimodality treatment
options in gastrointestinal cancer should be guided by
these individual genetic tumor characteristics. Therefore,
we assessed the genetic variations in the primary tumor,
lymph node metastases and DTCs of patients with esophageal cancer.
PATIENTS AND METHODS: In this translational analysis 86 patients with esophageal cancer undergoing multimodality therapy were included. Initially, we established
a protocol for double immunofluorescence labeling for
simultaneous visualization of epithelial cell adhesion molecule (EpCAM) expression on cytokeratin positive cells for
the detection of DTCs in bone marrow and lymph nodes.
After isolation of positively stained cells, their genomic
DNA was globally amplified using the MSE-adapter PCR
method. Finally, we applied comparative genomic hybridization (CGH) for the genome-wide screening of DNAgains/-losses on paired samples from primary tumors,
lymph node metastases and DTCs of the study patients.
RESULTS: DTCs were detected in 25% of the bone marrow and 38% of the lymph node samples. Interestingly,
CGH analysis revealed differences between the numbers of
chromosal aberrations in DTCs of the bone marrow compared to the lymph node samples with a higher frequency
of aberrations in DTCs in the lymph node samples. In addition, genomic analysis revealed differences in the nature
of chromosomal aberrations between primary tumors and
corresponding lymph node metastases. Moreover, cluster
analysis demonstrated similarities of the aberration spectrum between the DTCs and lymph node metastases while
primary tumors showed distinct profiles.
BACKGROUND/AIM: Previous studies have demonstrated
that sevoflurane protects liver from ischemia/reperfusion
(I/R) injury however it was not shown yet if this protection is by preconditioning or if it depends on a continuous administration of the anesthetic during the whole I/R
period. In the present study we evaluated the mechanism
of the protective effect of sevoflurane in ischemia/reperfusion injury
METHODS: Wistar male rats underwent partial liver ischemia performed by clamping the pedicle from medium
and left anterior lateral segments. Liver pedicle clamp was
removed after 1 hour of partial ischemia. Anesthesia was
induced with cetamine and xylazine and rats were intubated and mechanical ventilated. Rats were divided in 3
groups: Group1-Sevo Continued (n = 15): sevoflurane was
administered during the whole I/R injury time and animals remained intubated during the whole I/R time, Group
2-Sevo 30 minutes (n = 15): sevoflurane was administered
during 30 minutes and discontinued before liver ischemia,
and Group-3 Control (n = 15): animals was submitted to
I/R and no sevoflurane was administrated. Just as group
2, rats were extubated after reperfusion. Four hours after
reperfusion blood was collected for determinations of AST,
ALT. Liver tissues were assembled mitochondrial oxidation
and phosphorylation and malondialdehyde (MDA) content. Pulmonary vascular permeability and myeloperoxidade (MPO) were also determined.
RESULTS: Four hours after reperfusion Sevo Continued
group presented elevation of AST and ALT serum levels significantly lower than Sevo 30 minutes and Control groups
(p < 0.05). A significant reduction on liver mitochondrial
dysfunction and pulmonary vascular permeability was
observed in Sevo Continued group compared to Sevo 30
minutes and Control groups (p < 0.05). No differences in
liver MDA and pulmonary MPO activity were observed
CONCLUSION: Sevoflurane attenuates liver ischemia/
reperfusion injury probably by a mechanism not related to
a by preconditioning effect.
160
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Basic: Pancreas
Tu2058
Tu2057
LRP6 Overexpression as a Potential Marker of Early
Stage Tumor Progression in Pancreatic Ductal
Adenocarcinoma
Anti-Inflammatory Effects of Hypertonic Saline
Solution in Pancreatic Ischemia/Reperfusion Injuries
Renato S. Godoy*, ANA Maria M. Coelho, Sandra N. Sampietre,
Nilza A. Molan, Oscar M. Takayanagi, Marcel C. Machado, José
Jukemura, Luiz C. D’Albuquerque
Gastroenterology, University of São Paulo, São Paulo, Brazil
BACKGROUND/AIM: Injury caused by ischemia/reperfusion (I/R) may result in pancreatic graft loss in pancreas
transplants. Therapeutics strategies to reduce pancreatic I/R
injury are extremely important to improve the outcomes
of clinical transplantation. We have previously demonstrated that hypertonic saline 7.5% had anti-inflammatory
response in acute pancreatitis and liver ischemia/reperfusion models. The aim of this study was to evaluate the
effects of hypertonic saline solution 7.5% in I/R pancreatic.
METHODS: Pancreatic ischemia was performed in Wistar
rats during one hour by clamping the splenic vessels under
mechanical ventilation. The vascular clamp was removed
1 hour after ischemia and pancreatic revascularization was
achieved, followed by 4h or 24h of reperfusion. The animals divided into 3 groups: Group NT (n = 20): subjected to
pancreatic I/R without treatment; Group NS (n = 20): subjected to I/R and treated with normal saline solution (NaCl
0.9%), 15 minutes before reperfusion; Group HTS (n = 20):
subjected to I/R pancreatic and treated with hypertonic
saline solution (NaCl 7.5%), 15 minutes before reperfusion.
Four and twenty four hours after reperfusion blood were
collected for determinations of amylase, TNF-α, IL-6, and
IL-10, creatinine, urea. Pancreatic malondialdehyde (MDA)
content was also performed. After 24hours of reperfusion
pulmonary tissues were assembled for myeloperoxidade
(MPO) analyses.
RESULTS: There was a decrease of inflammatory cytokines in the Group HTS compared with control, NT and NS
groups. It was observed a significant decrease in serum urea
and creatinine in the animals treated with normal (NS) and
hypertonic saline (HTS) compared to not treated animals
(NT). The serum amylase levels and the determination of
pancreatic MDA showed no significant differences between
groups with I/R.
CONCLUSIONS: Hypertonic saline solution decreases the
systemic inflammatory response by cytokines reduction
(TNF-α, IL-6, and IL-10)in pancreatic I/R injury. Further
studies will be necessary to prove the clinical benefits in
patients subject to pancreatic transplantation.
Nicolas Zea1,3, William C. Conway1, John S. Bolton1,
Nancy K. Davis6, Cruz Velasco5, Paul B. Fossier4,
Jovanny Zabaleta*2,3
1. General Surgery, Ochsner Clinic Foundation, New Orleans, LA;
2. Pediatrics, LSU Health Sciences Center, New Orleans, LA;
3. Stanley S. Scott Cancer Center, LSU Health Sciences Center, New
Orleans, LA; 4. School of Medicine, LSU Health Sciences Center, New
Orleans, LA; 5. School of Public Health, LSU Health Sciences Center,
New Orleans, LA; 6. Anatomic Pathology, Ochsner Clinic Foundation,
New Orleans, LA
INTRODUCTION: The Wnt-β-Catenin signaling pathway,
in particular the canonical pathway, has been implicated in
pancreatic ductal adenocarcinoma (PDAC) development.
Since mutations in the key intracellular components of
this pathway are rare in PDAC, understanding the molecular mechanisms by which the signaling pathway is aberrantly activated, and how it influences tumor behavior, is
of utmost importance. In this study, we hypothesized that
over-expression of components upstream of the signaling
pathway, in particular the Wnt signaling co-receptor LRP6,
are involved in PDAC tumorigenesis.
METHODS: Twelve lymph node negative (LN–) and twelve
lymph node positive (LN+) paraffin embedded tumor tissues were randomly selected to perform screening gene
identification via gene chip microarray analysis. Once
genes of interest were identified by fold-change, 61 tumor
samples were obtained and then subcategorized in terms of
lymph node status, survival time, and grade of differentiation and used to validate the results using real-time PCR
(RT-PCR).
RESULTS: 20,817 genes were investigated with the microarray analysis. Using gene chip microarray software, we
removed the background and used scatter graphs to select
those genes with at least 2-fold difference (up or down)
between LN– and LN+. Further selection by p value (p <
0.05) identified 957 genes significantly different between
the two groups. The LRP6 gene expression showed a 2.46fold increase in the LN– when compared to LN+ samples
(1192.9 vs 485). RT-PCR for LRP6 in LN– (n = 29) and LN+
(n = 32) confirmed results of the microarray (p-value =
0.00044). In addition, LRP6 showed a trend of over-expression towards tumors of lower grades of differentiation
(Table). In terms of survival time, no statistical significance
was found between LN– and LN+.
Tuesday
Poster Abstracts
161
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSIONS: The Wnt signaling co-receptor LRP6 is one
of the most upstream genes involved in the Wnt-β-Catenin
signaling pathway. Our data shows that LRP6 is significantly
over-expressed in patients with negative nodal status, as well
as portraying a tendency of over-expression in lower differentiation grades of pancreatic tumor. Our results reflect an overexpression of LRP6 early in the series of tumorigenesis events
and depict the importance of further studies to understand its
relationship to tumor behavior and prognosis.
Difference within Tumor Samples Regarding Grade of Differentiation
Gene
N Samples
Grade
Average Fold Induction
LRP6
6
na
2.24
1
undifferentiated
2.28
15
poor
2.08
27
moderate
2.45
12
well
3.41
by 55% (4.8 ± 0.16 vs 2.2 ± 0.19; p < 0.05) and 56% (5.0 ±
0.0 vs 2.2 ± 0.2; p < 0.05), respectively compared to WT+S.
CONCLUSIONS: These data suggest that the NK-1R mediates leukocyte migration into the peritoneum indicating a
new role for the NK-1RA in adhesiogenesis.
Tu2060
Sphingosine-1-Phosphate Prevents LPS-Induced Loss
of Permeability in Intestinal Epithelial Cells
Ruiyun LI*1,2, Alexis D. Smith1,2, Ping Jiang1,2, Lan Liu1,2,
Jiang-Yang Wang1,2, Jaladanki N. Rao1,2, Douglas J. Turner1,2
1. University of Maryland, Baltimore, MD; 2. Baltimore VAMC,
Baltimore, MD
Intestinal epithelial barrier dysfunction results from a wide
variety of pathologic conditions; at the gastrointestinal
mucosal layer cells must be capable of maintaining barrier integrity, and do this through the interplay of multiple
active processes. Previous reports from our lab have shown
that Sphingosine-1-phophate (S1P) promotes intestinal
epithelial barrier function in part through regulation of
barrier proteins, and S1P has also been found to be protective in various pathologic states. Lipopolysaccharide (LPS)
has been shown to increase paracellular permeability, and
recently, to also decrease intracellular S1P. In the current
study we hypothesized that S1P would decrease paracellular permeability upon LPS exposure, and would act in part
through regulation of caveolin-1 expression
Basic: Small Bowel
Tu2059
A Neurokinin-1 Receptor (NK1R) Antagonist (NK-1RA)
That Reduces Postoperative Adhesions Reduces the
Adhesion Related Chemokines CXCL1(KC) and CXCL2
(MIP-2) and Their Receptor, CXCR2
Hisashi Kosaka*, Michael R. Cassidy, Arthur F. Stucchi,
James M. Becker
surgery, Boston University School of Medicine, Boston, MA
INTRODUCTION: Postoperative adhesions occur in 90–100%
of patients after abdominopelvic surgery. We previously
showed that adhesiogenesis is associated with leukocyte
migration into the peritoneum and that the NK1R plays an
important role in adhesiogenesis. The aim of this study was
to characterize the temporal changes and the effects of a
NK-1RA on the gene expression of the leukocyte chemoattractants CXCL1 and CXCL2 during adhesiogenesis.
METHODS: Adhesions were induced in mice using our
previously published cecal cauterization model. Wild-type
(WT) mice (n = 7/group) were administered saline (WT+S) or
a NK-1RA (WT+NK) (25 mg/kg) intraperitoneally at surgery.
At 0, 3, and 6-hrs post-operatively, cecal adhesion tissue was
measured for CXCL1, CXCL2 and CXCR2 mRNA levels by
real-time-PCR. Adhesions were measured on POD 7 (n =
7/group) in WT, WT+NK and CXCR2 knockout (KO) mice.
RESULTS: In WT+S mice, CXCL1 and CXCL2 mRNA levels
increased at 3-hrs post-operatively compared to non-operated controls (380.8 ± 143 vs 0.04 ± 0.08; p < 0.05; 198.3 ±
105 vs 0.07 ± 0.05; p < 0.05) while CXCR2 mRNA increased
at 6-hrs (16.5 ± 2.9 vs 0.17 ± 0.06; p < 0.05). Administration
of the NK-1RA significantly reduced mRNA levels of CXCL1
and CXCL2 3hrs post-operatively compared to controls
(380.8 ± 143 vs 89.9 ± 23.7; p < 0.05; 198.3 ± 105 vs 22.7 ±
6.2; p < 0.05) while CXCR2 mRNA levels were reduced by
64% (16.5 ± 2.8 vs 5.9 ± 1.6; p < 0.05) at 6hrs. Adhesion formation was reduced in both WT+NK and CXCR2 KO mice
IEC-Cdx2L1 (Cdx) differentiated intestinal epithelial
cells were utilized. Western blot analysis, real-time PCR,
immunohistochemical staining, were utilized by standard
techniques. Transwell permeability to C14-mannitol, FITCdextran, and measurement of transepithelial electrical resistance (TEER) were utilized for permeability assessments.
Sphingosine Kinase 1 (SphK-1) overexpression stable cell
lines were selected in rat intestinal epithelial cells (IECs).
SphK-1 activity and S1P production were measured by
radioactive isotope assay.
LPS-treated (50 mcM) Cdx cells show dramatically increased
permeability at 4h, but pretreatment with S1P (0.5 mcM
for one hour) was protective of this LPS-induced increase
in permeability, and returned permeability to normal levels. S1P also prevented LPS-associated decreases in phosphorylated occludin, and in immunofluorescence studies
S1P preserved cortical accumulation of occludin that was
disrupted with LPS administration alone. S1P was found
to increase levels of toll-like receptor (TLR) 2 in Cdx cells,
with no change in levels of TLR4. Similarly, cells stably
overexpressing SphK1 demonstrated increased levels of S1P
and also increased levels of TLR2 and not TLR4. Cells overexpressing SphK1 and S1P showed dramatically increased
plasma membrane levels of Stim1, TRPC1, and the scaffolding protein caveolin-1. Phosphorylated caveolin-1
was significantly decreased with exposure to LPS (5 mcM),
however co-treatment with S1P preserved basal caveolin-1
levels. Finally, inhibition of caveolin-1 with siRNA prevented S1P rescue of LPS loss of permeability.
Our findings demonstrate that S1P prevents LPS-associated
loss of permeability, and this is in part through its ability to
prevent LPS-associated loss of caveolin-1.
162
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu2061
Clinical: Biliary
Changes in Peptidergic Neurotransmission with VIP
and Substance P During Postoperative Ileus in Rat
Tu2044
Brigitte Goetz*, Petra Benhaqi, Martin E. Kreis, Michael S. Kasparek
Department of Surgery, Ludwig-Maximilians-University Munich,
Munich, Germany
Abdeen Elfateh2, Tariq Chundrigar2, Bilal O. AL-Jiffry*1,2
1. Surgery, Taif University, Taif, Saudi Arabia; 2. Surgery, AlHada
Military Hospital, Taif, Saudi Arabia
BACKGROUND: Common bile duct stones (CBDs) are the
most common cause of obstructive jaundice and cholangitis. This occurs in about 10% of patients with symptomatic
gallstone. This study aimed to find non-invasive preoperative tests for predicting CBDs to select patients for preoperative endoscopic retrograde cholangiopancreatography
(ERCP) before laparoscopic cholecystectomy (LC).
METHODS: We conducted a prospective preoperative
study on 896 patients with symptomatic gall stones who
underwent LC at Al Hada military Hospital, Taif, Saudi Arabia from April 2006 to April 2010. All patients were subjected
to clinical, laboratory (LFT) and ultrasound (US) examination. Patients with normal LFTs and US were referred to LC.
Patients with jaundice and US proven CBD abnormality
(stones, dilatation >7 mm or both) were referred for ERCP
for diagnosis confirmation and stone removal, followed by
LC. Patients with jaundice and normal US were referred to
magnetic resonance cholangiopancreatography (MRCP).
When MRCP detected CBDs, the patients were referred for
ERCP for confirmation and stone extraction followed by
LC. MRCP and ERCP negative cases were subjected to LC
with Intraoperative cholangiography (IOC).
RESULTS: There were 707/896 patients (78.5%) who had
LC without the need for preoperative ERCP or/and MRCP.
193/896 patients (21.5%) were diagnosed to have obstructive jaundice on clinical and laboratory bases. 102/193
(52.8%) had normal bile ducts by US, the other 91 (47.2%)
had CBD abnormalities on US. CBDs were found in 23/91
(25.3%), dilatated CBD in 28/91 (30.8%), and 40/91
(40.3%) had dilated CBD with stones. These 91 patients
were referred to ERCP. Stones were extracted in 20/23
(87%) who had CBDs, 24/28 (85.7%) with dilated CBD and
38/40 (95%) who had both. The 102 patients with normal
CBD on US were referred to MRCP, 70/102 (68.6%) were
normal by MRCP and were subjected to LC with IOC. CBDs
were detected in 2/70 (2.9%). 32/102 (31.4%) had stones by
MRCP and referred to ERCP which detected CBDs in 25/32
(78.2%). When CBD was abnormal, ERCP detected stones
in 82/91 patients (90%) and when normal ERCP detected
stones in 27/102 (26.5%). MRCP helped avoid un-necessary
ERCP in 68/102 (66.7%) with false negative results of 2/102
(1.96%) and false positive results of 7/102 (6.7%).
163
Tuesday
Poster Abstracts
BACKGROUND: Changes in peptidergic neurotransmission might participate in pathophysiology of postoperative ileus (POI), but have not been studied yet. We aimed
to explore changes in neurotransmission with Vasoactive
Intestinal Polypeptide (VIP; inhibitory) and Substance P
(Sub P; excitatory) during POI.
METHODS: Mucosa free, circular, jejunal muscle strips (n
= 8/rat) were studied in organ chambers. Six male Sprague
Dawley rats were studied per group: Naïve controls (NC),
rats 12h (P12h) and 3d (P3d) after laparotomy and standardized small bowel manipulation to induce POI, and
sham controls after 12h (SC12h) and 3d (SC3d) to study
combined effects of anesthesia and sham laparotomy.
Dose-responses to exogenous VIP (10–10–10–7M) and Sub P
(3 × 10–10–3 × 10–7M) were studied without and with L-NNA
(blocking nitric oxide (NO)-synthase; 10–4M) or L-NIL (selective blocker of inducible NO-synthase; 3 × 10–5M). Effects of
endogenously released neurotransmitters were studied during electrical field stimulation (EFS; 20V, 4ms, 3Hz) without
and with L-NNA, VIP antagonist ([D-p-Cl-Phe6,Leu17]-VIP;
10–6M), or Sub P antagonist ([D-Pro2,D-Trp7,9]-Sub P; 10–6M).
Studies were performed under non-adrenergic, non-cholinergic conditions (propranolol 5 × 10–7M, phentolamine
10–5M, atropine 10–7M). Intestinal transit was measured
by charcoal gavage ([%] small bowel passed by marker).
Histology for myeloperoxidase positive cells (MPO), macrophages, and mast cells was performed in whole mounts
(cells/mm2). Data: mean ± SEM.
RESULTS: VIP caused dose-dependent inhibition in all
groups (p < 0.05). Inhibition was more pronounced in
P12h, P3d, and SC3d (p < 0.05 vs NC). L-NNA reduced VIPinduced inhibition in NC and P12h (p < 0.05), while L-NIL
had no effect on VIP responses (p = NS). Sub P caused dosedependent excitation in all groups (p < 0.05), which was
reduced in P12h and increased in P3d (both p < 0.05 vs.
NC), while it was unaffected in sham controls (p = NS). EFS
induced inhibition was more pronounce in P12h (-67 ± 8%)
compared to NC (–33 ± 8; p < 0.05). VIP and Sub P antagonists had no effect on EFS responses (all p = NS), while
L-NNA prevented EFS-induced inhibition in all groups (all
p < 0.05). Intestinal transit was delayed in POI groups and
SC12h (P12h 27 ± 2; P3d 40 ± 3; SC12h 48 ± 2%; all p <
0.05 vs NC 60 ± 3%). MPO positive cells and mast cells were
increased in P12h and P3d, but not in sham controls (MPO:
NC 9 ± 2; P12h 551 ± 86; P3d 579 ± 45; mast cells: NC 21
± 3; P12h 694 ± 73; P3d 460 ± 10; all p < 0.05 vs NC) and
macrophages were increased only in P3d (NC 347 ± 7; P3d
1163 ± 31 p < 0.05 vs NC).
CONCLUSION: Induction of POI causes specific changes
in neurotransmission with VIP and Sub P that are accompanied by intramural inflammatory response and delayed
gastrointestinal transit. Therefore, changes in peptidergic
neurotransmission with VIP and Sub P appear to participate in pathophysiology of POI in rat. DFG KA2329/5–1
Non Invasive Pathway to Reduce Negative ERCP
in Patients Presented by Obstructive Jaundice with
Gallstones
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
CONCLUSION: We have documented a considerably
higher incidence of obstructive jaundice in our area, one
that makes this simple disease a community health issue.
Also, with the small number of MRCP machines most hospitals have a long waiting time facility. Our aim was to find
a simple pathway to get the cost-effective balance between
MRCP and ERCP. Therefore, patients with obstructive jaundice and abnormal CBD on US are considered of high risk
for CBDs and the use of MRCP is not justified. However, if
any of the tests were normal MRCP is indicated to decrease
the incidence of negative ERCP.
Tu2045
Prognostic Impact of Human Equilibrative Nucleoside
Transporter 1 Expression in Adjuvant GemcitabineBased Chemotherapy After Surgical Resection for
Cholangiocarcinoma
vant gemcitabine-based chemotherapy and those who did
not was observed among patients with high hENT1 expression (P = 0.002), but not among patients with low hENT1
expression (P = 0.525). Intratumoral hENT1 expression was
only an independent predictive factor for patients treated
with adjuvant gemcitabine-based chemotherapy by multivariate analysis (P = 0.027).
CONCLUSION: High intratumoral hENT1 expression
was associated with increased overall survival in patients
with cholangiocarcinoma who received adjuvant gemcitabine-based chemotherapy. Intratumoral hENT1
expression may be a potent predictive marker for cholangiocarcinoma patients treated with adjuvant gemcitabinebased chemotherapy.
Tu2046
Image Documentation and Textual Operative
Description of the Technique and the Findings of
Laparoscopic Intraoperative Cholangiography Are
Sub-Optimal
Hironori Kobayashi , Yoshiaki Murakami, Kenichiro Uemura,
Takeshi Sudo, Yasushi Hashimoto, Akira Nakashima, Naru
Kondo, Hiroki Ohge, Taijiro Sueda
Hiroshima Univ, Hiroshima, Japan
*
OBJECTIVE: Although the prognosis in patients with
biliary carcinoma remains poor, adjuvant gemcitabinebased chemotherapy after surgical resection for biliary carcinoma has been shown to improve survival. There have
been no reports concerning a useful predictive biomarker
in patients with cholangiocarcinoma treated with adjuvant gemcitabine chemotherapy. To clarify the relationship between expression of intratumoral enzymes related
to the metabolism of gemcitabine and its derivatives and
response to adjuvant chemotherapy with gemcitabine for
cholangiocarcinoma, we evaluated human equilibrative
nucleoside transporter 1 (hENT1) expression immunohistochemically in resected cholangiocarcinoma tissues.
METHODS: Polyclonal antibodies were used to immunostain sections of 105 formalin-fixed paraffin-embedded
specimens of cholangiocarcinoma resected between 1989
and 2010. The relationship between intratumoral hENT1
expression and prognosis was evaluated statistically. This
study was a retrospective analysis on retrospectively collected tissue and data.
RESULTS: Out of 105 patients, 51 (49%) received adjuvant
gemcitabine-based chemotherapy. High and low intratumoral hENT1 expression was present in 74 (70%) and 31
(30%) cases, respectively. There were no significant differences in clinicopathological factors between patients with
high hENT1 expression and those with low hENT1 expression. Survival of patients with high hENT1 expression was
significantly better than that of patients with low hENT1
expression among patients who received adjuvant gemcitabine-based chemotherapy (P = 0.008), but not among
patients who did not (P = 0.894). Moreover, a significant
difference in survival between patients who received adju-
Alex Karran*, Ashleigh Majoe, Ashraf M. Rasheed
Gwent Institute of Minimal Access surgery, Newport, United Kingdom
BACKGROUND: There is a wealth of data to dispute the
role of laparoscopic intra-operative cholangiography (IOC)
but there little published literature to describe the optimal
technique or to recommend a standardised reporting system. The operative report is a legal document that must
contain details of all interventions.
AIMS: This study aims to examine the details of the technique of IOC and to audit the quality of the captured
images and the content of operative notes in relation to
documentation of essential IOC anatomical landmarks
METHOD: A retrospective analysis of 100 consecutive
laparoscopic intra-operative cholangiograms that were
attempted at the Aneurin Bevan Health Board (ABHB)
between February 2009 and March 2010 was undertaken.
The visualisation of 7 essential anatomical landmarks on
captured IOC images and specific reference made to each in
the operation notes were assessed.
RESULTS: A significant inter-operator variability was
noted in the performance and the interpretation of IOC.
Only 34% of captured images identified all 7 recognised
essential IOC landmarks. The majority (63.8%) of operation notes failed to make reference to all 7 landmarks, with
a mean number of landmarks referred to as 1. There was a
significant difference (p < 0.001) between landmarks identified on the captured images and their documentation
within the operation notes.
CONCLUSIONS: This study confirms that laparoscopic
IOC is sub-optimally performed and poorly reported. It
highlights the need for standardisation of the IOC technique and systematisation of its reporting.
164
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu2047
Is Cholecystostomy a Safe Procedure in Patients with
Cirrhosis?
Rajiv Jayadevan*1, Malika Garg1, Thomas Schiano2,
Celia M. Divino1
1. Surgery, The Mount Sinai School of Medicine, New York, NY;
2. Division of Liver Disease, The Mount Sinai School of Medicine,
New York, NY
INTRODUCTION: Abdominal surgical intervention in
cirrhotic patients is correlated with high mortality due to
coagulopathy, bleeding, and sepsis from ascitic breach.1
Although percutaneous cholecystostomy has been advocated as a safer alternative to cholecystectomy in high-risk
critically ill patients with concurrent gallbladder disease,
no study has focused exclusively on the outcomes of cholecystostomy in patients with cirrhosis. As a result, it is
unknown whether the outcomes of cholecystostomy in
cirrhotics are as encouraging as those of their non-cirrhotic
counterparts. Physicians thus often face a predicament in
treating cirrhotic patients with gallbladder disease refractory to medical management. The purpose of this investigation was to determine whether cholecystostomy is a safe
and viable option in the treatment of gallbladder disease in
patients with cirrhosis.
RESULTS: No significant difference in gender, age, race,
ASA score, LFTs, duration of tube placement, gallbladder
disease, ultrasound findings or CT findings was found
between cirrhotic and non-cirrhotic patients. Cirrhotic
patients were found to be more likely to have HCV (p =
0.001), ascites (p = 0 .004), jaundice (p = 0.045), and
encephalopathy (p = 0.012). While cirrhotic patients had
a significantly greater amount of post-operative complications (p < 0.001), e.g. bleeding (p = 0 .041), no significant
difference was found in post-operative survival between
cirrhotic and non-cirrhotic patients.
METHODS: A retrospective chart review was performed
which identified 16 cirrhotic and 49 non-cirrhotic patients
treated with cholecystostomy tubes between 2000 and
2011. Information investigated included demographics,
common comorbidities, markers of disease severity (relevant labs and ASA scores), type of gallbladder and liver
disease, post-operative complications, and post-operative
survival time. Differences in survival time was assessed
with Kaplan-Meier survival analysis. Qualitative and quantitative variables were compared with Chi-square and two
independent sample t-tests respectively.
REFERENCE:
CONCLUSION: Although cirrhotic patients have a greater
number of complications than their non-cirrhotic counterparts after cholecystostomy, there is no significant difference in survival between the two types of patient. Cirrhosis
does not appear to be a contraindication to performing
cholecystostomy, which is an appropriate temporizing procedure for cirrhotic patients with gallbladder disease.
1. Mansour A, Watson W, Shayani V, Pickleman J. Abdominal operations in patients with cirrhosis: still a major
surgical challenge. Surgery. 1997;122 (4):730–735; discussion 735–736.
Tuesday
Poster Abstracts
165
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu2048
clarify the anatomy in Calot’s triangle. Planned IOC was
performed in 58 cases (8.1%): 34 for gallstone pancreatitis,
10 for choledocolithiasis, 9 for biliary colic, 3 for cholangitis, and 1 for primary biliary sclerosis.
Dome-Down Dissection Is a Safe and Practical Primary
Approach to Laparoscopic Cholecystectomy: Results of
a Ten Year Experience
Dylan Nieman*1, Neil Ghushe2, Jacob Moalem1,
Marabel D. Schneider1, Kendra Klein1, D. Owen Young1,
Brandon Stein1, Luke O. Schoeniger1
1. Department of Surgery, University of Rochester, Rochester, NY;
2. Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
PURPOSE: To audit our experience with a dome down
technique for laparoscopic cholecystectomy (DDLC) regarding clinical outcomes, safety, and demonstration of the critical view of safety (CVS).
METHODS: We reviewed a prospectively collected data
set of all patients who underwent cholecystectomy (CCY)
from 2000 through 2010 by a single surgeon. All patients
were planned for primary DDLC and transection of the cystic artery with a Harmonic Scalpel. Electronic records were
queried for additional data.
CONCLUSIONS: This 10 year, single-operator experience
demonstrates that DDLC is a safe and practical approach
to CCY in a diverse group of patients and can be used as
a primary approach to laparoscopic cholecystectomy (LC)
with a low complication rate. We hypothesize that because
this approach requires circumferential visualization of the
contents of Calot’s triangle, the CVS is readily identified
in all cases. Improved visualization enhances the safety of
this approach and has caused some to advocate DDLC as a
way to avoid conversion to open CCY in patients with “difficult gallbladders”. We posit that the high rate of bile duct
injuries associated with the dawn of laparoscopy, may have
been a byproduct of the shift from dome-down to bottomup infundibular dissection rather than the shift from open
to laparoscopic techniques, per se. While we acknowledge
that experienced surgeons should continue to use techniques with which they have experienced success, we propose a greater role for DDLC as an initial approach to LC
in surgical training, to demonstrate the CVS and to allow
a safe laparoscopic cholecystectomy in all circumstances.
Tu2049
Use the Duodenum, It’s Already There: A Retrospective
Cohort Study Comparing Biliary Reconstruction to the
Either the Jejunum or Duodenum
John B. Rose*, John A. Ryan, Thomas R. Biehl
General Surgery, Virginia Mason Medical Center, Seattle, WA
BACKGROUND: Surgical reconstruction of the biliary system is required for a variety of reasons. Roux-en-Y jejunal
anastomoses (RJA) are the current gold standard for repair.
Direct duodenal anastomoses (DDA) are a less common
approach, however it has the benefit of operative simplicity and ease of endoscopic evaluation. We compared the
outcomes of non-palliative DDA to RJA.
The Critical View of Safety in Dome Down Laparoscopic Cholecystectomy:
(A) cystic artery (B) cystic duct (C) common bile duct (D) infundibulum of
gallbladder (E) gallbladder fossa.
RESULTS: 715 consecutive patients (72% female) underwent CCY; 581 (74%) elective, 134 (26%) acute. One
(0.14%) required conversion to open CCY; all others underwent DDLC. Five (0.69%) had minor complications: ileus
in 2 cases, trocar site hernia in 1. Biloma was found in 2
patients however there were no bile duct injuries or biliary
strictures on subsequent evaluation. A single enterotomy
occurred during Hasson canula placement in a patient
with extensive adhesions; this led to the sole conversion
to open CCY. Estimated blood loss was minimal in all
cases. Most patients (84%) were discharged on the day of
surgery. Length of stay and complication rate did not vary
between patients who had acute or elective indications
for surgery. The CVS was identified in all (566) patients
since 2001, when we began documenting identification or
non-identification of the CVS. In cases for which precise
operative times were available, DDLC averaged 37 minutes.
Intra-operative cholangiogram (IOC) was never needed to
METHODS: A retrospective cohort study was performed at
a single tertiary care center comparing DDA to RJA between
the years 2000 and 2010. Standard patient demographics,
complications rates, mortality rates, need for endoscopic
or radiologic interventions, and long term outcomes were
compared.
RESULTS: A total of 105 non palliative reconstructions
were performed between 2000 and 2010. 67 DDA and 38
RJA reconstructions were performed in an end-to-side fashion for either bile duct injury, cholangiocarcinoma, choledochal cysts, or benign strictures. The groups were similar
with regard to demographics, preoperative diagnoses, postoperative length of stay (7 days vs. 7.5 days), postoperative
mortality rates (1.7% vs. 2.9%; P = 0.72), and overall (Grade
III or greater) complication rates (47.1% vs. 47.1%; P =
0.83). However, anastomotic related complications (leaks,
abscesses/bilomas, or strictures) were fewer in the DDA
cohort (11.7% vs. 35.3%; P = 0.01). Of those developing
stricture, 5 of 6 in RJA cohort required percutaneous transhepatic access for management, as opposed to only 1 of 3
in the DDA cohort.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
CONCLUSION: Direct duodenal anastomosis is a safe and
often preferable method for biliary reconstruction. It may
have decreased anastomotic complication rates, while benefiting from easier postoperative endoscopic management.
Tu2050
CONCLUSIONS: the colposcopic NOTES access has proved
to be safe, with excellent outcomes, no complications and
void of sequelae in the gynecologic and sexual aspects. The
risks of rectal injury, infection and sexual or pregnancy
dysfunctions are considered to be minimal.
Tu2051
Gynecologic and Fertility Issues in NOTES Colposcopic
Procedures
Gallbladder Wall Changes in Patients with and
Without Metabolic Syndrome
Anibal Rondan*, Rafael A. Redondo, Marcelo Fasano, Mariano
Gimenez, Mauricio Ramirez, Alberto R. Ferreres
Department of Surgery, University of Buenos Aires, Buenos Aires,
Argentina
BACKGROUND: the clinical application of NOTES procedures have raised issues regarding the ways of access to the
abdomen. The transvaginal access has been long and widely
used and eliminates the disadvantages and risks associated
with other NOTES approaches. With the development of
laparoscopic techniques, the vagina was used not only as a
port of entry but also as an excellent channel for removal
of surgical specimens. The easy closure of the incision and
the minimal risk of infection represent some of the benefits
of this access, outweighting the other NOTES alternatives.
OBJECTIVE: to present the followup of our first 107
patients who were operated on through a hybrid NOTES
transvaginal access
METHODS AND MATERIALS: after institutional IRB
approval a program of NOTES surgery was started at our
single institution in august 2007. Between that date and
august 2009 107 procedures were attempted (100 cholecystectomies and 7 appendectomies) with a colposcopic
NOTES approach with hybrid technique. The average age
was 33.5 years with ranges between 22 to 46. After discharge, refrain from sexual activity was prescribed for 15
days (first 30 patients) and for 30 days in the following
patients, due to inobservance. The postoperative follow up
included gynecologic assessment at postoperative days 7,
30, 60, 180 and 360. The evaluation included: guided questionnaire, physical examination and colposcopy to assess
healing, presence of anatomical injuries, vaginal secretion
and other alterations.
BACKGROUND: Recent research has described that obesity and high carbohydrates intake increases fat content of
the gallbladder, decreases its motility and mucosal absorption, leading to a condition known as steatocholecystitis.
Gallstone disease (GD) and the metabolic syndrome (MS)
share common risk factors.
OBJECTIVE: To identify if MS contributes to the development of functional disorders and wall changes of the
gallbladder.
METHODS: A Prospective study was conducted from
August 2010 to July 2011 on patients with symptomatic
gallbladder disease undergoing laparoscopic cholecystectomy. Forty two patients were included and divided into
two groups; 22 patients with MS and 20 patients without
MS. Family history, risk factors, anthropometric, clinical
and laboratory variables were evaluated before surgery. Gallbladder specimens were analyzed, measured and graded by
two pathologists at 3 standardized areas (cystic duct, liver
bed, free margin and fundus).
RESULTS: Thirty three patients who underwent cholecystectomy were female. A family history of GD and MS
were present in 90% of patients. Chronic cholecystitis was
the most frequent diagnostic (93%). Median weight was
75.5kg ± 14.3 and 67.1kg ± 9.2 for MS and No-MS groups
respectively. Gallbladder wall thickness was significantly
increased (P = 0.012) in the MS group. This thickness
was secondary mainly observed in the cystic duct area of
patient with MS. The percentage of fatty infiltration of the
gallbladder wall, muscle degeneration and cholesterolosis
did not show significant differences between groups.
CONCLUSIONS: MS is associated with an increased gallbladder wall thickness. Muscle fibrosis in the cystic duct
was the most important wall modification in these patients.
In our series, MS was not associated to fat infiltration of the
gallbladder wall or cholesterolosis.
The systematic assessment proved adequate healing of
the vaginal access with no local complications as well as
absence of granulomas, hematomas, adhesions or retractions. None of the patients refer dyspareunia. Thirteen
patients (12%) got pregnant after the procedure, 10 with
a normal birth delivery and 3 cesarean sections, without
complications due to the previous access
167
Tuesday
Poster Abstracts
RESULTS: the cholecystectomy with the NOTES colposcopic hybrid technique could be completed in 99 of
the 100 patients (95%). In the remaining case the operation had to be performed laparoscopically due to pelvic
adhesions (5 previous cesarean sections). One case ( # 6)
required a minilaparotomy through a previous Pfannestiel incision for checking hemostasis of the vaginal cul de
sac and 8 required the placement of an additional 2.5 mm
trocar. The appendectomy was completed in all 7 cases, in
2 with the placement of an additional 2.3 mm trocar. No
major complications were attained.
Maria Fernanda Gonzalez-Medina*, Antonio Ramos-De La Medina,
Jose Remes-Troche, Gustavo M. Melgarejo Ortiz, Peter Grube
Pagola, Isabel Ruiz JuáRez, Alfonso Perez-Morales,
Joaquin Valerio-Ureña, Federico B. Roesch
Gastrointestinal Surgery and Investigation Department, Hospital
Regional de Alta Especialidad de Veracruz, Veracruz, Mexico
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Colon-Rectal
Tu1746
Tu1745
Predictive Factors of Acute Respiratory Failure in Colon
and Rectal Surgery
Hossein Masoomi*, Joseph C. Carmichael, Steven Mills,
Matthew O. Dolich, Alessio Pigazzi, Michael J. Stamos
Surgery (Colorectal Division), University of California, Irvine-Medical
Center, Orange, CA
Emergent Restorative Surgery for Ulcerative Colitis:
Expertise May Matter Most When It’s Hard to Find
Caitlin W. Hicks*1,2, Richard A. Hodin1, Liliana Bordeianou1
1. Surgery, Massachusetts General Hospital, Boston, MA;
2. Cleveland Clinic Lerner College of Medicine, Cleveland, OH
INTRODUCTION: The aim of our study was to compare
outcomes of patients treated with elective vs. urgent surgery for active Ulcerative Colitis (UC) in the hopes of defining modifiable factors that could decrease complications.
METHODS: We performed a retrospective review of 179
UC patients undergoing surgery for failure of medical management. Patients treated urgently (while hospitalized)
were compared to those treated electively with univariate
(chi square, t test) and multivariable regression analyses.
RESULTS: Patients undergoing urgent (n = 99) vs. elective
(n = 80) surgery were younger (28.3 ± 1.6 vs. 32.6 ± 1.6 years;
p = 0.05) with lower mean BMI (22.3 ± 0.1 vs. 25.9 ± 0.6 kg/
m2; p = 0.0001). Significantly more urgent patients were on
steroids at the time of surgery (93.5% vs. 66.7%; p < 0.0001).
Use of anti-TNF drugs (21.3% vs. 26.3%; p = 0.44) and other
immunomodulators (42.5% vs. 43.4%; p = 0.91) were equivalent between the two groups. Urgent patients reported
more daily bowel movements at the time of surgery (11.7 ±
0.7 vs. 9.0 ± 0.8; p = 0.01) and had an increased prevalence
of severe disease on final pathology (87.5% vs. 73.7%; p =
0.02) compared to patients treated electively.
During surgery, urgent and elective patients had similar
degrees of hemodynamic stability (mean apgar scores 6.1 ±
0.2 vs. 6.5 ± 0.1; p = 0.1). However, urgent cases had more
than a 5-fold increase in the proportion of subtotal colectomies (5.1% vs. 29%; p < 0.0001) and half as many laparoscopic procedures (8.8% vs. 18%; p = 0.07). Postoperatively,
patients treated urgently had more short-term complications (1.0 ± 0.3 vs. 0.6 ± 0.2; p = 0.05), but no increase in
anastamotic leaks [OR 1.7 (0.5, 6.5); p = 0.26] or in-hospital
length-of-stay (7.3 ± 0.5 vs. 6.5 ± 0.4 days; p = 0.21) at their
initial operation. Long-term complications, including pouchitis, fistula/abscess, ileus/SBO, stricture, and pouch failure
were similar regardless of urgency status (p ≥ 0.08). Multivariate regression analysis controlling for disease severity,
steroid use, and infliximab use suggested that short-term
complications were attributable to higher BMI in addition
to urgent status (p ≤ 0.05). Surgeon inexperience and use of
immunomodulators other than infliximab were associated
with increased odds of long-term fistula/abscess [OR 5.56
(1.1, 33); p = 0.05) and pouch failure [OR 13.3 (1.75, 318);
p = 0.01], respectively.
CONCLUSION: Although urgent surgery is associated with
an increased number of short-term complications, it does
not affect the risk of anastomotic leak, in-hospital lengthof-stay, or long-term complications provided that the
surgery is performed by an expert. Weaning from immunomodulators other than infliximab and early transfer to an
institution with IBD expertise would likely decrease complications overall for patients undergoing both elective and
urgent interventions for severe UC.
INTRODUCTION: Postoperative acute respiratory failure
(ARF) is a major factor of morbidity and mortality in colon
and rectal surgery.
OBJECTIVES: To evaluate the prevalance of ARF following colorectal surgery and to evaluate the effect of patient
characteristics, comorbidities, pathology, resection type,
surgical technique and admission type on ARF in colorectal
surgery.
METHODS: Using the National Inpatient Sample (NIS)
database, we examined the clinical data of patients who
underwent colon and rectal resection from 2006–2008.
Multivariate regression analysis was performed to identify
factors predictive of ARF.
RESULTS: A total of 975,825 patients underwent colorectal resection during this period. Overall, the rate of acute
respiratory failure was 10.42% (elective surgery: 4.51% vs.
emergent surgery: 18.59%; p < 0.01). Patients who experienced ARF following colorectal surgery had a significantly
higher rate of in-hospital mortality (26.84% vs. 1.90%) and
a longer mean length of hospital stay (22.31 days vs. 9.32
days) compared with patients without ARF. Using multivariate regression analysis, patient factors including emergent
operation (odds ratio [OR]: 2.91), congestive heart failure
(OR, 2.51), alcohol abuse (OR, 2.13), pulmonary hypertension (2.01), chronic renal failure (OR, 2.0), chronic lung
disease (OR, 1.96), age over 65 (OR, 1.92), diverticulitis
(OR, 1.71), liver disease (OR, 1.66), peripheral vascular
disease (OR, 1.58), malignant tumor (OR, 1.53), obesity
(OR, 1.41) and ulcerative colitis (OR, 1.25) significantly
impacted the risk of ARF. Technical factors including total
colectomy (OR: 2.66), open procedure (OR, 1.71), left colectomy (OR, 1.50), and transverse colectomy (OR, 1.41),
were also associated with higher risk of ARF. Although male
sex (OR: 1.09), teaching hospital (OR, 1.07), Black race (OR:
1.04), and Hispanic race (AOR, 1.03) also had statistically
significant impact on rates of ARF, these were less clinically
significant than the other factors. There was no association
with hypertension, diabetes, smoking, Asian race, sigmoidectomy, proctectomy or Crohn’s disease and ARF.
CONCLUSIONS: Respiratory failure is a relatively common complication following colorectal surgery. Emergent
surgery is the strongest predictor of acute respiratory failure in colorectal surgery. Surgical approaches such as total
colectomy, left colectomy and transverse colectomy, that
classically involve upper abdominal incisions, are associated with a higher rate of respiratory failure.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1747
Altered Rectal Tone and Compliance and
Hyposensitivity for Non-Noxious Stimuli in Patients
with Fecal Incontinence After Anorectal Surgery
Richard A. Awad*1, Francisco Flores-Judez2, Santiago Camacho1,
Alfredo Serrano1, Evelyn Altamirano1
1. Experimental Medicine and Motility Gastroenterology Service
U 107, Mexico City General Hospital, Mexico, Mexico; 2. Surgery
Service, Mexico City General Hospital, Mexico, Mexico
INTRODUCTION/OBJECTIVES: It is reported that fecal
incontinence may present as a late complication of anal
fissure (1) or other anorectal procedures, that rectal distensibility and volume thresholds for sensations decrease
after stapled hemorrhoidopexy (2), and that noxious and
non-noxious distensions stimulate different afferent nerve
pathways (3). This study aimed to search anal sphincter
and rectal factors that determine fecal incontinence after
anorectal surgery (FIAS).
METHODS: Seventeen patients (50 ± 15 years, 11 females)
with fecal incontinence (10 ± 15 CI: 3–17 incontinence episodes per week) after anorectal surgery (sphincterotomy =
5, fistulotomy = 5, rectal prolapse = 4, hemorrhoidectomy
= 1, others = 2; 2 ± 1 CI:1.2–3.2 years after surgery) were
studied [clinical assessment, rectosigmoidoscopy, anorectal
manometry (MMS, Netherlands) and barostat (G&J, ON,
CA)] and compared with healthy subjects (n = 11, 22 ± 2
years, 10 females for manometry and; n = 10, 25 ± 7 years,
three females, for barostat studies). Rectal sensory thresholds, tone and compliance were evaluated with an electronic barostat using the ascending method of limits. Mean
± SD, binominal 95% confidence interval, and nonpaired
Student two-tailed t test with alpha = 0.05.
RESULTS: (Table). Compared with healthy subjects, FIAS
patients showed lesser rectal compliance (p = 0.0129) and
rectal tone at lower volume (p = 0.0029). The thresholds
for non-noxious stimuli of gas sensation (p = 0.0272) and
urge-to-defecate sensation (p = 0.0245) were reported by
FIAS patients at higher pressure than healthy subjects. The
noxious stimulus of pain was reported by FIAS patients at
similar pressure than healthy subjects (p = 0.9). Compared
with healthy subjects FIAS patients showed greater anal
squeeze pressure (p = 0.041). However, anal resting pressure and rectoanal inhibitory reflex parameters (RAIR) were
similar.
CONCLUSION: FIAS patients preserve internal anal
sphincter function but present with impaired rectal tone
and compliance and hyposensitivity for non-noxious stimuli. The results also support the concept that noxious and
non-noxious distensions stimulate different afferent nerve
pathways and suggest that an impaired afferent nerve
pathway and abnormal rectal structure and function are
involved in the genesis of fecal incontinence after anorectal surgery.
REFERENCES:
1. Levin A et al. Int J Colorectal Dis 2011.
2. Corsetti M et al. J Gastrointest Surg 2009;13:2245–51.
3. Awad RA et al. Gastroenterology 2011;140:S744.
Table
Variable
(Mean ± SD)
Fecal Incontinence
After Surgery
Healthy
Subjects
43 ± 42 CI: 23−63
103 ± 51 CI: 71–135*
5 ± 5 CI: 2–7
11 ± 6 CI: 7–16*
First sensation (mmHg)
16 ± 4 CI: 14–18
14 ± 5 CI: 10–17
Gas sensation (mmHg)
23 ± 5 CI: 20–25
17 ± 6 CI: 14–21*
Urge to defecate (mmHg)
30 ± 8 CI: 25–35
22 ± 7 CI: 17–26*
Pain sensation (mmHg)
36 ± 7 CI: 32–40
35 ± 8 CI: 30–41
Tone (ml)
Compliance (v/p)
46 ± 25 CI: 34–58
34 ± 22 CI: 21–48
Anal squeeze pressure (mmHg)
87 ± 65 CI: 56–118
43 ± 24 CI: 28–57*
20 ± 7 CI: 17–24
19 ± 5 CI: 16–23
59 ± 17 CI: 51–-67
74 ± 31 CI: 55–93
RAIR duration (s)
RAIR relaxation (%)
Tuesday
Poster Abstracts
Anal resting pressure (mmHg)
* = p < 0.05 compared with healthy subjects
169
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu1748
Tu1749
Laparoscopic Right Hemicolectomy: A Comparison
of Natural Orifice vs. Transabdominal Specimen
Extraction
Colorectal Cancer in Patients Under 50 Years of Age:
Frequent and More Often Advanced?
Reginald L. Griffin*1, Irfan Qureshi1, Eve Oganesyan1,2,
Ziad Awad1
1. University of florida, Jacksonville, FL; 2. LECOM, Bradenton, FL
BACKGROUND: Conventional laparoscopic assisted right
hemicolectomy (LARH) involves making an abdominal
incision to remove the specimen and perform the anastomosis. The skin incision extraction site continues to be a
major source of morbidity after both open and LARH, specifically with regard to postoperative pain, wound infection
and hernia formation. Totally laparoscopic right hemicolectomy with intracorporeal anastomosis and transvaginal
extraction ie. natural orifice specimen extraction (NOSE)
eliminates the skin incision extraction site and may possible leads to better outcome compared to LARH.
METHODS: Our study reviewed two consecutive case
matched cohorts: LARH and NOSE performed during 2007
and 2011. Forty consecutive female patients total were
reviewed: 20 LARH and 20 NOSE. The two groups were
matched for benign and malignant disease, sex, age, race,
American Society of Anesthesiologist (ASA) score, pathology,
tumor stage, lymph node (LN) number, body mass index
(BMI), previous abdominal surgeries, and comorbidities
including chronic obstructive pulmonary disease (COPD),
coronary artery disease (CAD), hypertension, diabetes mellitus (DM), chronic kidney disease (CKD), and nicotine
dependence. Our goal was to determine significant differences between the two groups with regard to postoperative
pain, wound infection, hernia formation, postoperative
ileus, septic complications, length of hospital stay, readmission rate, time interval for postoperative chemotherapy
if indicated, symptom distress score (SDS), Visick grade,
Quality of life Index (QLI) and cosmetic score.
RESULTS: The two groups were comparable for all categories. Follow up was available on all patients (100%).
At a mean follow-up of 25.23 months (range 6–53, there
was no difference between postoperative pain between
the two groups on postoperative day one, postoperative
day two or greater than 2 weeks (p = .571),(p = .861),(p =
.688), respectively. The NOSE group had no postoperative
hernia formation or wound infections compared to the
LARH group which had 10% hernia formation rate and 5%
wound infection rate, however the difference was not significant (p = .439)and (p = .267), respectively. There was
no difference between groups in postoperative ileus (p =
.192), septic complications (p = 1.000), length of hospital
stay (p = .243), readmission rate (p = .394), time interval
for postoperative chemotherapy (p = .645), SDS (p = .446),
Visick grade (p = .176) or QLI (p = .175). The NOSE group,
however, have statically significant better cosmetic scores
(p = .018).
CONCLUSION: NOSE is comparable LARH with regard to
short and long term postoperative outcomes. NOSE is associated with better cosmetic outcome.
Elizabeth Myers*1, Joon Ho Jang1, Daniel L. Feingold2,
Tracey D. Arnell2, Kenneth A. Forde2, Jon Kluft2, Samer Naffouje1,
Sonali A. Herath1, Richard L. Whelan1
1. Colorectal Surgery, St. Luke’s Roosevelt Hospital Center, New
York, NY; 2. Surgery, College of Physicians and Surgeons, Columbia
University, New York, NY
INTRODUCTION: The overall incidence of colorectal
cancer (CRC) in Western countries is falling in part due
to aggressive adenoma surveillance programs. It has been
previously noted that more patients (pts) under age 50 are
developing CRC and are more likely to present with Stage 3
or 4 disease yet average risk pts under 50 are excluded from
CRC screening programs. This review was undertaken to
investigate CRC in pts under 50 at 2 institutions to determine if the above trends are observed in this population.
METHODS: The records of pts under the age of 50 who
underwent an operation for CRC between July 1996 and July
2011 at 2 hospitals were reviewed. The main study variables
included: age, symptoms, family history, tumor location,
resection performed, and stage & differentiation of disease.
RESULTS: Over the 15 year period, a total of 174 CRC
pts under age 50 were identified that underwent surgery
(90 males, 85 females; mean age 41.4, range 17–49). Pts
under 50 accounted for 12% of all CRC cases (all ages) for
the 5 year period (2006–2011) for which the full data set
was available. Sixteen pts (9%) had a first degree, 17 pts
(10%) had a second degree, and 3% had both a first and
second degree family history of CRC; 125 pts (71%) had a
negative family history. The vast majority (93%) presented
with symptoms: the most common were bleeding (57%),
obstruction (9%), and abdominal/rectal pain (35%). Not
uncommonly, work-up and diagnosis were delayed because
of patient and/or doctor complacence. Bleeding was often
attributed to hemorrhoids; 2 pts had symptoms for 18–24
months prior to colonoscopy. Advanced CRC (Stage 3 or 4)
was found in 95 pts (55%). The tumor locations were: right
or transverse, 46 (26%); descending or sigmoid, 59 (34%);
rectal, 69 (40%). The vast majority of pts had segmental
resections. Five pts had a subtotal/total abdominal colectomy, of which 2 had a first degree family history. Most
pts (70%) had moderately or well differentiated cancers,
whereas 21 pts (12%) had poorly differentiated lesions and
34 (19%) had mucin producing CRC’s, of which almost two
thirds had Stage 3 or 4 disease.
CONCLUSIONS: Young patients with sporadic CRC continue to present with advanced disease. In this series the
tumors were predominantly located in the distal colon and
rectum. The vast majority of these pts had no contributing family history similar to the situation for the over 50
CRC population. An alarming number of young pts have
symptoms that are often attributed to common benign
colorectal problems and that lead to a delay in diagnosis.
Clinicians must maintain a low threshold for evaluating
young symptomatic patients to exclude an occult cancer
as the outcome of CRC treatment strongly depends on the
stage at diagnosis.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1750
CONCLUSIONS: Clostridium difficile colitis is a serious
problem that carries significant morbidity and mortality.
The majority of the patients did not require surgery, but
those who did had a fourfold increase in mortality risk.
Patients over 65 years old and those who develop acute
renal failure also had a higher risk of in-hospital mortality.
Clostridium Difficile Colitis: 21st Century Pandemia
Haisar E. Dao*, Peter E. Miller, Justin Lee, Reza Kermani,
Alan W. Hackford
Surgery, St. Elizabeth’sMedical Center. Tufts University School of
Medicine, Boston, MA
OBJECTIVE: Clostridium difficile colitis has become a
significant problem among healthcare facilities in the
United States. Our objective is to analyze Clostridium difficile colitis associated hospitalizations and contemporary
outcomes.
METHODS: Analysis of the Nationwide Inpatient Sample
(NIS) was performed for the years 2005–2007. This database
incorporates 100% of all hospital discharges from a 20%
stratified sample of US hospitals. Diagnosis and procedures
were identified using ICD-9 codes. Primary outcomes were
in-hospital mortality and need for surgical intervention.
Multivariable analysis was performed to determine the relationship between independent variables and in-hospital
mortality.
RESULTS: 859,350 discharges were identified with a diagnosis of Clostridium difficile colitis. The mean age of the
population was 68.5 ± 19.4 years (Female 58.8%), and the
median length of stay was 8.0 days (0–360). Overall inhospital mortality was 8.1%. Total abdominal colectomy
was performed in 6722 patients (0.8%). Multivariable analysis revealed that patients who underwent total abdominal colectomy had a higher mortality rate than patients
that did not require surgical intervention, 31.8% vs.7.8%,
respectively (OR 4.0, 95% CI 3.7–4.3, p < 0.0001). In addition to total abdominal colectomy, acute renal failure was
independently associated with an increase in in-hospital
mortality (OR 2.8, 95% CI 2.7–2.8, p < 0.0001).
Multivariable Analysis of Risk Factors Associated with In-hospital
Mortality in Patients with Clostridium Difficile Colitis
n = 859,350
Odds Ratio
95% CI
p
Total abdominal colectomy
4.0
3.71–4.30
<0.0001
1.0
1.01–1.06
0.06
09
0.92–0.95
<0.0001
Age over 65
1.5
1.5–1.6
<0.0001
CHF
1.2
1.2–1.3
<0.0001
HTN
0.8
0.8–0.9
<0.0001
COPD
1.1
1.1–1.2
<0.0001
CRF
1.0
0.9–1.0
0.2
DM
0.5
0.5–0.6
<0.0001
CHF: Congestive heart failure, HTN: Hypertension, COPD: Chronic obstructive
pulmonary disease,CRF: Chronic renal failure, DM: Diabetes mellitus.
Never Too Old for Abdominal Surgical Repair of Rectal
Prolapse
Jaime Benarroch-Gampel*, Aakash Gajjar, Casey A. Boyd, Kristin
Sheffield, Taylor S. Riall
Surgery, University of Texas Medical Branch, Galveston, TX
BACKGROUND: The effect of age on short-term outcomes
in patients undergoing surgical repair for full-thickness rectal prolapse is unknown.
METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database (2005–2010) we selected
a total of 1,876 patients with full-thickness rectal prolapse
who underwent either perineal or abdominal repairs. Outcome variables included any or major postoperative complications (unplanned intubation, pulmonary embolism,
acute renal failure, stroke, coma, cardiac arrest, myocardial infarction, sepsis/septic shock, bleeding requiring
blood transfusion and death). Multivariate logistic regression models were used to describe the impact of age on
outcomes.
RESULTS: A total of 909 patients (48.5%) underwent an
abdominal procedure. Comorbid illness increased with
age. Use of an abdominal approach decreased from 80.95%
in the youngest patients (≤54 years) to 14.76% in the oldest patients (≥85 years, P < 0.0001). When compared to
patients younger than 54 years old, patients between 55–69
years were 51% less likely (OR = 0.49, 95% CI 0.36–0.66),
patients between 70–84 years were 87% less likely (OR =
0.13, 95% CI 0.09–0.17) and patients older than 85 years
were 95% less likely (OR = 0.05, 95% CI 0.03–0.07) to
have an abdominal procedure. Even in patients with no
comorbidities (N = 495) the use of an abdominal approach
decreased with increasing age (83.78% to 10.42%, P <
0.0001). When patients in the overall cohort were stratified by age (≤54 y, 55–69 y, 70–84 y, and ≥85 y), there were
no differences within each strata with regards to overall
or major complication rates between the two approaches.
After adjusting for patient comorbidities and surgical
approach, no differences in overall complications or major
complications were observed across age groups. (Table 1)
CONCLUSIONS: With older age, fewer people with fullthickness rectal prolapse undergo abdominal surgical repair,
even after controlling for baseline condition. Our data suggest that in carefully selected older patients, an abdominal
approach to repair a rectal prolapse can be safely used.
171
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Poster Abstracts
White
Female
Tu1751
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Table 1. Effect of Age on Postoperative Complications: Bivariate and Multivariate Analysis
Any Complication
Unadjusted Model
Age Groups
OR
95% CI
≤54 years
Major Complications
Adjusted Model*
OR
95% CI
Adjusted Model#
Unadjusted Model
OR
Reference group
95% CI
OR
95% CI
Reference group
55–69 years
1.04
0.69–1.57
0.91
0.60–1.39
1.87
0.86–4.06
1.33
0.62–3.07
70–84 years
1.13
0.77–1.67
0.95
0.61–1.48
3.11
1.52–6.35
2.05
0.94–4.48
≥85 years
0.88
0.57–1.37
0.71
0.42–1.19
2.55
1.18–5.48
1.60
0.68–3.78
*Adjusted to surgical approach, ASA class and dyspnea. #Adjusted to surgical approach, ASA class, cardiac comorbidities and chronic obstructive pulmonary disease
Tu1752
Tu1753
Ventral Rectopexy with Biological Mesh: Surgical
Option for Selected Patients with Obstructed
Defecation Syndrome
Complications of Hartmann Takedown in the Era of
Primary Anastomosis
Ari Garber*, Neil Hyman, Turner Osler
Surgery, University of Vermont College of Medicine, Burlington, VT
Angelo Stuto , Francesca Da Pozzo , Andrea Braini ,
Alessandro Favero1
1. 1st Surgical Department, Az. Osp “SMA”, Pordenone, Italy;
2. Department of Gen Surgery, Trieste University Hospital,
Trieste, Italy
*1
2
1
OBJECTIVE: The aim of this study is a retrospective analysis of our experience in Laparoscopic Ventral Rectopexy
(LVR) with biological mesh to assess the safety and the efficacy of this surgical treatment for Obstructed Defecation
Syndrome (ODS).
METHODS: Between July 2010 and November 2011, fifteen patients had LVR with biological mesh for symptomatic ODS with enterocele, recto-rectal prolapse and third
degree rectocoele. All patients underwent preoperative
anoscopy, colonoscopy and perineo-defecography. The
operative technique was standardized and in all cases a
biological mesh was used. No colon resection or Stapled
Transanal Rectal Resection (STARR) was performed in association with LVR. ODS score and Symptom Severity Score
(SSS) were both used in follow up to assess morbidity and
efficacy of this surgical procedure.
RESULTS: Perioperative morbidity was 6,6% (one patient
required reintervention for ileal volvolus) with no mortality. No major and minor complication as sepsis, bleeding,
fecal urgency and urinary retention were recorded. The
median hospital stay was . No recurrence after a mean follow up period of 5,7 months was observed with good overall patient satisfaction. The mean ODS score was 18 preop
vs 5 postop, SSS 16 vs 7.
CONCLUSION: In our experience LVR is a safe and effective procedure for treatment of ODS in selected patient.
However for patient with internal rectal prolapse STARR
procedure remains the gold standard. LVR is an innovative
feasible technique for patients with ODS associated with
complex pelvic disease.
INTRODUCTION: Primary anastomosis with or without
proximal diversion is increasingly applied to pts requiring
urgent colectomy for complicated disease of the sigmoid
colon. Conversely, the Hartmann procedure (HP) is now
often restricted to patients who are unstable or otherwise
ill suited to primary anastomosis. As such, pts who are
evaluated for Hartmann takedown often have formidable
comorbities and considerable judgment is often required in
pt selection. We sought to define the complication rate of
Hartmann takedown in this setting.
METHODS: A prospective complication database was
searched for consecutive adult patients undergoing colostomy takedown with colorectal anastomosis (HP) at an
academic teaching hospital from 1/1/02 to 12/31/10.
Demographics, BMI, ASA classification, interval between
Hartmann procedure and subsequent takedown, surgical
indication, surgeon volume and specialty, length of stay
and complications were recorded. Fisher’s exact test was
used to identify risk factors for postoperative complications.
RESULTS: 104 pts underwent Hartmann reversal by 16
different surgeons; 7 of these surgeons did 4 or fewer procedures during the study period. 39 pts had their original
Hartmann procedure done elsewhere; 38 of these reversals
were done by a colorectal surgeon. During the same time
period, 334 patients underwent a Hartmann procedure at
our institution. 77/104 pts (74%) had their HP for complicated diverticulitis; anastomotic leak was the second most
common indication. The median age was 61 years (31–84
yrs) and the interval from Hartmann procedure to reversal
ranged from 87–1489 days. Only 8 pts (7.7%) had an ASA
of 1 and at least 30 patients required a concomitant ventral hernia repair. 30 pts (29%) had complications and 12
(11%) had two or more complications (Table 1). There were
two deaths, four anastomotic leaks, and seven patients
had inadvertent enterotomies. Only ASA status predicted
postop complications (p = .01)
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
pre-operative comorbidities {cardiac (p = 0.009) and neurological (p = 0.005)}. Operative time was longer with a laparoscopic approach (mean 135 min vs. 87 min, p = 0.0001).
Univariate analysis showed no difference in the complication rate between laparoscopic and perineal approach (4%
vs 6.9%, p = 0.09). After risk adjustment for age, ASA, preoperative comorbidities and operative time, the difference
in major complications between laparoscopic and perineal
approach remained non significant on multivariate analysis. Independent predictors of major complication included
presence of pulmonary disease (OR = 1.91, 95% CI = [1.03,
3.55], p = 0.04), bleeding disorder (OR = 3.42, 95% CI =
[1.65, 7.10], p = 0.001), and anemia (OR = 2.09, 95% CI =
[1.06, 4.10], p = 0.033).
Table 1: Complications (n = 30 pts)
SSI
7
Inadvertent enterotomy
7
Blood transfusions
6
Anastomotic leak
4
Arrhythmia
4
Urinary
3
MI
2
Death
2
Other
14
CONCLUSIONS: Hartmann takedown is a morbid operation with a substantial risk of inadvertent enterotomy and
serious complications. Excluding cases referred from elsewhere, there were more than fivefold the number of Hartmann procedures than takedowns performed during the
study period. This suggests that Hartmann procedures are
largely restricted to patients who are poor candidates for
takedown and that their colostomy is highly likely to be
permanent.
Tu1754
Rectal Prolapse Repair: Laparoscopic or Perineal
Approach?
Aaron S. Rickles*, Abhiram Sharma, James C. Iannuzzi,
Andrew-Paul Deeb, Fergal Fleming, John R. Monson
Surgery, University of Rochester, Rochester, NY
INTRODUCTION: The perineal approach to rectal prolapse repair is commonly chosen over open abdominal
rectopexy for high-risk patients. A higher risk of recurrence
has been accepted as a tradeoff for reduced morbidity.
Increasingly rectopexy is now performed laparoscopically
and this approach may reduce the incidence of complications while maintaining the durability of an abdominal
procedure. The aim of this study was to compare the 30-day
outcomes of laparoscopic versus perineal rectal prolapse
repair using outcomes from a national clinical database.
RESULTS: During the study period 1385 patients underwent rectal prolapse repair by perineal approach and 248
had laparoscopic rectopexy. Perineal cases were older (p =
0.0001) with a higher ASA class (p = 0.0001) and more
Tu1755
Effect of Iatrogenic Spleen Injuries During Colorectal
Carcinoma Surgery on the Early Postoperative Result
Meyer Frank*1,5, Rene Mettke2,5, A. Schmidt3,5, Stefanie Wolff1,5,
Andreas Koch4,5, Henry Ptok2,5, Hans Lippert1,5, Ingo Gastinger5
1. Department of General, Abdominal & Vascular Surgery, University
Hospital, Magdeburg, Germany; 2. Department of Surgery, Municipal
Hospital, Cottbus, Germany; 3. Oncological Practice, Municipal
Health Care, Cottbus, Germany; 4. Surgical Practice, Municipal
Health Care, Cottbus, Germany; 5. Institute for Quality Assurance in
Operative Medicine, University Hospital, Magdeburg, Germany
INTRODUCTION: Unlike in gastric carcinomas, the consequences of a spleen injury during operative treatment
of the colorectal carcinoma are hardly investigated, as a
splenectomy is not performed on these tumour patients to
extend the radicality. In this context, the only interest is
in the iatrogenic intraoperative spleen lesions, which make
a splenectomy necessary or require reconstructive spleen
preservation.
METHODS: During the study period 01/01/2000–12/31/2004,
the perioperative data of a prospective multi-center observational study of 46,682 patients whose tumour had been
removed with a curative or palliative intention were analysed with respect to the early postoperative consequences
of an iatrogenic spleen lesion.
RESULTS: Of these 46,682 patients, 640 patients (1.4%)
suffered an iatrogenic spleen injury during the operative
therapy. The spleens of 127 patients (0.3%) were removed,
the spleens of 513 patients (1.1%) were able to be left in situ
following repair. In more than 80% of the cases with an iatrogenic spleen injury, the tumour was localised in the left
colon and in the rectum. In the logistic regression, the decisive risk factor for this organ lesion was the mobilisation of
the left colonic flexure on tumour localisation in the left
colon and rectum. Following a spleen lesion, compared to
the patients without spleen injury (36.5%), a significantly
higher morbidity rate was registered (47.2% following
173
Tuesday
Poster Abstracts
METHODS: Laparoscopic and perineal rectal prolapse surgeries were selected from the American College of Surgeons
National Surgical Quality Improvement Program (NSQIP,
2005–2010) by cross referencing Current Procedural Terminology codes (CPT codes 45400, 45130, and 45541) and
International Classification of Disease, 9th edition codes
(ICD-9 codes) for rectal prolapse. Patient demographics, preoperative risk factors and operative variables were
recorded. The primary outcome was occurrence of major
complication (mortality, organ space infection, return to
OR, renal failure, venous thromboembolism, cardiac, neurological or respiratory complications). Univariate (2), and
multivariate (logistic regression) analysis was performed to
identify independent predictors of major complications.
CONCLUSION: This study shows that even after risk
adjustment the complication rate for laparoscopic rectopexy is no higher than perineal approach. Laparoscopic
approach for repair of rectal prolapse should therefore be
the preferred approach in most patients in view of the
lower recurrence rate.
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
splenectomy; 48.5% following spleen repair). Anastomotic
leaks requiring operation were most frequently observed
following a splenectomy (7.9%). This rate was significantly
lower following spleen preservation with 3.3% (p = 0.003).
The total hospital mortality was 3.1%. In patients with
splenectomy the hospital mortality was 11.8% and following repair with organ preservation was 4.7% (p < 0.0001).
CONCLUSION: Iatrogenic spleen lesion during colorectal
carcinoma surgery represents a significant risk factor for a
poorer early postoperative result. In particular, this concerns
the high rate of anastomotic leaks and infectious—septic complications. This also affects the rate of higher total
morbidity and hospital mortality. By comparison, a significantly worse postoperative result is found in the group of
splenectomised patients compared to the group with organ
preservation through repair of the injured spleen.
Tu1757
Rectal Cancer in the Young: Is It a Different Disease?
Dana M. Hayden*, Neha Hippalgaonkar, Marylise Boutros, Eric
G. Weiss, Steven Wexner
CCF, Weston, FL
BACKGROUND: Patients under 50 years old are not
screened for colorectal cancer (CRC) unless they have
symptoms or family history. However, recent studies have
shown a rising incidence of rectal cancer in young patients.
This study examines patient and tumor characteristics of
rectal cancer patients younger than 50.
METHODS: Retrospective chart review was performed on
patients who had radical resection for primary rectal cancer at two tertiary institutions by board-certified colorectal
surgeons, 2002–2008.
RESULTS: 57 of 294 patients (19.4%) were less than 50
years of age. 28 (49.1%) were male and the mean age was
42 (24–49 years). One patient had IBD (1.8%), 12 (21.1%)
a family history of CRC and 13 (22.8%) a family history
of CRC-related cancer. No patients had personal history
of CRC or CRC-related cancer. The most common indication for colonoscopy was rectal bleeding (48%). 77.3%
of the patients with accurate preoperative stage recorded
had locally advanced tumors (>T2) and 41 out of the 57
(71.9%) received neoadjuvant treatment. When compared
to patients over 50, young rectal cancer patients were
more likely to be female (X2 = 4.63, p = 0.031), however,
there were no differences in personal history of CRC or
CRC-related cancer, family history or smoking. 20 of 41
patients with complete preoperative data had low tumors
(<6 cm from anal verge; not different than patients over
50). Younger patients were more likely to have poorly or
undifferentiated tumors (X2 = 9.276, p = 0.002); this difference remained significant in a logistic regression model
(Wald test 8.11, p = 0.004), controlling for gender and
other factors. Lymphovascular or perineural invasion and
the presence of mucin were not more commonly found
in the younger group. Six (14.6%) young rectal cancer
patients had complete response to neoadjuvant therapy;
complete and any response to neoadjuvant was not different between the groups.
CONCLUSIONS: Patients younger than 50 with rectal
cancer are more likely to have poorly or undifferentiated tumors. They may also be more likely diagnosed at
an advanced stage. Interestingly, these young patients are
not more likely to have a family history or personal history
of CRC or CRC-related cancer. These results suggest that
younger patients may have worse prognostic factors and
we should be aggressive in evaluating symptoms in young
patients regardless of their history.
Tu1758
Tumors Confined to the Presacral Space: A Diverse
Group Requiring Individualized Evaulation and
Surgery
Craig A. Messick*, Tracy L. Hull, Jorge M. Rosselli Londono,
Pokala R. Kiran
Colorectal Surgery, Cleveland Clinic Foundation, Cleveland, OH
Purpose: Tumors occurring within the presacral space are
a heterogeneous group and occur with very low incidence.
Their low incidence has led to a paucity of published experience regarding surgical approaches, recurrence rates, and
survival. This study aims to update the current literature
on these tumors from a single-center with three decades of
experience.
METHODS: Patients were identified using a combination
of a natural language search and SNOWMED codes queried from a prospectively maintained Pathology database
from 1981–2011. A retrospective chart review was conducted recording patient demographics, tumor characteristics, operative procedure, recurrence, and survival data.
Only patients ≥18 years old and with complete data were
included.
RESULTS: Presacral tumors were identified in 87 patients;
77% (67/87) female, median age at diagnosis was 44 years
(19–88), and median follow-up was 8 months (0.1–225).
Fourteen patients developed recurrence. Of the 27 different
histologic tumors diagnosed, hamartomas were the most
common (29%; n = 28) followed by both teratomas and
epidermal cysts each at 10% (n = 9). 52% (14/27) of tumor
types were malignant totaling 43% (37/87) of all tumors.
CT scans were obtained in 84% (73/87) of patients, MRI
in 59% (51/87), and TRUS in only 16% (14/87). While
74% (64/87) of tumors were at or below the S4 level,
operative approach was strictly posterior in 73% (46/63)
of those tumors (one tumor not resected). Cumulatively,
3/87 patients were treated non-operatively. 28% (24/87) of
patients had a diagnostic biopsy with no reported biopsy
site recurrences. Malignant tumors recurred in 24% (8/34),
while benign tumors recurred in 12% (6/50). Chordomas
recurred in 5/7 patients. Overall survival was 93% (81/87),
84% (31/37) for malignant tumors and 98% (49/50) for
benign tumors.
174
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1759
Histologic Types of Presacral Tumors
Hamartoma
28
Teratomas*
9
Epidermal Cyst
9
Schwannoma
7
Chordoma
7
Dermoid Cyst
4
B-Cell Lymphoma
2
Myelolipoma
2
Neuroendocrine Tumor
2
Rectal Duplication Cyst
2
Chondrosarcoma
1
Ewing’s Sarcoma
1
Fibrosarcoma
1
Fibrous Histiosarcoma
1
Ganglioneuroma
1
Gastrointestinal Stromal Tumor
1
Hemangiopericytoma
1
Liposarcoma
1
Mucinous Cystic Neoplasm
1
Pecoma
1
Neurofibroma
1
Smooth Muscle Tumor
1
Spindle Cell Tumor
1
Squamous Cell Tumor (metastasis)
1
Squamous Cell Cyst (Ovarian)
1
Diabetic Patients Take Longer to Recover Than
Non-Diabetics Within an Enhanced Recovery
Programme
Alison Luther*, Sofoklis Panteleimonitis, Peter Kang, John Evans
Northampton General Hospital, Northampton, United Kingdom
INTRODUCTION: The enhanced recovery after surgery
(ERAS) protocol encompasses a number of evidence-based
interventions designed to lessen the impact of surgery
upon the patient. It has been shown to reduce the length of
stay and improve outcomes in elective colorectal surgical
patients when compared to traditional post-operative management. NHS diabetes has recently released guidelines on
the management of adults with diabetes undergoing surgery. Despite this, no studies have assessed the impact of
diabetes on patients in an ERAS programme.
METHODS: Two laparoscopic colorectal surgeons trained
in the national Fellowship Programme were appointed in
early 2010. Consecutive patients undergoing elective major
colorectal procedures from March 2010 to September 2011
had data regarding length of stay, comorbidities and major
complications prospectively collected.
RESULTS: 143 patients were included in the study. Average age was 64 (range 21–88). The median length of stay
in the non-diabetic group was 5 days (Interquartile range
4–7.5, n = 125) whilst in the diabetic group the median
length of stay was significantly longer at 7 days (5–15.5, n =
18, P = .041, Mann-Whitney).
DISCUSSION: Diabetic patients who have elective colorectal procedures have a significantly longer length of stay in
hospital than non-diabetic patients despite being managed
with an ERAS protocol. This has implications for perioperative management of diabetic patients. It is unclear whether
the increased length of stay is due to a higher rate of major
complications or a slower return of gut function. Further
work needs to be undertaken to look at markers of gut
function in the postoperative period.
*Teratomas included those that were only teratomas (6) and those with both
adenocarcinoma (2) and carcinoid (1) components, totalling 27 different
histologic types of presacral tumors.
CONCLUSIONS: Presacral tumors remain a heterogeneous
group and continue to be a diagnostic and treatment
challenge. Even though these tumors are confined to one
space, surgeons must individualize preoperative work-up
and operative approach based on each individual patient.
A selective biopsy, which would influence treatment decisions, appears to be safe for tumors not associated with
cord lesions. Presacral tumors are rare and studies such as
this add to our understanding and guide patient recommendations regarding treatment.
Tuesday
Poster Abstracts
175
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Esophageal
Tu1760
Radiation Therapy for Locally Advanced Colon Cancer
Sekhar Dharmarajan*1, James W. Fleshman1, Robert J. Myerson2,
Bashar Safar1
1. Surgery, Washington Univ, St. Louis, MO; 2. Radiation Oncology,
Washington University School of Medicine, St. Louis, MO
Tu1761
Does Morbid Obesity Worsen Outcomes After
Esophagectomy?
PURPOSE: The surgical management of locally advanced
colon cancer is associated with higher rates of positive surgical margins, which translates to higher local recurrence
rates and reduced overall and disease-free survival. While
the use of radiation therapy in rectal cancer is well established to downstage tumors preoperatively and reduce local
recurrence, its application to patients with locally advanced
colon cancer has not been well studied. The purpose of this
study was to examine the use of radiation therapy in the
pre- and post-operative management of locally advanced
colon cancer.
METHODS: This study was conducted as a retrospective
review of patients with locally advanced colon cancer
treated with radiation therapy at a single institution from
1997 to 2008. Only patients with adenocarcinoma located
at least 15 cm above the anal verge were included in the
study. The primary endpoints of the study were ability to
achieve margin-negative resection, local recurrence rates
and overall and disease-free survival.
RESULTS: 32 patients with locally advanced colon cancer treated with RT were identified, with an average age at
presentation of 58. 6 of these patients had distant metastases at the time of presentation. 19 patients received neoadjuvant RT and 13 were treated in the adjuvant setting.
All patients received chemotherapy concurrent with RT. 1
patient developed hematologic toxicity and 6 developed GI
toxicity. 57% of cancers were located in the sigmoid colon,
36% in the right colon, and 7% in the transverse colon. Of
the 19 patients treated with preoperative RT, 18 underwent
definitive surgery and 17/18 (94%) achieved an R0 (margin
negative) resection. Of the 13 patients treated with postoperative chemoRT, 2 had positive surgical margins at the
time of resection. Pathologic staging revealed, 18 patients
had stage II disease, 8 patients had stage III disease. Average
followup was 4.33 years. The overall survival was 97%; 1
death that occurred prior to surgical intervention. The disease free survival was 69% (22/32); 2 with local recurrence
only, 6 with distant recurrence only, and 2 with both local
and distant recurrence.
Neil H. Bhayani*1, Aditya Gupta2, Valerie J. Halpin2,
Kevin M. Reavis1, Christy M. Dunst1, Lee L. Swanstrom1
1. Providence Portland Cancer Center, Portland, OR;
2. Legacy Weight Management Institute, Portland, OR
INTRODUCTION: With national and worldwide increases
in both esophageal cancer and obesity, the number of
esophagectomies in morbidly obese patients will increase.
Proper surgical risk stratification and patient counseling
require a better understanding of the esophagectomy morbidity associated with obesity.
METHODS: We studied non-emergent, subtotal or total
esophagectomies with reconstruction in the National Surgical Quality Improvement Project database from 2005–
2009. After excluding patients with disseminated disease
and with body mass index (BMI) <18.5, the outcomes of
normal BMI patients, (BMI 18.5–25) were compared to
morbidly obese patients (BMI ≥35). Outcomes were mortality, aggregated morbidity, wound, pulmonary and cardiac
morbidity. Multivariable regression controlled for pre-operative comorbidities differing between groups (p < 0.2) and
established confounders of outcomes.
Table 1. Adjusted Odds of Morbidity with Morbid Obesity
CONCLUSIONS: The use of radiation therapy in locally
advanced colon cancer is safe and potentially provides better local disease control, negative resection margins and
improved survival. Further studies are warranted in order
to delineate the role of radiation therapy in the treatment
of locally advanced colon cancer.
Adjusted Odds
Ratio
Confidence
Interval
p-Value
Death
1.1
0.7–1.7
0.8
Any Morbidity
1.1
0.9–1.3
0.2
Superficial SI
1.2
0.9–1.5
0.1
Deep SI
1.7
1.04–2.8
0.04
Organ SI
0.9
0.7–1.3
0.7
Pneumonia
1
0.8–1.2
0.7
Reintubation
1
0.9–1.3
0.7
Fail to Wean
1
0.8–1.2
0.9
PE
1.4
1.0–2.1
0.09
DVT
1.3
0.9–1.8
0.2
Cardiac Arrest
0.6
0.3–1.3
0.2
Myocardial Infarction
1.4
0.5–3.5
0.5
Bleeding
1.6
0.6–4.1
0.3
Sepsis
1
0.8–1.2
0.3
Shock
1.1
0.9–1.4
0.4
Return to OR
0.9
0.7–1.1
0.3
** compared to normal-weight patients † Adjusted for age, smoking, diabetes,
hypertension, red cell transfusion, American Society of Anesthesiologists class
≥3, and weight loss of >10%.
176
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
RESULTS: Of the 483 patients, 373 (77%) had a normal
BMI and 315 (29%) were morbidly obese. The overall population was 77% male, with a mean age of 62 years with 43%
of patients older than 65 years. Normal BMI patients were
older (p = 0.02) and more likely to smoke (37% v. 15%, p
< 0.001). Pre-operative co-morbidities were similar except
for a significantly higher incidence of hypertension (62%
v. 48%) and diabetes (24% v. 13%) and a lower incidence of
preoperative weight loss of ≥10% (11% v. 23%) in the obese
population (p < 0.001). Morbidly obese patients received
fewer red cell transfusions intraoperatively (12% v. 22%, p
= 0.02). Overall, the rate of major morbidity was 51% and
mortality was 3.5%; there was no difference between the
groups. On multivariable analysis, all outcomes were the
same between groups except deep space infections (DSI).
Morbidly obese patients were at 70% higher risk (OR 1.7,
95% CI 1.04–2.8, p = 0.04) of DSI.
RESULTS: A total of 5,851 patients underwent partial
(65.60%) and total (34.30%) esophagectomy during this
period. The mean age was similar between groups (partial:
63.3, total: 64.4 years; p = 0.07) and the majority of patients
were male (partial: 81.8%, total: 79.3%; p = 0.02) and Caucasian (partial: 84.92%; total: 87.55%; p = 0.02). Most of
the comorbidities were similar between groups (hypertension, congestive heart failure, chronic lung disease, liver
disease, renal failure, weight loss, anemia, smoking, peripheral vascular disorder and alcohol abuse). Outcome measures between groups are shown below.
Perioperative Outocomes of Partial Esophagectomy vs. Total
Esophagectomy
Outcome
Measures
CONCLUSIONS: In our study, there were no differences
in post-operative mortality or pulmonary, cardiac, and
thrombo-embolic morbidity between morbidly obese and
normal BMI patients. Morbidly obese patients had elevated
odds of deep wound infections. Overall, a BMI >35 does
not confer significant morbidity after esophagectomy.
Obese patients with esophageal pathology should not be
denied resection based on BMI alone.
Tu1762
Outcomes of Partial Versus Total Esophagectomy for
Malignancy
Hossein Masoomi*, Brian R. Smith, Michael J. Stamos,
Ninh T. Nguyen
Surgery (Colorectal Division), University of California, Irvine-Medical
Center, Orange, CA
Partial
Esophagectomy
Total
Esophagectomy
Number
3838
2013
Acute respiratory failure
(%)
23.2
32.4
Pneumonia (%)
10.3
11.3
0.25
Empyema (%)
3.5
1.8
<0.01
P-Value
<0.01
Fistula (%)
1.9
1.6
0.47
Overall complication
rate* (%)
43.0
50.7
<0.01
In-hospital mortality (%)
5.8
8.4
<0.01
Mean length of hospital
stay (days)
16.9
18.1
0.20
146,542
161,962
0.12
Mean total hospital
sharges ($)
*Patient who had at least one postoperative complication
INTRODUCTION: Despite improvement in surgical
technique, morbidity and mortality is still significant
after esophagectomy. Operative technique might be considered as an important factor in the outcomes of this
operation. This study was intended to evaluate the perioperative outcomes of partial versus total esophagectomy for
malignancy.
CONCLUSION: The most frequent procedure for esophageal malignancy is partial esophagectomy. Compared
to the total esophagectomy, partial esophagectomy was
associated with lower morbidity and lower mortality and
comparable hospital stay and hospital charges. Partial
esophagectomy may improve morbidity and mortality in
esophageal malignancy.
METHODS: Using the Nationwide Inpatient Sample (NIS)
database, clinical data of patients who underwent esophagectomy (partial or total) with the diagnosis of esophageal
malignancy including carcinoma in situ from 2006–2008
were examined. Patient characteristics, comorbidities, perioperative complications, length of stay, hospital charges
and in-hospital mortality were evaluated.
177
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu1763
Tu1764
Esophageal Perforation: Trend Towards Endoscopic
Treatment
Esophageal Stripping Creates a Clear Operative Field
for Lymph-Node Dissection along the Left Recurrent
Laryngeal Nerve in Prone Video-Assisted Thoracoscopic
Surgery of Esophagus (VATS-E)
Peter P. Grimminger*1, Till Herbold1, Hartmut SchäFer1,
Jan Brabender2, Wolfgang SchröDer1, Arnulf H. HöLscher1
1. Department of General-, Visceral- and Tumor surgery, University
Clinic Cologne, Cologne, Germany; 2. General- and Visceral Surgery,
St. Antonius Hospital, Cologne, Germany
INTRODUCTION: Esophageal perforation is rare, but
despite improvements in detection, surgical techniques,
and intensive care medicine, esophageal perforation
remains potentially fatal. For treatment of esophageal perforation, there are several treatment options. Depending
on the cause and extent of the perforation the treatment
is primary surgical, endoscopic interventional or conservative. The intention for the presented retrospective study is
to evaluate the causes and treatment in order to draw conclusions for appropriate therapy for this disease.
MATERIALS AND METHODS: Esophageal perforations
treated between 1996 and 2011 were assessed. These
were 71 patients (46 men and 25 women) with a median
age of 52 years. Clinical data was reviewed and analyzed
retrospectively.
RESULTS: Iatrogenic injury was the most frequent cause
of esophageal perforation (n = 43, 60%), followed by Boerhaave syndrome (n = 19, 27%) and traumatic perforation
caused by accidentally swallowed foreign bodies (n = 7,
10%). In two patients, the reasons were not determinable
(3%). The patients were operated in 50.7%, 25 patients
(35.2%) were treated endoscopically with stent (n = 23)
or endo-VAC (n = 2), 9 patients (12.7%) were treated conservatively with antibiotics and nasogastric tube and one
patient (1.4%) with a perforated aortic aneurism into the
esophagus died before treatment. Before 2008 operation
was performed in 57% (25/44) and after 2008 the proportion of patients who underwent surgery dropped to 41%
(11/27), while 50.2% (14/27) received endoscopic management (stent, n = 12 and endo-VAC, n = 2). The hospital
mortality was 7% (6.8% before 2008 and 7.4% after 2008).
CONCLUSION: The evaluation of the individual management of esophageal perforation in a 15 year period shows
a trend towards endoscopic treatment, with low mortality.
Hiroshi Makino*1,2, Hiroshi Yoshida1, Tsutomu Nomura2,
Takeshi Matsutani2, Nobutoshi Hagiwara2, Tadashi Yokoyama1,
Atsushi Hirakata1, Masao Miyashita2, Eiji Uchida2
1. Surgery, Nippon Medical School, Tama-Nagayama Hospital,
Tokyo, Japan; 2. Gastro-Enterological Surgery, Nippon Medical
School, Tokyo, Japan
INTRODUCTION: Video assisted thoracoscopic surgery of
the esophagus (VATS-E) in prone position is remarkable in
Japan because the lung moves below by the gravity, and
a good operative field is obtained. A clear operative view
of the middle and lower mediastinum has been obtained;
however, the working space in the upper mediastinum is
limited.
PATIENTS: Twenty patients in left lateral position and
17 patients in prone position, with esophageal squamous
cell carcinomas underwent VATS-E since 2005 and 2009,
respectively.
METHODS: At first the patients are fixed at semi-prone
position because both prone and left lateral positions can
be set by rotating. Three 5 mm ports and two 10 mm ports
are used at the 3rd, 7th, 9th and 5 th, 9th intercostal space
(ICS). The pneumothorax by maintaining CO2 insufflation
pressure of 6 mmHg is made, and esophagectomy is performed in prone position. In the case of emergent thoracotomy the patient will be rotated to the left lateral position.
The lymph nodes around the trachea and bronchus, above
the diaphragm and along the bilateral recurrent laryngeal
nerves are dissected. Working space at the left upper mediastinal area for lymph nodes dissection around recurrent
laryngeal nerve is limited in prone position. To obtain
the space the residual esophagus is stripped in the reverse
direction and retracted toward the neck after the stomach
tube is removed through the nose.
RESULTS: 1. Mean estimated blood loss was 166 ml of
chest procedure in prone position. 2. The rate of recurrent
laryngeal nerve paralysis was 11.7% (2/17), and anastomotic leak and postoperative pneumonia was 5.8% (1/17),
respectively. 3. There was no incidence of conversion to
open method. 4. Lymphadenectomy along the left recurrent laryngeal nerve after esophageal stripping is available
in prone position of VATS-E.
CONCLUSION: Our result indicates that esophageal stripping in prone VATS-E allows for safe and straight forward
lymph node dissection along the left recurrent laryngeal
nerve. Our technique overcame the difficulty of the lymph
node dissection along the left recurrent laryngeal nerve in
prone position.
178
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1765
METHODS: Patients with GERD confirmed by pHmonitoring and manometric pattern of DES (simultaneous contractions 20–90% of wet swallows), NE (increased mean
distal amplitude greater than 180 mmHg), or HLES (lower
esophageal sphincter pressure greater than 45 mmHg) that
underwent LNF were studied. A group of 50 consecutive
patients with normal esophageal motility that underwent
LNF were used as controls. Groups were comparable to controls for age, gender, pre-operative symptoms, hiatal hernia
and barrett s esophagus, except for NE that had younger
individuals (Table 1).
Outcomes of Laparoscopic Nissen Fundoplication
in Patients with Manometric Patterns of Esophageal
Motility Disorders
Bruna D. Cassao1, Fernando A. Herbella*1, Jose F. Farah1, Adorisio
Bonadiman1, Luciana C. Silva1, Alberto Goldenberg1, Marco G.
Patti2
1. Surgery, Federal University of São Paulo, São Paulo, Brazil; 2.
Department of Surgery, University of Chicago, Chicago, IL
INTRODUCTION: Manometric pattern of either diffuse
esophageal spasm (DES), nutcracker esophagus (NE), or
hypertensive lower esophageal sphincter (HLES) can be
considered a primary esophageal motility disorder only in
the absence of gastroesophageal reflux disease (GERD). If
GERD is present, the motility abnormality is considered
secondary, and treatment is directed toward reflux. This
study aims to evaluate the outcomes of laparoscopic Nissen
fundoplication (LNF) in patients with manometric patterns
of esophageal motility disorders.
RESULTS: Symptomatic outcome was similar when groups
were compared to controls (Table 2).
CONCLUSION: LNF is an adequate treatment for patients
with GERD and manometric patterns of esophageal motility disorders.
Table 1. Preoperative Data
N
Age
(Years)
% Females
Dysphagia
Esophageal
Symptoms
Hypertensive Les
3
57
66
66
100
Diffuse Spasm
14
52
50
15
86
Extra-Esophageal
Symptoms
% Barrett’s
Esophagus
% Hiatal
Hernia
0
0
66
29
29
86
Nutcracker
13
46
61
15
100
23
8
69
Controls
50
57
64
14
84
28
10
88
Table 2. Postoperative Data
Follow-Up (Months)
Dysphagia
Esophageal Symptoms
Extra-Esophageal Symptoms
Hypertensive Les
21
33
0
0
Diffuse Spasm
32
7
7
7
Nutcracker
25
0
8
8
Controls
36
20
18
2
179
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Prognostic Factors of Very Long-Term Survival and
Causes of Death in Early Esophageal Adenocarcinoma
Juha T. Kauppi1, Ines Gockel2, Tuomo Rantanen1,
Torsten Hansen3, Ari RistimäKi4, Hauke Lang2, Theodor
Junginger2, Jarmo A. Salo*1
1. Division of General Thoracic and Esophageal Surgery, Department
of Cardiothoracic Surgery, Helsinki University Central Hospital,
Helsinki, Finland; 2. Department of General and abdominal Surgery,
University Medical Center, Mainz, Germany; 3. Institute of Pathology,
University Medical Center, Mainz, Germany; 4. Department of
Pathology, HUSLAB, Helsinki University Central Hospital and
Haartman Institute and Genome-Scale Biology Research Program,
University of Helsinki, Helsinki, Finland
PATIENTS AND METHODS: 85 patients (p) (36 women
and 49 men, median age 72, range 40–94) without neoadjuvant treatment were operated on because of EEAC
(pT1N0-1, M0) between 1984–2011. Autopsy records and
death certificates were acquired. Medical and pathology
reports were reviewed and 75 (88%) specimens could be
reanalyzed for cancer penetration by two experienced
pathologists (HT and RA). Survival was calculated according to Kaplan-Meier and the Cox regression proportional
hazards model. 39 p had transhiatal, 36 transthoracic enbloc, 5 vagal-sparing esophageal resection and, 5 solely
endoscopic mucosal resection.
RESULTS: Cancer penetration: pT1a in 33 p and pT1b in
42 p. Overall survival probability: 67.7% at 5, 49.2% at 10,
41% at 20 years. Disease specific survival: 78.3% at 5, 72.3%
at 10 years. Lymph-node metastasis: (HR 7.9 [95%CI 2.53–
24.78] p < 0.0001 and Sm2–3 infiltration (HR 4.85 [95% CI
1.36–17.3] p = 0.015) showed worse prognosis. Cumulative
mortality: 33/85 (38.8%). Cause of death: esophageal adenocarcinoma (EAC) 13 (39.4%), secondary malignancy 5
(15.2%), cardiovascular 3 (9.1%), miscellaneous 9 (27.2%).
Lowest number of EEAC-deaths in patients with infiltration depth pT1a and pT1b (Sm1): 4 p (12.1%).
CONCLUSION: Patients with intramucosal and superficial submucosal (Sm1) cancer infiltration die mostly not
of EEAC. Less invasive therapy may be sufficient in this
group. For patients with deeper cancer infiltration (Sm2Sm3) more radical treatment options should be considered.
Tu1767
Laparoscopic Ischemic Conditioning as a Modality
to Reduce Gastric Conduit Morbidity Following
Esophagectomy
Laparoscopic Ischemic Conditioning As a
Modality to Reduce Gastric Conduit Morbidity
Following Esophagectomy
Marco Zahedi*1, Sabha Ganai2, Amy K. Yetasook1, Mark Talamonti1,2,
Michael B. Ujiki1,2, Joann Carbray1, John Howington1,2
1. Surgery, NorthShore University HealthSystem, Evanston, IL;
2. Surgery, University of Chicago, Chicago, IL
INTRODUCTION: Several complications after esophagectomy with gastric pull-up are associated with ischemia
within the gastric conduit. We aimed to assess conduit
morbidity in a two stage operation involving laparoscopic
ischemic preconditioning of the stomach prior to esophagectomy and gastric pull-up, compared to a single stage
operation.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
METHODS: We conducted a retrospective review comparing conduit morbidity of 63 consecutive patients who
underwent an esophagectomy for Stage I-III esophageal
cancer. Twenty three patients received pre-conditioning,
which included laparoscopic ligation of the left and short
gastrics, celiac node dissection, and jejunostomy tube
placement, followed by formal resection and reconstruction between 3–9 days later. Forty patients underwent
thoracotomy, esophagectomy and gastric pull-up without
pre-conditioning.
RESULTS: The two groups were similar with respect
to gender and mean age. More patients in the preconditioned group received neoadjuvant therapy (88% vs 40%,
p < 0.0001). There were no conversions to open in the
pre-conditioned group. Mean time interval between the
conditioning procedure and esophagectomy was 6.6 ± 1.5
days. Seventeen percent of the preconditioned group demonstrated ischemic changes along the fundus leading to
modification of the planned transection line. There were
significantly less post-operative strictures in the preconditioned group (8% vs 32%, P < 0.03), and a trend toward
less anastomotic leaks (13% vs 26%, P < 0.20), and delayed
gastric emptying (25% vs 45%, P < 0.12). There was no statistical difference between groups in terms of morbidity or
mortality. Mean follow-up in months was 11.4 ± 8.9 in the
preconditioned group, and 26.0 ± 27.6 (P < 0.02) in the
single-stage group.
CONCLUSIONS: Laparoscopic ischemic conditioning
results in less strictures and a trend toward less gastric conduit morbidity (anastomotic leaks, delayed gastric emptying) when compared to single-stage esophagectomy and
gastric pull-up.
PATIENTS AND METHODS: Data of 1127 patients with
esophageal cancer presenting from 2000 to 2008 at the
Regional Center of the Esophageal Diseases were prospectively collected. Detailed anthropometric data about the
BMI before the disease onset were available for 464 patients
who were then included in this study. Sixty seven of them
were classified as obese (BMI >30), 199 were classified as
overweight (BMI 25–29.9) and 168 were classified as normal weight (BMI <24.9). Outcome and survival of the three
groups were compared. Frequency and survival analysis
were preformed.
RESULTS: Overweight and obese patients with esophageal cancer were more often male (p < 0.01), they tended
to have more frequently multiple tumours (p = 0.06) and
they more often suffered high blood pressure (p < 0.01)
than normal weight patients. Adenocarcinoma was more
frequent in overweight and obese patients (p < 0.01). No
significant difference was observed among the three groups
in term of preoperative neoadjuvant therapy, type of operation, radicality of the esophagectomy and postoperative
outcome. Nodal metastasis were more frequently localized
in paraesophageal nodes in overweight and obese patients
(p = 0.01). No significant difference was observed among
the three groups in term of disease free survival. At multivariate survival analysis the only independent predictors
of overall survival after radical esophagectomy were a BMI
between 25 and 29.9 [HR = 0.63 (0.43–0.93), p = 0.02], pT
stage 3 or 4 [HR = 2.13 (1.34–3.26), p < 0.01] and pN 1 status [HR = 1.84 (1.20–2.82), p < 0.01].
CONCLUSION: This data seem to suggest that in spite of
several unfavorable features a moderate increase of weight
may be associated to increased long-term survival after
esophagectomy for cancer.
Tu1768
Overweight Patients Operated on for Cancer of the
Esophagus Survive Longer Than Normal Weight and
Obese Patients
Marco Scarpa*1, Matteo Cagol1, Silvia Bettini2, Rita Alfieri1,
Amedeo Carraro1, Francesco Cavallin1, Elisabetta Trevellin2,
Alberto Ruol3, Roberto Vettor2, Ermanno Ancona3,1, Carlo
Castoro1
1. Oncological Surgery Unit, Venetian Oncology Institute (IOV-IRCCS),
Padova, Italy; 2. Department of Medical and Surgical Sciences,
University of Padova, Padova, Italy; 3. Department of Surgical and
Gastroenterological Sciences, University of Padova, Padova, Italy
BACKGROUND: Esophageal adenocarcinoma is often
associated to obesity and the relative risk to develop an
esophageal adenocaricoma is 1.52 if the Body Mass Index
(BMI) is increased of 5 Kgm-2. The aim of this study was
to assess the surgical and oncological outcome and the
survival of overweight and obese patients with esophageal
cancer.
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Tu1770
Esophageal Failure and Refractory Dysphagia
Following Roux-en Y Esophagojejunostomy
Esophageal Perforation: Review of Outcomes from a
Single-Institution Series
Alfredo Amenabar*, Toshitaka Hoppo, Omar Awais, Blair A. Jobe
Cardiothoracic Surgery, University of Pittsburgh Medical Center,
Pittsburgh, PA
Hugo Santos-Sousa*1, Tiago Bouca-Machado1, Attila Dubecz2,
André GonçAlves1, John Preto1, José Barbosa1, José Costa-Maia1
1. Esophageal and Gastric Surgery Unit, General Surgery Department,
Centro Hospitalar de São João/Faculty of Medicine, University of
Porto, Porto, Portugal; 2. General, Visceral and Thoracic Surgery
Department, Klinikum Nord Nuremberg, Nuremberg, Germany
BACKGROUND: Roux-en-Y esophagojejunostomy (RYEJ)
is an effective treatment option in some patients with
complicated gastroesophageal reflux disease (GERD). Postoperative dysphagia is common, and is most often caused
by mechanical problems such as stricture or bowel obstruction; however some patients develop refractory dysphagia in the absence of mechanical obstruction and do not
respond to empiric dilation. The objective of this study was
to evaluate the patients who underwent RYEJ and subsequently developed dysphagia, and assess the etiology of
dysphagia.
METHODS: This is a retrospective review of patients
who had undergone RYEJ to treat GERD following prior
upper gastrointestinal surgery. Prior to RYEJ, all patients
underwent esophageal physiology testing including upper
endoscopy, high-resolution manometry (HRM) and pH
testing. Patients who developed postoperative dysphagia
underwent both radiographic and endoscopic assessment
to evaluate stricture formation and bowel obstruction, and
subsequently underwent dilation (empiric or therapeutic).
Patients who were un-responsive to dilation in the absence
of mechanical obstruction, underwent HRM combined
with antegrade impedance using both liquid and paste
(pudding) to assess esophageal motility as a possible etiology of dysphagia.
RESULTS: From July 2009 to July 2011, 13 patients underwent RYEJ, 10 of whom had prior surgery including Nissen fundoplication (n = 2), vertical banded gastroplasty
(n = 3), Heller myotomy with Dor fundoplication (n = 1),
gastric bypass (n = 3) and Billroth II gastrectomy (n = 1).
Mean age and BMI were 55.3 years (range, 44–66 years) and
34.3 (range, 26.3–48.1), respectively. Eight of 13 (61.5%)
patients developed dysphagia after RYEJ. No patients had
radiographic evidence of small bowel obstruction. Upper
endoscopy demonstrated anastomotic stricture (n = 8) or
roux limb narrowing within the transverse mesocolon (n
= 2), which was successfully treated with dilation. Three
patients had incapacitating dysphagia with regurgitation
in the absence of mechanical obstruction. HRM demonstrated esophageal primary peristaltic failure as evidenced
by low mean wave amplitude ordered contractions and
dropped peristaltic waves. All three patients had 100%
incomplete bolus clearance with paste and this correlated
with symptom of dysphagia. Two of three patients underwent esophagectomy with neck anastomosis and had complete symptom resolution.
CONCLUSION: For patients with non-obstructive, dilation refractory dysphagia following RYEJ, HRM combined
with antegrade impedance testing using a defined liquid
and paste protocol with symptom correlation is effective
in determining etiology. Esophagectomy is an effective
treatment option in this setting but long-term follow-up
is required.
BACKGROUND: Esophageal perforation is an important
therapeutic challenge. The aim of this study was to review
the outcomes of esophageal perforations treated by a specialized unit in esophageal surgery.
METHODS: We performed a retrospective review of 52
consecutive patients with non-neoplasic esophageal perforation, between January 1991 and December 2008.
Demographics, cause and location of perforation, time of
diagnosis, management results and outcomes were evaluated. The management and outcomes trends over time
were evaluated. For that, the cases were catalogued in three
groups of 6 consecutive years.
RESULTS: Spontaneous perforation occurred in 9 (17,3%)
patients. Iatrogenic perforations were present in 15 (28,8%)
patients and 28 (53,8%) patients had traumatic perforations. In half of the patients diagnosis was done in the
first 24 hours. The perforation’s location was cervical in 14
(26,9%) cases, thoracic in 31 (59,6%) and abdominal in 7
(13,5%). The traumatic perforations were diagnosed significantly later than the other causes (p = 0,02). In 9 patients
(17,3%) the treatment was non-operatively. For the patients
submitted to surgery (82,7%), a primary repair was done in
23 cases (53,5%), a bipolar exclusion was performed in 18
(41,9%) and a conservative operative approach (drainage
only) performed in 2 (3,8%). There were significant differences in the type of operative treatment according to
the location (p = 0,035) [thoracic perforations were more
times treated with bipolar exclusion]. In the analysis of
the trends over time, there were significant differences in
the location (p = 0,027) and the type of management (p =
0,012) [more patients treated surgically with primary repair
in the last periods]. The morbidity and mortality rates were
46,2% and 13,5%, respectively. There were significant differences in morbidity according to the cause of perforation
(p = 0,047) [the iatrogenic perforations had less morbidity] and the type of management (p = 0,041) [the patients
treated conservative either operatively or non-operatively
had lower morbidity rate], but only the type of management was an independent risk factor in the logistic regression analysis (OR 0,071, CI95% 0,007–0,696, p = 0,003).
There were significant differences in mortality according
to the age (p = 0,022) [older patients with higher mortality
rate] and age was an independent risk factor in multivariate
analysis (OR 1,095, CI95% 1,003–1,196, p = 0,005). There
weren’t significant differences in morbidity and mortality
rate over time.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
CONCLUSION: An approach to esophageal perforation
based on injury severity and the degree of mediastinal
and pleural contamination is of paramount importance.
Although operative management remains the standard in
the majority of patients with esophageal perforation, nonoperative management may be successfully implemented
in selected patients with a low morbidity rate.
Tu1771
Comparative Manometric Characteristics of 3
Anti-Reflux Operations
Alia Qureshi*1, Ralph W. Aye1, Brian E. Louie1,
Alexander S. Farivar1, Ariel Knight1, Lee L. Swanstrom2
1. Swedish Medical Center, Seattle, WA; 2. Legacy Health, Portland, OR
BACKGROUND: The impact of antireflux operations on
esophageal motility and lower esophageal sphincter characteristics is incompletely understood. Comparing the
manometric features of various repairs may provide insight
through differences and similarities.
MATERIALS AND METHODS: 153 patients with gastroesophageal reflux and/or hiatal hernia underwent one
of 3 laparoscopic operations at 2 institutions through 1 of
2 IRB-approved prospective protocols evaluating Nissen
fundoplication (NF), Hill repair (HR), or a combination of
Nissen plus Hill hybrid repair (NH). Clinical and objective
testing and quality of life metrics were administered preoperatively and at 6–12 month follow-up. Ninety patients
underwent pre-and post-operative manometry (NF = 27;
HR = 37; NH = 26).
RESULTS: Manometric results are listed in the table. Postoperative lower esophageal sphincter pressure (LESP) was
increased significantly for NF and NH but not HR; residual
LESP was highest in NF. DeMeester scores were equivalent,
NF = 6.58; HR = 10.89, NH = 7.3. Postoperative quality of
life scores were equivalent, NF = 6.24; HR = 6.24; NH = 6.69;
Postoperative dysphagia scores were better for NH, 43.0 vs
NF = 37.2 and HR = 38.1 (p = 0.019). Postoperative medication use was less for NH, 2.4% vs NF = 19.5% and HR =
17.0%.
CONCLUSIONS: Combining NF and HR in one operation results in manometric lower esophageal sphincter
characteristics that are similar to the individual component repairs, with low medication use and reduced longterm dysphagia. This suggests that there may be benefit to
intra-abdominal fixation of the gastroesophageal junction
Further study of the relative contributions of the fundoplication and the diaphragmatic repair are warranted.
Trivariate Manometric Comparisons
Preoperative
NF (N = 46)
Preoperative
HR (N = 55)
Preoperative
NH (N = 43)
P Value
Postoperative NF
Postoperative HR
Postoperative NH
p Value
Average LESP
(mmHG)
14.3
18.2
18.5
0.152
26.3
19.3
23.2
0.027
Average residual
LESP (mmHg)
4.6
9.48
4.6
0.059
14.7
8.5
11.1
0.042
Average mean distal
amplitudes (mmHg)
75.6
85.4
72.3
0.238
81.6
99.0
76.1
0.074
Peristalsis normal
92%
92%
84%
79%
87%
77%
Peristalsis moderate
dysfunction
4%
4%
9%
7%
8%
23%
Peristalsis severe
dysfunction
4%
4%
7%
14%
5%
0%
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Tu1773
The Influence of Postoperative Complications
on Recurrence and Long-Term Survival After
Esophagectomy for Esophageal Cancer
Fully Covered Self Expanding Removable Metal
Stents Are Effective for Esophageal Fistulas, Leaks,
Perforations and Benign Strictures
Arzu Oezcelik*1,2, Shahin Ayazi1, Steven R. Demeester1,
Joerg Zehetner1, Jeffrey A. Hagen1, Tom R. Demeester1
1. Surgery, University of Southern California, Los Angeles, CA;
2. General, Visceral and Transplantation Surgery, University of Essen,
Essen, Germany
Jennifer L. Kramer*, Alexander S. Farivar, Eric VallièRes,
Ralph W. Aye, Brian E. Louie
Swedish Medical Center and Cancer Institute, Seattle, WA
BACKGROUND: The aim of this study was to identify factors associated with postoperative complications and to
evaluate whether the severity of postoperative complications as classified using the Clavien classification was associated with cancer recurrence and survival.
METHODS: The records of all patients who underwent an
esophagectomy for cancer between 2002 and 2007 were
reviewed. Postoperative complications were graded using
the Clavien Classification, and scored from minor (GradeI) through the most serious (GradeIV). We defined major
complications as those ≥ Grade IIIb.
RESULTS: The study population consisted of 422 patients
with a median age of 63 years. Neoadjuvant therapy was
given in 94 patients (22%). En bloc, transhiatal and minimally invasive esophagectomies were performed. Postoperative complications occurred in 191 patients (45%).
Complications were considered minor (Clavien Grade I-IIIa)
in 116 (27%) and major (Grade IIIb or IV) in 75 (18%). On
multivariate analysis, increasing age, stage, blood transfusion and Clavien classification ≥ Grade IIIb complications
were independent negative predictors of survival. Factors
associated with cancer recurrence included tumor stage,
blood transfusion and major postoperative complications.
Factors associated with Clavien Grade IIIb or higher complications included increasing age and blood transfusion.
Neoadjuvant therapy, tumor stage and type of resection
were not associated with postoperative complications.
CONCLUSION: The study suggests that in addition to
known prognostic factors such as tumor stage, the occurrence of major complications are associated with a higher
frequency of recurrence and decreased survival after
esophagectomy for cancer. Esophagectomy should be done
in experienced centers where major complications are
minimized.
PURPOSE: Expandable plastic stents are the only stent
approved for benign esophageal disease. However these
stents are prone to migration and inadequate leak control.
The self-expanding design of fully covered metal stents
(CS), approved for malignancy only, is ideally suited for
benign esophageal disease. Not only are they removable,
but the continued radial force may reduce migration, result
in durable stricture resolution and effect control of fistulas,
leaks and perforations. We reviewed our experience with
CS in 2 groups: benign strictures and fistulas/leaks/perforations to evaluate our outcomes and define the role of CS in
the treatment algorithms these complex problems.
METHODS: Chart review of all stents inserted for fistulas, leaks, perforations, and benign strictures from 2005 to
2011.
RESULTS: A total of 56 CS were placed in 39 patients. Indications were stricture (14), anastomotic leak (12), perforation (4), staple line leak (4), fistulas (4) and other (1). There
was no procedural mortality. There were complications in
32%: 10 stent migrations, 3 upper GI bleeds, 4 impactions
and 1 erosion.
Benign Stricture Group: Strictures had been previously
dilated a median of 2.5 times prior to stenting in 13/14
patients. Stents were removed at a mean of 25 days. At a
mean of 219 days of follow up, strictures remained patent. Eleven patients were managed with a single stent but
3 patients required sequentially larger stents to achieve
patency. Adjunctive intralesional steroids were used in
11/14 patients.
Fistula/Leak/Perforation Group: Control of the disruption
was achieved in 79% of patients with fistulas (3/4), leaks
(12/16) and perforations (4/4), but needed to be combined
with drainage, VATS or laparoscopy in 12/24 leaks. All disruptions healed but 13/24 had to remain NPO during this
time. Stents were removed at a mean of 42 days in this
group.
CONCLUSIONS: CS are effective in the management of
benign refractory strictures, fistulas, leaks, and perforations. A CS with intralesional steroids is an alternative to
serial dilations for stricture. Whereas fistulas, leaks and perforations when combined with minimally invasive drainage, may avoid open repair or even salvage a prior open
repair. CS are well tolerated and removable, with acceptable
complication rates and have a low migration rate.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1774
Tu1775
Predictors of Complicated Diaphragmatic Hernia
Pathologic Response in Esophageal Cancer Does
Not Necessarily Correlate with Improved Survival
Roman Grinberg*, Muhammad Asad Khan, John Afthinos,
Karen E. Gibbs
Surgery, Staten Island University Hospital, Staten Island, NY
OBJECTIVE: Due to their relatively infrequent occurrence,
it has been historically difficult to predict which patient
with a diaphragmatic hernia (DH) will go on to either
obstruct or strangulate and result in a surgical emergency.
Given that patients with DH tend to be older and have
multiple comorbidities, avoiding such an emergent situation would be beneficial. Our goal was to define potential
comorbidities which could predict the likelihood of developing a complicated diaphragmatic hernia.
METHODS: Using the NSQIP database, we identified all
diaphragmatic hernias and grouped them by ICD9M code
as either uncomplicated (553.3—without obstruction or
gangrene) or complicated (551.3—with gangrene,552.3—
with obstruction). Preoperative comorbidities, operative
time, length of hospitalization and perioperative mortality and morbidity were compared between the two groups
using chi-square and independent t-test as appropriate. A
multivariate regression analysis was used to analyze potential factors contributing to obstruction or strangulation.
Logistic regression was used to select correlates of 30 day
mortality that were subsequently weighted and integrated
into a scoring system based on the number of comorbidities.
RESULTS: We identified 4778 patients, of which 4059
(85%) had an uncomplicated DH and 719 (15%) who had a
complicated DH. The mean age for uncomplicated DH was
statistically less than for a complicated DH (62.2 ± 14.1 vs
66.9 ± 15.2, p < .001). Independent predictors associated
with a complicated DH included dyspnea at rest (AOR 2.9),
partially or totally dependent functional status (AOR 4.4
and 7.1), CHF (AOR 4.3), history of MI (AOR 7.97) and >10%
weight loss (AOR 1.82). Active smoking, alcohol consumption, dyspnea at exertion and use of steroids had no significant association. Risk stratification based on the number
of preoperative comorbid factors demonstrated a step-wise
increase in the rate of complicated DH: 12.1% (0–2 comorbidities), 21.5% (3–4 comorbidities), and 38.5% (≥5 comorbidities). Analysis of perioperative outcomes revealed that
the mortality rate in the complicated DH group is much
higher when compared to that of the uncomplicated DH
group (5.1% vs 0.7%, P < .001). The same is true for the
reoperation rate (6.3% vs 3.2%, p < .001) and length of stay
(9.1+9.6 d, vs 4.1+6.7 d, p < .001).
Veeraiah Siripurapu*, Amit S. Khithani, John Jay,
Dhiresh R. Jeyarajah
Surgery, Methodist Dallas Medical Center, Dallas, TX
INTRODUCTION: Esophageal cancer presents with a
high mortality amongst the solid tumors with a threefold
increase in the incidence of adenocarcinoma in recent
decades. Despite the use of better diagnostic and staging
modalities such as EUS and PET- CT, treatment of locally
advanced tumors is associated with a poor survival. We
aim to see if preoperative treatment with chemo-radiation
has improved survival in those patients who respond compared to those who do not.
METHODS: All esophageal surgeries performed cooperatively by two surgeons between 2005 to 2010 were retrospectively reviewed. Only those patients deemed locally
advanced (>T2, Node positive) who received preoperative
chemoradiation were included for analysis. All patients
were staged by CT & endoscopic ultrasound.
RESULTS: 52 patients were identified, with 5 patients
excluded due to outside institution referral. Of the 47
patients, 38 (81%) had adenocarcinoma versus 9 patients
(19%) who had squamous cell carcinoma. Majority of the
patients received Paclitaxel, Carboplatin and 5FU with radiation. The operative surgery was either a minimally invasive or open transhiatal esophagectomy with no difference
in survival (p = 0.09). There were 2 operative mortalities
and no anastamotic leaks. Patient response to chemotherapy was designated either as No response, Partial response
or complete pathologic response (cPR). 21 patients (45%)
had no response, 9 ( 19%) had partial response, while 17
patients (36%) had a cPR. Median survival was respectively
22 months, 23 months and 27 months (p = 0.53) (see Fig2).
CONCLUSIONS: Preoperative treatment with esophageal
cancer can lend to a high complete pathologic response.
Despite the encouragement of a cPR, this data would suggest that this does not translate to an improvement in
survival.
CONCLUSION: This tool provides a simple, accurate and
easily applicable method for predicting a complicated DH.
Of note, history of a prior MI and dependent functional
status most strongly predicted a complicated diaphragmatic hernia. Our findings suggest that if patients with
uncomplicated DH are discovered and have a high score,
elective repair should be sought expeditiously to avoid a
life-threatening emergency. More studies are needed to further evaluate the timing of the progression from diagnosis
of an uncomplicated DH to complication.
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Tu1776
Clinical: Hepatic
Does FDG-Uptake on PET-CT Provide Additional
Prognostic Information for Patients with Esophageal
Carcinoma?
Tu1777
Preoperative Chemotherapy, Histological Tumor
Regression and Long-Term Outcome After Resection
of Colorectal Liver Metastasis
David Bowrey, Sukhbir Ubhi, Claire N. Brown*
Surgery, University Hospitals of Leicester NHS Trust, Leicester,
United Kingdom
BACKGROUND: Several previous studies have reported
that the FDG standardised uptake value (SUVmax) on PETCT imaging may be a useful prognostic marker. The majority of these studies have assessed selected populations. The
aim of this study was to report the influence of FDG SUVmax on the outcome of an unselected cohort of patients
undergoing PET-CT for esophageal carcinoma.
METHODS: The SUVmax was determined for 105 patients
undergoing PET-CT during the time period 2007–10.
Patients were subdivided into quartiles according to SUVmax and its influence on prognosis assessed by univariate
and multi-variate analysis.
RESULTS: The study population was 105 patients (77 male)
of median age 65 years (range 41–83). Histology was adenocarcinoma in 77 patients, squamous carcinoma in 28.
Treatment intent was curative for 64 patients (resection 31,
radical chemoradation 31, endoscopic mucosal resection 2)
and palliative for the remaining 41 patients. On univariate analysis, SUVmax was not influenced by sex (p = 0.08),
age (p = 0.19), histology (p = 0.81) or tumor site (p = 0.07),
but was heavily linked to UICC stage (p < 0.001). Survival
was significantly associated with quartile of SUVmax score
(p = 0.03). This effect disappeared on multivariate analysis because prognosis was so strongly linked to UICC stage
(p = 0.01). However, subgroup analysis identified that for
patients treated by radical chemoradiation, UICC stage (p =
0.002) and SUVmax (p = 0.01) were the only factors linked
to prognosis.
CONCLUSIONS: This study did not confirm the FDG SUVmax on PET-CT to offer additional prognostic information
for most patients with esophageal carcinoma. It may be
helpful in patients treated by primary chemoradiation.
Frank Makowiec*1, Peter Bronsert2, Gerald Illerhaus3, Tobias
Keck1, Oliver Drognitz1, Hannes P. Neeff1, Ulrich T. Hopt1
1. Department of Surgery, University of Freiburg, Freiburg, Germany;
2. Pathological Institute, University of Freiburg, Freiburg, Germany;
3Department of Oncology, University of Freiburg, Freiburg, Germany
INTRODUCTION: In patients with colorectal liver metastases (CRC-LM) preoperative chemotherapy (preCTx) is frequently used in a perioperative setting and/or to downsize
irresectable CRC-LM. Especially in the perioperative setting,
however, the exact role of preCTx is not well defined. To
improve patient selection for preCTx factors predicting
response and/or prognosis should be identified. In our study
we analyzed the pathohistological response to preCTx in
almost 150 patients who had had any form of CTx before
liver resection, and correlated this response with survival.
METHODS: We could evaluate the outcome of 147 patients
who had hepatic resection for CRC-LM during the last
decade in our institution, with pathohistological assessment
of tumor regression grade (TRG) of metastatic disease and
sufficient follow-up. Preoperatively the patients had undergone various regimens of CTx (42% FU-based, 40% Oxaliplatin and/or Irinotecan, 18% CTx plus antibodies/targeted
therapy). 55% of the resections were at least a hemihepatectomy, 45% segmental or wedge resections. Free hepatic margins were achieved in 90%, free overall margins (including
extrahepatic disease) in 81%. For this study all pathological
specimens were reanalysed to classify TRG (grade 1 = total
regression to grade 5 = no regression/vital tumor). Survival
was estimated by Kaplan-Meier- and Cox-methods.
RESULTS: Only 3% of the patients showed TRG grade 1
(total regression), 28% had good or moderate regression
(TRG 2/3), and 69% had minor or no regression (TRG 4/5).
TRG was better after CTx + targeted therapy (11% TRG1,
33% TRG 2/3; p < 0.01 vs CTx alone). TRG was also better in patients receiving more than 6 months of preCTx
(p < 0.03 vs preCTx < 6 months). Overall 5 year survival
(5y-Surv) was 42%. 5y-Surv was formally 100% in the few
patients with total tumor regression (TRG 1), but comparable in the groups with TRG2/3 or TRG 4/5 (44%/38%;
p = 0.1). In univariate and multivariate analysis in this
subgroup of 147 patients with assessment of TRG only the
hepatic margin (p < 0.01) or the overall margin (p < 0.001)
significantly influenced survival. Type and duration of preCTx, extent of hepatic resection, nodal disease of primary
CRC, number and size of metastases, and gender did not
influence survival.
CONCLUSION: Only few patients with preoperative chemotherapy show total regression of the resected colorectal liver metastases. Addition of targeted therapy to CTx
may enhance pathohistological tumor regression. Total
response to preoperative chemotherapy may be associated
with a clearly improved prognosis.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1779
Clinical: Pancreas
Impact of Non-Alcoholic Fatty Liver Disease on
Long-Term Survival for Resected Intrahepatic
Cholangiocarcinoma
Tu1780
Role of Endoscopic Retrograde Pancreatography
to Detect Early Pancreatic Ductal Adenocarcinoma
Concomitant with Intraductal Papillary Mucinous
Neoplasm of the Pancreas
Clancy J. Clark*1, Shahzad M. Ali1,2, Victor M. Zaydfudim1,
Michael L. Kendrick1, Kaye M. Reid Lombardo1, John H.
Donohue1, Michael B. Farnell1, David M. Nagorney1,
Florencia G. Que1
1. Gastroenterologic and General Surgery, Mayo Clinic, Rochester, MN;
2. 2nd Department of Internal Medicine, University Hospital and
Faculty of Medicine, Hradec Kralove, Czech Republic
BACKGROUND: Non-alcoholic fatty liver disease (NAFLD)
leads to a chronic inflammatory state hypothesized as carcinogenic. The clinical significance of NAFLD for patients
diagnosed with ICC is not known. The aim of this study
was to evaluate the significance of NAFLD on overall survival (OS) for patients with ICC.
METHODS: In this single-institution, retrospective cohort
study, all patients who underwent curative resection for ICC
from 1997 to 2011 were identified. NAFLD was defined as
pathologic evidence of steatosis or steatohepatitis in uninvolved liver parenchyma at time of resection or preoperative liver biopsy. Patients with clinical history or pathologic
evidence of underlying liver disease other than NAFLD (n
= 17) and patients who died of perioperative complications
(n = 2) were excluded from survival analyses. Kaplan-Meier
estimates and Cox regression proportional hazards were
used to evaluate predictors of OS.
RESULTS: One-hundred and thirty-eight patients (median
age 60.5; 39.9% male) underwent curative resection for ICC
with pathologic evidence of NAFLD in 18 (13.0%) patients.
Median follow-up was 29 months (IQR 43) and median
OS was 55 months. Age, sex, ASA, MELD score, CA 19–9,
and BMI were similar between NAFLD and non-NAFLD
patients. AJCC 7th Edition T-Stage was significantly lower
in NAFLD patients compared with non-NAFLD patients: T1
50% vs 44%; T2a 22% vs 2.5%; T2b 6% vs 23%; T3 11% vs
13%, and T4 11% vs 18% (p = 0.02). However, AJCC 7th
Edition TNM Stage was not significantly different between
NAFLD and non-NAFLD patients (p = 0.56). In univariate
analysis, predictors of decreased OS were larger tumor size
(p < 0.01), node positive disease (p < 0.01), and presence of
multiple tumors (p = 0.02). Pathologic evidence of NAFLD
did not predict decreased OS (HR 1.5, 95% CI 0.8–3.0,
p = 0.20). In subgroup analysis of node-negative patients
(n = 77), NAFLD was a predictor of decreased OS (HR 3.7,
95% CI 1.6–8.5, p < 0.01). Other predictors of worse OS in
node-negative patients were tumor size, ASA, and positive
resection margin (all p ≤ 0.04). After adjusting for other
significant covariates in the node-negative cohort, NAFLD
was an independent predictor of decreased OS (HR 2.7,
95% CI 1.1–6.6, p = 0.03).
CONCLUSIONS: Although NAFLD is not a predictor of
OS for all patients undergoing hepatic resection for ICC,
NAFLD is associated with decreased OS in patients with
node-negative ICC. This adverse correlation of NAFLD and
OS in patients with ICC suggests that treatment strategies
should include management of NAFLD.
Takao Ohtsuka*, Noboru Ideno, Teppei Aso, Yousuke Nagayoshi,
Hiroshi Kono, Yasuhisa Mori, Junji Ueda, Shunichi Takahata,
Kazuhiro Mizumoto, Masao Tanaka
Surgery and Oncology, Kyushu University, Fukuoka, Japan
BACKGROUND: Intraductal papillary mucinous neoplasm
(IPMN) of the pancreas often has distinct pancreatic ductal adenocarcinoma (PDAC) in the same pancreas. Roles of
endoscopic retrograde pancreatography (ERP) during the
management of IPMN in terms of early diagnosis of concomitant PDAC have not been well documented. The aim
of this study was to clarify whether ERP would be useful
for the early detection of concomitant PDCAs in patients
with IPMNs.
METHODS: Medical records of 179 patients who were histologically confirmed to have IPMNs by resected specimens
at our department between 1987 and 2011 were retrospectively reviewed. The patients having concomitant PDACs
were selected, and then the diagnostic abilities to detect
concomitant PDACs of computed tomography (CT), magnetic resonance imaging/cholangiopancreatography (MRI/
MRCP), endoscopic ultrasonography (EUS), and ERP were
compared between early-stage (stage 0 or I according to the
Japanese general rules for pancreatic cancer) and advanced
PDACs (stage II, III, and IV). Abnormal findings to suspect
the presence of PDAC in CT, MRI/MRCP, and EUS included
an irregular solid mass lesion and stenosis/dilation of pancreatic duct, distinct from IPMNs. Abnormalities suspicious
of the presence of PDAC in ERP were defined as irregularity
of pancreatic duct such as stenosis and obstruction, and/or
positive results (class IV or V) of pancreatic juice/brushing
cytology.
RESULTS: A total of 23 PDACs developed synchronously
or metachronously in 20 patients, and the prevalence of
PDACs concomitant with IPMNs was 11.2% (20/179).
Sensitivities to detect PDACs of CT, MRI, and EUS in early
group (16%, 29%, 29%, respectively) were significantly
lower than those in advanced group (87%, 93%, 92%,
respectively) (p < 0.01). On the other hand, sensitivity of
ERP in early group was as high as that in advanced group
(86% vs. 82%, p > 0.99). Among 7 early PDACs, 3 were
diagnosed only by ERP.
CONCLUSION: ERP has an important role in the early
diagnosis of distinct PDACs in patients with IPMNs. Further investigation is necessary to clarify the indication and
timing of ERP during the management of IPMNs in term of
early detection of concomitant PDACs.
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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu1781
Major Pancreatic Resections in Octogenarians: A
Community Hospital Experience
Paritosh Suman*1,2, John Rutledge2, Anusak Yiengpruksawan2
1. Surgery, Harlem Hospital Center, New York, NY; 2. The Daniel and
Gloria Blumenthal Cancer Center, The Valley Hospital, Ridgewood, NJ
BACKGROUND: Major pancreatectomies are increasingly
being performed in octogenarian (≥80 y) patients with
reported clinical outcomes from large-volume medical
centers. In this study we analyzed the outcomes of pancreatic resections in octogenarians at our community-based
institution.
vs. 27%, p = 0.56), Clavien grade I and II complications
(46% vs. 43%, p = 0.84), Clavien grade III and IV complications (21% vs. 21%, p = 0.99), clinically significant fistulas
(21% vs. 14%, p = 0.43), and perioperative mortalities (8%
vs. 5%, p = 0.49). Malignancy had a higher incidence in the
older group (87% vs. 62%, p = 0.02). The median length of
hospital stay was also significantly higher in ≥80 y patients
(14 vs. 9 days, p = 0.03). Although survival was significantly
less in the octogenarian group for all pathologies (p = 0.04),
notably, for pancreatic cancer patients, one and two year
survival outcomes were similar (p = 0.25).
Perioperative and Survival Outcomes
METHODS: A retrospective chart review of 148 patients
undergoing pancreatic resections by a single surgeon (A.Y.)
between 2006 and 2010 was performed. Data was collected
for demographics, clinical presentation, perioperative
course, histology, and survival. We compared patients who
were older and younger than 80 years with statistical significance of p < 0.05. Survival analysis was performed using
the Kaplan-Meier method.
Patient Characteristics and Histopathology
Age (years)
≥80 years
(n = 24)
<80 years
(n = 124)
P-Value
≥80 years
(n = 24)
<80 years
(n = 124)
P-value
Pancreaticoduodenectomy (PD)
16 (67%)
83 (67%)
0.98
Distal Pancreatectomy (DP)
8 (33%)
41 (33%)
Operative time
228
(160–290)
245 (125–560)
0.09
Estimated blood loss (ml)
273
(20–1400)
312 (20–3000)
0.60
Perioperative blood transfusion
8 (33%)
34 (27%)
0.56
Clavien grade I and/or II
complications
11 (46%)
54 (43%)
0.84
83 (80–90 y)
67 (26–79)
26 (21%)
0.99
16 (67%)
47 (38%)
0.01
Clavien grade III and/or IV
complications
5 (21%)
Female
ASA class ≥3
10 (59%)
47 (46%)
0.35
Perioperative mortality
2 (8%)
6 (5%)
0.49
Cardiovascular comorbidity
17 (71%
78 (63%)
0.46
24 (19%)
0.53
5 (21%)
35 (28%)
0.46
Postoperative pancreatic fistula:
ISGPF (§)
6 (25%)
Diabetes Mellitus
Preoperative ERCP
5 (21%)
18 (14%)
0.43
Clinically significant pancreatic
fistula ISGPF (§) grade B or C
5 (21%)
14 (18%)
0.43
9 (3–108)
0.03
21 (87%)
77 (62%)
0.02
Median length of hospital stay
(days)
14 (4–41)
Pancreatic carcinoma
Neuroendocrine tumor
2 (8.3%)
11 (8.8%
Reoperation
1 (4%)
15 (12%)
0.25
1 (4%)
14 (11%)
4 (17%)
25 (20%)
0.69
Other benign lesions
0
15 (12%)
30-days postdischarge
readmission
Chronic pancreatitis
0
5 (4%)
Delayed Gastric Emptying (DGE)
6 (25%)
17 (14%)
0.16
Peripancreatic invasion
11 (52%)
44 (57%)
0.80
Positive surgical margins
4 (19%)
17 (22%)
0.75
1 year survival
45.7%
69.1%
0.04
Lymphovascular invasion
9 (43%)
42 (54%%)
0.46
2 year survival
32.6%
51.8%
Positive lymph node
spread
11 (52%)
47 (61%)
0.62
Histopathology
IPMN
Survival
Median survival (months)
RESULTS: Twenty-four patients ≥80 y old underwent pancreatectomies (n = 24, range 80–90 y) compared to 124
patients <80 y (n = 124, range 26–79 y). The two groups
were similar in the distribution of their clinical characteristics, including ASA class. Pancreaticoduodenectomy (PD)
was the most common procedure performed in the two
groups (≥80 y n = 16, 67%; <80 y n = 83, 67%; p = 0.98).
There were no significant differences between the older and
younger patients in respect to the operative time (228 vs.
245 min, p = 0.09), perioperative blood transfusions (33%
8.7
33.2
Cancer only 1 year survival
40.7%
56.2%
Cancer only 2 year survival
27.1%
33.5%
§
0.25
ISGPF: International study group definition of postoperative pancreatic fistula.
CONCLUSION: Major pancreatic resections can safely be
performed in octogenarians in a community-based hospital
with similar perioperative outcomes to younger patients.
Comparable survival outcomes can be achieved in octogenarians when surgery is limited to malignant indications.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1782
Tu1783
Neoadjuvant Chemoradiation Therapy Using S-1
for Patients with Pancreatic Cancer
Meta-Analysis of Trials Comparing Central and Distal
Pancreatectomies: Short and Long-Term Outcomes
Sohei Satoi*, Hideyoshi Toyokawa, Hiroaki Yanagimoto,
Tomohisa Yamamoto, Satoshi Hirooka, so Yamaki, Taku
Michiura, Kentaro Inoue, Yoichi Matsui, a-Hon Kwon
Department of Surgery, Kansai Medical University, Hirakata, Japan
Mohammad Sarhan*1, Alan S. Rosman4, John D. Allendorf2,
Leaque Ahmed1, Zahra Shafaee3
1. Columbia University at Harlem Hospital Center, New York, NY;
2. Columbia University College of Physicians and Surgeons, New York,
NY; 3. Lawrence Hospital, Bronxville, NY; 4. Mount Sinai School of
Medicine and Bronx VAMC, New York, NY
INTRODUCTION: The results of surgical therapy alone
for pancreatic cancer are disappointing. We have reported
that surgical resection following neo-adjuvant chemoradiation therapy (NACRT) can be associated with the higher
rate of R0, and with the lower rate of metastastic lymph
nodes, resulting in improved prognosis of patients with
T3/4 pancreatic cancer (Pancreas 2009 and 2011 in press).
However, there is no consensus on the regimen of NACRT
for pancreatic cancer. The aim of this study is to explore the
short-term results of the new regimen of NACRT using S-1
followed by surgical resection.
PATIENTS: Among 103 consecutive patients with potentially resectable pancreatic cancer between January 2006
and September 2010, 43 patients were classified as adjuvant
group between Jan. 2006 and Sep 2008, and 34 patients
who underwent NACRT between Oct 2008 and Sep 2010
were classified as NACRT group. The regimen of NACRT
was consisted of S-1 (orally twice daily, 5days in a week,
80mg/m2/day) and concurrent radiotherapy (total of 50.4
Gy). The primary endpoint was the frequency of pathological curative resection (R0). All patients who underwent pancreatectomy were planned to receive adjuvant
chemotherapy.
RESULTS: The overall response rate and disease control
rate in NACRT group were 18% and 88.0%, respectively.
There was no difference in resection rate between NACRT
and adjuvant groups (30/34 vs 36/43). Other organ resection including vascular resection was done for 17 of 36
patients in adjuvant group and for 19 of 30 patients in
NACRT group. The primary end point analysis of this study
demonstrated that in accordance with our study hypothesis, NACRT followed by surgical resection improved R0 rate
in NACRT group compared with adjuvant group (28/30 vs
21/36, p = 0.005). The number of metastatic lymph nodes
in NACRT group was significantly lower than in adjuvant
group (p = 0.0363). On the comparisons of extension of
metastatic lymph nodes, the frequency of N0/1 in NACRT
group was also higher than in adjuvant group (p = 0.041).
There were no significant differences in mortality and morbidity except intractable ascites between two groups. The
rate of intractable ascites in NACRT group was significantly
higher than in adjuvant group (8/22 vs 2/34, p = 0.035).
The frequency of local relapse in NACRT group was significantly lower than in adjuvant group at 1year after surgical
resection (0% vs 26%, p = 0.021).
INTRODUCTION: Recent literature suggests superior pancreatic function after Central Pancreatectomy (CP) compared
to Distal Pancreatectomy (DP) in patients with benign or
low grade malignant neoplasms of the neck or body of
pancreas. Available data is limited to single institutional
studies with small sample size. In order to overcome these
shortcomings, we performed the first systematic meta-analysis in this subject.
METHODS: A systematic English literature review was performed using Pubmed database. All related articles comparing central and distal pancreatectomy from 1990 to 2010
were reviewed. The end-point was to compare peri-operative complication rate and long-term outcomes (new onset
or worsening diabetes, tumor recurrence) after each procedure. Meta-analysis was performed based on random-effect
model.
RESULTS: Eight eligible studies were found, including
615 patients (CP: 343, DP: 272). Both groups were similar
(age, sex, baseline pancreatitis, and incidence of IPMN and
malignancy on final pathology). Baseline DM was higher
in DP group (Odds Ratio: 0.35). Short term outcomes: CP
was associated with longer Operative time (257 vs. 232min,
P: 0.34) and less blood loss (378 vs. 651ml, P: 0.0006). Hospital stay was longer (12.75 vs. 9.63 days, P: 0.0038) and
pancreatic fistula rate was higher in CP compared with DP
(OR: 1.6, P: 0.04). Incidence of types B and C pancreatic
fistulas were similar in two groups (OR: 1.3, P 0.44). The
rate of new onset diabetes (OR: 0.11, P: 0.00) or worsening diabetes (OR: 0.03, P: 0.00) was significantly lower in
the CP. There was no difference in tumor recurrence rate
in both groups.
CONCLUSION: NACRT using S-1 can improve the rate
of pathologically curative resection and the number and
extension of metastatic lymph nodes in patients with T3/4
pancreatic cancer, resulting in better local control.
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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
of 25 months (CI 95% 19.5–30.8) compared to 30.5 months
(CI 95% 25.7–35.2) for those without complications (P =
0.144). Adjuvant treatment was administered in 70.5% of
patients with abdominal complications and in the 82% of
those with an uneventful postoperative course (P = 0.010).
On multivariable analysis factors independently associated
with survival were: the presence of abdominal complications (HR 1.40; P = 0.009), adjuvant treatment (HR 0.628; P
= 0.001), N1 status (HR 1.93; P < 0.0001), R1 resection (HR
1.87; P < 0.0001), G3 vs G1 (HR 4.33; P < 0.0001) and G2 vs
G1 (HR 2.99; P = 0.005).
CONCLUSIONS: Postoperative abdominal complications
are independent predictors of survival after resection for
PDAC. The mechanism behind this association may be
related to an immunologic impairment due to surgical
complications and to a lower rate of adjuvant therapy
administration in this subgroup.
CONCLUSION: Our analysis suggests that CP is associated with lower rate of pancreaticogenic diabetes. This will
justify for slight increase in operative time, pancreatic fistula rate, and length of hospital stay. Preservation of uninvolved pancreas leads to conservation of the pancreatic
function and make CP a good alternative to more radical
distal pancreatectomy for benign and low-grade malignant
neoplasms.
Tu1784
The Presence of Abdominal Complications Is an
Independent Predictor of Poor Survival After Resection
for Pancreatic Cancer
Stefano Crippa*1,2, Stefano Partelli1,2, Claudio Bassis1,
Domenico Tamburrino1, Giuliano Barugola1,2, Riccardo F. Rossato1,
Silvia Laiti1, Anna Neri1, Massimo Falconi1,2
1. Department of Surgery, Università di Verona, Verona, Italy;
2. Department of Surgery, Ospedale Sacro Cuore-Don Calabria,
Negrar, Italy
BACKGROUND: Postoperative complications significantly
affect disease-specific survival (DSS) after surgery for different tumors. The aim of the study is to assess the impact on
survival of postoperative course after surgery for pancreatic
ductal adenocarcinoma (PDAC).
METHODS: Retrospective analysis of 431 patients who
underwent pancreatic resections with curative intent (R0-R1)
for PDAC between 2000 and 2009.
RESULTS: Surgical procedures included pancreaticoduodenectomy (n = 347, 80.5%), distal pancreatectomy (n =
68, 16%) and total pancreatectomy (n = 16, 3.5%). Overall
morbidity was 37%. In-hospital or 30-day mortality rate
was 1.6%. Overall, 132 patients (31%) had abdominal complications, including 72 (17%) patients with pancreatic fistula and 46 (10.5%) with abdominal collections/abscesses.
The median length of stay (LOS) was 10 days (IQR 8;15).
Patients with abdominal complications had a significantly
higher LOS (15 vs 9.5 days, P < 0.0001). The median DSS
for the entire cohort was 28.4 months (CI 95% 24.5–32.3).
Patients with abdominal complications had a median DSS
Tu1785
Splenic Vein Thrombosis Is Associated with Specific
Increased Complications and Reduced Survival in
Patients Undergoing Distal Pancreatectomy for
Pancreatic Ductal Adenocarcinoma
Nishi Dedania, Nidhi Agrawal, Matthew Klinge, Salil Gabale,
Jordan M. Winter, Leonidas Koniaris, Ernest L. Rosato,
Patricia K. Sauter, Eugene P. Kennedy, Charles J. Yeo, Harish Lavu*
Department of Surgery, Thomas Jefferson University, Philadelphia, PA
INTRODUCTION: Distal pancreatectomy and splenectomy (DPS) is the procedure of choice for the surgical treatment of ductal adenocarcinoma (PDA) localized to the
body and tail of the pancreas. Due to a lack of early symptoms, patients with distal pancreatic lesions can present at
an advanced disease stage with large tumors. Splenic vein
thrombosis (SVT) can occur in these patients secondary to
direct tumor invasion or peri-tumoral inflammation. SVT is
most commonly associated with chronic pancreatitis and
little is known regarding its implications for patients with
PDA. This study documents our institution’s experience
with SVT in patients undergoing DPS for PDA and examines it’s effect on postoperative outcomes.
METHODS: In this retrospective cohort study, we queried
our pancreatic surgery database to identify all patients who
underwent DPS from October 2005 to June 2011. These
cases were evaluated for evidence of preoperative SVT
through review of clinical records and imaging studies (CT,
MRI, endoscopic ultrasound). Perioperative outcomes for
patients undergoing DPS for PDA with and without SVT
were compared.
RESULTS: A total of 284 DPS were performed during the
study period. Of these, 70 were for patients with PDA and
were distributed into 27 (39%) who had preoperative SVT
and 43 (61%) who did not. Both groups had similar demographic characteristics (Table). The median estimated blood
loss was significantly higher in the SVT group versus the
non- SVT group (675mL vs. 250mL, p < 0.001). Although
the overall morbidity rate was similar between groups (48%
vs 56%, p = NS respectively), the group with SVT had significantly higher rates of serious complications, such as
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
pancreatic fistula (33% vs 7%, p < 0.01) and delayed gastric emptying (15% vs 0%, p < 0.05). Tumor pathology was
similar between groups with the SVT group having 67%
T3 stage and 52% lymph node positive tumors while the
non-SVT group had 56% T3 stage and 56% lymph node
positive tumors. The median postoperative length of stay
in the hospital (6 days) and readmission rates (30% vs 28%,
p = NS) were similar between groups. Neither group had
a perioperative mortality within 30 days of surgery. How-
ever, one-year survival for patients with SVT was reduced
compared to the non-SVT group (52% vs 76%, p = 0.08), a
difference that approached significance.
CONCLUSIONS: DPS for PDA can be performed safely
in patients with preoperative SVT, but our findings reveal
higher rates of intraoperative blood loss, pancreatectomyspecific complications, and suggests lower long term survival rates.
Total n (%)
SVT n (%)
Without SVT n (%)
70 (100%)
27 (39%)
43 (61%)
67
63
68
<0.05
Male
42 (60%)
18 (67%)
24 (56%)
NS
BMI
26.1
24.5
26.9
NS
Total
p-Value
Preoperative Demographics
Age (years)
DM
20 (29%)
7 (26%)
13 (30%)
NS
Tobacco Use*
26 (36%)
10 (37%)
16 (37%)
NS
400
675
250
<0.0001
Any Complication
37 (53%)
13 (48%)
24 (56%)
NS
P. Fistula
12 (17%)
9 (33%)
3 (7%)
<0.01
4 (6%)
4 (15%)
0 (0%)
<0.05
EBL* (ml)
Complications**
DGE
Chyle Leak
3 (4%)
1 (4%)
2 (5%)
NS
Intra-abdominal Abscess
4 (6%)
2 (7%)
2 (5%)
NS
Cardiac
6 (9%)
1 (4%)
5 (12%)
NS
UTI
5 (7%)
4 (15%)
1 (2%)
NS
Wound Infection
11 (16%)
4 (15%)
7 (16%)
NS
Sepsis
3 (4%)
2 (7%)
1 (2%)
NS
C. diff. colitis
2 (3%)
0 (0%)
2 (5%)
NS
DVT/PE
3 (4%)
2 (7%)
1 (2%)
NS
Pulmonary
6 (9%)
1 (4%)
5 (12%)
NS
6
6
6
NS
Length of Postoperative Hospital Stay (days)
Pathology
T3 Stage
42 (60%)
18 (67%)
24 (56%)
NS
Lymph Node Positive
38 (54%)
14 (52%)
24 (56%)
NS
Readmission
20 (29%)
8 (30%)
12 (28%)
NS
1-year Overall Survival***
36 (67%)
11 (52%)
25 (76%)
NS
DM, Diabetes Mellitus; EBL, Estimated Blood Loss; SVT, Splenic Vein Thrombosis; P. Fistula, Pancreatic Fistula; UTI, Urinary Tract Infection; DGE, Delayed Gastric
Emptying; C. diff. colitis, Clostridium difficile colitis; DVT/PE, Deep Vein Thrombosis/Pulmonary Embolism. All values represent medians.
*Tobacco Use data not available for 2 patients, EBL data not available for 4 patients. Total numbers for these variables exclude these patients
**Number of patients with one or more complications.
***Only includes patients with date of surgery from 10/2005–06/2011.
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THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu1786
Tu1787
Hepaticojejunostomy Leaks Following
Pancreaticoduodenectomy: A Closer Look at a Rare
Complication
Parenteral Nutrition After Pancreatoduodenectomy:
Who Needs It?
Richard Burkhart*, Salil Gabale, Danielle Pineda, Patricia K. Sauter,
Ernest L. Rosato, Leonidas Koniaris, Harish Lavu, Eugene P. Kennedy,
Charles J. Yeo, Jordan M. Winter
Department of Surgery and the Jefferson Pancreas, Biliary, and Related
Cancer Center, Thomas Jefferson University, Philadelphia, PA
Ian K. Ferries*, Michael G. House, Thomas Z. Hayward,
C. Max Schmidt, Nicholas J. Zyromski, Attila Nakeeb,
Keith D. Lillemoe, Thomas J. Howard, Henry A. Pitt
Surgery, Indiana University School of Medicine, Indianapolis, IN
BACKGROUND: Hepaticojejunostomy (HJ) leaks after
pancreaticoduodenectomy (PD) are poorly characterized in
the literature, in contrast to more commonly encountered
complications such as pancreaticojejunostomy (PJ) leaks.
BACKGROUND: The impact of proactive nutritional
repletion in reducing postoperative morbidity in patients
undergoing pancreatoduodenectomy (PD) remains poorly
understood. This study analyzes the clinical factors which
are associated with the utilization of parenteral nutrition
(PN) after PD.
METHODS: We reviewed 650 consecutive PDs performed
at our institution between 2005 and 2011 and categorized
patients according to whether or not they experienced an
HJ leak. Leaks were identified on either transhepatic-cholangiography or an abdominal drain contrast study. Preoperative variables were analyzed to identify risk factors for
an HJ leak. The clinical presentation, morbidity, and treatment plan were examined in detail.
METHODS: Between 2005 and 2009, 600 consecutive
patients who underwent PD were included in the analysis. The most common indications for PD were adenocarcinoma (n = 249, 41%), pancreatitis (n = 88, 15%), and cystic
neoplasms (n = 83, 14%). Two-way statistical comparisons
were performed between patients who did (+PN) or did not
(-PN) receive postoperative parenteral nutrition within 30
days of PD.
RESULTS: An HJ leak was identified in 14 patients (2.2%),
whereas 87 patients (13.5%) in the cohort developed a PJ
leak. Univariate analysis demonstrated that low preoperative albumin was the only pre- or intraoperative factor
found to be associated with increased risk of HJ leaks (3.5
vs. 4.0 mg/dL no leak; p = 0.001). Six of 14 patients (43%)
had a preoperatively placed endostent in the common bile
duct. Patients typically presented on the 6th postoperative day (range: 1 to 14 days), and in all cases a diagnosis was made prior to hospital discharge. Presenting signs
and symptoms included leukocytosis (86%, median 15.3,
range 6.6 to 26.1), increased abdominal pain (64%), fever
(43%), failure to tolerate a diet (36%), abdominal distension (21%), and bilious drainage from the abdominal drain
(21%). Thirteen of 14 patients were managed with a percutaneous intervention. Seven patients were managed with
a percutaneous transhepatic biliary drain and six patients
required manipulation of an intraoperatively placed surgical drain. No patients required surgical intervention. In
addition to the HJ leak, patients also frequently developed
a wound infection (71%), PJ leak (43%), and sepsis (29%).
The median length of stay was 18 days (range: 16 to 55),
as compared to 8 days in patients without an HJ leak (p =
0.000). Readmission rates were 26% in the HJ leak group
and 15% in the total cohort (p = NS). There was a single
90-day mortality in the HJ group (7%) as compared to 17
(2.7%) in the entire cohort (p = 0.356).
RESULTS: Pylorus-preserving PD was performed in 491
patients (82%), and a classic PD in 109 (18%). Operative mortality occurred in 18 (3%) patients. One hundred
twenty-two (20%) patients were prescribed PN at a median
of 8 days (range, 1–19) after PD. The median duration of PN
usage was 9 days (range, 1–246). There were no differences
in age, gender, renal function, operative time, or blood
loss between the +PN and -PN groups. Patients requiring
PN had lower preoperative (2.80 v. 2.93 g/dl, p = 0.03) and
hospital discharge (2.05 v. 2.32 g/dl, p < 0.001) albumin
levels. Higher preoperative total bilirubin levels were associated with postoperative PN usage (2.95, +PN v. 2.14 mg/
dl, -PN, p = 0.02). Operative outcomes with regards to postoperative PN utilization are listed in the table. Forty-seven
percent of the patients who developed delayed gastric emptying (DGE) required PN. PD was complicated by a pancreatic fistula (all grades) in 13% of patients, 35% of whom
required PN.
CONCLUSIONS: HJ leaks are rare complications after PD
and can result in substantial morbidity with increased
length of hospital stay. However, early recognition with
effective drainage typically results in a full recovery, without the need for surgical intervention when skilled interventional services are available. Low volume leaks are
managed with effective abdominal drainage, while larger
leaks may require placement of a transhepatic biliary drainage catheter.
CONCLUSIONS: Postoperative parenteral nutrition is
required frequently in patients undergoing pancreatoduodenectomy. Strong associations between poor nutritional
parameters, postoperative morbidity, and PN utilization
emphasize the crucial role of adequate nutrition in achieving good surgical outcomes. Establishing enteral nutritional
access at the time of PD should be considered in patients at
risk for postoperative complications.
Postop
PN
192
All
Major
RePancreatic
Complications Complications Operation Fistula
DGE
No
(n = 478)
198 (41%)
25 (26%)
20 (4%)
51 (10%)
44
(9%)
Yes
(n = 122)
79 (65%)
68 (56%)
18 (14%)
27 (21%)
39
(32%)
p–value
<0.001
<0.001
<0.01
0.001
<0.001
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1788
CONCLUSION: 13C-MTG-T as well as residual pancreatic
exocrine cells represented by histological degree of pancreatic exocrine cells at cut margin, reliably show long-term
fat absorptive function after PPPD. Glucose metabolism
disturbance is also related to post operative fat absorption.
Fat Absorptive Function After Pylorus Preserving
Pancreatoduodenectomy Assessed by 13C-Labeled
Mixed Triglyceride Breath Test
Masahiko Morifuji*1, Yoshiaki Murakami2, Kenichiro Uemura2,
Takeshi Sudo2, Yasushi Hashimoto2, Taijiro Sueda2,
Akio Sakamoto1
1. Sanmu Medical Center, Chiba, Japan; 2. Department of Surgery,
Division of Clinical Medical Science, Graduate School of Biomedical
Sciences, Hiroshima University, Hiroshima, Japan
Tu1789
Autoimmune Pancreatitis (AIP): Short and LongTerm Outcomes in Patients Treated Initially by
Pancreaticoduodenectomy, a Comparative Study
BACKGROUND: Long-term survival after pancreatic surgery has increased gradually due to recent improvements
in surgical techniques and experiences; therefore, postoperative evaluation of fat absorption and glucose metabolism disturbances is important. We have been reported
that the non-invasive 13C-mixed triglyceride breath test
(13C-MTG-T), labelled long chain triglyceride mixture can
reliably diagnose pancreatic exocrine insufficiency (Surgery,
2009). In this study, we investigate fat absorptive function
in patients status post pylorus preserving pancreatoduodenectomy (PPPD) with pancreaticogastrostomy (PG) reconstruction more than 12 months after the procedure.
METHODS: 13C-MTG-T (200 mg 13C-MTG, 20 g fat,
and breath samples over 7 hours) was performed for 52
patients undergoing PPPD with PG reconstruction and 12
healthy volunteers, forming our control group. Pancreatic
exocrine insufficiency was defined as percent of cumulative 7-hour 13CO2 exhalation (% dose 13C cum 7 h) <5%,
assessed by 13C-MTG-T. Sections from the surgical pancreatic cut margin were used for histological assessment.
The degree of pancreatic exocrine cells was calculated as
ratio of the pancreatic exocrine cells area to total area measured in the entire section. We analyze the relationship
between 13C-MTG-T as a measure of pancreatic exocrine
insufficiency postoperatively and the degree of pancreatic
exocrine cells by histology as well as the development of
diabetes mellitus (DM) as a measure of pancreatic endocrine insufficiency.
RESULTS: % dose 13C cum 7 h was significantly lower in
patients with PPPD (6.8 ± 4.8%) than in healthy controls
(15.5 ± 6.0%; P < 0.01). Pancreatic exocrine insufficiency
assessed by 13C-MTG-T (% dose 13C cum 7 h < 5%) was
observed in 20 patients (38%) in PPPD group but none in
the control group. Of the 52 patients undergoing PPPD,
the histological degree of pancreatic exocrine cells was significantly higher in patients with% dose 13C cum 7 h ≥
5% (81.7 ± 5.4%) than those with <5% (67.8 ± 8.5%; P =
0.01). Patients with pancreatic insufficiency (% dose 13C
cum 7 h <5%) significantly decreased body mass index
at 12 months after PPPD comparing to those with% dose
13C cum 7h ≥ 5% (–10.9 ± 8.4% vs +0.9 ± 9%; P < 010).
6 patients had been diagnosed with DM prior to undergoing the procedure, and, of the remaining 46 patients,
5 (11%) became diabetic after the procedure. Patients with
DM demonstrated significantly lower% dose 13C cum 7 h
comparing to patients without DM (5.9 ± 4.3% vs. 10.5 ±
5.2%; P < 0.01).
Greg Roberts*1, Lee Mchenry3, Romil Saxena2, Seth A. Moore4,
Thomas J. Howard1
1. Surgery, Indiana University Medical Center, Indianapolis, IN;
2. Pathology, Indiana University Medical Center, Indianapolis, IN;
3. Gastroenterology, Indiana University Medical Center, Indianapolis,
IN; 4. Gastroenterology, Ohio State University School of Medicine,
Columbus, OH
INTRODUCTION: Autoimmune pancreatitis (AIP) is a rare,
benign inflammatory disease that clinically and radiographically mimics pancreatic adenocarcinoma (PA). When
diagnosed, AIP responds well to steroid therapy, but can
recur in either the pancreas or biliary system. The inability
to accurately distinguish between these two diseases leads
many AIP patients to undergo initial pancreaticoduodenectomy. While a 25% disease recurrence rate following steroid
therapy in AIP is well established, disease recurrence rates
following initial pancreaticoduodenectomy (PD) remains
unknown.
METHODS: With IRB authorization, 10 patients over a
10 yr period (1999–2009) with pathologically confirmed
AIP treated with PD were identified. The study group was
matched against two comparison groups of patients with
idiopathic chronic pancreatitis (CP) or PA. Clinical presentation, operative variables, and postoperative clinical courses
were analyzed. Long-term follow-up, along with quality
of life (QOL) data using a validated instrument {Gastrointestinal Symptom Rating Scale (GSRS)} given by structured
telephone survey were analyzed. Appropriate statistical tests
were applied for nominal and ordinal variables.
RESULTS: The AIP group was 50% male with a mean age of
62 (40–77) yrs. Presenting symptoms were similar between
the AIP and PA groups. All groups (AIP, CP, PA) had similar
gland morphology on radiographic imaging. Fifty percent
of the AIP group had atypia on preoperative FNA biopsy.
No AIP pts were diagnosed preoperatively and none had a
history of autoimmune diseases. No statistically significant
differences were found in operative times, blood loss, perioperative morbidity or mortality (90-day) rates between
groups. Mean follow-up for the AIP group was 42 (4.5–83.2)
months. Three AIP patients (30%) had disease recurrence:
2 with jaundice and 1 with pancreatitis, at a mean time of
7.7 (1.6–12.1) months postop. All 3 were treated with steroids and 2 had an additional recurrence once the steroids
were stopped. Six patients (60%) had no recurrence during
follow-up of whom 2 were treated with postoperative “prophylactic” steroids. One patient’s recurrence status remains
unknown. Long-term rates of diabetes mellitus, pancreatic
193
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
exocrine deficiency, and GSRS scores [AIP (N = 5); 33 (20–
59): CP (N = 3); 28 (18–45)] were similar between AIP and
CP groups.
excluded patients who received narcotics within 7 days
before their surgery in this group. All Alvimopan patients
received their first dose immediately preoperatively.
CONCLUSION:Preoperative diagnosis of AIP remains
uncommon in our experience in patients with a pancreatic
head mass and no history of autoimmune disease. PD in
AIP is as safe an operation as it is for CP or PA. AIP recurrence following PD is approximately 30%, with similar
long-term postoperative QOL as patients with CP.
RESULTS: When comparing the two groups, significance
was noted for the mean length of hospital stay (P = 0.0483),
mean time to first clear liquid diet (P = 0.00212), and mean
time to first soft/solid food diet (P = 0.0406). There was no
significant difference noted between age, BMI, Co-morbidity, and mean time to first bowel movement (see Table 1).
CONCLUSION: With a comparison between the Alvimopan and non-Alvimopan group, we recognize a significant
decrease in the length of hospital stay with a possible cost
benefit, due to a significantly earlier intake of diet in the
Alvimopan’s group. We believe with a radical procedure,
such as pancreaticoduodenectomy, Alvimopan results in
earlier recovery.
Tu1790
Alvimopan Patients Show Significant Improvement in
Recovery Post Pancreaticoduodenectomy Surgeries
Elizabeth T. Liu*, Veeraiah Siripurapu, Tanyss L. Winston,
Dhiresh R. Jeyarajah
Surgery, Methodist Dallas Medical Center, Dallas, TX
INTRODUCTION: In recent publications, Alvimopan
has been shown to improve gastrointestinal recovery in
patients who are undergoing bowel resections. We intend
to see if patients undergoing Pancreaticoduodenectomies, a
major surgical resection, and who were administered Alvimopan demonstrate a significant improvement in bowel
movement recovery, first intake of clear liquid diet, and
first intake of soft/solid food diet; compared to patients not
administered with Alvimopan.
Table 1: Patients Treated with Alvimopan and No Alvimopan
Alvimopan
No
Alvimopan
15
30
Mean Age
67.6
65.3
P = 0.430 [NS]
Mean BMI
25.4
24.9
P = 0.738 [NS]
Mean Co Morbidity
Number of Patients
P-Value
2.53
2.53
P = 1.00 [NS]
Mean Length of Hospital Stay
(days)
12
14.6
P = 0.0483 [S]
Meant Time to 1st Bowel
Movement (days)
6
6.77
P = 0.148 [NS]
Mean Time to 1st Clear Liquid
Diet (days)
6
7.63
P = 0.00212 [S]
8.67
9.9
P = 0.0406 [S]
Mean Time to 1st soft/solid
food diet (days)
*[S] Significant *[NS] Not Significant
METHODS: From a retrospective review of 255 pancreaticoduodenectomy patients under a single surgeon between
years 2005–2011, 23 patients in 2011 were given Alvimopan. After excluding patients who received narcotics within
7 days before their surgery and after excluding Whipplepylorus preserving, 15 Whipple-standard patients were left
to analyze. For every one patient who was given Alvimopan, we found 2 patients who shared similar age, BMI, and
pathology diagnosis and same Co-Morbidity and pT stage.
We collected 30 patients ranging from years (2005–2011)
who met these criteria, were not given Alvimopan, and
who underwent a Whipple-standard procedure. We also
Tu1791
Total Pancreatectomy with Islet Autotransplantation
for Chronic Pancreatitis: Who Is Undergoing This
Radical Procedure?
Katherine A. Morgan*, Stefanie M. Owczarski, Jingwen Zhang,
Patrick Mauldin, Amy R. Wilson, David B. Adams
Medical University of South Carolina, Charleston, SC
BACKGROUND: Total pancreatectomy with islet autotransplantation (TPIAT) is utilized for management of
intractable pain due to chronic pancreatitis. Patient selection is a major factor in improving clinical outcomes.
Identifying characteristics of the population undergoing
TPIAT is an important step in defining the patient selection
process.
METHODS: Inpatient and outpatient data were reviewed
retrospectively utilizing a prospectively collected database
(TPIAT patients) and a hospital administrative database
(TPIAT patients and controls). Data from 70 TPIAT patients
were compared to a random sampling of 140 controls (with
pancreatitis, total population 1,889). For all patients, data
were captured from January 2008 forward, allowing for
14 months prior to the first TPIAT patient in March 2009.
Patients were considered to have a particular co-morbidity if they had 1inpatient ICD-9 or ≥2 outpatient ICD-9s
recorded in the data. ICD-9 codes captured pre and posttransplant were not distinguished for transplant patients.
Non-MUSC data was not available for this analysis. Fisher’s exact test was used to determine differences between
groups, significance determined at 0.05.
RESULTS: TPIAT patients were more likely to be women
(p < 0.001), younger (p < 0.005) and more frequently white
(p < 0.003) than controls. A higher proportion of TPIAT
patients had drug dependence (p < 0.0001) and depression
(p < 0.0001), compared to controls. Conversely controls
more likely had hypertension (p = 0.0050) and renal failure
(p = 0.0031).
CONCLUSIONS: Patients undergoing TPIAT differ from
the overall population of patients with chronic pancreatitis.
Depression and narcotic dependence are important considerations in the selection of candidates for the procedure and
are disorders which need targeted postoperative therapy.
194
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1792
Patient and Tumor Characteristics
Neoadjuvant Chemoradiotherapy for Locally Advanced
Pancreas Cancer Does Not Lead to Radiologic Tumor
Regression
Vikas Dudeja*1, Sidney P. Walker2, Edward W. Greeno3,
Eric H. Jensen1
1. Surgery, University of Minnesota, Minnespolis, MN; 2. Radiology,
University of Minnesota, Minneapolis, MN; 3Medical Oncology,
University of Minnesota, Minneapolis, MN
Age in years
Median (range)
64 (45–78)
Gender:% (n)
Male
69% (11)
Female
31% (5)
Explored before neoadjuvant chemoradiation:% (n)
INTRODUCTION: Neo-adjuvant chemo-radiotherapy
is proposed to improve resectability of locally-advanced/
borderline-resectable pancreas cancer (LAPC). The ability
of neo-adjuvant therapy to provide tumor regression has
not been reported.
METHODS: We reviewed pre and post treatment CT scans
of patients undergoing neo-adjuvant chemo-radiotherapy
(cisplatin, interferon-alpha, 5-FU, radiation) in a phase II
clinical trial for LAPC between 2005 and 2008. Response to
therapy and rates of surgical resection were assessed.
RESULTS: 16 patients (median age 64years, males 69%)
received neo-adjuvant therapy for LAPC during 2005–08
(Table). Mean tumor size before neo-adjuvant treatment
was 3.85 cm. Indications for neo-adjuvant treatment
included one or more of the following: Involvement of
superior mesenteric artery (SMA) (≤180 degree-3 patients,
>180 degree-1 patient), celiac axis (CA) (≤180 degree-2
patients, >180 degree-3 patients), hepatic artery (HA) (>180
degree-6 patients), and/or superior mesenteric vein/portal vein (SMV/PV) (≤180 degree-6 patients, >180 degree-7
patients). Regression of major vascular involvement, i.e.
un-encasement or regression of abutment of any involved
vessels was not observed in any patients. Pre-treatment
and post-treatment CA19-9 levels as well as tumor density
(Hounsfield units) were not statistically different. 50% of
patients with borderline resectable disease (tumor involving ≤180 degree circumference of the SMA; short-segment
encasement/abutment of the common HA; or tumor-associated deformity, abutment or short-segment occlusion of
SMV/PV that was amenable to vascular resection and reconstruction) and none of the patients with locally advanced
un-resectable pancreatic cancer (vascular involvement
more than that described for borderline resectable pancreatic cancer) eventually underwent surgical resection. Out
of 5 patients who eventually underwent resection, 4 had
macroscopic tumor and 1 had only microscopic tumor.
CONCLUSION(S): Neo-adjuvant treatment does not provide tumor regression of LAPC with major vascular involvement. Patient selection for neo-adjuvant trial enrollment
should remain focused on borderline disease which may
have potential for surgical resection.
Yes
31% (5)
No
69% (11)
Location of tumor:% (n)
Head
69% (11)
Body
18% (3)
Tail
13% (2)
Tumor size (mean ± SD)
Pre-Treatment
3.85 ± 1.92 (NS)
Post-Treatment
3.39 ± 1.81
Tumor extension at presentation:% (n)
Borderline Resectable
62.5% (10)
Locally Advanced
37.5% (5)
CA 19–9 levels:
Pre-Treatment
1436 ± 772 (NS)
Post-Treatment
772 ± 220
Tumor density in Hounsfield units
Pre-Treatment
60.4 ± 6.5 (NS)
Post-Treatment
58.2 ± 6.9
Radiological Response:% (n)
Regression
6.25% (1)
Stable
56.25% (9)
Progression
37.5% (5)
Surgical resection of cancer after neo-adjuvant
chemoradiation:% (n)
Yes
31% (5)
No
69% (11)
Patients undergoing surgical resection classified by
tumor extension at presentation:% (n)
Borderline Resectable
50% (5)
Locally Advanced
0% (0)
Pathologic response in those undergoing resection
(n = 5)
Macroscopic tumor
4
Microscopic tumor only
1
NS: non significant.
195
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu1793
Tu1794
National Database Research Beyond ICD-9 Codes:
Evaluating Post-Pancreatectomy Diabetes Using
Pharmacy Claims
Early Enteral Nutrition Support Does Not Improve
Postoperative Outcome in Patients After Whipple
Resection
Elan R. Witkowski*1, Elizaveta Ragulin-Coyne1, Zeling Chau1,
Sing Chau NG1, Heena P. Santry1, Shimul A. Shah1,
Jennifer F. Tseng1,2
1. Surgical Outcomes Analysis & Research (SOAR), University
of Massachusetts Medical School, Worcester, MA; 2. Beth Israel
Deaconess Medical Center, Harvard Medical School, Boston, MA
Mario Muller*, Paul Karanicolas, Natalie G. Coburn,
Calvin H. Law
Department of Surgery, Torornto, ON, Canada
BACKGROUND: Large databases are central tools in
surgical research, but the utility of certain diagnosis and
procedure codes may be limited. Diabetes can occur after
pancreatic cancer (PC) resection, but being insulin-dependent vs. non-insulin-dependent may impact quality of
life more than the simple diabetes/no diabetes dichotomy
would suggest. We demonstrate novel use of the newly
available Medicare Part D pharmacy claims as an improved
method of describing the presence and clinical impact of
post-pancreatectomy diabetes mellitus.
METHODS: Patients (pts) who underwent PC resection
between 5/1/07 and 5/1/08 were identified in the SEERMedicare linked database, including Part D. Neuroendocrine pts, pts who died during their index hospitalization,
and pts without continuous Part D were excluded. Claims
for insulin and oral hypoglycemic medications were identified during three intervals: (1) four months prior to
operation until the day prior to operation, (2) postoperative day 0–60, and (3) >60 days after operation. Based on
preoperative diabetes status, probabilities of developing
oral-med-dependent or insulin-dependent DM were calculated. These results were compared to results determined by
ICD-9 diagnosis code.
RESULTS: After screening 455 patients, a cohort of 123
patients met the inclusion criteria. Using ICD9 codes, 53
patients (43.1%) were identified as having preoperative
diabetes, of whom 37 (30.1%) had preop claims for diabetic medications. All patients who received treatment had
an ICD9 diabetes diagnosis coded. Among these patients,
29 (23.6%) took oral hypoglycemics and 19 (15.5%) took
insulin preoperatively, with some overlap between groups.
Postoperative diabetes (>60 days) was examined in 114
patients with survival sufficient for analysis. Using ICD9
codes, 75 patients (65.8%) were identified as diabetic. Part
D claims indicated that 67 (58.8%) never required medication, 19 (16.7%) required only oral hypoglycemics, and 28
(24.6%) insulin. Only 13 patients (11.4%) developed a new
insulin requirement.
INTRODUCTION: Pancraeticoduodenectomy (Whipple
procedure) is still associated with a significant postoperative complication rate. There is evidence that early enteral
nutrition support may reduce postoperative septic complications. However, the true value of early enteral nutrition
support is still controversial. The aim of the present study
was to investigate the postoperative outcome of Whipple
patients with and without early enteral nutrition support.
PATIENTS AND METHODS: By using a prospective institutional database, we identified 202 patients from 2001
through 2009 undergoing Whipple procedure. 121 patients
matched the inclusion criteria such as non-pylorus preserving Whipple and assessment by a clinical dietitian within
48 hours post-operatively. 67 of 121 (55.4%) patients
received early enteral nutrition support, whereas 54 of 121
(44.6%) patients had no early nutrition support (control
group). Postoperative course, morbidity and mortality were
recorded and analyzed.
RESULTS: No significant differences were found in the
postoperative course of the patients. Median length of
hospital stay was 15 in the early nutrition support group
compared to 14 days in the control group. Postoperative
leak rate was 13.8% with and 14.8% without early enteral
nutrition support (P = 0.964). 11 (13.4%) patients in the
early enteral support group developed postoperative organ
failure compared to 9 (11%) in the control group. Overall
mortality was 4.9%. There was no difference in mortality
within the two groups (4% vs. 5%, P = 0.881). 33 patients
(33.3%) in the control group needed total parenteral nutrition initiation which was significant higher compared to
the 9 patients (13.4%) in the early nutrition support group
(P < 0.05).
CONCLUSION: Early enteral nutrition support is not associated with lower rates of postoperative morbidity and mortality and does not enhance postoperative recovery after
Whipple resection. However, TPN initation is less likely
in the early enteral nurtrion support group and might be
therefore usefull to reduce risks associated with TPN.
CONCLUSIONS: Administrative database research is limited by the quality and clinical relevance of available data.
Our pilot study demonstrates a novel use of outpatient
pharmacy claims to define medication-dependent diabetes
after pancreatic cancer resection. The utilization of pharmacy claims may augment researchers’ ability to detect the
presence of various diseases and ascertain both their clinical relevance and potential quality of life impact.
196
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Clinical: Small Bowel
Tu1797
Tu1795
Early Complications Following Diverting Loop
Ileostomy: An Audit of 182 Consecutive Patients with a
Special Emphasis on Preoperative Risk Stratification
Surgical Therapy for Gastrointestinal Stromal Tumors
(GIST) of the Duodenum
Jens Hoeppner*, Goran Marjanovic, Birte Kulemann,
Frank Makowiec, Ulrich T. Hopt
Department of Surgery, University of Freiburg, Freiburg, Germany
BACKGROUND: GIST of the duodenum are rare and represent only a small subgroup of all GIST. Up to now, various
surgical procedures have been described for their treatment.
Both radical resections by pancreaticoduodenectomy and
limited local resections are performed. This retrospective
analysis was conducted for the evaluation of the results of
radical and limited resections for duodenal GIST.
METHODS: We retrospectively reviewed the medical
records of all patients which were surgically treated for duodenal GIST at our medical institution between 2002 and
2011.
RESULTS: Nine Patients (5M/4F) with am median age
of 58 years were surgically treated. The median follow-up
period was 45 month (range 6–111 month). Most often
the initial symptom was gastrointestinal bleeding in 5 of
9 patients (56%). Tumors were found in all 4 parts of the
duodenum, with most frequent location at the descending part of the duodenum in 4 of 9 patients (44%). In one
patient the resection of the GIST was done by pancreaticoduodenectomy. Eight patients were treated by wedge or
segmental resections of the duodenum. One of these limited resections was done minimally invasive; seven were
done in open fashion. The median diameter of the tumors
was 54 mm (14–110 mm). Seven resections showed microscopically negative transsection margins (R0), two showed
positive margins (R1). During follow up no patient developed local recurrence. The one patient in who underwent
pancreaticoduodenectomy died due to progressive disease with hepatic metastasis but without evidence of local
recurrence. Another patient died of cardiac disease in complete remission. Seven out of the nine patients are alive
disease-free.
CONCLUSION: In patients with duodenal GIST, limited
surgical resection with microscopically negative margins,
but interestingly also with microscopically positive margins
leads to very good local and systemic disease-free survival.
Alexandre Descloux1,3, Annelies Schnider2, Markus Weber2,1,
Matthias Turina*1,2
1. University of Zürich, Zürich, Switzerland; 2. Surgery, Triemlispital,
Zurich, Switzerland; 3. Surgery, Kantonsspital Baden, Baden,
Switzerland
INTRODUCTION: Diverting loop ileostomy is commonly
used for a variety of indications in general surgery and
is generally considered a safe technique. However, some
patients develop ostomy-related complications necessitating revision surgery or early ostomy closure. The aim of
this study was to better define the incidence and nature of
early complications in relation to specific risk factors, and
to recognize patients at risk in order to avoid preventable
complications.
METHODS: Single-center case-control study including all
patients undergoing a protective loop ileostomy between
2001 and 2009. Complications were necrosis and retraction, peristomal infection, parastomal herniation, bowel
obstruction, and individual problems related to postoperative ostomy care. Risk factors analyzed included age, gender, urgency of surgery, underlying pathology, body mass
index, steroid use, diabetes mellitus, alcohol abuse, previous abdominal operations, dementia, renal insufficiency,
inflammatory bowel disease (IBD), and chronic obstructive
pulmonary disease (COPD). Univariate and subsequent
multivariate analysis were performed using SPSS 18.0.
RESULTS: 182 patients (43% female) were included, the
majority of which (68%) were admitted for elective colorectal resections. Early complications were recorded in 16% of
all cases (with 0% mortality), and occurred most frequently
following emergency resections for obstructive colorectal
cancer (44.4% complications) and perforated diverticulitis
(18.7% complications). Median delay until ostomy closure
was 74 (6–343) days in patients without and 51 (4–182)
days in patients with complications. Problems with inadequate ostomy care (7.7%) were the main reason for early
stoma closure. Parastomal herniation and peristomal infection occurred in 2.7% and 2.2%, respectively. Steroid use,
diabetes mellitus, IBD, COPD and asthma were each associated with an increased risk for early ostomy complications
and premature ostomy closure.
CONCLUSIONS: The incidence of early complications
after ileostomy formation is high, indicating the need for
well-defined indications for this procedure. Patients admitted for emergency surgery due to colonic obstruction are at
greatest risk for ostomy-related morbidity, especially those
suffering from comorbidities such as diabetes. The most
frequent complication is an overwhelmed patient unable
to deal safely and appropriately with his ostomy. Home
support with trained ostomy nurses should be encouraged
in all ostomy patients to avoid premature ostomy closure.
197
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Clinical: Stomach
Table 1: Subsequent Surgical Procedures and Complications After
GES Insertion
Nutrition
Tu1798
Surgical Outcomes After Gastric Electric Stimulator
Placement for Refractory Gastroparesis
Deborah Keller*1, Daniel Boucek1, Abhinav Sankineni2,
John E. Meilahn1, Henry P. Parkman2, Sean Harbison1
1. Surgery, Temple University Hospital, Philadelphia, PA;
2. Medicine, Temple University Hospital, Philadelphia, PA
Central Access for TPN
21
PEG/ Gastrostomy Tube
19
Jejunostomy Tube
33
G-J Tube
4
SUBTOTAL
72
GES Explanted
BACKGROUND: Gastric electric stimulation (GES) is
used for refractory symptoms of gastroparesis. Although
improvement in symptoms has been reported with GES,
few studies have described the need for additional surgery
after placement of gastric stimulators. The aim of this study
was to evaluate the surgical outcomes of a large series of
GES at a single institution. Secondary goals were to determine the need for additional surgery after insertion of GES.
METHODS: A retrospective review of a prospective database was performed for patients undergoing GES placement for refractory gastroparesis at our single institution
from 10/2000 to 10/2011. Demographic and clinical information was gathered from medical records.
RESULTS: 266 patients had a GES implanted at our institution over the 11-year period. Medical records were available for 233 patients, with long-term outcome data for 74.
All had delayed gastric emptying and refractory symptoms
despite aggressive medical therapy. The mean age was 38
years (range 18–67), and 80% were female. The mean BMI
was 24.8 ± 6.7 (SD), and pre-operative albumin level was
4.1 ± 0.7 (SD). The most frequent etiologies for gastroparesis were idiopathic (51.1%) and diabetic (42.9%). Common co-morbidities included depression/ anxiety (14.9%),
chronic renal insufficiency (8.1%), and treated hypothyroidism (6.8%). GES were placed by 1 of 2 surgeons using
a standardized surgical procedure and post-operative protocol. Mortality during the follow-up period was 2.1%, all
unrelated to the procedure. The overall clinical outcomes
for GES were favorable, with 70% of patients reporting
improved symptoms. However, in a subset of patients, readmissions were common, with 90/233 patients re-presenting
mainly for gastroparetic symptoms. The mean number of
re-admissions for these 90 patients was 4.4 (range, 1–41).
Additional surgery for nutrition was common- 45/233
patients required at least 1 procedure for nutritional access
post-GES insertion. Reoperations were performed for device
issues and surgical complications, including revision of
GES stimulator in subcutaneous pocket (21), incisional
hernia (4), battery failure (3), lead erosion (2), and small
bowel obstruction (2). 12% of patients (29/233) had the
GES explanted, mainly for continued gastroparetic symptoms (11), mechanical issues (9), and infection (4).
No Relief of Symptoms
11
Mechanical Device Issues
9
Persistent Infection
4
Stimulator eroded through skin
3
Symptoms improved
2
SUBTOTAL
29
Revisions/ Surgical Complications
Revision of stimulator in subcutaneous pocket
21
Incisional hernia repair
4
Battery failure
3
Laparotomy for Small Bowel Obstruction
2
Lead erosion
2
Colectomy for Colitis
1
Takedown enterocutaneous fistula
1
SUBTOTAL
34
Non-Operative Surgical Complications
Wound Infection
5
Small Bowel Obstruction
4
Hematoma
2
Bleeding from Gastrostomy tube site
1
Suture Granuloma
1
Enterocutaneous Fistula
1
SUBTOTAL
14
CONCLUSIONS: Although there is symptomatic improvement in most patients undergoing GES for refractory gastroparesis, a significant number of patients (34%) required
additional surgery after GES placement. This need for
additional surgery was most frequently for surgical nutrition (53%) for ongoing gastroparesis symptoms. Removal
was performed in 12% of patients and revision of the GES
pocket in 9% of patients. Despite these additional surgeries, the majority of patients report good overall outcomes
for GES.
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1799
Tu1800
Current Problems in General and GI Surgery for
Super-Old Patients with Age over 85 Years
Effect of Bariatric Surgery on Comorbidities vs Medical
Treatment in a Cohort of Morbidly Obese Patients: A
Prospective Study
Tatsuya Ueno*1, Michinaga Takahashi1, Shinji Goto1, Shun Sato1,
Masanori Akada1, Kyohei Ariake1, Minoru Kobayashi1,
Chikashi Shibata2, Hiroo Naito1
1. Surgery, South Miyagi Medical Center, Miyagi-Pref, Japan;
2. Surgery, Tohoku University, Sendai, Japan
Paolo Gentileschi*, Marco D’Eletto, Stefano D’ Ugo, Mara
Capperucci, Domenico Benavoli, Pierpaolo Sileri, Achille Gaspari
General Surgery, University of Rome Tor Vergata, Roma, Italy
INTRODUCTION: As it is being common in Japan to perform surgery in patients over 85 years old, postoperative
complications such as pneumonia, heart failure, dementia,
and bedridden status become big problems for patients and
their family. Although some prognostic scoring systems
such as POSSUM score are available, these scoring systems
do not precisely predict the postoperative complications.
Aim of the present study was to evaluate mortality and
morbidity after the surgery and consider surgical indication in super-old patients.
METHODS: We retrospectively reviewed 222 patients who
underwent surgery from 2003 to 2010 at the age over 85
years and analyzed postoperative mortality and morbidity rate. In our hospital, indications of surgery in super-old
patients were, 1) informed consent from patient and his/
her family and 2) good pulmonary and cardiac function to
tolerate operation. We evaluated POSSUM score for information, and poor POSSUM score was not considered as an
absolute contraindication.
RESULTS: Among 222 operations, emergent operations
were 114, while elective operations were 108. Diseases
for operation were gastric cancer in 24, colorectal cancer in 49, cholecystolithiasis in 9, inguinal hernia in 19
patients. Emergent operations included perforation of GI
tract for 26, acute cholecystitis for 22, intestinal obstruction for 21, inguinal hernia for 20, acute appendicitis for
10, and colorectal cancer for 7 patients. Mortality and morbidity rates in elective surgery were 1.9% (2 patients) and
31.5% (34 patients), respectively, while those in emergent
operation increased to 14.9% (17 patients) and 58.4% (66
patients) (p < 0.01 vs. elective operation), respectively. Pulmonary complications were observed in 5 (1.9%) and 24
(21.1%) patients in elective and emergent surgeries, respectively. In 19 patients with postoperative deaths, 15 (79.4%)
suffered from pulmonary diseases including aspiration
pneumonia. Mortality rate in patients with pulmonary
complications increased to 51.7% in elective and emergent
operations. In patients undergoing operations for upper
GI tract, pulmonary complications were observed in 8.3%
in elective operations and 42.9% (3/7) in emergent operations, and all 3 patients died of pulmonary complications.
BACKGROUND: Aim of this study was to evaluate the
role of bariatric surgery in a population of morbidly obese
patients versus a medical treated cohort. We prospectively
compared patients submitted to surgery with a cohort of
surgically fit patients waiting for surgery and not operated
for extra surgical reasons.
MATERIALS AND METHODS: We divided the patients
into two groups: not operated (group A) and operated
(group B). The recruitment of the patients started in January 2003 and the study ended in November 2011. Median
follow-up was 29.2 months (range 13.8–105.3 months) for
group A and 38.2 months (range 11.8–106.7 months) for
group B. Two hundred eighty-nine patients (M = 80; F =
209) entered the study, 81 in group A (M = 16; F = 65) and
208 in group B (M = 64; F = 144). In group B, we performed
laparoscopic gastric bypass in 100 patients, laparoscopic
sleeve gastrectomy in 71 patients and laparoscopic gastric
banding in 37. Mortality, variation of BMI and comorbidities (diabetes, hypertension, obstructive sleep apnea syndrome and need for pharmacologic treatment) have been
evaluated in both groups.
RESULTS: Initial BMI was 41.5 ± 5.9 Kg/m2 for group A
and 42.2 ± 7.0 Kg/m2 at last follow up visit (p = 0.56). The
difference of comorbidities in group A are shown in Table
1. Four patients in group A (4.9%) died during the follow
up for heart attack.
Initial BMI for group B was 46.6 ± 7.0 Kg/m2 and 30.9 ± 6.4
Kg/m2 at the end of the follow up period (p < 0.001). Variation of comorbidities during follow-up are shown in Table 1.
There was one death in group B.
The difference between the two groups at last follow up
visit are shown in Table 2.
CONCLUSIONS: In super-old patients, mortality and morbidity rates in emergent operations were high compared to
those in elective operations. These results indicate importance of preoperative estimation in super-old patients, and
indication of the operation should be carefully considered
in patients with poor pulmonary function.
199
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu1801
Table 1
Medical Treatment
Group
First Visit
(n° pts)
Last Follow-Up
Visit
p
Diabetes
18
23
0.37
Hypertension
22
25
0.61
Obstructive Sleep
Apnea Syndrome
10
14
0.39
Pharmacologic
treatment
26
32
0.33
Pre-Operative
(n° pts)
Last Follow-Up
After Surgery
(n° pts)
Surgery group
Primary Squamous Cell Carcinoma of the Stomach:
Case Report and Literature Review
Mohummed R. Khani*, Antonio I. Picon
Surgery, Staten Island University Hospital, Staten Island, NY
BACKGROUND: Primary gastric squamous cell carcinoma
(PGSCC) is extremely rare, it accounts for 0.2% of all gastric
carcinomas with fewer than one hundred cases have been
reported in the literature.
CASE PRESENTATION: We report a case of 70-year-old
male who presented with melena and hypotension the
same day he was discharged home after undergoing aortic
valve replacement. He referred a 15 lb weight loss over few
months. His past medical history is significant for smoking (60 pack-year) and aortic stenosis. His physical exam
was unremarkable. Esophago-gastro-duodenoscopy (EGD)
revealed a five-centimeter ulcerated mass in the fundus of
the stomach, 2 cm from gastroesophageal junction without
active bleeding. Imaging of the abdomen revealed a 7 × 4
cm mass in the fundus of the stomach with no evidence
of locoregional extension or distant metastasis. Biopsy
was not attempted. He was taken to the operating room
and intraoperatively the mass was locally invading the
left hemidiaphragm. He underwent partial left diaphragmatic resection, total gastrectomy with Roux-en-Y esophago-jejunostomy and feeding tube jejunostomy insertion.
Histological studies revealed infiltrating moderately differentiated gastric squamous cell carcinoma with free margins
resection, one perigastric lymph node was positive for metastatic disease, for a T4, N1, and M0 disease. Immunohistochemical studies result was positive for cytokeratin 5/6, P63
and negative for CD117, CK20, and P16. He is currently
undergoing chemoradiation therapy.
p
Diabetes
64
9
<0.001
Hypertension
96
25
<0.001
Obstructive Sleep
Apnea
21
2
<0.001
Pharmacologic
treatment
106
29
<0.001
Table 2
BMI
Group A (81 pts)
Group B (208 pts)
p
42.2 ± 7.0
30.9 ± 6.4
<0.001
Diabetes
23
9
<0.001
Hypertension
25
25
<0.001
Obstructive Sleep
Apnea Syndrome
14
2
<0.001
Pharmacologic
treatment
32
29
<0.001
Mortality
4
1
= 0.02
CONCLUSION: We observed no significant changes in
weight loss and comorbidities in group A during the follow
up. In group B we observed a significant reduction of BMI
and all comorbidities. We observed significant changes in
BMI and comorbidities variation between the two groups.
In our study bariatric surgery influences the natural history of morbidly obese patients, determining a reduction
of BMI, comorbidities and mortality.
CONCLUSION: Primary gastric squamous cell carcinoma is
more common in men with peak incidence in 6th decade.
Most of the data available regarding PGSCC are case reports
and no clear pathogenesis of this tumor has been reported.
PGSCC is considered an aggressive tumor due to higher
incidence of lymphovascular and serosal invasion which
are responsible for poor prognosis. Aggressive approach
with radical surgical resection is recommended in the
absence of distant metastasis. Surgery followed by combined adjuvant chemoradiation is recommended despite
the absence of adequate data to support this strategy.
200
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1802
Tu1803
Laparoscopic Bariatric Surgery Is Safe in Patients with
Mild to Moderate Pulmonary Hypertension
Recurrence Pattern of Gastric Cancer After Curative
Gastrectomy
Hernan Urrego*, William S. Richardson, James Wooldridge
General Surgery, Ochsner Clinical Foundation, New Orleans, LA
Wee Boon Tan*
Department of General Surgery, Singapore National University
Hospital, Singapore, Singapore
BACKGROUND: Pulmonary hypertension (PH) has significant perioperative risks that may outweigh the benefit
of elective surgery. There is very little data on laprascopic
surgery in the setting of PH. Our objective was to look at
our outcomes of bariatric surgery in patients with PH.
METHODS: A retrospective review of a prospectively gathered database of all bariatric procedures was conducted for
patients treated from 2007–2011. All patients with PH who
underwent a bariatric procedure were reviewed for their
preoperative evaluation, intra-operative monitoring and
management, post-operative care, and clinic follow up.
RESULTS: 809 bariatric procedures were performed from
2007–2011, 5 patients (0.6%), 3 males and 2 females, had
PH. 2 patients had Type 1 PH, 2 had Type III PH, and the
final patient did not have information on the etiology. The
mean PAP of the 5 patients was 40 mmHG (range 25–60).
The mean age of the patients was 58 years of age, and
the mean BMI was 52. 3 laparoscopic Roux-N-Y, 1 laparoscopic sleeve gastrectomy, and 1 laparoscopic band were
performed. Invasive monitoring, arterial line and/or pulmonary catheter, was used in 2 patients with mean PAP
≥40. There were no intra-operative complications and only
one patient had a long term complication; band slipped
and underwent removal. The mean length of stay was 2
days and mean follow up was 8 months. Mean excess body
weight loss (EBL) at 3 months was 29% (N = 5), at 6 months
was 42% (N = 4), and at 1 year 35% (N = 2). Over an average
of 6 months, exercise tolerance in all 3 Roux-N-Y patients
was doubled in terms of length of exercise time and distance walking, and remained the same in the other two.
Postoperative pulmonary hypertension follow up with
2d echo was only performed in one patient. A decrease of
mean PAP from 39 to 26, 1 year after surgery, without concomitant change in medical therapy was demonstrated.
CONCLUSIONS: Laparoscopic surgery seems safe in
patients with pulmonary hypertension without significant
morbidity, mortality or increased length of stay. Invasive
monitoring in patients with mean PAP >25 mmHG <40
mmHG may not be necessary. Exercise tolerance improves
in most patients. EBL was modest but few patients had 1
year follow up. Further research is needed to determine
long term weight loss, improvement in comorbidities and
improvement in PH.
Radical surgery with D2 extended lymphadenectomy
together with various regimens of peri- or post-operative
adjuvant therapy have been shown to be effective for
advanced gastric cancer. We aim to evaluate the outcomes
of patients who underwent intended curative gastrectomy
in our institution and our recurrence rate and pattern.
All patients who underwent radical gastrectomy with curative intent were selected from a prospective gastric cancer
database at the National University Hospital, Singapore.
Each patient was discussed at a multidisciplinary tumor
meeting where decision on adjuvant therapy was made.
Patients were followed up at regular intervals. Postoperative complications and recurrence were recorded. Survival
and cause of death were confirmed with national registry.
Between year 2000–2010, 645 patients with gastric cancer
were treated in our hospital. 274 patients underwent radical surgery with curative intent. The median age was 69
(range: 19–89) and 67% are males. Most tumors were in
antrum (53%) or body (28%) and proximal tumors were
found in 19% of patients. Subtotal and total gastrectomies
were performed in 70% and 30% of patients respectively.
R0 resection was achieved in 252 patients (92%). 195 (71%)
and 79 (29%) patients underwent extended lymphadenectomy (D2 or D1+) or limited lymphadenectomy (D1)
respectively, according to Japanese Gastric Cancer Treatment Guideline 2010. There were 7 (2.5%) peri-operative
deaths. Lymph nodes were harvested by pathologists and
the median number was 25 for D2/D1+ (range: 15–64) and
18 (range: 3–25) for D1 respectively. Pathological staging
(American Joint Committee on Cancer [AJCC] 7th edition)
was as follows: I, 24%; II, 22%; III, 43%; IV, 10%. Peri-operative chemotherapy, postoperative chemo-radiotherapy
and postoperative chemotherapy were received by 23, 39
and 21 patients respectively. Median follow-up was 25
months. Tumor recurrence occurred in 31% of our patients
and the sites of recurrence were: local (29%); lymph nodes
(15%); peritoneum (23%); hematogenous (33%). The overall median survival and recurrence free survival are 25 and
21 months respectively. Factors predictive of recurrence
pattern will be analyzed and the results will be presented.
Prognosis of gastric cancer remains poor despite earlier
detection and improvement in treatment modalities. Recurrence is the most important factor associated with death
after curative gastrectomy. Various disease and treatment
factors may help to predict the pattern of recurrence and
thus provide a tailored treatment guide for our patients.
201
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu1804
Tu1805
Surgical Treatment of Gastrointestinal Stromal Tumors
(GIST) of the Stomach: Data Analysis of the East
German Gastric Cancer Study (“EGGC Study 02”)
Management of Synchronous Primary
Adenocarcinoma and Carcinoid Tumor of the Stomach
Maithao LE*, Rebecca Nelson, Rebecca Wiatrek, Steven L. Chen,
Joseph Kim
General & Oncologic Surgery, City of Hope, Duarte, CA
Meyer Frank*1,5, Karsten Ridwelski2,5, Lutz Meyer3,5,
Uwe Schmidt6,5, Henry Ptok4,5, Hans Lippert1,5, Ingo Gastinger5
1. Department of General, Abdominal & Vascular Surgery, University
Hospital, Magdeburg, Germany; 2. Department of General &
Abdominal Surgery, Municipal Hospital, Magdeburg, Germany;
3. Department of Surgery, Municipal Hospital, Plauen, Germany;
4. Department of Surgery, Municipal Hospital, Cottbus, Germany;
5. Institute for Quality Assurance in Operative Medicine, University
Hospital, Magdeburg, Germany; 6. StatConsult, StaConsult,
Magdeburg, Germany
INTRODUCTION: Patients with gastric adenocarcinoma
with concurrent primary gastric carcinoid are rarely
observed. Since little is known about the course of synchronous disease, our objective was to compare the outcomes
of patients with concurrent gastric adenocarcinoma and
primary gastric carcinoid with patients harboring isolated
gastric adenocarcinoma.
BACKGROUND: Within the East German Gastric Cancer Study (“EGGC 02”), 1,199 gastric tumor lesions were
documented. As a separate tumor entity, gastrointestinal
stromal tumors (GIST, n = 55) were compared with gastric
adenocarcinomas. The evaluation aimed, in particular, on
early postoperative and oncosurgical outcome as a parameter for the quality of surgical results. In near future, data
of a re-initiated, currently ongoing study over a 3-year time
period (n = approximately 300 patients) can be compared
to elucidate what (neo-)adjuvant treatment can additionally achieve with regard to the oncosurgical outcome of
gastric GIST patients.
PATIENTS AND METHODS: A systematic clinical multicentre observational study design with prospective items in
a well characterized area (East Germany) was used including hospitals of each level of surgical care.
RESULTS: From January 01 to December 31, 2002, data of
1,199 patients with gastric tumor lesions from 80 hospitals
were documented. Ninety five% of 1,139 gastric carcinomas were preoperatively diagnosed with histologic investigation whereas this rate was 47.3% in 55 GISTs. 61.8% of
the GIST patients were treated with local wedge resections
or with a limited approach. The rate of radical surgical
interventions (30%; e.g., gastrectomy, multivisceral resection) was relatively high. The surgical results achieved by
operation alone showing i) a hospital mortality of 1.8%,
and ii) a 5-year-survival rate of 78% (follow-up investigation period, 67 months; including 90.9% of all patients)
compared with gastric carcinoma (30.6%, 70 months and
87.4%, respectively) are acceptable.
METHODS: Patients surgically treated for concurrent
primary gastric adenocarcinoma and carcinoid tumors
from1973 to 2008 were identified from the Surveillance,
Epidemiology, and End Results (SEER) database. These
patients were case-matched 3:1 with isolated gastric adenocarcinoma patients for year of diagnosis, age, stage, type of
surgery, and receipt of radiation. Clinical and pathologic
characteristics and survival were compared between the
two cohorts.
RESULTS: Our investigation identified 32 patients treated
for concurrent gastric adenocarcinoma and primary gastric
carcinoid. During the same period, 84 932 cases of isolated
gastric adenocarcinoma were diagnosed. After case-matching, patient demographics and tumor characteristics were
similar, with the exception of gender, whereby synchronous tumor patients were more likely to be female (p =
0.038). Kaplan-Meier curves were constructed to compare
survival between the 2 cohorts, but no difference in survival was observed (5-year survival, 60 vs 47 months, p =
0.52). Univariate and multivariate analysis showed that
synchronous disease was not a predictor of poor outcome
(p = NS).
CONCLUSIONS: Development of synchronous gastric
adenocarcinoma and carcinoid tumor is extremely rare.
Nevertheless, our results indicate that patients with synchronous disease fare similarly to patients with isolated
gastric adenocarcinoma. Therefore, our results suggest
that the prognosis of patients with synchronous disease
is primarily driven by appropriate management of gastric
adenocarcinoma.
DISCUSSION: Results achieved by surgical intervention
alone as reported can serve as an appropriate basis for
the initiation and comparison of multimodal therapeutic concepts with the (neo-)adjuvant use of the tyrosin
kinase inhibitor Imatinib according to the currently relevant guidelines (as being expected soon by novel data on
patients treated surgically including [neo-]adjuvant protocols). Related to the exclusively surgical aspects of gastric GIST treatment, it appears to be indicated to achieve a
reduction of the, in part, surgical overtreatment using such
protocols including a significant improval of the preoperative diagnostic rate in clarifying gastric GIST appropriately
for an adequate therapeutic approach.
202
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Tu1806
Tu1808
Laparoscopic Resection of Gastric Gastrointestinal
Stromal Tumours Is Safe and Effective
Does Helicobacter Pylori Migrate with Proton Pump
Inhibitor Use?
Rabih Wassel*1, Yasser Abdulaal1, Haythem Ali1, Ashraf M. Rasheed2
1. Maidstone Cancer Centre, Maidstone Hospital, Maidstone, United
Kingdom; 2. Gwent Institute for Minimal Access Surgery, Royal Gwent
Hospital, Newport, United Kingdom
Joshua W. Long*, Ayman Obeid, Manasi S. Kakade,
Jayleen M. Grams, Allison A. Gullick, Mary T. Hawn
Surgery, UAB, Birmingham, AL
INTRODUCTION: Minimal access surgical therapy is the
emerging gold standard technique for treatment of gastric
gastrointestinal stromal tumours (GISTs). Despite the above
there continue to be lack of guidance or standardisation of
the techniques.
OBJECTIVES: To assess the safety, effectiveness and functional outcomes of a minimal access surgical strategy for
gastric GISTs.
METHODS: Thirty eight symptomatic gastric GISTs diagnosed during the years 2006–2010 satisfied the inclusion
criteria for minimal access surgical resection. All procedures were performed according to an agreed surgical strategy based on the anatomical location of the gastric lesions.
The size, site, histology, resection margin, complications,
hospital stay, functional outcome, recurrence rate, survival
and mutational analysis of the 38 consecutive resections
were maintained on a prospective computerised database.
All entered data was validated by the operating surgeon
and the reporting pathologist.
RESULTS: Twenty nine patients (76%) underwent a laparoscopic extra-gastric tangential resection while seven
patients (18%) underwent a posterior trans-gastric resection, and two had a distal gastrectomy (5%). There were no
conversions to open, no major intra-operative complications and no episodes of tumour rupture. There were no
major immediate or early complications of surgery. Complete resection (R0) was achieved in 100% of cases with a
mean lesion size of 44 mm (range 20–90 mm).
There was no peri-operative (30 day or in-hospital) mortality and the mean post-operative length of stay was 5.6 days.
The median follow-up for the surviving population (37/38
or 97.4%) is 24.5 months with a range of 4–77 months without any reported dysphagia, reflux, dumping syndrome
or any CT evidence of disease recurrence. 25/26 (96.2%)
of the low risk group remain alive with a median follow
up of 24.5 months (range 4–77 months). The 8 patients
in the intermediate risk group remain alive (100%) with a
median follow-up of 51 months (range 20–77 months) and
the 4 high risk group patients remain alive (100%) with a
median follow-up of 15 months (range 8–24 months). The
only death in this series occurred in the low risk group at
11 months secondary to a dissecting thoracic aneurysm.
CONCLUSION: Most gastric GISTs are resected by simple
tangential excision. Lesions close to gastro-oesophageal
junction are best suited for laparoscopic intra-gastric
excision to ensure complete resection while maintaining
oesophageal patency and sphincteric competency. Juxtapyloric endophytic lesions are best treated via an anterior
gastrotomy or by extra-gastric tangential excision if exophytic. This anatomic and function-based strategy for minimal access surgical resection of gastric GISTs conserve the
organ and preserve its function leading to a quicker recovery and a better quality of life without breaching oncological principles.
INTRODUCTION: Laparoscopic paraesophageal hernia
(PEH) repair has classically been performed using a fundoplication as an adjunct to aid in resolution of reflux.
However, fundoplication can be a morbid procedure with
long term complaints of bloating and dysphagia. Optimal
performance of the fundoplication requires the wrap to be
around the esophagus and in the abdominal cavity. Slipped
and herniated fundoplication following PEH repair contribute to symptoms associated with recurrence. Alternatively,
lateral gastropexy (LGP) can be used with PEH repair. The
purpose of this study was to determine whether LGP was
an effective alternative in preventing postoperative morbidity and still promoting resolution of symptoms when
compared to fundoplication.
METHODS: A retrospective review was performed of
patients who underwent PEH repair with fundoplication
± LGP (45%) or with LGP alone (55%) from 2005 to 2011.
Inclusion criteria consisted of all patients with symptomatic type II, III or recurrent PEH. There were 71 patients
who met inclusion criteria. Preoperative GI symptom score
surveys, esophogram, and esophagogastroscopy were used
to determine clinical symptoms and to diagnose gastroesophageal reflux, esophageal dysmotility, and aspiration.
Postoperatively, GI symptom score surveys were used to
evaluate for clinical symptoms and repeat esophogram
and/or esophogastroscopy was performed in these symptomatic patients. Data were then recorded and compared
using chi square analysis with SAS statistical software (version 9.2).
RESULTS: Fundoplication at the time of PEH was more
frequently performed in younger patients (59 ± 13 v 70 ±
13 years, p < 0.001), those with preoperative symptomatic
reflux (97% v 55%, p < 0.001), and those with a prior fundoplication (44% v 21%, p = 0.035). The median length
of stay was 2 days for each group, and there were 11 postoperative complications. Fundoplication had 2 complications (mean age 47 years) and LGP had 9 (mean age 72
years), but this was not statistically significant. Postoperatively, fundoplication and LGP had improvement of their
preoperative reflux symptoms (93% each), although a significantly greater number of patients experienced early
complete resolution of reflux after fundoplication (80%
v 48%, p = 0.011). LGP demonstrated a trend toward an
absence of postoperative dysphagia (76% v 54%, p = 0.063)
or chest pain (81% v 63%, 0.099), although these were not
significant. LGP did result in decreased complaints of postprocedure nausea and/or vomiting (5% v 33%, p = 0.047).
CONCLUSION: In older patients with diminished esophageal motility and non-reflux dominant symptoms, PEH
repair without fundoplication does not result in complaints
of post-operative reflux. Consideration for LGP with PEH
repair may be warranted to minimize postoperative morbidity associated with fundoplication in elderly patients.
203
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Translational Science: Colon-Rectal
In those experiments, complete remission was obtained
in 4/7 cases. Response to other drugs was again individual
between xenografted cells.
Tu2062
CONCLUSION: Here, we describe the successful establishment of three new MSI+ CRC cell lines. These well-characterized and low-passage lines provide a useful tool for
subsequent investigating the biological characteristics of
MSI+ CRCs, both of sporadic and hereditary origin. Additionally, matched EBV-transformed B cell lines are available
for comparative genetic studies.
Establishment and Characterization of Three
Microsatellite-Instable Cell Lines Derived from
Sporadic and Inherited Primary Colorectal Carcinomas
Claudia Maletzki1, Ernst Klar1, Friedrich Prall2, Michael
Linnebacher*1
1. General Surgery, University of Rostock, Rostock, Germany;
2. Institute of Pathology, University of Rostock, Rostock, Germany
Tu2064
BACKGROUND: Microsatellite instability (MSI) is detected
in about 15% of all colorectal cancers (CRC). In order to
identify new biomarkers that potentially allow for evaluating the response to new cytostatic drugs, pre-clinical in
vitro models are mandatory. We here describe the successful establishment and comprehensive characterization of
three patient-derived MSI+ cell lines along with their corresponding xenografts.
METHODS: Three primary CRC cell lines (HROC24,
HROC87, and HROC113) were established from a total of
ten clinicopathological well defined MSI+ cases. Cells were
comprehensively characterized by phenotype, morphology, growth kinetics and molecular profile. Subsequently,
the response to clinically relevant chemotherapeutics was
examined in vitro and in vivo.
Morphology of established MSI+ cell lines
RESULTS: Two of the MSI+ cell lines derived from sporadic
CRC showing CIMP-H (HROC24: APCmut p53wt, K-raswt,
B-rafmut, HROC87: APCwt p53mut, K-raswt, B-rafmut),
whereas one cell line (HROC113: APCwt p53wt, K-rasmut,
B-rafwt) was HNPCC-associated. All cell lines were characterized as epithelial (EpCAM+, CEACAM+) tumor cells
secreting different levels of cytokines. Response to chemotherapeutics was different between cell lines when analyzing in vitro and in vivo. Generally, the HNPCC-derived
HROC113P cells tended to be more resistant than the
sporadic MSI+ lines in vitro. However, when tested in
nude mice, most pronounced effects were observed for
HROC113P, especially following gemcitabine treatment.
Development of a Novel Murine Model of Portal Vein
Catheterization as a Strategy to Analyze
Liver-Directed Therapies for Colorectal Cancer
Metastasis
Joe Valentino*1,2, Piotr Rychahou1,2, W.C. Mustain1,2, B. Mark
Evers1,2
1. Markey Cancer Center, University of Kentucky, Lexington, KY; 2.
Department of Surgery, University of Kentucky, Lexington, KY
INTRODUCTION: Colorectal cancer (CRC) is the second
leading cause of cancer deaths in the US. Despite progress in earlier stage disease, survival has only minimally
improved in patients with systemic metastases (Stage IV),
which occur primarily to the liver; therefore, more effective and targeted therapies are required. Small interfering
RNA (siRNA) provides a highly selective method to target
mutated pathways; however, its use is complicated by the
inability to specifically target tumor cells. The purpose of
this study was to: i) develop a novel murine model of portal
vein catheterization for the chronic delivery of therapeutic agents to liver metastases, and ii) determine the utility
of epithelial cell adhesion molecule (EpCAM) as a selective
target for siRNA delivery to CRC metastases.
METHODS: i) To establish a chronic portal vein catheterization model, a midline laparotomy was performed in 2
mo-old Balb/C mice and a 1.2F catheter inserted into the
portal vein. Distribution of portal venous flow and catheter
patency was evaluated using fluorescently-labeled microspheres. Uptake of siRNA within the liver was tested using
DY-547-labeled siRNA followed by IVIS imaging 4h post
injection. For metastatic studies, splenic injection of CT26
murine colon cancer cells, transfected with a luciferase vector, was performed and metastasis confirmed 10d later by
IVIS imaging; siRNA delivery to liver metastases was confirmed using DY547-labeled siRNA and fluorescent microscopy. ii) The presence of EpCAM was evaluated using IHC
staining of microarrays containing a total of 89 normal
colon samples, 129 primary CRCs, 4 liver metastases and a
normal liver specimen.
RESULTS: i) Fluorescence was noted throughout the
majority of the liver following injection of the microspheres thereby confirming excellent distribution; microsphere injection at 2 wks confirmed catheter patency. Portal
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53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
venous injection of DY547-labeled siRNA demonstrated a
high level of fluorescence throughout the entire liver. In
the metastatic model, fluorescent microscopy confirmed
the presence of siRNA within the liver metastases demonstrating effective delivery to metastatic lesions. ii) EpCAM
staining was absent in normal hepatocytes; mild staining
was present in the biliary radicals. All primary CRCs and
liver metastases stained strongly for EpCAM.
CONCLUSIONS: Liver directed therapy provides an effective method for the delivery of siRNA to CRC metastases.
Furthermore, the presence of EpCAM on the cell surface
of CRC metastases, but not normal liver, may provide a
method to selectively target hepatic metastases of epithelial origin. This targeted delivery, combined with the
specific effects of siRNA, would provide a highly selective
therapeutic strategy for treatment of CRC metastasis.
Figure 1
Translational Science: Esophageal
Tu2065
In Rats After Esophagojejunostomy, Reflux Esophagitis
Is Accompanied by the Expression of SOX-9 in Basal
Cells of the Squamous Epithelium and in Barrett’s
Metaplasia
Thai H. Pham*, David H. Wang, Robert M. Genta,
Shelby D. Melton, Chunhua Yu, Stuart J. Spechler,
Rhonda F. Souza, William Neumann
Surgery, North Texas VAMC; UT Southwestern Medical Center,
Dallas, TX
INTRODUCTION: Metaplasia involves the change from
one adult cell type into another that is phenotypically different, but that is often of similar embryonic origin. The
embryonic esophagus initially is lined by columnar cells
that are replaced by squamous cells as maturation proceeds.
Barrett’s metaplasia involves the change from esophageal
squamous cells back into columnar cells in the setting of
gastroesophageal reflux disease. SOX-9, a transcription factor that regulates the development of columnar cell morphological features, is expressed in Barrett’s metaplasia and
in the mouse embryonic, columnar-lined esophagus, but
not in the normal adult squamous-lined esophagus. Furthermore, forced expression of SOX-9 in cultured esophageal squamous cells induces a columnar phenotype. We
sought to determine whether SOX-9 expression is involved
in the development of Barrett’s metaplasia in rats that have
reflux esophagitis induced by esophagojejunostomy (EJ).
METHODS: Groups of 5 Sprague-Dawley rats were sacrificed at 8, 10, 16, and 24 weeks after EJ. The distal esophagus
was removed, sectioned, paraffin-embedded and mounted
on slides, which were stained with H&E for histological evaluation; immunohistochemistry was performed to determine
SOX-9 protein expression. We evaluated the specimens for
1) squamous basal cell and papillary hyperplasia, 2) Barrett’s
metaplasia with and without dysplasia, and 3) adenocarcinoma. SOX-9 expression was assessed only in squamous
epithelium and in non-dysplastic Barrett’s metaplasia. Shamoperated animals were used as controls.
Figure 2
RESULTS: At 8 weeks after EJ, erosive esophagitis with
prominent squamous basal cell and papillary hyperplasia
was present in all animals. In addition, some of the squamous cells appeared to produce mucin, which was present
both within and between cells. At 8 weeks, non-dysplastic
Barrett’s metaplasia, dysplastic Barrett’s metaplasia, and
adenocarcinoma were found in 4, 3 and 1 of the 5 rats,
respectively (Figure 1B-D). Similar histologic findings were
seen at the later time points but not in sham-operated animals (Figure 1A). SOX-9 was expressed by basal cells of the
squamous epithelium close to the EJ anastomosis (Figure
2A), but not in squamous epithelium further from the anastomosis. Intense expression of SOX-9 was detected in areas
of non-dysplastic Barrett’s metaplasia (Figure 2B). Control
animals did not show any esophageal SOX-9 expression.
CONCLUSIONS: In rats after esophagojejunostomy, the
development of reflux esophagitis is accompanied by
expression of SOX-9 in the basal cell layer of esophageal
squamous epithelium near the anastomosis. In addition,
SOX-9 is expressed in Barrett’s metaplasia in this rat model.
These data suggest that this is a relevant model for studying
the role of SOX-9 in the development of Barrett’s esophagus and esophageal adenocarcinoma.
205
THE SOCIETY FOR SURGERY OF THE ALIMENTARY TRACT
Tu2066
Translational Science: Other
AKT Expression Is Associated with Degree of Pathologic
Response in Adenocarcinoma of the Esophagus Treated
with Neoadjuvant Therapy
Tu2067
Maki Yamamoto*1, Jill Weber1, Ravi Shridhar2, Sarah Hoffe2,
Khaldoun Almhanna1, Richard Karl1, Ken L. Meredith1
1. Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL;
2. Radiation Oncology, Moffitt Cancer Center, Tampa, FL
OBJECTIVE: Neoadjuvant chemoradiation (NCRT) has
become standard in the treatment of locally advanced
esophageal cancer with survival correlated to degree of
pathologic response. The activation of the PI3K/Akt/mTOR
pathway plays an important role in tumorigenesis and
resistance to anticancer drugs. The aim of this study was
to elucidate the role of the Akt/mTOR pathway in chemoresistance and the prognosis of patients with esophageal
adenocarcinoma cell carcinoma (AC) who received NCRT.
METHODS: After IRB approval, a prospective trial was
instituted in which patients with locally advance esophageal requiring NCRT were consented for endoscopic biopsies of normal and tumor tissue prior to instituting therapy.
The tissues underwent gene expression profiling using the
Affymetrix 133 Plus 2.0 Gene chip. SAM method was used
to analyze significant differentially expression of AKT
within normal and tumor tissue. Expression was then correlated to degree of pathologic response. All patients were
treated with NCRT followed by esophagectomy. Pathologic
complete response (pCR) was defined as no residual tumor,
partial pathologic response (pPR) as a 50% reduction in
tumor size or nodal down-staging, and non-response (pNR)
as no difference between pre-operative and post-operative
stage based upon endoscopic ultrasound.
RESULTS: Nineteen patients with adenocarcinoma had
biopsies of normal and tumor tissue that were subsequently
analyzed via microarray. Comparisons of expressions
between normal and tumor revealed consistently significant
overexpression of AKT in tumor tissues p = 0.007. We identified 10 patients exhibiting pathologic complete response,
6 partial pathologic response, and 3 non-responders. When
comparing the expression of AKT between normal and
tumor tissue in those ultimately designated as pCR, there
persisted a significant over-expression of AKT in the tumor
tissues p = 01. However in analyzing the degree of expression between pathologic response to NCRT we consistently
demonstrated a linear correlation between the expression
of AKT and degree of pathologic response. Partial and non
pathologic responders consistently had higher expressions
of AKT compared to pCR with the non-responders consistently illustrating the highest expression of AKT.
CONCLUSIONS: AKT is overexpressed in patients with
adenocarcinoma of the esophagus. Moreover, pathologic
response to neoadjuvant chemoradiation may be correlated with degree of AKT expression. Additional data is
needed to clarify this relationship further and potentially
add targeted therapies to the neoadjuvant regimen.
Nurses Attitudes Towards Women Surgeons
Sharona B. Ross*1,2, Franka Co2, Krishen Patel2, Kenneth Luberice2,
Harold Paul2, Alexander S. Rosemurgy2
1. Surgery, University of South Florida, Tampa, FL; 2. Tampa General
Hospital, Tampa, FL
INTRODUCTION: Best surgical care involves a team
approach; nurses are an integral part of the team. Interactions between surgeons and nurses impact the working
environment and, potentially, quality of care. Given the
growing number of women surgeons, this study was undertaken to determine the attitudes of nurses towards women
surgeons.
METHODS: Nurses in a tertiary care university-affiliated
hospital were queried about their attitudes toward women
surgeons utilizing a validated questionnaire.
RESULTS: 135 nurses, 93% women and 80% Caucasian,
were queried; 60% had been nurses for more than 10
years and 25% for 1–5 years. Relative to men surgeons,
60% of nurses believe that women surgeons interact differently with them and 86% feel women surgeons are as
reliable. 60% of nurses believe men surgeons have better
doctor-nurse relationships. Relative to men surgeons, 79%
of nurses feel women surgeons are “good surgeons”, 80%
feel women surgeons are confident in their skills, and 49%
believe that women surgeons bring “something unique
to Surgery.” 38% of nurses feel women surgeons have the
same opportunities for advancement as men, 38% feel that
the discipline of Surgery is sexist against women surgeons,
and 50% believe the discipline of Surgery is responsible
for women leaving the field, which is perceived as a frequent event; 72% of nurses think there are too few women
surgeons.
CONCLUSIONS: A significant number of nurses believe
women surgeons interact differently with them and
patients; the majority of nurses believe they have better
doctor-nurse relationships with men surgeons and that
women surgeons have inferior surgeon-patient relationships. Most, but not all, nurses see admirable qualities in
women surgeons; the majority of, though not all, nurses
believe women surgeons are as “good,” confident, capable,
and reliable as men surgeons. Less than half of the nurses
believe women surgeons bring “something unique to Surgery”. Many nurses believe women surgeons have reduced
opportunities in Surgery and that Surgery is sexist against
women surgeons. Most nurses believe Surgery promotes
women to leave Surgery and there are too few women
surgeons. Nurses note discrimination in Surgery against
women surgeons and a notable number, though a minority, are biased against women surgeons. Intervention in
the work place is warranted to improve the perception of
nurses towards women surgeons.
206
53RD ANNUAL MEETING • MAY 18–22, 2012 • SAN DIEGO, CA
Translational Science: Small Bowel
Translational Science: Stomach
Tu2068
Tu2069
Does Small Intestinal Atresia Impact on Amino Acid
and Monosaccharide Transporter Expression in the
Newborn Gut?
Gastric Bypass and Duodenal Switch Cause Body
Weight Loss Through Different Mechanisms in Rats
Yosuke Kodama*1, Helene Johannessen1, Marianne W. Furnes1,
Chun-Mei Zhao1, Gjermund Johnsen2, Ronald MåRvik2,
Baard Kulseng2,1, Duan Chen1
1. Department of Cancer Research and Molecular Medicine, NTNU,
Trondheim, Norway; 2. Department of Surgery, St. Olav’s Hospital,
Trondheim University Hospital, Trondheim, Norway
Raphael N. Vuille-Dit-Bille , Simone M. Camargo ,
Luca Mariotta1, Tom Sasse1, Eva E. Kummer1, Schirin Hunziker1,
Luca Emmenegger1, Ueli MöHrlen2, Martin Meuli2,
FrançOis Verrey1
1. Institute of Physiology, University of Zurich, Zurich, Switzerland;
2. Pediatric Surgery, Childrens Hospital of Zurich, Zurich, Switzerland
*1
1
BACKGROUND: Intestinal segments distal to congenital
atresia have been suggested to be immature due to lack of
luminal access of amniotic fluid (before birth) and nutrition (after birth). Whether the concomitant deficiency of
luminal amino acids (AA) and glucose (Glc) has an impact
on small intestinal amino acid- and glucose transporter
expression, has never been tested.
PATIENTS AND METHODS: We therefore analyzed protein- (by immunoflurescence) and mRNA (by Real time
RT-PCR) expression of several AA- and Glc transporters
proximal and distal to small intestinal atresia in human
newborns. To assess transporter function, we measured
radiolabeled AA- and Glc uptake into small intestinal
enterozytes located proximal and distal to the atretic segment. Furthermore villus morpholgy was analyzed by
Hematoxylin-Eosin staining.
RESULTS: Proximal sections showed morphological
changes from normal intestinal architecture, consisting of
villus atrophy and hemorrhages, necrotic areas and some
lymphid aggregates within the lamina propria, whereas
distal sections showed physiologic morphology. Preliminary results indicate a similar mRNA expression distal and
proximal to small intestinal atresia for amino acid-, dipeptide-, monosaccharide- and fatty acid transporters, as well
as for genes belonging to the Renin Angiotensin System
(RAS). Protein expression of the amino acid transporter
B0AT1 and its accessory RAS Protein Angiotensin Converting Enzyme 2 (ACE2), was similar in proximal- and distal
segments. Radiolabeled uptake measurements showed a
slight decrease in proximal sodium-independent Glucoseand Glutamine uptake, when compared to distal transport.
CONCLUSIONS: With respect to the genes and proteins
tested, the absence of intestinal continuity in case of Small
Intestinal Atresia seems not to affect epithelial gene and
protein expression or function. This indicates amino acidand monosaccharide transporter development independently of luminal components.
BACKGROUND/AIM: It is still a challenge how to select
the most suitable surgical procedure for each individual
obese patient. Both gastric bypass (GB) and duodenal switch
associated with sleeve gastrectomy (DS) have been widely
used as bariatric surgery, and DS appears to be superior to
GB, particularly for morbid obesity. The aim of the present
study was to compare these procedures with respect to the
mechanisms leading to body weight loss in rats.
METHODS: Male Sprague-Dawley rats were subjected to
GB, DS, or laparotomy (as controls) and followed for 2–14
weeks by an open-circuit indirect calorimeter composed in
comprehensive laboratory animal monitoring system and
adiabatic bomb calorimeter.
RESULTS: Body weight loss was greater after DS than GB.
Calorie intake in terms of kcal/day/rat, kcal/day/100 g body
weight, and kcal/meal was reduced after DS but not GB.
The fecal energy content (expressed as J/g) was increased
after DS but not after GB. Energy expenditure (kcal/hr/100
g body weight) was increased during nighttime at 3 weeks
and then during daytime at 14 weeks after GB. The energy
expenditure was increased both at 2 weeks (during daytime) and 8 weeks (during both daytime and nighttime)
after DS. Respiratory exchange ratio, i.e., VCO2/VO2, was
unchanged after GB, but reduced after DS. Serum ghrelin
levels were reduced at 3 weeks after GB but no longer afterwards. Serum CCK levels were greatly increased at least at
8 weeks after DS.
CONCLUSION: GB induced body weight loss by increasing energy expenditure, whereas DS induced body weight
loss by reducing food intake (probably due to hyperCCKemia), causing malabsorption, and increasing both fat
metabolism and energy expenditure.
ACKNOWLEDGEMENTS: The research leading to these
results has received funding from the Central Norway
Regional FUGE programme, Central Norway Regional
Health Authority, and the European Union Seventh Framework Programme (FP7/2007–2013) under grant agreement
n°266408.
207
2013 ANNUAL MEETING
Be sure to join us for next year’s Annual Meeting—
mark your calendars now!
May 17–21, 2013, Orlando, FL
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 San Diego Convention Center unless otherwise indicated.
indicates a ticketed session requiring a separate registration and fee.
FRIDAY, 5/18/2012
7:30 AM – 2:30 PM
RESIDENTS & FELLOWS RESEARCH CONFERENCE (by invitation only)
28ab
SATURDAY, 5/19/2012
8:00 AM – 4:35 PM
MAINTENANCE OF CERTIFICATION COURSE
Evidence Based Treatment of
Hepatopancreatobiliary Diseases
10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM
(ASGE-accredited)
Treatment of Early Gastrointestinal Cancer:
When is it Safe?
Sponsored by:ASGE, SSAT
10:30 AM – 12:00 PM DDW COMBINED TRANSLATIONAL SYMPOSIUM (AGA-accredited)
Probiotics in Health and Disease
Sponsored by: AGA, AASLD, ASGE, SSAT
28abcd
6a
7ab
SUNDAY, 5/20/2012
7:45 AM – 8:15 AM
8:15 AM – 9:15 AM
8:30 AM – 10:00 AM
OPENING SESSION
28ab
PRESIDENTIAL PLENARY A (PLENARY SESSION I)
28ab
DDW COMBINED CLINICAL SYMPOSIUM 31abc
(ASGE-accredited)
Management of the Patient at High Risk for
Colon Cancer
Sponsored by: ASGE, SSAT
9:15 AM – 10:00 AM PRESIDENTIAL ADDRESS
28ab
Relationships Matter
10:30 AM – 11:15 AM PRESIDENTIAL PLENARY B (PLENARY SESSION II)
28ab
10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 32ab
(AGA-accredited)
Gastrointestinal Management of the
Patient With Obesity
Sponsored by: AGA, ASGE, SSAT, AASLD
11:15 AM – 12:00 PM MAJA AND FRANK G. MOODY 28ab
STATE-OF-THE-ART LECTURE
The Treatment of Obesity: How Science
CAN Influence Public Policy
12:00 PM – 2:00 PM POSTER SESSION I (non-CME)
Halls C-G
12:30 PM – 1:45 PM
MEET-THE-PROFESSOR LUNCHEONS
Operative Therapies for GERD: What are the Options? 28cd
The Difficult Gallbladder: Tricks to Get Out of Trouble 29d
2:15 PM – 3:45 PM
CONTROVERSIES IN GI SURGERY A
28cd
Debate 1: C. Difficile Colitis: Ileostomy and
Lavage vs. Resection
Debate 2: Is Surgical Intervention for Cystic
Neoplasms of the Pancreas Being Overutilized?
2:15 PM – 3:45 PM
DDW COMBINED CLINICAL SYMPOSIUM
20a
Management of Fecal Incontinence
Sponsored by: SSAT, AGA, ASGE
2:15 PM – 4:30 PM
VIDEO SESSION I: ROBOTIC, ENDOSCOPIC, AND 26ab
ADVANCED LAPAROSCOPIC GI SURGERY
2:15 PM – 4:45 PM
STATE-OF-THE-ART CONFERENCE
28ab
Technological Advances in the Surgical
Treatment of Colon and Rectal Cancer
2:15 PM – 5:00 PM
PLENARY SESSION III
27b
4:00 PM – 5:00 PM
CLINICAL WARD ROUNDS I
28cd
The Difficult Bile Duct Stone:
Case Presentations and Tricks of the Trade
MONDAY, 5/21/2012
7:30 AM – 9:15 AM
8:30 AM – 9:30 AM
8:30 AM – 10:00 AM
9:30 AM – 11:00 AM
VIDEO SESSION II: BREAKFAST AT THE MOVIES
28ab
CLINICAL WARD ROUNDS II
28cd
Diverticulitis: Lavage and Resection—
Which Treatment When?
SSAT PUBLIC POLICY AND ADVOCACY 27b
COMMITTEE PANEL
Will There Be a General Surgeon When You Need One?
SSAT/AHPBA JOINT SYMPOSIUM
28ab
Evaluation and Treatment of Benign Liver Neoplasms
10:00 AM – 11:15 AM
10:00 AM – 11:15 AM
10:00 AM – 11:15 AM
10:30 AM – 12:00 PM
PLENARY SESSION IV
27b
QUICK SHOTS SESSION I
26ab
VIDEO SESSION III: HPB & FOREGUT VIDEOS
28cd
DDW COMBINED CLINICAL SYMPOSIUM
20a
Functional Disorders of the Esophagus
Sponsored by: SSAT, AGA, ASGE
11:15 AM – 12:00 PM DORIS AND JOHN L. CAMERON GUEST ORATION
28ab
Bringing Health Information to Life
12:00 PM – 2:00 PM POSTER SESSION II (non-CME)
Halls C-G
12:30 PM – 1:45 PM
MEET-THE-PROFESSOR LUNCHEONS
Cystic Tumors of the Pancreas: To Operate or Not?
9
Diverticulitis: Two and Out or Not?
10
2:15 PM – 3:15 PM
QUICK SHOTS SESSION II
28ab
2:15 PM – 3:45 PM
CONTROVERSIES IN GI SURGERY B
28cd
Debate 3: Ban the Band? Which is the Best
Operation for Morbid Obiesity?
Debate 4: 360 vs. Partial Fundoplication:
Which is the Standard for GERD?
2:15 PM – 3:45 PM
DDW COMBINED CLINICAL SYMPOSIUM 20a
(AGA-accredited)
Multidisciplinary Management of Complicated
Crohn’s Disease
Sponsored by: AGA, SSAT, ASGE
2:15 PM – 4:00 PM
PLENARY SESSION V
27b
3:15 PM – 4:45 AM
SSAT/ASCRS JOINT SYMPOSIUM
28ab
Controversies in Surgery for Ulcerative Colitis
4:00 PM – 5:00 PM
CLINICAL WARD ROUNDS III
28cd
The GI Surgeon and Endoscopy:
Case Presentations Where the Endoscope Matters
4:00 PM – 5:00 PM
QUICK SHOTS SESSION III
27b
4:00 PM – 5:30 PM
DDW COMBINED CLINICAL SYMPOSIUM
20bc
Pancreatic Cystic Neoplasms and IPMN
Sponsored by: SSAT, AGA
5:00 PM – 6:00 PM
ANNUAL BUSINESS MEETING (non-CME)
28ab
7:00 PM – 9:00 PM
MEMBERS RECEPTION
The Don Room at El Cortez
TUESDAY, 5/22/2012
7:30 AM – 9:30 AM
SSAT/ISDS JOINT BREAKFAST SYMPOSIUM
28ab
Optimizing Outcomes for Our Patients:
Data and Practice: Combining Perioperative Patient
Management and Expert Technical Tips
8:00 AM – 9:30 AM PLENARY SESSION VI
27b
8:30 AM – 10:00 AM DDW COMBINED CLINICAL SYMPOSIUM 20bc
(AASLD-accredited)
Management of HCC: Chemotherapy,
Reduction of Tumor Load, or Transplant?
Sponsored by: AASLD, SSAT
9:30 AM – 12:00 PM PLENARY SESSION VII
27b
10:30 AM – 12:00 PM DDW COMBINED CLINICAL SYMPOSIUM 20bc
(AGA-accredited)
Can You Eliminate Barrett’s Esophagus?
Sponsored by: AGA, ASGE, SSAT
10:30 AM – 12:00 PM SSAT HEALTH CARE QUALITY & 28cd
OUTCOMES COMMITTEE PANEL
Three Ways to Bend thd Cost Curve in GI
Surgery Without Sacrificing Quality
12:00 PM – 2:00 PM POSTER SESSION III (non-CME)
Halls C-G
12:00 PM – 3:00 PM KELLY AND CARLOS PELLEGRINI SSAT/
28ab
SAGES JOINT LUNCHEON SYMPOSIUM
Current Concepts and Controversies in Foregut Motility
12:30 PM – 1:45 PM
MEET-THE-PROFESSOR LUNCHEONS
CBD Stones: Laparoscopic or Endoscopic?
7ab
Modern Staging and Treatment of Rectal Cancer
26ab
2:00 PM – 4:00 PM
BEST OF DDW 2012 (non-CME)
28cd
2:15 PM – 3:45 PM
DDW COMBINED CLINICAL SYMPOSIUM 20bc
(ASGE-accredited)
Endoscopic Biliary Complications: What Can You Do?
Sponsored by: ASGE, SSAT