Advanced Esophageal Carcinoma: Is It Still Worth to Operate?

for risk stratification in colon and rectal surgery can be assessed, possibly in combination with ASA (American Society of Anesthesiologists score) and BMI (body mass index), to predict operative risk. METHODS: CR-POSSUM, Physiological and Operative Severity Score for the enUmeration of Mortality and Morbidity uses 6 physiologic (age, cardiac, systolic pressure, heart rate, hemoglobin and urea level) and 4 operative (operation type, peritoneal contamination, malignancy status and operative urgency) parameters to calculate risk of morbidity and mortality from colorectal surgery. From a systematic sample of 112 inpatients on the colon and rectal surgery service at our institution over a 5-year period, we calculated CR-POSSUM scores using the web-based algorithm [www.riskprediction.org.uk]. We also noted ASA score and BMI. STATA9 was used to calculate differences in means using twosided t-tests. RESULTS: Preoperative risk by CR-POSSUM was relatively stable over time, as was BMI and ASA [see table]. CR-POSSUM scores for obese (BMI>=30) and morbidly obese (BMI>=35) patients did not vary significantly (P=0.08 and 0.57, respectively), indicating it is an independent factor. CR-POSSUM scores varied significantly by ASA score: ASA 12 mean 4.1 (SD 8.2) versus mean 7.9 (SD 8.1) for ASA 3-4 patients (P=0.03). CONCLUSIONS: From this preliminary work, we propose that Medicare policy-makers consider this simple, validated, European-developed risk stratification for patients undergoing lower gastrointestinal surgery. Obesity is an increasing epidemic in the U.S. and should be given its due role in the equation, while ASA could be left out. We will present morbidity/mortality data on this group to relate CR-POSSUM scoring to our surgical outcomes. Preoperative CR-POSSUM Scores, ASA, and BMI over 5 years of a Systematic Sample of Colon and Rectal Surgery Inpatients

(n=2) or laparoscopic esophagectomy (n=1) and currently complain of occasional dysphagia and gained weight. CONCLUSION:.Heller's myotomy and fundoplication relieves dysphagia even in patients with massive dilated esophagus. Su1614 Efficacy and Durability of Laparoscopic Heller Myotomy: Patient Symptoms and Satisfaction at Long Term Follow up John G. Linn, Anthony N. Chan, Sarwat Ahmad, Peter Muscarella, W. S. Melvin, Kyle A. Perry INTRODUCTION: Laparoscopic Heller myotomy with partial gastric fundoplication has become the standard treatment for achalasia. While this procedure has demonstrated excellent short term outcomes, there is a paucity of data regarding long term patient symptoms and satisfaction after the operation. We report a single institution series of minimally invasive Heller myotomy with long term evaluation of gastroesophageal reflux (GERD) symptoms, dysphagia, and patient satisfaction. METHODS: A retrospective review of a prospectivelycollected database was conducted for patients undergoing laparoscopic Heller myotomy from 1995-2006 under an institutional review board approved protocol. Long term followup evaluation was performed by mail or telephone questionnaire. Outcomes included operative data, treatment for recurrent dysphagia, GERD symptoms, and patient satisfaction with their operation. Post-myotomy reflux symptoms were assessed using the validated GERDHRQL instrument. A score greater than 20 was considered indicative of significant reflux symptoms, as this correlated with patient dissatisfaction. RESULTS: 56 patients underwent primary laparoscopic Heller myotomy during the study period. At long term follow-up, 7 patients were deceased and follow-up was obtained in 29. Median follow up interval was 6 years (range 4-14 years). All operations were completed laparoscopically, and 18 utilized robotic assistance. All patients reported relief of dysphagia postoperatively. At long term follow up, 72% of patients had received no further treatment for dysphagia. Of those with recurrent dysphagia, 2 patients underwent Botox injection, 5 underwent pneumatic dilatation, and 1 required a second esophageal myotomy. All patients reported adequate relief of dysphagia after repeat intervention. 55% of patients use acid-reducing medications to control GERD symptoms; however, only 10% of patients reported Velanovich scores indicative of severe GERD that impacts patients' overall satisfaction with their operation. When asked to reconsider their achalasia treatment, 97% of patients would choose laparoscopic Heller myotomy again. CONCLUSION: Laparoscopic Heller myotomy provides durable, effective, long term dysphagia relief in the vast majority of patients. At a median follow-up interval of 6 years, patients remain highly satisfied with the operation. While many patients report mild reflux symptoms, up to 10% report symptoms indicative of significant GERD that negatively impacts overall satisfaction with the operation.

(no significant variation over time) Su1612 Ileocecectomy for Crohn's Disease (CD): Which Factors Augment Intraoperative Small Bowel Preservation? Liliana Bordeianou, Richard A. Hodin, Abdulmetin Dursun, Joshua R. Korzenik, Vanessa P. Ho, Toyooki Sonoda, Sang Lee, Sharon L. Stein

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Introduction: Preservation of small bowel is a crucial element in surgery for patients with CD, yet it is not known whether perioperative factors or preoperative therapies influence specimen length. Our aim was to utilize a large multicenter database of CD patients treated with ileocecectomies (IC) to determine predictors of length of small bowel resection. Methods: Retrospective analysis of prospectively collected data on patients with CD who underwent IC between 9/1993-10/2010 at two academic centers was performed. T-tests were used to determine whether the mean length of small bowel resection (length of colon excluded) was modified by patient demographics, preoperative medical treatment, type of CD, or surgeon expertise. A Multiple Linear Regression model was fitted to account for confounders and to identify predictors of length of resection. Results: 269 CD patients (51% female, mean age 39 y) were included. On univariate analysis, the mean length of small bowel resection(20.8 cm, SD 17.18 cm) was not affected by age (p= 0.23), sex (p=0.12), history of prior resections (p=0.12), emergency surgery (p=0.23), presence of fibrostenotic (p= 0.51), penetrating (p=0.78) or active disease (p=0.97). Patients with microscopically positive margins were not spared bowel length (22.5 vs. 19.8 cm, p=0.34). Patients with suspected malignancy had wider resection margins(54.7 vs. 19.6 cm, p=0.01). 5-ASA (p=0.54), steroids (p=0.51), azathioprine (p=0.59) and TNF agents (p=0.13) did not augment length of resection, however exposure to 6-MP within 3 months of surgery decreased resection length (17.1 vs. 22.4, p=0.03). Surgeons with expertise in CD were more likely to salvage bowel (19.9 vs. 29.5 cm; p=0.0008). On multiple linear regression history of prior resections (p= 0.0001), suspected malignancy (p=0.02) and surgery by a non-expert (p=0.0004) were predictive of longer resections. Conclusions: Length of small bowel resection during ileocolic resection for CD is most affected by surgical expertise, concerns for malignancy and history of prior resections. Various preoperative medical regimes do not appear to have an effect on ultimate resection length.

ABSTRACT Objective: The role of surgical therapy in patients with locally advanced esophageal cancer is still controversially discussed. There is also controversy about whether neoadjuvant chemo or radio-chemotherapy should be the standard management in patients with locally advanced esophageal carcinoma. Furthermore, many gastroenterologists and oncologists believe that surgery should be avoided in locally advanced esophageal cancer due to high mortality and morbidity rates related to the procedure and the very low benefit for the patient. Material and Methods: Retrospective analysis of prospectively collected data of 256 patients with locally advanced esophageal cancer (220 patients with pT3 and 36 patients with pT4) that were not neoadjuvantly treated and had surgical resection with curative intend. One-hundred-sixty-one patients underwent extensive Ivor-Lewis thoracoabdominal esophagectomy (TAE) whereas 95 had limited transhiatal (TH) resection. Locally advanced esophageal cancer was defined, based on the final histological report of the resection specimen, as a tumor infiltrating the paraesophageal tissue or the adjacent structures, without respect of the lymph node affection, the distant metastases or the histological grading. Results: Complete resection (R0) was achieved in 74.5% of patients that underwent TA esophagectomy and in 61.1% of the patients with TH resection (p=0.016). The median lymph node yield in TAE was significantly higher (25 lymph nodes, range 2-89) than in patients operated TH (14 LN, range 2-100; p=0.008), although no benefit for overall survival was found for patients with radical lymphadenectomy (lymph node yield of 19 or more median 9 months vs. lymph node yield of 18 or less - median 10.8 months; p=0.480). Patients with locally advanced esophageal cancer but without evidence of tumor rest disease (pT3 & pM0 & R0, irrespective of the lymph node status) had similar overall survival (median 23.7 months, 5-Y of 22.4%) as pT2 without evidence of tumor rest disease (median 33 months, 5-Y of 27%; p=0.152). The operative method had significant influence on the disease free survival (TAE-median 12.1 months, 5-Y 22.9%; or TH - median 10 months, 5-Y 8.9%; p=0.049, data not shown). Discussion: Our results in the treatment of the patients with locally advanced esophageal carcinoma (median 13.7 months, 5-Y of 14.4%) are comparable to the results of the patients neoadjuvantly treated with chemoradiotherapy (median 10 to 14 months; 5-Y of 19-23%).

Su1613 Laparoscopic Heller's Myotomy and Fundoplication in Patients With Massive Dilated Megaesophagus Carlos Pantanali, Fernando A. Herbella, Maria A. Henry, Jose F. Farah, Marco G. Patti, Jose C. Del Grande INTRODUCTION: Laparoscopic Heller's myotomy and fundoplication is considered the treatment of choice for non-advanced achalasia. The optimal treatment for end-stage achalasia with esophageal dilation is still debatable. AIMS: This study aims to evaluate in a multicenter and retrospective study the outcomes of patients with massive dilated esophagus submitted to laparoscopic Heller's myotomy. METHODS: 11 patients (mean age 56 years, 6 men) with massive dilated megaesophagus (maximum esophageal diameter >10cm) underwent a laparoscopic Heller myotomy and Pinotti fundoplication between 2000 and 2009 at 3 different institutions. Preoperative workup included upper digestive endoscopy, esophagram and esophageal manometry in all patients. Symptoms were evaluated at the last follow-up. RESULTS: On follow-up (mean 29, range 3-81, months), postoperative complaints were mild and occasional dysphagia to solid food in 4 (36%), severe dysphagia in 3 (27%) and absence of dysphagia in 4 (36%) patients. All patients gained weight except for the 3 patients with severe dysphagia. The 3 patients with severe dysphagia underwent esophageal dilatation

Su1616 Dysphagia After Esophagectomy for Esophageal Cancer: A Common Problem After Collar but Not After Intrathoracic Anastomosis Alexandra Koenig, Dean Bogoevski, Maximilian Bockhorn, Matthias Reeh, Yogesh K. Vashist, Thomas Roesch, Emre F. Yekebas, Jakob Izbicki ABSTRACT Objective: To assess the impact of site of anastomosis on dysphagia in esophageal carcinoma. Summary Background Data: As overall survival after esophageal cancer surgery remains poor, postoperative quality of life has gained importance as an additional outcome parameter. While the two most commonly used reconstructive methods, intrathoracic and

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SSAT Abstracts

SSAT Abstracts

Advanced Esophageal Carcinoma: Is It Still Worth to Operate? Dean Bogoevski, Matthias Reeh, Maximilian Bockhorn, Alexandra M. Koenig, Asad R. Kutup, Thomas Roesch, Jakob Izbicki