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Mo1599 Anti-Reflux Surgery Before Lung Transplantation Is Associated With Decreased Early Rejection Compared to Surgery After Transplantation
to reflux, even in the early post-transplant period, may have significant impact on allograft injury, inflammation, and survival. ARS was overall safe among our cohort of lung transplant patients. Additional prospective studies should be performed to further identify the optimal candidates and timing for ARS in the lung transplant population. Pre-lung transplant ARS may be considered in suitable lung transplant candidates with objective signs of reflux on pre-transplant assessment.
Figure 2. Eckardt score as a function of lower esophageal sphincter relaxation pressure. Pearson's correlation of 0.00835 (p=0.956) Mo1598
SSAT Abstracts
Do Outcomes of Surgical Treatment for Achalasia Depend on the Manometric Subtype? Oscar M. Crespin, Roger P. Tatum, Keliang Xiao, Ana V. Martin, Saurabh Khandelwal, Brant K. Oelschlager, Carlos A. Pellegrini Background: High Resolution Manometry (HRM) yields better understanding of esophageal motility than does conventional manometry, and a new classification system which describes three distinct HRM subtypes of achalasia based on esophageal body contraction patterns appears to be a promising tool in predicting results of treatment with standard Heller Myotomy. The aim of this study is to analyze the outcomes of surgical treatment with extended Heller myotomy) for each subtype and to identify additional parameters that may predict success of therapy. Methods: From 2008 to 2013 at a single institution 72 patients underwent laparoscopic extended Heller myotomy for first time. In addition to manometric parameters, clinical records were reviewed for symptom duration, patient age at the time of referral, and preoperative esophageal dilation (stage I-III) as assessed by radiography. We defined treatment failure as no improvement in symptoms and/or need for a second therapy within one year after the operation. Long term follow up data (15 to 46 months) was available for a subset of 25 patients in the form of a survey evaluating overall satisfaction with the operation. Results: The 72 myotomy patients included 11 with type I (no contractions), 56 with type II (pan-esophageal pressurizations), and 5 with type III (high-amplitude distal spasm). Failure was found in 1 patient with manometric type I and radiologic stage III esophageal dilation, 1 patient with manometric type II and radiologic stage II esophageal dilation, and none with manometric type III. All of the type I patients had at least some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group. Treatment failure was not observed in any of the patients under 50 years old (n= 35) nor in any patients with stage I esophageal dilation. Only one of the 25 patients with long term follow up reported dissatisfaction with the treatment result; this patient had type II achalasia on HRM and esophageal dilation was stage I. Conclusions: Overall, laparoscopic extended Heller myotomy is a highly successful treatment for patients with achalasia, and outcomes do not appear to vary significantly according to HRM subtypes. Stage I esophageal dilation and age below 50 may be better indicators of consistent symptom relief after surgical therapy for this disease.
Figure 1. Kaplan-Meier Analysis of time to early rejection by timing of fundoplication. Posttransplant surgical fundoplication was associated with early rejection. Mo1600 Mesh Cruroplasty in Laparoscopic Repair of Paraesophageal Hernias Is Not Associated With Better Long-Term Outcomes Compared to Primary Repair Vernissia Tam, James D. Luketich, Ryan Levy, Neil A. Christie, Ghulam Abbas, Omar Awais, Manisha Shende, Katie S. Nason Background: Due to high rates of radiographic recurrence, mesh cruroplasty has been advocated as a necessary component of the laparoscopic repair of large paraesophageal hernias(PEH). Recently, however, ~50% recurrence rates were reported for both groups in long-term follow-up from a randomized trial and the question of whether radiographic recurrence is clinically important was posed. In our center, mesh is used selectively when a tension-free primary closure cannot be achieved. We aimed to determine whether selective use of mesh cruroplasty is associated with differences in recurrence and quality of life outcomes. Methods: We performed nonemergent PEH repair with fundoplication in 795 patients (n=106 with mesh). Multivariable logistic regression identified factors associated with mesh cruroplasty. Radiographic follow-up at least 3 months postoperatively (n=556) and symptom outcomes (n=688) were compared between mesh and no mesh groups as were radiographic recurrence (n=101; defined as at least 10%[or 2 cm] of proximal stomach above the hiatus), and reoperation rates (n=30). Impact of recurrence on quality of life was evaluated. Results: A completely intrathoracic stomach, male sex, age 75 or greater and a history of connective tissue disorder were independently associated with mesh cruroplasty. Radiographic recurrence was identified in 22% of mesh patients (n=15) and 17% of nonmesh patients (n=86;p=0.32) at a median 27 months (IQR 14 to 53 mo). Time to radiographic assessment for recurrence (p=0.40) and symptoms (median 25 months [IQR 12 to 49 mo]; p=0.92) was similar between groups. Reoperation rates were higher in the mesh cohort (9% vs 3%; p=0.01). Good to excellent quality of life was reported by 88% in both groups (p=0.98). Comparing pre- and post-operative symptoms, the proportion with heartburn, regurgitation, epigastric pain, and PPI use decreased significantly in both groups while postoperative dysphagia in the mesh group (p=0.14) and bloating in the non-mesh group (p=0.32), were unchanged. Patients with radiographic recurrence were more likely to be dissatisfied with surgical outcome compared to those without recurrence (13% vs 4%; p= 0.007) despite similar scores in the physical (p=0.51) and mental components (p=0.29) of the SF-36 and GERD-HRQoL (p=0.20). Conclusions: Our data support selective use of mesh for laparoscopic repair of large PEH based on similar radiographic recurrence rates and symptom outcomes between groups. Reflecting the greater complexity of patients in whom we find mesh is needed, reoperations were more common in the mesh cohort. Quality of life was good-to-excellent in both groups, with symptom resolution in the majority of patients. Radiographic recurrence was associated with dissatisfaction with surgical outcomes, emphasizing the need to continue efforts to optimize the laparoscopic approach to large PEH repair.
Mo1599 Anti-Reflux Surgery Before Lung Transplantation Is Associated With Decreased Early Rejection Compared to Surgery After Transplantation Wai-Kit Lo, Robert Burakoff, Natan Feldman, Walter W. Chan Background: Anti-reflux surgery (ARS) has been associated with improved long term outcomes following lung transplantation. Pre-transplant ARS has been shown in small studies to improve pulmonary function among transplant candidates with evidence of reflux. The optimal timing of ARS in transplant recipients, whether before or after transplantation, has not been assessed previously. Aim: To evaluate the time to early acute rejection between lung transplantation patients undergoing ARS before versus after transplantation. Methods: This was a retrospective cohort study of lung transplant recipients undergoing ARS before or after transplantation at a tertiary care center since 2007, with follow-up time of at least one year. Early acute rejection was defined clinically and histologically as allograft rejection occurring within the first year after transplantation. Both cumulative incidence and timeto-event analysis using the Cox proportional hazards model were applied to assess the relationship between timing of surgery and rejection. Subjects not meeting this outcome were censored at one year in the time-to-event analysis. Fisher's exact test for binary variables and student's t-test for continuous variables were performed to assess for differences between surgical timing groups. Results: 40 subjects (62% men, mean age: 54, average followup: 3.1 years) met inclusion criteria for the study. Patient demographics, pre-transplant cardiopulmonary function, BMI, CMV status, and PPI exposure were similar between preand post- transplant ARS groups. Pre-transplant ARS was associated with a significantly lower rate of early acute rejection within the first year post-transplant compared to posttransplant ARS (0% versus 39%, p=0.03). Time-to-event analysis showed similar decrease in risk of acute rejection by pre-transplant ARS compared to post-transplant ARS (log-rank p=0.04). ARS was overall tolerated well in both groups, with no complications noted in the pre-transplant group. One subject in the post-transplant group died two weeks post-ARS from aspiration pneumonia. A second required surgical conversion after one month due to regurgitation symptoms. Conclusion: Pre-lung transplant ARS decreased the risk of early acute rejection following lung transplantation compared to post-transplant ARS. Exposure
SSAT Abstracts
Mo1601 Long-Term Symptomatic Outcomes After Laparoscopic Heller Myotomy for Achalasia Ezra N. Teitelbaum, Ryan T. Sieberg, Raymond Zhang, Fahd O. Arafat, Chen-Yuan Lin, Eric S. Hungness, Nathaniel J. Soper INTRODUCTION: Despite the proven short-term effectiveness of laparoscopic Heller myotomy (LHM) for the treatment of achalasia, over time a significant portion of patients develop recurrent symptoms and/or iatrogenic gastroesophageal reflux (GER). In this study we examined symptomatic outcomes from a LHM series and sought to determine preoperative patient characteristics and perioperative events that were predictive of poor long-term results.
S-1062
Figure 2. Eckardt score as a function of lower esophageal sphincter relaxation pressure. Pearson's correlation of 0.00835 (p=0.956) Mo1598
SSAT Abstracts
Do Outcomes of Surgical Treatment for Achalasia Depend on the Manometric Subtype? Oscar M. Crespin, Roger P. Tatum, Keliang Xiao, Ana V. Martin, Saurabh Khandelwal, Brant K. Oelschlager, Carlos A. Pellegrini Background: High Resolution Manometry (HRM) yields better understanding of esophageal motility than does conventional manometry, and a new classification system which describes three distinct HRM subtypes of achalasia based on esophageal body contraction patterns appears to be a promising tool in predicting results of treatment with standard Heller Myotomy. The aim of this study is to analyze the outcomes of surgical treatment with extended Heller myotomy) for each subtype and to identify additional parameters that may predict success of therapy. Methods: From 2008 to 2013 at a single institution 72 patients underwent laparoscopic extended Heller myotomy for first time. In addition to manometric parameters, clinical records were reviewed for symptom duration, patient age at the time of referral, and preoperative esophageal dilation (stage I-III) as assessed by radiography. We defined treatment failure as no improvement in symptoms and/or need for a second therapy within one year after the operation. Long term follow up data (15 to 46 months) was available for a subset of 25 patients in the form of a survey evaluating overall satisfaction with the operation. Results: The 72 myotomy patients included 11 with type I (no contractions), 56 with type II (pan-esophageal pressurizations), and 5 with type III (high-amplitude distal spasm). Failure was found in 1 patient with manometric type I and radiologic stage III esophageal dilation, 1 patient with manometric type II and radiologic stage II esophageal dilation, and none with manometric type III. All of the type I patients had at least some degree of esophageal dilation on radiography, whereas no dilation was found in the type III group. Treatment failure was not observed in any of the patients under 50 years old (n= 35) nor in any patients with stage I esophageal dilation. Only one of the 25 patients with long term follow up reported dissatisfaction with the treatment result; this patient had type II achalasia on HRM and esophageal dilation was stage I. Conclusions: Overall, laparoscopic extended Heller myotomy is a highly successful treatment for patients with achalasia, and outcomes do not appear to vary significantly according to HRM subtypes. Stage I esophageal dilation and age below 50 may be better indicators of consistent symptom relief after surgical therapy for this disease.
Figure 1. Kaplan-Meier Analysis of time to early rejection by timing of fundoplication. Posttransplant surgical fundoplication was associated with early rejection. Mo1600 Mesh Cruroplasty in Laparoscopic Repair of Paraesophageal Hernias Is Not Associated With Better Long-Term Outcomes Compared to Primary Repair Vernissia Tam, James D. Luketich, Ryan Levy, Neil A. Christie, Ghulam Abbas, Omar Awais, Manisha Shende, Katie S. Nason Background: Due to high rates of radiographic recurrence, mesh cruroplasty has been advocated as a necessary component of the laparoscopic repair of large paraesophageal hernias(PEH). Recently, however, ~50% recurrence rates were reported for both groups in long-term follow-up from a randomized trial and the question of whether radiographic recurrence is clinically important was posed. In our center, mesh is used selectively when a tension-free primary closure cannot be achieved. We aimed to determine whether selective use of mesh cruroplasty is associated with differences in recurrence and quality of life outcomes. Methods: We performed nonemergent PEH repair with fundoplication in 795 patients (n=106 with mesh). Multivariable logistic regression identified factors associated with mesh cruroplasty. Radiographic follow-up at least 3 months postoperatively (n=556) and symptom outcomes (n=688) were compared between mesh and no mesh groups as were radiographic recurrence (n=101; defined as at least 10%[or 2 cm] of proximal stomach above the hiatus), and reoperation rates (n=30). Impact of recurrence on quality of life was evaluated. Results: A completely intrathoracic stomach, male sex, age 75 or greater and a history of connective tissue disorder were independently associated with mesh cruroplasty. Radiographic recurrence was identified in 22% of mesh patients (n=15) and 17% of nonmesh patients (n=86;p=0.32) at a median 27 months (IQR 14 to 53 mo). Time to radiographic assessment for recurrence (p=0.40) and symptoms (median 25 months [IQR 12 to 49 mo]; p=0.92) was similar between groups. Reoperation rates were higher in the mesh cohort (9% vs 3%; p=0.01). Good to excellent quality of life was reported by 88% in both groups (p=0.98). Comparing pre- and post-operative symptoms, the proportion with heartburn, regurgitation, epigastric pain, and PPI use decreased significantly in both groups while postoperative dysphagia in the mesh group (p=0.14) and bloating in the non-mesh group (p=0.32), were unchanged. Patients with radiographic recurrence were more likely to be dissatisfied with surgical outcome compared to those without recurrence (13% vs 4%; p= 0.007) despite similar scores in the physical (p=0.51) and mental components (p=0.29) of the SF-36 and GERD-HRQoL (p=0.20). Conclusions: Our data support selective use of mesh for laparoscopic repair of large PEH based on similar radiographic recurrence rates and symptom outcomes between groups. Reflecting the greater complexity of patients in whom we find mesh is needed, reoperations were more common in the mesh cohort. Quality of life was good-to-excellent in both groups, with symptom resolution in the majority of patients. Radiographic recurrence was associated with dissatisfaction with surgical outcomes, emphasizing the need to continue efforts to optimize the laparoscopic approach to large PEH repair.
Mo1599 Anti-Reflux Surgery Before Lung Transplantation Is Associated With Decreased Early Rejection Compared to Surgery After Transplantation Wai-Kit Lo, Robert Burakoff, Natan Feldman, Walter W. Chan Background: Anti-reflux surgery (ARS) has been associated with improved long term outcomes following lung transplantation. Pre-transplant ARS has been shown in small studies to improve pulmonary function among transplant candidates with evidence of reflux. The optimal timing of ARS in transplant recipients, whether before or after transplantation, has not been assessed previously. Aim: To evaluate the time to early acute rejection between lung transplantation patients undergoing ARS before versus after transplantation. Methods: This was a retrospective cohort study of lung transplant recipients undergoing ARS before or after transplantation at a tertiary care center since 2007, with follow-up time of at least one year. Early acute rejection was defined clinically and histologically as allograft rejection occurring within the first year after transplantation. Both cumulative incidence and timeto-event analysis using the Cox proportional hazards model were applied to assess the relationship between timing of surgery and rejection. Subjects not meeting this outcome were censored at one year in the time-to-event analysis. Fisher's exact test for binary variables and student's t-test for continuous variables were performed to assess for differences between surgical timing groups. Results: 40 subjects (62% men, mean age: 54, average followup: 3.1 years) met inclusion criteria for the study. Patient demographics, pre-transplant cardiopulmonary function, BMI, CMV status, and PPI exposure were similar between preand post- transplant ARS groups. Pre-transplant ARS was associated with a significantly lower rate of early acute rejection within the first year post-transplant compared to posttransplant ARS (0% versus 39%, p=0.03). Time-to-event analysis showed similar decrease in risk of acute rejection by pre-transplant ARS compared to post-transplant ARS (log-rank p=0.04). ARS was overall tolerated well in both groups, with no complications noted in the pre-transplant group. One subject in the post-transplant group died two weeks post-ARS from aspiration pneumonia. A second required surgical conversion after one month due to regurgitation symptoms. Conclusion: Pre-lung transplant ARS decreased the risk of early acute rejection following lung transplantation compared to post-transplant ARS. Exposure
SSAT Abstracts
Mo1601 Long-Term Symptomatic Outcomes After Laparoscopic Heller Myotomy for Achalasia Ezra N. Teitelbaum, Ryan T. Sieberg, Raymond Zhang, Fahd O. Arafat, Chen-Yuan Lin, Eric S. Hungness, Nathaniel J. Soper INTRODUCTION: Despite the proven short-term effectiveness of laparoscopic Heller myotomy (LHM) for the treatment of achalasia, over time a significant portion of patients develop recurrent symptoms and/or iatrogenic gastroesophageal reflux (GER). In this study we examined symptomatic outcomes from a LHM series and sought to determine preoperative patient characteristics and perioperative events that were predictive of poor long-term results.
S-1062