- Email: [email protected]
Su1756 The Role of Syptom Index (SI) and Symptom Associated Probability (SAP) in the Surgical Treatment of Atypical GERD Symptoms
SSAT Abstracts
performed or reduce postoperative dysphagia. Methods and Procedures: We performed a retrospective review of all patients undergoing PEH repair between January 2011 and July 2014. Demographic, preoperative, operative, and outcome data were collected prospectively and maintained in an IRB approved database. The primary outcome measures included the type of fundoplication performed and post-operative dysphagia scores. Secondary outcomes included disease specific quality of life scores (GERD-HRQL) and patient satisfaction. Data were analyzed using Stata 12 software (Stata Corporation, College Station, TX) with significance set at p < 0.05. Results: One hundred twenty-five patients underwent laparoscopic PEH repair during the study period. Forty-seven (37%) patients underwent preoperative manometry, and 78 (62%) did not. The mean age was 65.6±14.3 years and 87 (70%) were female with a mean body mass index (BMI) of 29.9±5.8 kg/m2. Patients who did not undergo manometry were older (67.9 vs. 61.7, p=0.02), but the groups did not differ in terms of BMI, gender, Proton Pump Inhibitor (PPI) use, baseline dysphagia score, baseline GERDHRQL score or type of fundoplication performed. At a median follow-up of 16 months (range 4 - 44 months), the median dysphagia score was 0 for both groups (p=0.41). Five (14%) patients in the no manometry group required endoscopic dilation compared to 3 (17%) in the manometry group (p=0.76). Median GERD-HRQL score improved significantly in both the no manometry and manometry groups (7 vs. 2, p<0.01 and 16 vs. 2, p<0.01 respectively). Overall 96% of patients were satisfied with their operation and 96% would choose to have surgery again given the benefit of hindsight. Conclusions: Laparoscopic paraesophageal hernia repair with complete fundoplication is a safe and effective treatment that improves disease specific quality of life with a low rate of post-operative dysphagia. The use of preoperative manometry does not impact the choice of fundoplication and its omission does not increase the rate of post-operative dysphagia or the need for postoperative dilation. Hence, the routine use of preoperative manometry for patients undergoing paraesophageal hernia repair is not necessary. Further study is needed to define which patients may benefit from selective preoperative manometry.
Results
Su1757 Comparison of the 2cc Bolus and the 200cc Bolus Multiple Rapid Swallow Technique in the Evaluation of Patients With Dysphagia Shunsuke Akimoto, Se Ryung Yamamoto, Harit Kapoor, Tommy H. Lee, sumeet K. mittal High-resolution manometry (HRM) is considered ‘gold standard' for esophageal motility evaluation. The provocative Multiple Rapid Swallow technique (MRS) has been recently shown to augment functional characterization of the esophageal transit. The bolus volumes and intervals used in various studies vary and need comparison and standardization. The study aims to evaluate the test-characteristics of the 2cc bolus MRS and 200cc bolus MRS. Methods All patients undergoing HRM evaluation between June 2014 to October 2014 were also administered the MRS. In these patients, we selected the subjects who could perform both methods, 2cc bolus MRS and 200cc bolus MRS. 2cc method required four swallows of 2ml water boluses, four seconds apart whereas 200cc method required swallowing 200ml water continuously. The parameters measured were Post-deglutitory Inhibition (PDI) and the success of Rebound Esophageal Contraction (REC) using the 30mmHg isobaric contour. PDI was considered complete unless a contraction measuring > 3cm was identified during MRS, wherein it was considered incomplete. REC was considered failed when it had either no muscle contraction, when the intersegmental trough was >3cm or when smooth muscle contraction was interrupted for >3cm. We compared the sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of 2cc method and 200cc method in the detection of dysphagia. Patients with known achalasia or previous foregut surgery were excluded. Results Sixty-five patients underwent HRM during the study period, of which 45 met the inclusion criteria. The mean age of the group was 56.8 years with 19 (42.2%) males. Twenty-eight (62.2%) patients had dysphagia. On HRM, the mean Integrated relaxation pressures (IRP) was 9.4 and mean Distal contractile integral (DCI) was 2642. On comparing the manometric characteristics of the REC, the 200cc method had significantly lower IRP (0.8 vs. 3.3; p=0.0217) and lower DCI (1005 vs. 2129; p=0.0005) compared to 2cc method. REC failure was observed much more commonly when using the 200cc method (36, 80% vs 24, 53.3%; p=0.0076). Incomplete PDI was relatively more frequent when testing with the 2cc method (15, 33.3% vs 13, 28.9%; p=0.6507). Although, the Se of 200cc method was relatively higher (78.6% vs. 64.3%), the Sp, PPV and NPV was much lower than the 2cc method (Sp; 17.7% vs. 64.7%, PPV; 61.1% vs. 66.7%, NPV; 33.3% vs. 52.4%). The 2cc method had considerably better test characteristics than the conventional HRM alone (Se; 39.3%, Sp; 64.7%, PPV; 64.7%, NPV; 39.3%). Conclusion Very low values of IRP and DCI along with higher failure of REC when using the 200cc method, suggests profound suppression of rebound peristalsis affecting test parameters. The 2cc MRS method is more functionally acceptable with test characteristics substantially superior to conventional HRM.
Su1756 The Role of Syptom Index (SI) and Symptom Associated Probability (SAP) in the Surgical Treatment of Atypical GERD Symptoms Andreas M. Schneider, Brian E. Louie, Ralph W. Aye, Alexander S. Farivar
Su1758 Laparoscopic Right Hepatectomy: Comparative Analysis of 2013 ACS-NSQIP Data Steven M. Strasberg, Vanessa Thompson, Xiangju Meng, Bruce L. Hall, Henry Pitt
Introduction: Gastroesophageal reflux disease (GERD) is a common disease that causes a variety of symptoms that can significantly impair quality of life. Patients presenting with typical symptoms such as heartburn or regurgitation are well known to have an excellent response to surgery; whereas patients with atypical symptoms such as hoarseness, chronic cough, chest pain, aspiration and recurrent pneumonia have a less predictable surgical outcome and can pose a significant diagnostic and therapeutic challenge. PH monitoring and symptom indices such as Symptom Index (SI) and Symptom Associated Probability (SAP) are established parameters that help determine symptom correlation but have been studied primarily in patients with typical symptoms. We aimed to investigate the correlation of SI and SAP to postoperative outcomes and rate of symptom resolution to better predict the surgical response in patients with atypical symptoms. Methods: Retrospective, single center study presenting with atypical symptoms who underwent surgical fundoplication from 2009 - 2013. Three clusters of frequent symptoms were analyzed. 1) ENT - sore throat, hoarseness, throat clearing. 2) Chest pain other than heartburn, paraesophageal hernia's were excluded. 3) Respiratory - cough, asthma, aspiration, recurrent pulmonary infections. A positive surgical outcome was defined as a postoperative symptom improvement of more than 50% from baseline. SI and SAP were determined for each symptom and the corresponding sensitivity and specificity as well as positive predictive values (PPV) and negative predictive values (NPV) were calculated. Results: A total of 133 patient were identified: 115 with primary atypical symptoms, 72 with secondary atypical symptoms. The ENT group included sore throat (13), hoarseness (9), throat clearing (3) and 7 had other symptoms, of these 71% had an improvement of symptoms. Thirty patients presented with chest pain, of these 80% had significant improvement of their symptoms. Respiratory symptoms occurred in 72 patients and included cough (39), aspiration (15), recurrent infections (9), asthma (7) and SOB (2) and 79.2% had significant improvement of their symptoms. Table 1. shows the results of SI and SAP for each symptom complex. Conclusion: Patients with atypical symptoms continue to pose a significant diagnostic and prognostic challenge. Fundoplication results is symptom resolution in the majority of patients. The role of SI and SAP in predicting surgical outcomes remains unclear. Despite a wide variation in sensitivity and specificity, patients with a positive test may have a good likelihood of improving after fundoplication. Further prospective studies are needed to help improve predictability of surgical outcomes for patients with atypical symptoms.
SSAT Abstracts
In the Balliol Classification of innovative procedures laparoscopic right hepatectomy (LRH) is in the IDEAL 2b or "Exploration" phase. The purpose of this study was to evaluate outcome of this procedure in the USA using 2013 NSQIP data for LRH and open right hepatectomy (ORH). The 2013 NSQIP database was searched for LRH and ORH. 19 of 54 hospitals performing any right hepatectomy attempted at least one LRH. To avoid confounding by concomitant procedures only cases without additional concomitant procedures or cirrhosis were considered. 456 right hepatectomies were performed; 59 were attempted LRHs (started but not necessarily completed laparoscopically). After elimination of cases with concomitant procedures or cirrhosis 278 procedures remained, 47 (16.9%) of which were attempted LRHs. In all 19/47 LRH were completed by pure laparoscopy, 12/47 by hand assist, and 16/47 were converted to ORH from one of the former techniques. The conversion rate to ORH was 34%. Data were evaluated as intention to treat. Preoperative LFTs including AST, serum albumin, and ALP were significantly higher in ORH patients as was the ASA class. For instance, the preoperative ALP was abnormally high in 6.4% of patients having LRH and 23.4% of patients having ORH (p=0.01). But BMI was significantly higher and dyspnea significantly more common in LRH patients. There was a significant difference in the likelihood of LRH vs ORH to be performed for benign vs secondary disease in the liver with benign/secondary ratio higher in LRH (p<0.05). Drains were used less commonly in LRH 14/44 (31.8%) than in ORH 144/228 (63.2%)p=0.0002. There were no 30 day mortalities in LRH and 4 in ORH (NS). SSIs were significantly less common in LRH (p=0.004) predominantly due to fewer organ space infections, LRH (0%) vs ORH (8.2%) p=0.0509. LOS was significantly shorter in LRH, 5.5 days (2.9SD) vs 8.2 (8.1), p=0.0001. Based on ACS-NSQIP data LRH seems to be diffusing into wide use. Approximately one in three procedures started laparoscopically was converted to an open procedure. Based on 30 day outcomes, advantages of LRH in infection rates and LOS seem likely although some of the apparent advantages may be related to baseline differences between groups. Continued cautious introduction including close tracking of outcomes is indicated before entry into IDEAL phase 3 status.
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performed or reduce postoperative dysphagia. Methods and Procedures: We performed a retrospective review of all patients undergoing PEH repair between January 2011 and July 2014. Demographic, preoperative, operative, and outcome data were collected prospectively and maintained in an IRB approved database. The primary outcome measures included the type of fundoplication performed and post-operative dysphagia scores. Secondary outcomes included disease specific quality of life scores (GERD-HRQL) and patient satisfaction. Data were analyzed using Stata 12 software (Stata Corporation, College Station, TX) with significance set at p < 0.05. Results: One hundred twenty-five patients underwent laparoscopic PEH repair during the study period. Forty-seven (37%) patients underwent preoperative manometry, and 78 (62%) did not. The mean age was 65.6±14.3 years and 87 (70%) were female with a mean body mass index (BMI) of 29.9±5.8 kg/m2. Patients who did not undergo manometry were older (67.9 vs. 61.7, p=0.02), but the groups did not differ in terms of BMI, gender, Proton Pump Inhibitor (PPI) use, baseline dysphagia score, baseline GERDHRQL score or type of fundoplication performed. At a median follow-up of 16 months (range 4 - 44 months), the median dysphagia score was 0 for both groups (p=0.41). Five (14%) patients in the no manometry group required endoscopic dilation compared to 3 (17%) in the manometry group (p=0.76). Median GERD-HRQL score improved significantly in both the no manometry and manometry groups (7 vs. 2, p<0.01 and 16 vs. 2, p<0.01 respectively). Overall 96% of patients were satisfied with their operation and 96% would choose to have surgery again given the benefit of hindsight. Conclusions: Laparoscopic paraesophageal hernia repair with complete fundoplication is a safe and effective treatment that improves disease specific quality of life with a low rate of post-operative dysphagia. The use of preoperative manometry does not impact the choice of fundoplication and its omission does not increase the rate of post-operative dysphagia or the need for postoperative dilation. Hence, the routine use of preoperative manometry for patients undergoing paraesophageal hernia repair is not necessary. Further study is needed to define which patients may benefit from selective preoperative manometry.
Results
Su1757 Comparison of the 2cc Bolus and the 200cc Bolus Multiple Rapid Swallow Technique in the Evaluation of Patients With Dysphagia Shunsuke Akimoto, Se Ryung Yamamoto, Harit Kapoor, Tommy H. Lee, sumeet K. mittal High-resolution manometry (HRM) is considered ‘gold standard' for esophageal motility evaluation. The provocative Multiple Rapid Swallow technique (MRS) has been recently shown to augment functional characterization of the esophageal transit. The bolus volumes and intervals used in various studies vary and need comparison and standardization. The study aims to evaluate the test-characteristics of the 2cc bolus MRS and 200cc bolus MRS. Methods All patients undergoing HRM evaluation between June 2014 to October 2014 were also administered the MRS. In these patients, we selected the subjects who could perform both methods, 2cc bolus MRS and 200cc bolus MRS. 2cc method required four swallows of 2ml water boluses, four seconds apart whereas 200cc method required swallowing 200ml water continuously. The parameters measured were Post-deglutitory Inhibition (PDI) and the success of Rebound Esophageal Contraction (REC) using the 30mmHg isobaric contour. PDI was considered complete unless a contraction measuring > 3cm was identified during MRS, wherein it was considered incomplete. REC was considered failed when it had either no muscle contraction, when the intersegmental trough was >3cm or when smooth muscle contraction was interrupted for >3cm. We compared the sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of 2cc method and 200cc method in the detection of dysphagia. Patients with known achalasia or previous foregut surgery were excluded. Results Sixty-five patients underwent HRM during the study period, of which 45 met the inclusion criteria. The mean age of the group was 56.8 years with 19 (42.2%) males. Twenty-eight (62.2%) patients had dysphagia. On HRM, the mean Integrated relaxation pressures (IRP) was 9.4 and mean Distal contractile integral (DCI) was 2642. On comparing the manometric characteristics of the REC, the 200cc method had significantly lower IRP (0.8 vs. 3.3; p=0.0217) and lower DCI (1005 vs. 2129; p=0.0005) compared to 2cc method. REC failure was observed much more commonly when using the 200cc method (36, 80% vs 24, 53.3%; p=0.0076). Incomplete PDI was relatively more frequent when testing with the 2cc method (15, 33.3% vs 13, 28.9%; p=0.6507). Although, the Se of 200cc method was relatively higher (78.6% vs. 64.3%), the Sp, PPV and NPV was much lower than the 2cc method (Sp; 17.7% vs. 64.7%, PPV; 61.1% vs. 66.7%, NPV; 33.3% vs. 52.4%). The 2cc method had considerably better test characteristics than the conventional HRM alone (Se; 39.3%, Sp; 64.7%, PPV; 64.7%, NPV; 39.3%). Conclusion Very low values of IRP and DCI along with higher failure of REC when using the 200cc method, suggests profound suppression of rebound peristalsis affecting test parameters. The 2cc MRS method is more functionally acceptable with test characteristics substantially superior to conventional HRM.
Su1756 The Role of Syptom Index (SI) and Symptom Associated Probability (SAP) in the Surgical Treatment of Atypical GERD Symptoms Andreas M. Schneider, Brian E. Louie, Ralph W. Aye, Alexander S. Farivar
Su1758 Laparoscopic Right Hepatectomy: Comparative Analysis of 2013 ACS-NSQIP Data Steven M. Strasberg, Vanessa Thompson, Xiangju Meng, Bruce L. Hall, Henry Pitt
Introduction: Gastroesophageal reflux disease (GERD) is a common disease that causes a variety of symptoms that can significantly impair quality of life. Patients presenting with typical symptoms such as heartburn or regurgitation are well known to have an excellent response to surgery; whereas patients with atypical symptoms such as hoarseness, chronic cough, chest pain, aspiration and recurrent pneumonia have a less predictable surgical outcome and can pose a significant diagnostic and therapeutic challenge. PH monitoring and symptom indices such as Symptom Index (SI) and Symptom Associated Probability (SAP) are established parameters that help determine symptom correlation but have been studied primarily in patients with typical symptoms. We aimed to investigate the correlation of SI and SAP to postoperative outcomes and rate of symptom resolution to better predict the surgical response in patients with atypical symptoms. Methods: Retrospective, single center study presenting with atypical symptoms who underwent surgical fundoplication from 2009 - 2013. Three clusters of frequent symptoms were analyzed. 1) ENT - sore throat, hoarseness, throat clearing. 2) Chest pain other than heartburn, paraesophageal hernia's were excluded. 3) Respiratory - cough, asthma, aspiration, recurrent pulmonary infections. A positive surgical outcome was defined as a postoperative symptom improvement of more than 50% from baseline. SI and SAP were determined for each symptom and the corresponding sensitivity and specificity as well as positive predictive values (PPV) and negative predictive values (NPV) were calculated. Results: A total of 133 patient were identified: 115 with primary atypical symptoms, 72 with secondary atypical symptoms. The ENT group included sore throat (13), hoarseness (9), throat clearing (3) and 7 had other symptoms, of these 71% had an improvement of symptoms. Thirty patients presented with chest pain, of these 80% had significant improvement of their symptoms. Respiratory symptoms occurred in 72 patients and included cough (39), aspiration (15), recurrent infections (9), asthma (7) and SOB (2) and 79.2% had significant improvement of their symptoms. Table 1. shows the results of SI and SAP for each symptom complex. Conclusion: Patients with atypical symptoms continue to pose a significant diagnostic and prognostic challenge. Fundoplication results is symptom resolution in the majority of patients. The role of SI and SAP in predicting surgical outcomes remains unclear. Despite a wide variation in sensitivity and specificity, patients with a positive test may have a good likelihood of improving after fundoplication. Further prospective studies are needed to help improve predictability of surgical outcomes for patients with atypical symptoms.
SSAT Abstracts
In the Balliol Classification of innovative procedures laparoscopic right hepatectomy (LRH) is in the IDEAL 2b or "Exploration" phase. The purpose of this study was to evaluate outcome of this procedure in the USA using 2013 NSQIP data for LRH and open right hepatectomy (ORH). The 2013 NSQIP database was searched for LRH and ORH. 19 of 54 hospitals performing any right hepatectomy attempted at least one LRH. To avoid confounding by concomitant procedures only cases without additional concomitant procedures or cirrhosis were considered. 456 right hepatectomies were performed; 59 were attempted LRHs (started but not necessarily completed laparoscopically). After elimination of cases with concomitant procedures or cirrhosis 278 procedures remained, 47 (16.9%) of which were attempted LRHs. In all 19/47 LRH were completed by pure laparoscopy, 12/47 by hand assist, and 16/47 were converted to ORH from one of the former techniques. The conversion rate to ORH was 34%. Data were evaluated as intention to treat. Preoperative LFTs including AST, serum albumin, and ALP were significantly higher in ORH patients as was the ASA class. For instance, the preoperative ALP was abnormally high in 6.4% of patients having LRH and 23.4% of patients having ORH (p=0.01). But BMI was significantly higher and dyspnea significantly more common in LRH patients. There was a significant difference in the likelihood of LRH vs ORH to be performed for benign vs secondary disease in the liver with benign/secondary ratio higher in LRH (p<0.05). Drains were used less commonly in LRH 14/44 (31.8%) than in ORH 144/228 (63.2%)p=0.0002. There were no 30 day mortalities in LRH and 4 in ORH (NS). SSIs were significantly less common in LRH (p=0.004) predominantly due to fewer organ space infections, LRH (0%) vs ORH (8.2%) p=0.0509. LOS was significantly shorter in LRH, 5.5 days (2.9SD) vs 8.2 (8.1), p=0.0001. Based on ACS-NSQIP data LRH seems to be diffusing into wide use. Approximately one in three procedures started laparoscopically was converted to an open procedure. Based on 30 day outcomes, advantages of LRH in infection rates and LOS seem likely although some of the apparent advantages may be related to baseline differences between groups. Continued cautious introduction including close tracking of outcomes is indicated before entry into IDEAL phase 3 status.
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