- Email: [email protected]
466 Laparoscopic Release of Median Arcuate Ligament
esophagectomy for esophageal cancer and risk factors associated with readmission. Methods: Retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) 2011-12 database was performed to identify patients who underwent elective esophagectomy for esophageal cancer. Results: One thousand one hundred and three patients satisfied study criteria. One hundred and thirty seven patients (12.4%) were readmitted within 30 days of surgery. Readmitted patients were significantly older (mean age: 65.9 years vs. 63.8 years, p=0.02) and had a higher proportion of males (91.2% vs. 83.2%, p=0.01) than patients who were not readmitted. There was no significant difference between the groups in terms of other peri-operative variables like cardiac disease, neoadjuvant therapy (chemotherapy within 30 days and radiation within 90 days of surgery), type of esophagectomy performed and body mass index. Readmitted patients had a higher incidence of superficial surgical site infections (SSI) (13.1% vs. 4.9%, p<0.001), deep incisional SSI (8% vs. 1.8%, p<0.001), organ space infections (12.4% vs. 5.5%, p=0.002), sepsis (21.2% vs. 11.3%, p=0.001) and venous thromboembolism (11.7% vs. 3.9%, p<0.001). Readmitted patients had a significantly shorter mean length of index hospital stay (11.25 vs. 14.75 days, p<0.001). On multivariate logistic regression analysis, significant risk factors for 30 day readmission were: male gender, history of pulmonary disease, diabetes mellitus (DM), hypertension (HTN), postoperative wound complications, sepsis and shorter hospital stay. Patients who were readmitted had a significantly higher incidence of the following post discharge complications: SSI (7.3% vs. 1%, p<0.001), deep incisional SSI (3.6% vs. 0.4%, p<0.001), organ space infections (5.1% vs. 1.9%, p=0.05), pneumonia (7.3% vs. 2.1%, p=0.001) and venous thromboembolism (2.9% vs. 0.8%, p=0.02). Conclusions: Readmission rate after esophagectomy for esophageal cancer is around 12.4%. Patients, who are male, have co-morbid conditions like DM, HTN and pulmonary disease are at higher risk for readmission. Earlier discharge is not always ideal as it comes at the cost of a higher readmission rate. Emphasis should be placed on optimizing modifiable peri-operative factors namely, comorbid conditions, tissue handling, wound care and pulmonary toilet as a means to reduce readmission.
the treatment difficult. The laparoscopic approach can provide excellent visualization for dissection in addition to the known benefits of a minimally invasive procedure. We present a laparoscopic case in high-definition video. 467 Retrieval of the Eroded Gastric Band: A Hybrid Endoscopic and Laparoscopic Approach Monica Young, Nojan Toomari, Ninh T. Nguyen This is a 64-year-old female with a history of morbid obesity and previous laparoscopic gastric banding six years ago. She was taken to the operating room for retrieval of an eroded and embedded gastric band. The cathether was identified and found to be encased in a large inflammatory mass in the left upper quadrant. A hybrid endoscopic and laparoscopic approach is utilized to mobilize, transect and remove the device. 468 Totally Laparoscopic Right Hepatectomy With Roux-en-Y Hepaticojejunostomy Marcel C Machado, Rodrigo C. Surjan, Fabio F. Makdissi, Marcel Autran Machado We present a video of a totally laparoscopic right hepatectomy with hilar dissection and lymphadenectomy, en bloc resection of extrahepatic bile duct and Roux-en-Y hepaticojejunostomy in a 58-year-old patient with intraductal papillary neoplasm of the right hepatic duct. Operative time was 400 minutes. Postoperative recovery was uneventful. Surgical margins were free. Patient is well with no evidence of the disease 14 months after the procedure. Laparoscopic right hepatectomy with hepaticojejunostomy is feasible and safe, provided it is performed in a specialized center and staff with experience in hepatobiliary surgery and advanced laparoscopic. It is reserved for selected cases.
464 469
Immunoscoring for Prognostic Assessment of Colon Cancer: A Novel Complement to Ultrastaging Simon Lavotshkin, John R. Jalas, Hitoe Torisu-Itakura, Junko Ozao-Choy, Rafay A. Haseeb, Alexander Stojadinovic, Zev Wainberg, Anton Bilchik
Laparoscopic Redo Paraesophageal Hernia Repair With Collis Gastroplasty for Shortened Esophagus Rachel Jones, Carl Tadaki, Dmitry Oleynikov
Introduction: Although AJCC/TNM staging remains the gold standard for prognostic assessment of colon cancer, it cannot explain variable outcomes among patients with the same stage of disease. Several groups have examined a prognostic immunoscore based on immune infiltrates in the primary tumor. We hypothesized that an immunoscore based on five immune variables might improve the accuracy of ultrastaging in patients with colon cancer. Methods: Our study group comprised patients enrolled in an ongoing prospective trial of ultrastaging for colon cancer (RO1 CA090848). Resected tumor specimens were analyzed for CD3, CD4, CD8, CD68, and FoxP3 in a blinded fashion by a pathologist. Areas positive for tumor- infiltrating lymphocytes (TIL) were defined as hot spots and stratified as focal or diffuse based on their staining pattern on broad magnification. Hot spots were then scored as high or low, based on the briskness of the lymphocytic response, in the center of the tumor (CT) and in the invasive margin (IM). This categorical score was compared with a continuous score derived from analysis of 360 images on 36 patients with stage IIII colon cancer with ImageJ processing software. The immunoscore was then correlated with AJCC/TNM stage and with disease-free survival. RESULTS: The mean number of nodes was 17. Fisher's exact test showed that the continuous variable scored by ImageJ analysis software matched the pathologist's categorical scoring system (p-value = 0.0048-0.0421 for all but CD68 and FoxP3). Mean TIL counts in the CT region were consistently higher in stage I than in stage III tumors: CD3, CD4 and CD8 counts were 774, 872 and 745, respectively, in stage I tumors, as compared with 535 (p=0.05), 614 and 487, respectively, in stage III tumors. This increase was not observed for CD68 or FoxP3. Patients with a disease-free survival >5 years tended to have a higher CD8/CD3 ratio in both IM and CT regions, as compared to patients with disease-free survival <36 months (p=0.08). CONCLUSIONS: This is the first study to validate an immunoscore using specimens and data from a prospective clinical trial in which surgery and pathology techniques were standardized. Our preliminary results suggest that an immunoscore based on CD3, CD4 and CD8 corresponds with earlier stage colon cancer and improved disease-free survival and should be further examined for inclusion in the AJCC staging system.
Esophageal shortening can be seen in patients with chronic inflammation associated with gastroesophageal reflux disease (GERD) and paraesophageal hernias. During surgical treatment of these conditions it is important to address the esophageal shortening during the operation for optimal outcomes. Ideally, 2.5 to 3 cm of tension free intraabdominal esophagus is recommended. During this video we show a redo paraesophageal hernia repair in which we were unable to achieve adequate esophageal lengthening despite extensive mediastinal dissection. We therefore proceeded with Collis gastroplasty with Toupet fundoplication. 470
44 years old woman 6 months history of progressive dysphagia and regurgitation Unclear localization in the diagnosis approach Procedure: Laparoscopic excision of leiomyoma of the stomach and distal esophagus, and partial fundoplication. Uneventful postoperative course Discharged on postoperative day # 3 after soft diet Pathology report: Leiomyoma 506 Peri-Operative Patient Reported Outcomes Predict Serious Surgical Complications Juliane Bingener, Jeff Sloan, Paul Novotny, Barbara A. Pockaj, Heidi Nelson Background: Decreased survival after colon cancer surgery has been reported in patients with deficient baseline quality-of-life (QOL) as described in a recent secondary analysis of the COST(Clinical Outcomes of Surgical Therapy) trial. We hypothesized that deficits in baseline QOL are also associated with postoperative complications. Patients and methods: A secondary analysis of the COST trial 93-46-53 (INT 0146) was performed. Patient demographics, surgical complications (grade 0-4), composite and single item QOL scores were used for univariate and multivariate analysis. QOL deficit was defined as an overall QOL score <50 on a 100 point scale. Early changes in QOL were defined as changes from baseline to postoperative day 2 or day 14 (POD2 POD14). 416 patients provided the power to identify + 5 points (0.5 standard deviation [STD]) difference in the global QOL scale with a 95% confidence interval. Results: Of the 431 patients who were enrolled in the QOL portion of the COST trial, 81 patients (19%) experienced complications prior to discharge. Of these, 42 complications (7%) were serious (grade 2-4) including two deaths (0.5%). Eighty-nine patients (24%) experienced late complications within 2 months of the operation, including readmission. 55 patients (13%) had a QOL score < 50 at baseline. Patients with a baseline QOL deficit were more likely to have a serious early complication than patients without a QOL deficit (16 vs 6%, p=0.0234). Patients who experienced early complications reported worse ‘appearance' (0.25 STD, p=0.0126), and worsening breathing (0.3 STD, p= 0.033) on postoperative day 2. Patients with an early complication were 3 years older (p= 0.03) and more likely ASA III (p=0.0034). Gender, race, tumor stage and laparoscopic or open approach were not associated with an increased frequency of complications. Patients with complications experienced a 3.5 day longer hospital stay (p=0.0001). After adjusting for age, gender, race, tumor stage, ASA and operative approach, significant predictors for being readmitted to the hospital were baseline pain distress (OR 1.61, CI 1.11-2.34, p= 0.0125), changes from baseline to day 2 in fatigue (OR 1.34 CI 1.03-1.74, p=0.032) and from baseline to postoperative day 14 in activity (OR 1.56 CI 1.07-2.29, p=0.0225), daily living (OR 2.08, CI1.23-3.51, p= 0.0063) and outlook (OR 2.78, CI 1.19-6.53, p=0.0187).
465 Robotic Assisted Laparoscopic Total Pelvic Exenteration Sanjay S. Reddy, Radhika K. Smith, Rosalia Viterbo, Cynthia A. Bergman, Eric I. Chang, Jeffrey M. Farma The purpose of this video is to demonstrate the technique of a total pelvic exenteration using a robotic assisted laparoscopic approach with gracilis flap reconstruction. We present a case of a woman with recurrent anal squamous cell carcinoma invading the vagina and urethra. She had previously received chemoradiotherapy and presented with a recurrence. This procedure was done in coordination with surgical oncology, urology, gynecologic oncology, and plastic and reconstructive surgery. We present this multidisciplinary, minimally invasive approach to pelvic exenteration as a safe and effective modality of surgical therapy. 466 Laparoscopic Release of Median Arcuate Ligament Ankit Patel, Juan Toro, Nathan Lytle, S. Scott Davis, Edward Lin Median arcuate ligament syndrome is a complicated condition usually characterized by abdominal pain and weight loss caused by compression of the celiac artery by the median arcuate ligament. The anatomy of the ligament and its close proximity to the aorta makes
S-1015
SSAT Abstracts
SSAT Abstracts
Laparoscopic Excision of Leiomyoma of the Stomach and Distal Esophagus Bernardo Borraez, Marco E. Allaix, Fernando Herbella, Marco G. Patti
the treatment difficult. The laparoscopic approach can provide excellent visualization for dissection in addition to the known benefits of a minimally invasive procedure. We present a laparoscopic case in high-definition video. 467 Retrieval of the Eroded Gastric Band: A Hybrid Endoscopic and Laparoscopic Approach Monica Young, Nojan Toomari, Ninh T. Nguyen This is a 64-year-old female with a history of morbid obesity and previous laparoscopic gastric banding six years ago. She was taken to the operating room for retrieval of an eroded and embedded gastric band. The cathether was identified and found to be encased in a large inflammatory mass in the left upper quadrant. A hybrid endoscopic and laparoscopic approach is utilized to mobilize, transect and remove the device. 468 Totally Laparoscopic Right Hepatectomy With Roux-en-Y Hepaticojejunostomy Marcel C Machado, Rodrigo C. Surjan, Fabio F. Makdissi, Marcel Autran Machado We present a video of a totally laparoscopic right hepatectomy with hilar dissection and lymphadenectomy, en bloc resection of extrahepatic bile duct and Roux-en-Y hepaticojejunostomy in a 58-year-old patient with intraductal papillary neoplasm of the right hepatic duct. Operative time was 400 minutes. Postoperative recovery was uneventful. Surgical margins were free. Patient is well with no evidence of the disease 14 months after the procedure. Laparoscopic right hepatectomy with hepaticojejunostomy is feasible and safe, provided it is performed in a specialized center and staff with experience in hepatobiliary surgery and advanced laparoscopic. It is reserved for selected cases.
464 469
Immunoscoring for Prognostic Assessment of Colon Cancer: A Novel Complement to Ultrastaging Simon Lavotshkin, John R. Jalas, Hitoe Torisu-Itakura, Junko Ozao-Choy, Rafay A. Haseeb, Alexander Stojadinovic, Zev Wainberg, Anton Bilchik
Laparoscopic Redo Paraesophageal Hernia Repair With Collis Gastroplasty for Shortened Esophagus Rachel Jones, Carl Tadaki, Dmitry Oleynikov
Introduction: Although AJCC/TNM staging remains the gold standard for prognostic assessment of colon cancer, it cannot explain variable outcomes among patients with the same stage of disease. Several groups have examined a prognostic immunoscore based on immune infiltrates in the primary tumor. We hypothesized that an immunoscore based on five immune variables might improve the accuracy of ultrastaging in patients with colon cancer. Methods: Our study group comprised patients enrolled in an ongoing prospective trial of ultrastaging for colon cancer (RO1 CA090848). Resected tumor specimens were analyzed for CD3, CD4, CD8, CD68, and FoxP3 in a blinded fashion by a pathologist. Areas positive for tumor- infiltrating lymphocytes (TIL) were defined as hot spots and stratified as focal or diffuse based on their staining pattern on broad magnification. Hot spots were then scored as high or low, based on the briskness of the lymphocytic response, in the center of the tumor (CT) and in the invasive margin (IM). This categorical score was compared with a continuous score derived from analysis of 360 images on 36 patients with stage IIII colon cancer with ImageJ processing software. The immunoscore was then correlated with AJCC/TNM stage and with disease-free survival. RESULTS: The mean number of nodes was 17. Fisher's exact test showed that the continuous variable scored by ImageJ analysis software matched the pathologist's categorical scoring system (p-value = 0.0048-0.0421 for all but CD68 and FoxP3). Mean TIL counts in the CT region were consistently higher in stage I than in stage III tumors: CD3, CD4 and CD8 counts were 774, 872 and 745, respectively, in stage I tumors, as compared with 535 (p=0.05), 614 and 487, respectively, in stage III tumors. This increase was not observed for CD68 or FoxP3. Patients with a disease-free survival >5 years tended to have a higher CD8/CD3 ratio in both IM and CT regions, as compared to patients with disease-free survival <36 months (p=0.08). CONCLUSIONS: This is the first study to validate an immunoscore using specimens and data from a prospective clinical trial in which surgery and pathology techniques were standardized. Our preliminary results suggest that an immunoscore based on CD3, CD4 and CD8 corresponds with earlier stage colon cancer and improved disease-free survival and should be further examined for inclusion in the AJCC staging system.
Esophageal shortening can be seen in patients with chronic inflammation associated with gastroesophageal reflux disease (GERD) and paraesophageal hernias. During surgical treatment of these conditions it is important to address the esophageal shortening during the operation for optimal outcomes. Ideally, 2.5 to 3 cm of tension free intraabdominal esophagus is recommended. During this video we show a redo paraesophageal hernia repair in which we were unable to achieve adequate esophageal lengthening despite extensive mediastinal dissection. We therefore proceeded with Collis gastroplasty with Toupet fundoplication. 470
44 years old woman 6 months history of progressive dysphagia and regurgitation Unclear localization in the diagnosis approach Procedure: Laparoscopic excision of leiomyoma of the stomach and distal esophagus, and partial fundoplication. Uneventful postoperative course Discharged on postoperative day # 3 after soft diet Pathology report: Leiomyoma 506 Peri-Operative Patient Reported Outcomes Predict Serious Surgical Complications Juliane Bingener, Jeff Sloan, Paul Novotny, Barbara A. Pockaj, Heidi Nelson Background: Decreased survival after colon cancer surgery has been reported in patients with deficient baseline quality-of-life (QOL) as described in a recent secondary analysis of the COST(Clinical Outcomes of Surgical Therapy) trial. We hypothesized that deficits in baseline QOL are also associated with postoperative complications. Patients and methods: A secondary analysis of the COST trial 93-46-53 (INT 0146) was performed. Patient demographics, surgical complications (grade 0-4), composite and single item QOL scores were used for univariate and multivariate analysis. QOL deficit was defined as an overall QOL score <50 on a 100 point scale. Early changes in QOL were defined as changes from baseline to postoperative day 2 or day 14 (POD2 POD14). 416 patients provided the power to identify + 5 points (0.5 standard deviation [STD]) difference in the global QOL scale with a 95% confidence interval. Results: Of the 431 patients who were enrolled in the QOL portion of the COST trial, 81 patients (19%) experienced complications prior to discharge. Of these, 42 complications (7%) were serious (grade 2-4) including two deaths (0.5%). Eighty-nine patients (24%) experienced late complications within 2 months of the operation, including readmission. 55 patients (13%) had a QOL score < 50 at baseline. Patients with a baseline QOL deficit were more likely to have a serious early complication than patients without a QOL deficit (16 vs 6%, p=0.0234). Patients who experienced early complications reported worse ‘appearance' (0.25 STD, p=0.0126), and worsening breathing (0.3 STD, p= 0.033) on postoperative day 2. Patients with an early complication were 3 years older (p= 0.03) and more likely ASA III (p=0.0034). Gender, race, tumor stage and laparoscopic or open approach were not associated with an increased frequency of complications. Patients with complications experienced a 3.5 day longer hospital stay (p=0.0001). After adjusting for age, gender, race, tumor stage, ASA and operative approach, significant predictors for being readmitted to the hospital were baseline pain distress (OR 1.61, CI 1.11-2.34, p= 0.0125), changes from baseline to day 2 in fatigue (OR 1.34 CI 1.03-1.74, p=0.032) and from baseline to postoperative day 14 in activity (OR 1.56 CI 1.07-2.29, p=0.0225), daily living (OR 2.08, CI1.23-3.51, p= 0.0063) and outlook (OR 2.78, CI 1.19-6.53, p=0.0187).
465 Robotic Assisted Laparoscopic Total Pelvic Exenteration Sanjay S. Reddy, Radhika K. Smith, Rosalia Viterbo, Cynthia A. Bergman, Eric I. Chang, Jeffrey M. Farma The purpose of this video is to demonstrate the technique of a total pelvic exenteration using a robotic assisted laparoscopic approach with gracilis flap reconstruction. We present a case of a woman with recurrent anal squamous cell carcinoma invading the vagina and urethra. She had previously received chemoradiotherapy and presented with a recurrence. This procedure was done in coordination with surgical oncology, urology, gynecologic oncology, and plastic and reconstructive surgery. We present this multidisciplinary, minimally invasive approach to pelvic exenteration as a safe and effective modality of surgical therapy. 466 Laparoscopic Release of Median Arcuate Ligament Ankit Patel, Juan Toro, Nathan Lytle, S. Scott Davis, Edward Lin Median arcuate ligament syndrome is a complicated condition usually characterized by abdominal pain and weight loss caused by compression of the celiac artery by the median arcuate ligament. The anatomy of the ligament and its close proximity to the aorta makes
S-1015
SSAT Abstracts
SSAT Abstracts
Laparoscopic Excision of Leiomyoma of the Stomach and Distal Esophagus Bernardo Borraez, Marco E. Allaix, Fernando Herbella, Marco G. Patti