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507 Laparoscopic Enucleation of Benign and Low Grade Hepatic Lesions
507
513
Laparoscopic Enucleation of Benign and Low Grade Hepatic Lesions Nicholas N. Nissen, Vichin Puri, Vijay G. Menon
Robotic Assisted Laparoscopic Total Proctocolectomy With Ileal Pouch Anal Anastomosis Mehraneh D. Jafari, Alessio Pigazzi, Michael J. Stamos
Enucleation is a technique which can be applied to benign and low grade lesions of the liver such as select neuroendocrine tumors (NET), cysts, hemangiomas and focal nodular hyperplasia. The benefits of enucleation include the preservation of maximal hepatic parenchyma, as well as the low likelihood that underlying vascular or biliary structures will be compromised. A laparoscopic approach to enucleation not only offers the benefits of minimal access surgery, but also allows simultaneous access to multiple regions of the abdomen. This may be ideal for managing certain scenarios such as the patient with distal pancreatic NET and synchronous liver metastases. Illustrative cases are shown.
This is a 38 year old female with polyposis syndrome. A laparoscopic total colectomy is performed in a medial to lateral fashion. The ielocolic vessels, middle colic vessels, and inferior mesenteric vessels are divided. The four arm Di Vinci robot is docked and a total proctocolectomy is carried out to the level of the dentate line. The distal rectum is transected and the specimen removed through a Pfannenstiel incision. An ileal J-pouch is created and an end to end ileo-anal anastomosis is performed. Pathology revealed colonic polyposis with no evidence of malignancy.
508
587
Use of Fluorescence Angiography During 2-Field Minimally Invasive Esophagectomy C. Daniel Smith, Steven P. Bowers
Trends in the Surgical Treatment of Pancreatic Adenocarcinoma Siavash Raigani, John Ammori, Julian Kim, Jeffrey Hardacre Introduction: Multiple prospective, randomized trials have demonstrated that the addition of adjuvant therapy after surgical resection of pancreatic cancer improves survival compared to surgery alone. However, the optimal type of adjuvant therapy, chemotherapy alone or chemotherapy combined with chemoradiation therapy, remains controversial. Our aim was to determine whether the type of adjuvant therapy for pancreatic cancer given in the United States has changed by examining treatment trends using the National Cancer Data Base. Methods: The National Cancer Data Base (NCDB) is a national oncology outcomes database for over 1,500 Commission on Cancer-accredited cancer programs. Patients diagnosed with stage 1-2 pancreatic adenocarcinoma between 2003-2009 were selected from the NCDB Hospital Comparison Benchmark Reports. Attention was paid to the initial treatment regimen, such as surgery alone, surgery plus chemotherapy, or surgery plus chemoradiation. In addition, data on hospital setting (teaching-research hospitals vs. community hospitals) were collected and analyzed. The Cochran-Armitage test for trend was used to assess changes in treatment over time. Results: 47, 086 patients with stage 1-2 pancreatic adenocarcinoma were included in the analysis. Between 2003-2009, the use of surgery alone as first course treatment of stage 2 disease decreased significantly at both teaching-research hospitals and community hospitals by nearly 25% (p ,0.0001 for both cases). In the same period, the use of chemotherapy in addition to surgery as treatment of stage 1 and 2 disease increased two-fold at both types of hospitals (p ,0.0001 for all cases). Treatment with surgery plus chemoradiation decreased significantly for both stages in both hospital settings by approximately 30% (p,0.05 for all cases). Non-surgical treatment for stage 2 disease was surprisingly high and significantly increased over time (p ,0.0001 for both), ranging from approximately 30-37% at teaching-research hospitals and 40-49% at community hospitals. Conclusion: Data from the NCDB from 2003-2009 illustrate changes in the adjuvant treatment of pancreatic cancer. There is an alarmingly high rate of non-surgical therapy for stage 1 and 2 disease. The use of chemotherapy alone as adjuvant therapy increased whereas the use of multimodality therapy decreased.
This video depicts the use of fluorescence angiography using the SPY technology to assess the perfusion of the gastric conduit during 2-field minimally invasive technology. The SPY allowed real-time visualization of the perfusion of the gastric conduit and subsequent esophagogastrostomy. The tip of the conduit was found to have poor perfusion based on the fluorescence imaging and was resected. The distal end of the gastric conduit at the anastomosis showed good perfusion. 509 Surgical Treatment Options for Delayed Gastric Emptying Nathan Lytle, Juan Toro, Ankit Patel, Jahnavi Srinivasan, S. Scott Davis, Edward Lin Delayed gastric emptying is a common problem that is seen by both gastroenterologists and general surgeons. Poor gastric emptying from outlet obstruction or diabetic, post-surgical, and idiopathic gastroparesis can be difficult to treat. This video demonstrates four surgical options for treatment. Gastric stimulator, duodenojejunostomy, pyloroplasty, and distal gastrectomy are shown demonstrating technique, and indications for each are discussed. 510
SSAT Abstracts
Transanal Minimally Invasive Surgery Assisted Single Incision Low Anterior Resection With Total Mesorectal Excision (Tamis Assisted LAR Tme) in a Cadaver Model Elisabeth C. McLemore, Alisa M. Coker, Bikash Devaraj, Jeffrey Chakedis, Ali Maawy, Tazo Inui, Mark A. Talamini, Santiago Horgan, Michael R. Peterson, Patricia Sylla, Sonia Ramamoorthy The purpose of this video is to demonstrate the feasibility of an innovative technique for the surgical management of rectal cancer: trans anal minimally invasive surgery assisted low anterior resection with total mesorectal excision (TAMIS assisted LAR TME) in a cadaver model. Trans anal LAR via natural orifice translumenal endoscopic surgery (NOTES) has been reported in cadaveric series using rigid transanal platforms. This procedure has not been described using a combination of a single incision laparoscopy and TAMIS trans anal endoscopic platform. Herein, we describe the first cadaveric series of TAMIS assisted laparoscopic LAR with TME. 511 Central Pancreatectomy With Pancreatogastrostomy for Traumatic Transection of the Pancreas Farzad Alemi, Jonathan Carter, Carlos U. Corvera
No Surgical Therapy includes no first course therapy, chemotherapy only and chemoradiation only
A 22 year-old man sustained abdominal trauma resulting in complete transection of the pancreas at the neck of the gland. Pancreatic ascites and mesenteric hematoma was found at exploration. Given the normalcy of the distal pancreatic remnant, a central pancreatectomy and pancreatogastrostomy was done. The operation entailed 1) partial mobilization of the distal pancreatic remnant, 2) cannulation and stenting of the pancreatic duct, 3) opposing anterior and posterior gastrotomies, and 4) a two-layer, interrupted anastomosis. The proximally transected segment was treated with biologic adhesive and wide drainage. Postoperatively the patient exhibited normal digestion and glucose homeostasis.
588 Does the Incidence of Adenocarcinoma of the Esophagus and Gastric Cardia Continue to Rise in the 21st Century? Attila Dubecz, Norbert Solymosi, Michael Schweigert, Rudolf J. Stadlhuber, Hubert J. Stein, Jeffrey H. Peters Background: The rising incidence and histologic change to adenocarcinoma in esophageal cancer over the past four decades has been among the most dramatic changes ever observed in human cancer. Recent reports have suggested that its increasing incidence may have plateaued over the past decade. Our aim was to examine the latest trends in esophageal adenocarcinoma incidence and analyze its correlation with time and population density. Patients and Methods: We used the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute to identify all patients with adenocarcinoma of the esophagus and gastric cardia between 1973 and 2009. Both overall and stage specific trends in incidence were analyzed using joinpoint regression. The correlation of incidence with time and total population within the geographic areas covered by SEER was analyzed by linear regression. Results: The overall incidence of adenocarcinoma of the esophagus and the gastric cardia increased from 13.4 per million in 1973 to 51.4 per million in 2009, a nearly 400% increase. Jointpoint analysis demonstrated that the yearly increase in incidence has slowed somewhat from 1.27 per million before 1987 to 0.97 between 1987-1997 and 0.65 after 1997. Stage-specific analyses suggests, that incidence of early stages has actually declined after 2001 with a yearly decrease of 0.22. The percentage of patients diagnosed with early cancer declined after 2000 and remained under 2.5% through the study period. Regression analysis showed a substantially higher correlation of incidence of adenocarcinoma of the esophagus and the gastric cardia with population (r2=0.95) than with time (r2=0.65).
512 Laparoscopic Hilar Resection With Roux-en-Y Hepatico-Jejunostomy Juan Toro, Nathan Lytle, Ankit Patel, S. Scott Davis, Edward Lin, Juan M. Sarmiento Several series demonstrate the safety and feasibility of laparoscopy for complex hepatobiliary procedures. These reports show the results of laparoscopic liver resections for different types of neoplasms and benign diseases such as choledochal cysts. However, the adoption of laparoscopic resection with common bile duct excision is still uncommon due to technical complexity and longer operative times. We perform laparoscopic extended hepatectomies with biliary reconstructions using minimally invasive surgical technique. In this video, we demonstrate our technique for right and left extended hepatectomies with Roux-en-Y hepaticojejunostomy. This approach allows superior visualization.
SSAT Abstracts
S-1052
513
Laparoscopic Enucleation of Benign and Low Grade Hepatic Lesions Nicholas N. Nissen, Vichin Puri, Vijay G. Menon
Robotic Assisted Laparoscopic Total Proctocolectomy With Ileal Pouch Anal Anastomosis Mehraneh D. Jafari, Alessio Pigazzi, Michael J. Stamos
Enucleation is a technique which can be applied to benign and low grade lesions of the liver such as select neuroendocrine tumors (NET), cysts, hemangiomas and focal nodular hyperplasia. The benefits of enucleation include the preservation of maximal hepatic parenchyma, as well as the low likelihood that underlying vascular or biliary structures will be compromised. A laparoscopic approach to enucleation not only offers the benefits of minimal access surgery, but also allows simultaneous access to multiple regions of the abdomen. This may be ideal for managing certain scenarios such as the patient with distal pancreatic NET and synchronous liver metastases. Illustrative cases are shown.
This is a 38 year old female with polyposis syndrome. A laparoscopic total colectomy is performed in a medial to lateral fashion. The ielocolic vessels, middle colic vessels, and inferior mesenteric vessels are divided. The four arm Di Vinci robot is docked and a total proctocolectomy is carried out to the level of the dentate line. The distal rectum is transected and the specimen removed through a Pfannenstiel incision. An ileal J-pouch is created and an end to end ileo-anal anastomosis is performed. Pathology revealed colonic polyposis with no evidence of malignancy.
508
587
Use of Fluorescence Angiography During 2-Field Minimally Invasive Esophagectomy C. Daniel Smith, Steven P. Bowers
Trends in the Surgical Treatment of Pancreatic Adenocarcinoma Siavash Raigani, John Ammori, Julian Kim, Jeffrey Hardacre Introduction: Multiple prospective, randomized trials have demonstrated that the addition of adjuvant therapy after surgical resection of pancreatic cancer improves survival compared to surgery alone. However, the optimal type of adjuvant therapy, chemotherapy alone or chemotherapy combined with chemoradiation therapy, remains controversial. Our aim was to determine whether the type of adjuvant therapy for pancreatic cancer given in the United States has changed by examining treatment trends using the National Cancer Data Base. Methods: The National Cancer Data Base (NCDB) is a national oncology outcomes database for over 1,500 Commission on Cancer-accredited cancer programs. Patients diagnosed with stage 1-2 pancreatic adenocarcinoma between 2003-2009 were selected from the NCDB Hospital Comparison Benchmark Reports. Attention was paid to the initial treatment regimen, such as surgery alone, surgery plus chemotherapy, or surgery plus chemoradiation. In addition, data on hospital setting (teaching-research hospitals vs. community hospitals) were collected and analyzed. The Cochran-Armitage test for trend was used to assess changes in treatment over time. Results: 47, 086 patients with stage 1-2 pancreatic adenocarcinoma were included in the analysis. Between 2003-2009, the use of surgery alone as first course treatment of stage 2 disease decreased significantly at both teaching-research hospitals and community hospitals by nearly 25% (p ,0.0001 for both cases). In the same period, the use of chemotherapy in addition to surgery as treatment of stage 1 and 2 disease increased two-fold at both types of hospitals (p ,0.0001 for all cases). Treatment with surgery plus chemoradiation decreased significantly for both stages in both hospital settings by approximately 30% (p,0.05 for all cases). Non-surgical treatment for stage 2 disease was surprisingly high and significantly increased over time (p ,0.0001 for both), ranging from approximately 30-37% at teaching-research hospitals and 40-49% at community hospitals. Conclusion: Data from the NCDB from 2003-2009 illustrate changes in the adjuvant treatment of pancreatic cancer. There is an alarmingly high rate of non-surgical therapy for stage 1 and 2 disease. The use of chemotherapy alone as adjuvant therapy increased whereas the use of multimodality therapy decreased.
This video depicts the use of fluorescence angiography using the SPY technology to assess the perfusion of the gastric conduit during 2-field minimally invasive technology. The SPY allowed real-time visualization of the perfusion of the gastric conduit and subsequent esophagogastrostomy. The tip of the conduit was found to have poor perfusion based on the fluorescence imaging and was resected. The distal end of the gastric conduit at the anastomosis showed good perfusion. 509 Surgical Treatment Options for Delayed Gastric Emptying Nathan Lytle, Juan Toro, Ankit Patel, Jahnavi Srinivasan, S. Scott Davis, Edward Lin Delayed gastric emptying is a common problem that is seen by both gastroenterologists and general surgeons. Poor gastric emptying from outlet obstruction or diabetic, post-surgical, and idiopathic gastroparesis can be difficult to treat. This video demonstrates four surgical options for treatment. Gastric stimulator, duodenojejunostomy, pyloroplasty, and distal gastrectomy are shown demonstrating technique, and indications for each are discussed. 510
SSAT Abstracts
Transanal Minimally Invasive Surgery Assisted Single Incision Low Anterior Resection With Total Mesorectal Excision (Tamis Assisted LAR Tme) in a Cadaver Model Elisabeth C. McLemore, Alisa M. Coker, Bikash Devaraj, Jeffrey Chakedis, Ali Maawy, Tazo Inui, Mark A. Talamini, Santiago Horgan, Michael R. Peterson, Patricia Sylla, Sonia Ramamoorthy The purpose of this video is to demonstrate the feasibility of an innovative technique for the surgical management of rectal cancer: trans anal minimally invasive surgery assisted low anterior resection with total mesorectal excision (TAMIS assisted LAR TME) in a cadaver model. Trans anal LAR via natural orifice translumenal endoscopic surgery (NOTES) has been reported in cadaveric series using rigid transanal platforms. This procedure has not been described using a combination of a single incision laparoscopy and TAMIS trans anal endoscopic platform. Herein, we describe the first cadaveric series of TAMIS assisted laparoscopic LAR with TME. 511 Central Pancreatectomy With Pancreatogastrostomy for Traumatic Transection of the Pancreas Farzad Alemi, Jonathan Carter, Carlos U. Corvera
No Surgical Therapy includes no first course therapy, chemotherapy only and chemoradiation only
A 22 year-old man sustained abdominal trauma resulting in complete transection of the pancreas at the neck of the gland. Pancreatic ascites and mesenteric hematoma was found at exploration. Given the normalcy of the distal pancreatic remnant, a central pancreatectomy and pancreatogastrostomy was done. The operation entailed 1) partial mobilization of the distal pancreatic remnant, 2) cannulation and stenting of the pancreatic duct, 3) opposing anterior and posterior gastrotomies, and 4) a two-layer, interrupted anastomosis. The proximally transected segment was treated with biologic adhesive and wide drainage. Postoperatively the patient exhibited normal digestion and glucose homeostasis.
588 Does the Incidence of Adenocarcinoma of the Esophagus and Gastric Cardia Continue to Rise in the 21st Century? Attila Dubecz, Norbert Solymosi, Michael Schweigert, Rudolf J. Stadlhuber, Hubert J. Stein, Jeffrey H. Peters Background: The rising incidence and histologic change to adenocarcinoma in esophageal cancer over the past four decades has been among the most dramatic changes ever observed in human cancer. Recent reports have suggested that its increasing incidence may have plateaued over the past decade. Our aim was to examine the latest trends in esophageal adenocarcinoma incidence and analyze its correlation with time and population density. Patients and Methods: We used the Surveillance Epidemiology and End Results (SEER) database of the National Cancer Institute to identify all patients with adenocarcinoma of the esophagus and gastric cardia between 1973 and 2009. Both overall and stage specific trends in incidence were analyzed using joinpoint regression. The correlation of incidence with time and total population within the geographic areas covered by SEER was analyzed by linear regression. Results: The overall incidence of adenocarcinoma of the esophagus and the gastric cardia increased from 13.4 per million in 1973 to 51.4 per million in 2009, a nearly 400% increase. Jointpoint analysis demonstrated that the yearly increase in incidence has slowed somewhat from 1.27 per million before 1987 to 0.97 between 1987-1997 and 0.65 after 1997. Stage-specific analyses suggests, that incidence of early stages has actually declined after 2001 with a yearly decrease of 0.22. The percentage of patients diagnosed with early cancer declined after 2000 and remained under 2.5% through the study period. Regression analysis showed a substantially higher correlation of incidence of adenocarcinoma of the esophagus and the gastric cardia with population (r2=0.95) than with time (r2=0.65).
512 Laparoscopic Hilar Resection With Roux-en-Y Hepatico-Jejunostomy Juan Toro, Nathan Lytle, Ankit Patel, S. Scott Davis, Edward Lin, Juan M. Sarmiento Several series demonstrate the safety and feasibility of laparoscopy for complex hepatobiliary procedures. These reports show the results of laparoscopic liver resections for different types of neoplasms and benign diseases such as choledochal cysts. However, the adoption of laparoscopic resection with common bile duct excision is still uncommon due to technical complexity and longer operative times. We perform laparoscopic extended hepatectomies with biliary reconstructions using minimally invasive surgical technique. In this video, we demonstrate our technique for right and left extended hepatectomies with Roux-en-Y hepaticojejunostomy. This approach allows superior visualization.
SSAT Abstracts
S-1052