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514 A Standardized Approach to Minimally Invasive Transhiatal Esophagectomy
431 Waist Circumference Predicts Complications in Rectal Cancer Surgery Courtney Balentine, Celia Robinson, Christy Marshall, Jonathan Wilks, Kujtim Haderxhanaj, Shubhada Sansgiry, Nancy J. Petersen, Daniel Albo, David H. Berger BACKGROUND The impact of obesity on development of postoperative complications after gastrointestinal surgery remains controversial. This may be due to the fact that obesity is traditionally calculated by body mass index (BMI), an indirect measure that does not account for fat distribution. We hypothesized that a direct measure of obesity, waist circumference, would better predict complications after high-risk gastrointestinal procedures. METHODS Retrospective review of an institutional cancer database identified consecutive cases of men undergoing elective rectal resections. Waist circumference was calculated from preoperative CT. Multivariate logistic regression was used to calculate independent predictors of complications. RESULTS From 2002-2009, 152 patients with mean age 65.2±0.75 years and BMI 28.0±0.43kg/m2 underwent elective resection of rectal adenoma or carcinoma. Increasing BMI was not significantly associated with risk of postoperative complications including infection, dehiscence, and reoperation (Table 1). Greater waist circumference independently predicted increased risk of superficial infections (OR 1.98, 95% CI 1.19-3.30, p<0.008). Risk of wound disruption, dehiscence and reoperation were increased with expanding waist circumference but the association did not achieve statistical significance. Overall, increased waist circumference predicted a significantly greater risk of having one or more postoperative complication (OR 1.56, 95% CI 1.04-2.34, p<0.034). CONCLUSIONS Although BMI is easily calculated, it is an indirect measure of obesity that fails to account for differences in fat quantity and distribution. Waist circumference, a direct measure of central adiposity, is a better predictor of short-term complications and can be used to identify patients who may benefit from more aggressive infection control and prevention.
Statistically significant correlation as % in Grade or LOS varied similarly for EG vs. PD, p<0.0001 433 Predicting Post-Operative Mortality in Colorectal Cancer Surgery: A Systematic Review of the Accuracy of POSSUM, P-POSSUM and CR-POSSUM Colin Richards, Fiona Leitch, Paul G. Horgan, Donald C. McMillan Introduction The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth (P-POSSUM) and colorectal (CRPOSSUM) modifications are used extensively monitor post-operative outcome. This systematic review assessed the predictive accuracy of each POSSUM model after colorectal cancer resection. Methods The review was undertaken according to a predefined protocol. Major electronic databases, including Medline, Embase, Cochrane Library and Pubmed were searched using appropriate MeSH and free text terms. Abstracts were scanned and full text obtained for potentially relevant articles. The reference list of each article was then hand searched. Each study was entered into an electronic database using a data extraction tool. Two independent reviewers assessed each study against explicit inclusion criteria (colorectal cancer-specific data, actual and predicted mortality rates). Predictive accuracy for mortality was assessed by calculating weighted observed:expected (O:E) ratios with 95% confidence intervals (CI) for each POSSUM model. Results 345 abstracts were scanned before 48 articles were progressed to data extraction. After applying inclusion criteria, 18 studies, published between 1991 and 2009 were included in the final review. 10 studies (4799 patients) reported data on POSSUM, 17 studies (6576 patients) reported data on P-POSSUM and 13 studies (4998 patients) reported data on CR-POSSUM. The majority of operations were elective open colorectal cancer resections. Pooling of the data returned a weighted O:E ratio of 0.31 (CI 0.17-0.45, range 0.11-0.80) for POSSUM, 0.90 (CI 0.52-1.28, range 0.20-2.36) for P-POSSUM and 0.62 (CI 0.43-0.80, range 0.21-1.11) for CR-POSSUM. Conclusion There was also significant heterogeneity in the reported O:E ratio for each POSSUM model, in particular P-POSSUM. Pooling of the data demonstrated P-POSSUM as the most accurate with a weighted O:E ratio nearest to 1. POSSUM had a weighted O:E ratio furthest from 1. CR-POSSUM, despite development specifically for use within colorectal surgery, was not as accurate as P-POSSUM and consistently over-predicted mortality.
* indicates p<0.05 OR adjusted for age, ethnicity, smoking, DM, HTN, CAD, operative time and laparoscopic vs open approach. 432 Impact on Hospital Systems by Esophagectomy (EG) and Pancreaticoduodenectomy (PD): Objective Comparison of Surgical Complications Using the Accordion Severity Grading System Donald E. Low, MadhanKumar Kuppusamy, Yasushi Hashimoto, L. William Traverso
512
Introduction. EG and PD are complex GI operations that can impact a hospital system if the complication rate is high. The recently reported Accordion Severity Grading System of Surgical Complications (ASGS) quantifies the amount of treatment (Tx) required to manage surgical complication by using readily available variables with minimal subjectivity (Ann Surg. 2009 Aug;250(2):177-86). For the first time the ASGS will allow grading and comparison of complications between individual case series to determine the impact of each operation on a hospital supportive systems. Methods. From prospective IRB-approved databases we retrospectively assigned ASGS categories 1-6 to all post-operative complications documented in consecutive cases through December-2008 (EG=463 and PD=507) by a single esophageal or pancreatic surgeon respectively, in a tertiary-referral, resident-training hospital. Grade 1 - mild, Grade 2 - moderate with pharmacologic Tx, Grade 3 - severe with invasive Tx not requiring general anesthesia (GA), Grade 4 - severe invasive Tx with GA, Grade 5 - severe with organ failure, Grade 6 - postoperative death. Results. (Table. 1&2) Standard outcome measures were similar for EG and PD. As ASGS grade increased the number of cases decreased and this decrease was similar (significant correlation) for EG vs. PD. As ASGS increased so did LOS and the increase was similar for EG vs. PD. Conclusions. EG and PD have a remarkably similar incidence of standard outcome measures. As expected the new ASGS correlates with LOS. For the first time severity grading of a complication, based on the amount of intervention required to treat, provides a clinically relevant tool for comparing complication rates between very different complex operations. Surprisingly their impact on the hospital system was the same. Table.1
Treatment of symptomatic Zenker's diverticuli has traditionally been via a transcervical excision of the diverticulum with a cricomyotomy, or endoluminal division of the septum between the esophagus and diverticulum using a rigid laparoscopic GIA stapler. When these approaches are not feasible or desirable, a cricopharyngeal myotomy may be performed through a flexible endoscopic approach. This video demonstrates the procedure using a standard endoscope and needle-knife, specialized dissecting tips, and endoscopic clips for wound edge approximation. The operation is quick and straightforward, and results in a one night patient stay with excellent emptying of the diverticulum and no leak. 513 Laparoscopic Pancreaticoduodenectomy Sujit Kulkarni, David Vivas, Tanuja Damani, Paresh C. Shah Laparoscopic pancreaticoduodenectomy is technically challenging but gaining interest as international experience grows. We present a case of a 25 year old female who was diagnosed with a psuedopapillary tumor in the head of the pancreas abutting the SMV. Our video will demonstrate our technique for a totally laparoscopic pancreaticoduodenectomy with vascular isolation of the SMV via caudal-cranial approach. We have applied this technique to both benign and malignant lesions of the pancreas and ampulla with excellent results. 514 A Standardized Approach to Minimally Invasive Transhiatal Esophagectomy James Lopes, Steven N. Hochwald, Kfir Ben-David We present a case of a 76 year old male patient who was diagnosed with an esophageal cancer in the distal third of his esophagus. This was biopsy proven to be adenocarcinoma and staged by endoscopic ultrasound as a T2,N1 lesion. After receiving appropriate neoadjuvant chemoradiation, the patient was brought to the operating room for a transhiatal minimally invasive esophagectomy. Although there a variety of ways to perform the operation, we demonstrate our technique in attempts to standardize the operation. The benefits of our operative methods have led to improved patient outcomes, when compared to the results of open esophagectomies, as well as optimal oncologic treatment.
Table.2 Comparison of Complication Grades Between Procedures
S-853
SSAT Abstracts
SSAT Abstracts
Flexible Endoscopic Cricopharyngeal Myotomy for Zenker's Diverticulum Richard A. Pierce, Danny V. Martinec, Trudie A. Goers, Erwin Rieder, Lee L. Swanstrom
Statistically significant correlation as % in Grade or LOS varied similarly for EG vs. PD, p<0.0001 433 Predicting Post-Operative Mortality in Colorectal Cancer Surgery: A Systematic Review of the Accuracy of POSSUM, P-POSSUM and CR-POSSUM Colin Richards, Fiona Leitch, Paul G. Horgan, Donald C. McMillan Introduction The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) model and its Portsmouth (P-POSSUM) and colorectal (CRPOSSUM) modifications are used extensively monitor post-operative outcome. This systematic review assessed the predictive accuracy of each POSSUM model after colorectal cancer resection. Methods The review was undertaken according to a predefined protocol. Major electronic databases, including Medline, Embase, Cochrane Library and Pubmed were searched using appropriate MeSH and free text terms. Abstracts were scanned and full text obtained for potentially relevant articles. The reference list of each article was then hand searched. Each study was entered into an electronic database using a data extraction tool. Two independent reviewers assessed each study against explicit inclusion criteria (colorectal cancer-specific data, actual and predicted mortality rates). Predictive accuracy for mortality was assessed by calculating weighted observed:expected (O:E) ratios with 95% confidence intervals (CI) for each POSSUM model. Results 345 abstracts were scanned before 48 articles were progressed to data extraction. After applying inclusion criteria, 18 studies, published between 1991 and 2009 were included in the final review. 10 studies (4799 patients) reported data on POSSUM, 17 studies (6576 patients) reported data on P-POSSUM and 13 studies (4998 patients) reported data on CR-POSSUM. The majority of operations were elective open colorectal cancer resections. Pooling of the data returned a weighted O:E ratio of 0.31 (CI 0.17-0.45, range 0.11-0.80) for POSSUM, 0.90 (CI 0.52-1.28, range 0.20-2.36) for P-POSSUM and 0.62 (CI 0.43-0.80, range 0.21-1.11) for CR-POSSUM. Conclusion There was also significant heterogeneity in the reported O:E ratio for each POSSUM model, in particular P-POSSUM. Pooling of the data demonstrated P-POSSUM as the most accurate with a weighted O:E ratio nearest to 1. POSSUM had a weighted O:E ratio furthest from 1. CR-POSSUM, despite development specifically for use within colorectal surgery, was not as accurate as P-POSSUM and consistently over-predicted mortality.
* indicates p<0.05 OR adjusted for age, ethnicity, smoking, DM, HTN, CAD, operative time and laparoscopic vs open approach. 432 Impact on Hospital Systems by Esophagectomy (EG) and Pancreaticoduodenectomy (PD): Objective Comparison of Surgical Complications Using the Accordion Severity Grading System Donald E. Low, MadhanKumar Kuppusamy, Yasushi Hashimoto, L. William Traverso
512
Introduction. EG and PD are complex GI operations that can impact a hospital system if the complication rate is high. The recently reported Accordion Severity Grading System of Surgical Complications (ASGS) quantifies the amount of treatment (Tx) required to manage surgical complication by using readily available variables with minimal subjectivity (Ann Surg. 2009 Aug;250(2):177-86). For the first time the ASGS will allow grading and comparison of complications between individual case series to determine the impact of each operation on a hospital supportive systems. Methods. From prospective IRB-approved databases we retrospectively assigned ASGS categories 1-6 to all post-operative complications documented in consecutive cases through December-2008 (EG=463 and PD=507) by a single esophageal or pancreatic surgeon respectively, in a tertiary-referral, resident-training hospital. Grade 1 - mild, Grade 2 - moderate with pharmacologic Tx, Grade 3 - severe with invasive Tx not requiring general anesthesia (GA), Grade 4 - severe invasive Tx with GA, Grade 5 - severe with organ failure, Grade 6 - postoperative death. Results. (Table. 1&2) Standard outcome measures were similar for EG and PD. As ASGS grade increased the number of cases decreased and this decrease was similar (significant correlation) for EG vs. PD. As ASGS increased so did LOS and the increase was similar for EG vs. PD. Conclusions. EG and PD have a remarkably similar incidence of standard outcome measures. As expected the new ASGS correlates with LOS. For the first time severity grading of a complication, based on the amount of intervention required to treat, provides a clinically relevant tool for comparing complication rates between very different complex operations. Surprisingly their impact on the hospital system was the same. Table.1
Treatment of symptomatic Zenker's diverticuli has traditionally been via a transcervical excision of the diverticulum with a cricomyotomy, or endoluminal division of the septum between the esophagus and diverticulum using a rigid laparoscopic GIA stapler. When these approaches are not feasible or desirable, a cricopharyngeal myotomy may be performed through a flexible endoscopic approach. This video demonstrates the procedure using a standard endoscope and needle-knife, specialized dissecting tips, and endoscopic clips for wound edge approximation. The operation is quick and straightforward, and results in a one night patient stay with excellent emptying of the diverticulum and no leak. 513 Laparoscopic Pancreaticoduodenectomy Sujit Kulkarni, David Vivas, Tanuja Damani, Paresh C. Shah Laparoscopic pancreaticoduodenectomy is technically challenging but gaining interest as international experience grows. We present a case of a 25 year old female who was diagnosed with a psuedopapillary tumor in the head of the pancreas abutting the SMV. Our video will demonstrate our technique for a totally laparoscopic pancreaticoduodenectomy with vascular isolation of the SMV via caudal-cranial approach. We have applied this technique to both benign and malignant lesions of the pancreas and ampulla with excellent results. 514 A Standardized Approach to Minimally Invasive Transhiatal Esophagectomy James Lopes, Steven N. Hochwald, Kfir Ben-David We present a case of a 76 year old male patient who was diagnosed with an esophageal cancer in the distal third of his esophagus. This was biopsy proven to be adenocarcinoma and staged by endoscopic ultrasound as a T2,N1 lesion. After receiving appropriate neoadjuvant chemoradiation, the patient was brought to the operating room for a transhiatal minimally invasive esophagectomy. Although there a variety of ways to perform the operation, we demonstrate our technique in attempts to standardize the operation. The benefits of our operative methods have led to improved patient outcomes, when compared to the results of open esophagectomies, as well as optimal oncologic treatment.
Table.2 Comparison of Complication Grades Between Procedures
S-853
SSAT Abstracts
SSAT Abstracts
Flexible Endoscopic Cricopharyngeal Myotomy for Zenker's Diverticulum Richard A. Pierce, Danny V. Martinec, Trudie A. Goers, Erwin Rieder, Lee L. Swanstrom