- Email: [email protected]
525 Robotic-Assisted Transduodenal Resection of Ampullary Tumor With Bile and Pancreatic Duct Reconstruction
of the vagi, diverticulectomy by using a linear stapler, anterior myotomy and a Dor 180 degree anterior hemi-fundoplication.
excluded surgeons performing <10 cholecystectomies/year. We dichotomized surgeons into a high-IOC group (top 10%, using yearly ratio of IOC/cholecystectomy frequency) vs. standard group (lower 90%). Our outcomes included bile duct injury, overall complications, in-hospital mortality, length of stay (LOS), use of additional studies such as endoscopic retrograde cholangiopancreatography (ERCP), and hospitalization cost. Statistical analysis included weighted univariable and multivariable analysis, and Cochran-Armitage trend test. RESULTS: 518488 nationally weighted patients underwent cholecystectomy; 33.9% had IOC. Over time, IOCs utilization increased (31% to 34%, p<0.0001), annual number of cholecystectomies remained stable. 12,527 non-weighted annual surgeon volumes were included in analysis. On average, each surgeon performed 31.9 cholecystectomies and 7.9 IOCs annually, with mean annual surgeon-specific IOC/CCY ratio of 0.23. The high-IOC (top 10%) group used IOC for 100% of cases. Of note, 25% of surgeons used IOC for at least half of cases. Comparing high-IOC group to standard group, high-IOC had no difference in bile duct injury (0.25% vs. 0.27% for standard group, p=0.2; a higher rate of overall complications: 7.2% vs. 6.9%, p=0.04; and no difference in mortality 0.4% vs. 0.4% p= 0.8). Patients of high-IOC surgeons had shorter LOS, 3.9 vs. 4.2 days, p=0.002, and were more likely to use additional procedures: ERCP 16.0 % vs. 13.1%, p=<0.0001. CONCLUSION: IOC remains a frequently used procedure. In a national study, most surgeons appear to be using IOC selectively. A 10% minority of surgeons appear to approach IOC as mandatory. Intriguingly, a surgeon's routine use of IOC is correlated with increased rates of post-surgical procedures, and is associated with increased overall complications, with no additional decrease in CBD injury rate. Further studies are warranted to determine if additional surgeon, patient, or perioperative factors contribute to the apparently unhelpful effect of compulsory IOC.
523 Laparoscopic Reversal of Roux-en-Y Gastric Bypass to Treat Recalcitrant Hyperinsulinemic Hypoglycemia Jacob A. Greenberg, Dawn B. Davis, Haggi Mazeh, Guilherme M. Campos The video presents technical steps for Laparoscopic Reversal of Roux-en-Y Gastric Bypass (RYGB) to normal anatomy, and results of pre and post-op metabolic testing. The patient underwent RYGB at another institution (BMI 46). Two years after RYGB (BMI 25), presented with recalcitrant hyperinsulinemic hypoglycemia episodes and hypoglycemia unawareness. A laparoscopic gastrostomy was placed in the excluded stomach. A meal test (MT) administered orally and through the gastrostomy showed altered insulin and glycemic responses through the RYGB. Laparoscopic reversal was performed. Patient symptoms subsided; and 6 months later (BMI 29), a MT showed normal insulin and glycemic profiles. 524 Transanal NOTES Sigmoidectomy in a Cadaver Model Ezra N. Teitelbaum, Fahd O. Arafat, Byron F. Santos, Eric S. Hungness, Anne M. Boller This video shows a transanal hybrid natural orifice transluminal endoscopic surgery (NOTES) sigmoidectomy performed in a cadaver model using a TEM proctoscope. We employ a combined laparoscopic and endoscopic technique to place a stapler anvil in the proximal colon prior to initiation of colon dissection. This allows for a completely intra-corporeal anastomosis to be performed without the need for colon exteriorization. Techniques for occluding the rectal lumen with a purse-string suture, performing a full thickness dissection at the rectosigmoid junction, and creating a colorectal anastomosis through the TEM proctoscope are also shown.
528a Quality Assessment in Pancreatic Surgery: What Might Tomorrow Require? Brian T. Kalish, Charles M. Vollmer, Tara S. Kent, William H. Nealon, Jennifer F. Tseng, Mark P. Callery INTRODUCTION: The Institute of Medicine (IOM) defines healthcare quality across six domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability. Traditional quality metrics in high-acuity surgery (volume and mortality) cannot alone measure or satisfy these domains. We asked experts in pancreatic surgery (PS) whether broader quality metrics are needed, how important they might be, and whether they align to contemporary IOM healthcare quality domains. METHODS: Together with a professional market research firm, we created and distributed a web-based survey to pancreatic surgeons. These experts were identified through PS specialty societies, and verified by survey demographics. Respondents (Rpds) ranked 62 proposed PS quality metrics on level of importance (LoI). Next, Rpds aligned each metric to one or more IOM quality domains (MDA, multidomain alignment). Descriptive statistics were used to summarize responses. To calculate and rank relative quality scores, points were awarded for LoI (4-Essential, 3-Very important, 2-Somewhat important, 1-A Little important, 0-Not important) and MDA (1 point/each aligned domain). LoI Scores and MDA Scores for a given quality metric were averaged together to render a Total Quality Score (TQS=LoI + MDA/2) normalized to a 100-point scale. RESULTS: 106 surgeons (21%) completed the survey (82% North America and 84% Academic). On average, Rpds and their institutions perform 43 and 114 pancreatic operations per year, respectively. By descriptive analysis, 90% of Rpds indicated a definite or probable need for improved quality metrics in PS. 81% of Rpds indicated a definite or probable value for a “Quality Scorecard” in PS. Of 13 PS quality metrics rated as Essential by >25% Rpds, 10 aligned most strongly to the IOM Safety domain. 22/62 proposed metrics aligned to more than 1.75 IOM Domains, and were rated by >50% Rpds as High LoI (Essential or Very Important; Figure). 12 proposed scorecard metrics (Table) emerged with the highest TQS. Those related to mortality, to the rate and severity of complications, and to access to multidisciplinary services for pancreatic disease had the highest TQS. Technical and perioperative metrics had intermediate TQS. Metrics related to patient satisfaction with care, costs of care, and patient demographics had the lowest TQS. The least represented IOM domains were equitability, efficiency, and patient-centeredness. CONCLUSIONS: We propose a 12-item "Quality Scorecard" for PS based on rank-scoring of quality metrics that PS experts view as both highly important and aligned with more than one IOM healthcare quality domain. While the actual performance thresholds for these metrics require further definition and validation, they may reveal quality to an extent that volume and mortality alone cannot. Top Pancreatic Surgery “Quality Scorecard” Metrics by Total Quality Score (TQS)
525 Robotic-Assisted Transduodenal Resection of Ampullary Tumor With Bile and Pancreatic Duct Reconstruction John Prodromo, Mehmet F. Can, Jennifer R. Bonfili, Dev Patel, Herbert Zeh, A. James Moser
SSAT Abstracts
A 75 year old woman presented with recurrent pancreatitis and endoscopic evidence of a duodenal papillary mass that did not show high grade dysplasia extending up the common bile duct. Follow up after endoscopic ampullectomy demonstrated recurrence of the lesion. The adenoma was then resected using a robotic-assisted transduodenal approach with bile and pancreatic duct reconstruction. This case demonstrates the ability to establish precise excisional margins and to remove lesions that cannot be resected endoscopically via the use of robotic assistance. This method demonstrates an alternative option to avoid the morbidity associated with pancreaticoduodenectomy for benign lesions. 526 Per-Oral Endoscopic Myotomy (POEM): Techniques for Successful Submucosal Dissection Eric M. Pauli, Jeffrey M. Marks, Jeffrey L. Ponsky Recently, a new endoscopic method for reducing lower esophageal sphincter pressure in achalasia patients, per-oral endoscopic myotomy (POEM), has been developed. The most difficult part of POEM is the submucosal dissection, which spatially separates the mucosa and the musculature and provides an intact tissue plane for secure esophageal closure. The purpose of this video is to review six technical pearls identified over our series of POEM patients that permit successful, reproducible creation of the submucosal tunnel. 527 Thoracoscopic Esophageal Leiomyoma Enucleation Jason F. Richardson, Ninh T. Nguyen This is a video presentation of a patient who was incidentally found to have an esophageal mass. EUS revealed a 25 x 14mm hypoechoic submucosal lesion at 28-30cm arising from the muscularis propria with normal overlying mucosa and no obvious nodal involvement. FNA demonstrated spindle cells. A thoracoscopic enucleation was performed and is featured in this video. Final path was consistent with leiomyoma. Port positioning, endoscopy, esophageal mobilization, mass enucleation, and muscular layer reapproximation are featured in this video. 528 Is Routine Intraoperative Cholangiogram Necessary in the 21st Century? a National View Elizaveta Ragulin-Coyne, Elan R. Witkowski, Zeling Chau, Sing Chau Ng, Heena P. Santry, Mark P. Callery, Shimul A. Shah, Jennifer F. Tseng INTRODUCTION:Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, as the “critical view of safety” technique has become widespread, current practice and outcomes of IOC are unclear. METHODS: Nationwide Inpatient Sample 2004-2009 was queried for patients with acute/urgent biliary disease undergoing laparoscopic and/or open cholecystectomy; IOC was quantified. We limited analyses to states with consistent coding of provider and hospital ID data, and
SSAT Abstracts
S-1028
excluded surgeons performing <10 cholecystectomies/year. We dichotomized surgeons into a high-IOC group (top 10%, using yearly ratio of IOC/cholecystectomy frequency) vs. standard group (lower 90%). Our outcomes included bile duct injury, overall complications, in-hospital mortality, length of stay (LOS), use of additional studies such as endoscopic retrograde cholangiopancreatography (ERCP), and hospitalization cost. Statistical analysis included weighted univariable and multivariable analysis, and Cochran-Armitage trend test. RESULTS: 518488 nationally weighted patients underwent cholecystectomy; 33.9% had IOC. Over time, IOCs utilization increased (31% to 34%, p<0.0001), annual number of cholecystectomies remained stable. 12,527 non-weighted annual surgeon volumes were included in analysis. On average, each surgeon performed 31.9 cholecystectomies and 7.9 IOCs annually, with mean annual surgeon-specific IOC/CCY ratio of 0.23. The high-IOC (top 10%) group used IOC for 100% of cases. Of note, 25% of surgeons used IOC for at least half of cases. Comparing high-IOC group to standard group, high-IOC had no difference in bile duct injury (0.25% vs. 0.27% for standard group, p=0.2; a higher rate of overall complications: 7.2% vs. 6.9%, p=0.04; and no difference in mortality 0.4% vs. 0.4% p= 0.8). Patients of high-IOC surgeons had shorter LOS, 3.9 vs. 4.2 days, p=0.002, and were more likely to use additional procedures: ERCP 16.0 % vs. 13.1%, p=<0.0001. CONCLUSION: IOC remains a frequently used procedure. In a national study, most surgeons appear to be using IOC selectively. A 10% minority of surgeons appear to approach IOC as mandatory. Intriguingly, a surgeon's routine use of IOC is correlated with increased rates of post-surgical procedures, and is associated with increased overall complications, with no additional decrease in CBD injury rate. Further studies are warranted to determine if additional surgeon, patient, or perioperative factors contribute to the apparently unhelpful effect of compulsory IOC.
523 Laparoscopic Reversal of Roux-en-Y Gastric Bypass to Treat Recalcitrant Hyperinsulinemic Hypoglycemia Jacob A. Greenberg, Dawn B. Davis, Haggi Mazeh, Guilherme M. Campos The video presents technical steps for Laparoscopic Reversal of Roux-en-Y Gastric Bypass (RYGB) to normal anatomy, and results of pre and post-op metabolic testing. The patient underwent RYGB at another institution (BMI 46). Two years after RYGB (BMI 25), presented with recalcitrant hyperinsulinemic hypoglycemia episodes and hypoglycemia unawareness. A laparoscopic gastrostomy was placed in the excluded stomach. A meal test (MT) administered orally and through the gastrostomy showed altered insulin and glycemic responses through the RYGB. Laparoscopic reversal was performed. Patient symptoms subsided; and 6 months later (BMI 29), a MT showed normal insulin and glycemic profiles. 524 Transanal NOTES Sigmoidectomy in a Cadaver Model Ezra N. Teitelbaum, Fahd O. Arafat, Byron F. Santos, Eric S. Hungness, Anne M. Boller This video shows a transanal hybrid natural orifice transluminal endoscopic surgery (NOTES) sigmoidectomy performed in a cadaver model using a TEM proctoscope. We employ a combined laparoscopic and endoscopic technique to place a stapler anvil in the proximal colon prior to initiation of colon dissection. This allows for a completely intra-corporeal anastomosis to be performed without the need for colon exteriorization. Techniques for occluding the rectal lumen with a purse-string suture, performing a full thickness dissection at the rectosigmoid junction, and creating a colorectal anastomosis through the TEM proctoscope are also shown.
528a Quality Assessment in Pancreatic Surgery: What Might Tomorrow Require? Brian T. Kalish, Charles M. Vollmer, Tara S. Kent, William H. Nealon, Jennifer F. Tseng, Mark P. Callery INTRODUCTION: The Institute of Medicine (IOM) defines healthcare quality across six domains: safety, timeliness, effectiveness, patient centeredness, efficiency, and equitability. Traditional quality metrics in high-acuity surgery (volume and mortality) cannot alone measure or satisfy these domains. We asked experts in pancreatic surgery (PS) whether broader quality metrics are needed, how important they might be, and whether they align to contemporary IOM healthcare quality domains. METHODS: Together with a professional market research firm, we created and distributed a web-based survey to pancreatic surgeons. These experts were identified through PS specialty societies, and verified by survey demographics. Respondents (Rpds) ranked 62 proposed PS quality metrics on level of importance (LoI). Next, Rpds aligned each metric to one or more IOM quality domains (MDA, multidomain alignment). Descriptive statistics were used to summarize responses. To calculate and rank relative quality scores, points were awarded for LoI (4-Essential, 3-Very important, 2-Somewhat important, 1-A Little important, 0-Not important) and MDA (1 point/each aligned domain). LoI Scores and MDA Scores for a given quality metric were averaged together to render a Total Quality Score (TQS=LoI + MDA/2) normalized to a 100-point scale. RESULTS: 106 surgeons (21%) completed the survey (82% North America and 84% Academic). On average, Rpds and their institutions perform 43 and 114 pancreatic operations per year, respectively. By descriptive analysis, 90% of Rpds indicated a definite or probable need for improved quality metrics in PS. 81% of Rpds indicated a definite or probable value for a “Quality Scorecard” in PS. Of 13 PS quality metrics rated as Essential by >25% Rpds, 10 aligned most strongly to the IOM Safety domain. 22/62 proposed metrics aligned to more than 1.75 IOM Domains, and were rated by >50% Rpds as High LoI (Essential or Very Important; Figure). 12 proposed scorecard metrics (Table) emerged with the highest TQS. Those related to mortality, to the rate and severity of complications, and to access to multidisciplinary services for pancreatic disease had the highest TQS. Technical and perioperative metrics had intermediate TQS. Metrics related to patient satisfaction with care, costs of care, and patient demographics had the lowest TQS. The least represented IOM domains were equitability, efficiency, and patient-centeredness. CONCLUSIONS: We propose a 12-item "Quality Scorecard" for PS based on rank-scoring of quality metrics that PS experts view as both highly important and aligned with more than one IOM healthcare quality domain. While the actual performance thresholds for these metrics require further definition and validation, they may reveal quality to an extent that volume and mortality alone cannot. Top Pancreatic Surgery “Quality Scorecard” Metrics by Total Quality Score (TQS)
525 Robotic-Assisted Transduodenal Resection of Ampullary Tumor With Bile and Pancreatic Duct Reconstruction John Prodromo, Mehmet F. Can, Jennifer R. Bonfili, Dev Patel, Herbert Zeh, A. James Moser
SSAT Abstracts
A 75 year old woman presented with recurrent pancreatitis and endoscopic evidence of a duodenal papillary mass that did not show high grade dysplasia extending up the common bile duct. Follow up after endoscopic ampullectomy demonstrated recurrence of the lesion. The adenoma was then resected using a robotic-assisted transduodenal approach with bile and pancreatic duct reconstruction. This case demonstrates the ability to establish precise excisional margins and to remove lesions that cannot be resected endoscopically via the use of robotic assistance. This method demonstrates an alternative option to avoid the morbidity associated with pancreaticoduodenectomy for benign lesions. 526 Per-Oral Endoscopic Myotomy (POEM): Techniques for Successful Submucosal Dissection Eric M. Pauli, Jeffrey M. Marks, Jeffrey L. Ponsky Recently, a new endoscopic method for reducing lower esophageal sphincter pressure in achalasia patients, per-oral endoscopic myotomy (POEM), has been developed. The most difficult part of POEM is the submucosal dissection, which spatially separates the mucosa and the musculature and provides an intact tissue plane for secure esophageal closure. The purpose of this video is to review six technical pearls identified over our series of POEM patients that permit successful, reproducible creation of the submucosal tunnel. 527 Thoracoscopic Esophageal Leiomyoma Enucleation Jason F. Richardson, Ninh T. Nguyen This is a video presentation of a patient who was incidentally found to have an esophageal mass. EUS revealed a 25 x 14mm hypoechoic submucosal lesion at 28-30cm arising from the muscularis propria with normal overlying mucosa and no obvious nodal involvement. FNA demonstrated spindle cells. A thoracoscopic enucleation was performed and is featured in this video. Final path was consistent with leiomyoma. Port positioning, endoscopy, esophageal mobilization, mass enucleation, and muscular layer reapproximation are featured in this video. 528 Is Routine Intraoperative Cholangiogram Necessary in the 21st Century? a National View Elizaveta Ragulin-Coyne, Elan R. Witkowski, Zeling Chau, Sing Chau Ng, Heena P. Santry, Mark P. Callery, Shimul A. Shah, Jennifer F. Tseng INTRODUCTION:Intraoperative cholangiogram (IOC) can define biliary ductal anatomy. Routine IOC has been proposed previously. However, as the “critical view of safety” technique has become widespread, current practice and outcomes of IOC are unclear. METHODS: Nationwide Inpatient Sample 2004-2009 was queried for patients with acute/urgent biliary disease undergoing laparoscopic and/or open cholecystectomy; IOC was quantified. We limited analyses to states with consistent coding of provider and hospital ID data, and
SSAT Abstracts
S-1028