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592 Laparoscopic Transhiatal Esophagectomy With Retrograde Extraction
LSG, refractory to aggressive PPI therapy, received off label placement of a magnetic sphincter augmentation device. Placement of this magnetic sphincter resolved GERD symptoms, suggesting a feasible and safe surgical option. Technique presented as follows.
708 The Impact of Hepaticojejunostomy Anastomotic Leaks After Pancreatoduodenectomy: An Uncommon Complication but a Devastating Source of Morbidity and Mortality Andrea Jester, Catherine Chung, david becerra, E M. Kilbane, Michael G. House, Nicholas J. Zyromski, C. Max Schmidt, Attila Nakeeb, Eugene P. Ceppa
589 Laparoscopic Epiphrenic Diverticulectomy, Heller Myotomy, and Dor Fundoplication for a Giant Epiphrenic Diverticulum Rebecca G. Lopez, Mihir M. Shah, Benjamin M. Martin, Jamil L. Stetler, Ankit Patel, Jahnavi Srinivasan, John Sweeney, S. Scott Davis, Edward Lin
Purpose: Pancreaticojejunostomy (PJ) leak is a common source of major morbidity after pancreatoduodenectomy (PD). Isolated hepaticojejunostomy leaks (HJ) are less frequent after PD and not well studied. The purpose of this study was to determine if isolated HJ leaks or the combination of PJ + HJ leaks result in worse postoperative outcomes when compared to no leak or isolated PJ leaks. Methods: Consecutive cases of PD (n=924) were reviewed at a single high-volume institution over an 8-year period (November 2006-October 2014). Ninety-day outcomes were monitored through a prospectively maintained database. A retrospective analysis was performed to determine if there were statistically significant differences in patients with no leak, isolated PJ leak, isolated HJ leak, or combined PJ + HJ leaks. Results: PJ leaks were identified in 268 out of 924 patients (29%); 169 grade A (63%), 64 grade B (23%), and 32 grade C (12%). Isolated HJ leaks were identified in 23 out of 924 PD patients (2.5%), and PJ + HJ leaks were identified in 32 patients (3.5%). Demographics including age, gender and ASA were similar between the 4 groups. Those with HJ leaks or PJ + HJ leaks had a significantly increased risk of 90-day all cause morbidity when compared to those with isolated PJ leaks (56% and 59% vs. 34 %, respectively, p = 0.04). Those with no leak experienced significantly less morbidity (23 %, p = 0.01). Isolated HJ and PJ + HJ leaks were associated with a significantly increased risk of unplanned re-intubation, prolonged ventilator times, septic shock, and renal failure. The median length of stay was longer for isolated HJ and PJ + HJ leaks when compared to isolated PJ leaks and no leak (18 and 21 days vs. 11 and 8 days, p = 0.01). The need for re-operation was significantly increased in the isolated HJ and PJ + HJ groups when compared to the isolated PJ leak and no leak groups (22 and 21.7 % vs. 7.8 and 4.5 %, respectively, p = 0.001). Re-admission rates were similar amongst the PJ, HJ and PJ + HJ leak groups (25, 28 and 31 %, respectively, p = 0.8), but were higher than the no leak group (14 %, p = 0.02). Overall 30-day mortality was 3.6 %. Isolated HJ leaks and PJ + HJ leaks were associated with higher 30-day mortality rates compared to those with isolated PJ leaks or no leak (13 and 12.5 % vs. 4.5 and 2.7 %, p = 0.04 and 0.02, respectively). Conclusions: Leaks associated with the hepaticojejunostomy anastomosis after pancreatoduodenectomy result in significant risk for postoperative morbidity and mortality. Morbidity and mortality after pancreatoduodenectomy: No leak vs. PJ leak vs. HJ leak vs. PJ + HJ leak
This video demonstrates techniques used to successfully dissect a large epiphrenic diverticulum out of the mediastinum. This diverticulum was found to be densely adherent to the left pleura. With the use of an additional penrose drain around the diverticulum for traction and meticulous blunt and thermal dissection, soft tissue attachments were more easily visualized and dissected, allowing for successful excision of this large esophageal diverticulum. Subsequently, a Heller myotomy and Dor fundoplication were performed to complete the operation for resection of this large epiphrenic diverticulum.
590 Circumferential Long Segment Esophageal ESD for Intramucosal Esophageal Cancer in a Background of Barrett's: Oncologic Outcomes vs Postoperative Stricture Ahmed Sharata, Keerti Pally, Ashwin A. Kurian We present a 59 year old male with multifocal esophageal intramucosal cancer in a background of Barrett's esophagus. He underwent a long segment circumferential esophageal mucosal resection. A biologic matrix was applied to the intraluminal aspect of the esophagus post-resection to aid epithelialization reduce structuring. Patients should to be counseled on the need for multiple endoscopic procedures and close oncologic follow up postoperatively. Multiple modalities including antireflux surgery may be required in the management of strictures that develop in the postoperative period.
591 Treating Complete Occlusion of the Esophagogastric Anastomosis After Transhiatal Esophagectomy - A Laparoscopic-Assisted Double-Endoscopy Technique Edward Chau, Nikolai Bildzukewicz, John Lipham
592
* denotes p < 0.05 no leak; # denotes p < 0.05 PJ leak
Laparoscopic Transhiatal Esophagectomy With Retrograde Extraction Wendy Jo Svetanoff, Shunsuke Akimoto, Sumeet Mittal
709
A subset of patients present with end stage esophageal disease, where the only option is an esophageal resection. These patients usually are in poor condition due to weight loss and/ or recurrent aspiration. Transhiatal resection may be the preferred option in these situations to decrease morbidity. We present a case of a laparoscopic transhiatal resection performed with a trans-oral tube assisted inversion esophagectomy followed by a gastric pull-up. Additionally, a Foley catheter was used to dilate the mediastinal tract and pull up the gastric conduit. We believe this technique minimizes peri-operative morbidity and may be feasible in most benign conditions requiring esophageal resection.
The Prognostic Value of Lymph Node Status and Extent of Lymphadenectomy in Pancreatic Neuroendocrine Tumors Confined to and Extending Beyond the Pancreas Onur Kutlu, Jeffrey E. Lee, Jean-Nicolas Vauthey, David Adams, Michael P. Kim, Jason B. Fleming, Matthew H. Katz, Claudius Conrad Background: Evidence regarding the impact of lymph node status and the value of extended lymphadenectomy (LA) in predicting survival is controversial in pancreatic neuroendocrine tumors (pNET). We aim to identify the impact of tumor extension, grade and location on nodal metastasis, disease specific (DSS) and overall survival (OS). Methods: The SEER database was queried for patients with histologically proven pNET who underwent surgery from 1998-2012. Patients with unknown grade, T-, M-stage; or with M1-status, multifocal pNET, < 1-month follow-up, or no survival data were excluded. Binary logistic regression was performed for factors associated with nodal status. Kaplan Meier survival analyses were performed to assess the impact of T-stage, grade and nodal status on DSS and OS, and Cox analyses performed for independent predictors of DSS and OS. Patients without defined lymph node status were categorized as Nx (n=165, 16.8%); extended LA was defined ‡10 lymph nodes harvested (n=406, 41.4%). To assess the impact of N-status on DSS and OS, Nx vs. N0 vs. N1 was compared in two T-stage groups (T1-T2 and T3-T4). Further, for these T-stage groups, patients who had < vs. ‡ 10 nodes dissected were compared for the impact of extended LA. Results: 981 of 5349 patients fit the inclusion criteria. For T1-T2 tumors, N-status was affected only by tumor size; age, sex, location, and grade did not impact N-status. For T3-T4 tumors, neither age, grade, sex, location nor size impacted Nstatus. For T1-T2 tumors, Cox analyses showed that N status (p=0.001), grade (p<0.001), age (p=0.001) and sex (p=0.007) were associated with OS, while tumor size (p=0.260) and location (p=0.331) were not. For T3-T4 tumors, grade (p<0.001), sex (p=0.004), tumor size (p=0.013) and age (p=0.007) impacted OS; N-status did not impact OS(p=0.789;Table). Specifically, for T1-T2 tumors, OS(p=0.008) and DSS(p=0.003) were longer for N0 vs. N1 tumors, while N0 vs. Nx patients had similar OS (p=0.59) and DSS (p=0.80). Nx compared to N1 status showed a trend to improved OS(p=0.08) and improved DSS(p=0.04). For T3T4 patients, N-status did not affect OS(p=0.454) or DSS(p=0.365). For all T-groups and any N-status, extended LA was not associated with an improved survival (Figure). Conclusion: For pNETs confined to the pancreas (T1-T2), N1-status is a significant predictor of poor
593 Laparoscopic Hiatal Hernia Repair After Minimally-Invasive Ivor-Lewis Esophagectomy Vladimir P. Daoud, Gina Adrales This is a 69-year old female with esophageal cancer s/p minimally-invasive Ivor-Lewis esophagectomy and subsequent laparoscopic ventral hernia repair with mesh who presented with post-prandial chest pain. Workup revealed a diaphragmatic hernia containing transverse colon. In the video presented, the gastric conduit is noted to be in the chest, with adhesions to both the left and right crus. There is a defect to the left of the stomach. The crura were dissected. The conduit was mobilized and controlled with a penrose drain. The posterior crural closure was accomplished with pledgeted, non-absorbable suture. The anterolateral diaphragmatic defect was closed with the same.
S-1187
X : 10052$CH03 03-28-16 22:41:04 PDFd : 10052B : o
Page 1187
SSAT Abstracts
SSAT Abstracts
Anastomotic complications at the esophago-gastrostomy after esophagectomy are not uncommon, but complete occlusion developing in a delayed fashion poses a rare and complex problem. The surgical team devised a combined laparoscopic and double-endoscopy approach that would allow visualization of the occlusion from both sides of the anastmosis to allow for safe access, dilation, and stent placement under direct vision, with the option of surgical revision if any complications were to occur during the therapeutic lap-assisted endoscopy. The results have been durable thus far and the technique is presented here.
708 The Impact of Hepaticojejunostomy Anastomotic Leaks After Pancreatoduodenectomy: An Uncommon Complication but a Devastating Source of Morbidity and Mortality Andrea Jester, Catherine Chung, david becerra, E M. Kilbane, Michael G. House, Nicholas J. Zyromski, C. Max Schmidt, Attila Nakeeb, Eugene P. Ceppa
589 Laparoscopic Epiphrenic Diverticulectomy, Heller Myotomy, and Dor Fundoplication for a Giant Epiphrenic Diverticulum Rebecca G. Lopez, Mihir M. Shah, Benjamin M. Martin, Jamil L. Stetler, Ankit Patel, Jahnavi Srinivasan, John Sweeney, S. Scott Davis, Edward Lin
Purpose: Pancreaticojejunostomy (PJ) leak is a common source of major morbidity after pancreatoduodenectomy (PD). Isolated hepaticojejunostomy leaks (HJ) are less frequent after PD and not well studied. The purpose of this study was to determine if isolated HJ leaks or the combination of PJ + HJ leaks result in worse postoperative outcomes when compared to no leak or isolated PJ leaks. Methods: Consecutive cases of PD (n=924) were reviewed at a single high-volume institution over an 8-year period (November 2006-October 2014). Ninety-day outcomes were monitored through a prospectively maintained database. A retrospective analysis was performed to determine if there were statistically significant differences in patients with no leak, isolated PJ leak, isolated HJ leak, or combined PJ + HJ leaks. Results: PJ leaks were identified in 268 out of 924 patients (29%); 169 grade A (63%), 64 grade B (23%), and 32 grade C (12%). Isolated HJ leaks were identified in 23 out of 924 PD patients (2.5%), and PJ + HJ leaks were identified in 32 patients (3.5%). Demographics including age, gender and ASA were similar between the 4 groups. Those with HJ leaks or PJ + HJ leaks had a significantly increased risk of 90-day all cause morbidity when compared to those with isolated PJ leaks (56% and 59% vs. 34 %, respectively, p = 0.04). Those with no leak experienced significantly less morbidity (23 %, p = 0.01). Isolated HJ and PJ + HJ leaks were associated with a significantly increased risk of unplanned re-intubation, prolonged ventilator times, septic shock, and renal failure. The median length of stay was longer for isolated HJ and PJ + HJ leaks when compared to isolated PJ leaks and no leak (18 and 21 days vs. 11 and 8 days, p = 0.01). The need for re-operation was significantly increased in the isolated HJ and PJ + HJ groups when compared to the isolated PJ leak and no leak groups (22 and 21.7 % vs. 7.8 and 4.5 %, respectively, p = 0.001). Re-admission rates were similar amongst the PJ, HJ and PJ + HJ leak groups (25, 28 and 31 %, respectively, p = 0.8), but were higher than the no leak group (14 %, p = 0.02). Overall 30-day mortality was 3.6 %. Isolated HJ leaks and PJ + HJ leaks were associated with higher 30-day mortality rates compared to those with isolated PJ leaks or no leak (13 and 12.5 % vs. 4.5 and 2.7 %, p = 0.04 and 0.02, respectively). Conclusions: Leaks associated with the hepaticojejunostomy anastomosis after pancreatoduodenectomy result in significant risk for postoperative morbidity and mortality. Morbidity and mortality after pancreatoduodenectomy: No leak vs. PJ leak vs. HJ leak vs. PJ + HJ leak
This video demonstrates techniques used to successfully dissect a large epiphrenic diverticulum out of the mediastinum. This diverticulum was found to be densely adherent to the left pleura. With the use of an additional penrose drain around the diverticulum for traction and meticulous blunt and thermal dissection, soft tissue attachments were more easily visualized and dissected, allowing for successful excision of this large esophageal diverticulum. Subsequently, a Heller myotomy and Dor fundoplication were performed to complete the operation for resection of this large epiphrenic diverticulum.
590 Circumferential Long Segment Esophageal ESD for Intramucosal Esophageal Cancer in a Background of Barrett's: Oncologic Outcomes vs Postoperative Stricture Ahmed Sharata, Keerti Pally, Ashwin A. Kurian We present a 59 year old male with multifocal esophageal intramucosal cancer in a background of Barrett's esophagus. He underwent a long segment circumferential esophageal mucosal resection. A biologic matrix was applied to the intraluminal aspect of the esophagus post-resection to aid epithelialization reduce structuring. Patients should to be counseled on the need for multiple endoscopic procedures and close oncologic follow up postoperatively. Multiple modalities including antireflux surgery may be required in the management of strictures that develop in the postoperative period.
591 Treating Complete Occlusion of the Esophagogastric Anastomosis After Transhiatal Esophagectomy - A Laparoscopic-Assisted Double-Endoscopy Technique Edward Chau, Nikolai Bildzukewicz, John Lipham
592
* denotes p < 0.05 no leak; # denotes p < 0.05 PJ leak
Laparoscopic Transhiatal Esophagectomy With Retrograde Extraction Wendy Jo Svetanoff, Shunsuke Akimoto, Sumeet Mittal
709
A subset of patients present with end stage esophageal disease, where the only option is an esophageal resection. These patients usually are in poor condition due to weight loss and/ or recurrent aspiration. Transhiatal resection may be the preferred option in these situations to decrease morbidity. We present a case of a laparoscopic transhiatal resection performed with a trans-oral tube assisted inversion esophagectomy followed by a gastric pull-up. Additionally, a Foley catheter was used to dilate the mediastinal tract and pull up the gastric conduit. We believe this technique minimizes peri-operative morbidity and may be feasible in most benign conditions requiring esophageal resection.
The Prognostic Value of Lymph Node Status and Extent of Lymphadenectomy in Pancreatic Neuroendocrine Tumors Confined to and Extending Beyond the Pancreas Onur Kutlu, Jeffrey E. Lee, Jean-Nicolas Vauthey, David Adams, Michael P. Kim, Jason B. Fleming, Matthew H. Katz, Claudius Conrad Background: Evidence regarding the impact of lymph node status and the value of extended lymphadenectomy (LA) in predicting survival is controversial in pancreatic neuroendocrine tumors (pNET). We aim to identify the impact of tumor extension, grade and location on nodal metastasis, disease specific (DSS) and overall survival (OS). Methods: The SEER database was queried for patients with histologically proven pNET who underwent surgery from 1998-2012. Patients with unknown grade, T-, M-stage; or with M1-status, multifocal pNET, < 1-month follow-up, or no survival data were excluded. Binary logistic regression was performed for factors associated with nodal status. Kaplan Meier survival analyses were performed to assess the impact of T-stage, grade and nodal status on DSS and OS, and Cox analyses performed for independent predictors of DSS and OS. Patients without defined lymph node status were categorized as Nx (n=165, 16.8%); extended LA was defined ‡10 lymph nodes harvested (n=406, 41.4%). To assess the impact of N-status on DSS and OS, Nx vs. N0 vs. N1 was compared in two T-stage groups (T1-T2 and T3-T4). Further, for these T-stage groups, patients who had < vs. ‡ 10 nodes dissected were compared for the impact of extended LA. Results: 981 of 5349 patients fit the inclusion criteria. For T1-T2 tumors, N-status was affected only by tumor size; age, sex, location, and grade did not impact N-status. For T3-T4 tumors, neither age, grade, sex, location nor size impacted Nstatus. For T1-T2 tumors, Cox analyses showed that N status (p=0.001), grade (p<0.001), age (p=0.001) and sex (p=0.007) were associated with OS, while tumor size (p=0.260) and location (p=0.331) were not. For T3-T4 tumors, grade (p<0.001), sex (p=0.004), tumor size (p=0.013) and age (p=0.007) impacted OS; N-status did not impact OS(p=0.789;Table). Specifically, for T1-T2 tumors, OS(p=0.008) and DSS(p=0.003) were longer for N0 vs. N1 tumors, while N0 vs. Nx patients had similar OS (p=0.59) and DSS (p=0.80). Nx compared to N1 status showed a trend to improved OS(p=0.08) and improved DSS(p=0.04). For T3T4 patients, N-status did not affect OS(p=0.454) or DSS(p=0.365). For all T-groups and any N-status, extended LA was not associated with an improved survival (Figure). Conclusion: For pNETs confined to the pancreas (T1-T2), N1-status is a significant predictor of poor
593 Laparoscopic Hiatal Hernia Repair After Minimally-Invasive Ivor-Lewis Esophagectomy Vladimir P. Daoud, Gina Adrales This is a 69-year old female with esophageal cancer s/p minimally-invasive Ivor-Lewis esophagectomy and subsequent laparoscopic ventral hernia repair with mesh who presented with post-prandial chest pain. Workup revealed a diaphragmatic hernia containing transverse colon. In the video presented, the gastric conduit is noted to be in the chest, with adhesions to both the left and right crus. There is a defect to the left of the stomach. The crura were dissected. The conduit was mobilized and controlled with a penrose drain. The posterior crural closure was accomplished with pledgeted, non-absorbable suture. The anterolateral diaphragmatic defect was closed with the same.
S-1187
X : 10052$CH03 03-28-16 22:41:04 PDFd : 10052B : o
Page 1187
SSAT Abstracts
SSAT Abstracts
Anastomotic complications at the esophago-gastrostomy after esophagectomy are not uncommon, but complete occlusion developing in a delayed fashion poses a rare and complex problem. The surgical team devised a combined laparoscopic and double-endoscopy approach that would allow visualization of the occlusion from both sides of the anastmosis to allow for safe access, dilation, and stent placement under direct vision, with the option of surgical revision if any complications were to occur during the therapeutic lap-assisted endoscopy. The results have been durable thus far and the technique is presented here.