- Email: [email protected]
619 The Significance of Signet Ring Cell Histology in Early Esophageal Adenocarcinoma
530
in diagnosis and symptom correlation. This variability should be taken into consideration by clinicians when evaluating impedance results.
Robotic Heller Myotomy and Dor Fundoplication With Real-Time Functional Lumen Imaging Probe Hassanain Jassim, Jon Gould Achalasia is a well-known, but rare esophageal motility disorder caused by aperistalsis of the esophageal body and a failure of relaxation of the lower esophageal sphincter. We present a case of a 68 year old female who underwent a robotic Heller Myotomy with Dor Fundoplication. In addition, real-time esophageal distensibility was recorded using a functional lumen imaging probe at three time points: pre-myotomy, post-myotomy, and post-fundoplication. The video demonstrates key points in the operation, as well as realtime images from the imaging probe and intraoperative endoscopy. Lastly, data from our small series of three patients is graphically illustrated. 531 Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome Hugh G. Auchincloss, Peter J. Fagenholz, Ozanan Meireles A 21 year-old man presented with abdominal pain, vomiting and jaundice occurring 4 months after a motor vehicle accident that had left him a C6 paraplegic. In the interim he had lost 40lbs and now had a BMI of 19. On exam his abdomen was distended. His jaundice resolved with nasogastric decompression. CT scan demonstrated dilation of the stomach and proximal duodenum with a transition point at the crossing of the superior mesenteric artery. The SMA formed a 25 degree angle with the aorta, consistent with SMA syndrome. He was brought to the operating room for a laparoscopic duodenojejunostomy. His postoperative course was unremarkable and he was able to return to spinal cord rehabilitation.
618 Laparoscopic Revision Fundoplication of Transoral Fundoplication Reginald Bell Transoral fundoplication creates a full-thickness fusion of the distal esophagus to the fundus using small H-shaped polypropylene fasteners. With laparoscopic revision surgery there is potential for leak related to the treatment of these full-thickness fasteners. There have been reports that laparoscopic revision of a TF is associated with complications of postoperative leak and abscess. These complications a due to tension on or difficulties treating the fasteners, or unfamiliarity with the surgical changes of TF. This video illustrates a systematic approach to laparoscopic revision that has been used in over 25 procedures without any adverse outcome.
532 Turnbull-Cutait Pull Through for Recto-Vaginal Fistula Joseph Garvin, Jean Ashburn, Feza H. Remzi
619
This video demonstrates the utility of the Turnbull-Cutait abdominoperineal colonic pull through in the management of a complex recto-vaginal fistula. The patient presented with a fistula having previously undergone a low anterior resection for rectal cancer with preoperative chemoradiotherapy. A symptomatic vaginal fistula developed following closure of defunctioning ileostomy. We demonstrate the techniques used in this procedure including colonic mobilization, excision of phlegmon, mucosectomy, excision of scar tissue, staged placement of the anal sutures, tissue placement in order to prevent recurrence and acceptance of a degree of ectropion in order to prevent retraction and stricture.
The Significance of Signet Ring Cell Histology in Early Esophageal Adenocarcinoma Stephanie G. Worrell, Steven R. DeMeester, Joseph D. Dixon, Christina L. Greene, Daniel S. Oh, Jeffrey A. Hagen Background: Signet ring cell (SRC) histology is thought to confer a worse prognosis for gastric and esophageal cancers and the appropriateness of endoscopic therapy for superficial adenocarcinoma of the esophagus with SRC histology is controversial. Our aim was to evaluate the impact of SRC histology on lymph node metastasis and survival in patients with early esophageal adenocarcinoma. Methods: A retrospective chart review was performed of all patients with esophageal or gastroesophageal junction adenocarcinoma who underwent primary esophagectomy for a pT1-2 tumor that was ≤5cm in size from 4/1990 to 5/2012. Patient characteristics and survival were compared based on the presence or absence of SRC histology. Results: There were 200 patients that met inclusion criteria, 16 (8%) had SRC histology and 184 were non-SRC. Esophagectomy consisted of en bloc transthoracic (n=98), transhiatal (n=64), or vagal-sparing (n=38). There was no difference in type of esophagectomy between groups. Patient demographics, tumor characteristics, and survival are compared in the Table. Patients with SRC were younger and more likely to have involved nodes. All 4 patients with pT1a SRC tumors were N0 compared to 97 of 99 patients (98%) with nonSRC histology. In patients with T1b or T2 lesions, those with SRC histology were more likely to have lymph node metastases [7/12 (58%) for SRC versus 26/85 (31%) for nonSRC, p=0.09]. In addition, T1b or T2 patients with SRC histology were more likely to have N2-3 disease (SRC 58% versus 15% for non-SRC, p=0.002). Overall 5 year and disease specific survival were equivalent between groups. Conclusions: Intramucosal (T1a) adenocarcinoma with or without SRC histology has a low risk of lymph node metastases and endoscopic resection can be considered in these patients. However, deeper invasion with SRC histology was associated with a significantly increased risk of lymph node metastases compared to similar invasion without SRC histology. Further, patients with SRC histology were more likely to have multiple (N2-3) involved nodes. Neoadjuvant therapy prior to surgical resection is recommended for T1b or deeper lesions that show SRC histology.
533
SSAT Abstracts
Arterial Approach Distal Pancreatectomy Yi Miao Survival outcome after standard distal pancreatectomy (DP) for left-sided pancreatic adenocarcinoma is poor, which may be attribute to both the disease nature and the surgical procedure. Accordingly, several efforts could be taken to deal with this problem. One of our practice is to adopt an arterial approach for DP, which emphasize the dissection of superior mesenteric artery (SMA) and celiac trunk (CT) in the early stage of the procedure, and also deepens the retroperitoneal dissection plane beyond the Gerota fascia. Our technique could provide the best chance to achieve a negative margin and lymph node clearance after DP, hence improving the survival of the patients. 617 More Art Than Science: Impedance Analysis Prone to Interpretation Error Thomas Ciecierega, Benjamin L. Gordon, Anna Aronova, Carl V. Crawford, Rasa Zarnegar Background: Esophageal pH monitoring is the gold standard for diagnosis of acid reflux, and with the advent of the DeMeester score interpretation can be made with relative ease. However, impedance monitoring to evaluate for all reflux does not have a standardized scale, which can confound interpretation between observers. We aim to determine the interobserver variability of 24-hour impedance testing interpretations between physicians and computer software. Methods: Thirty-eight patients that underwent 24-hour impedance monitoring at a tertiary referral center were randomly selected between 2008 and 2013. Two physicians, who routinely use impedance testing, each interpreted raw impedance data generated by the Given Imaging Digitrapper pH-Z Monitoring Test for the same patient cohort. These interpretations were then compared to the computer interpretation of the same cohort. Normalized reflux episode activity (NREA) and reflux symptom association probability were evaluated to determine diagnostic accuracy. Results: NREA interpretations did not significantly differ between each physician and the computer for Total Acid Reflux (p=0.17) or for Total Nonacid Reflux (p=0.21). However, Physician 2 interpreted the number of Total Weakly Acidic Reflux episodes significantly differently than Physician 1 (p=0.0001) and the computer (p=0.006), whereas Physician 1's interpretations where not significantly different from the computer. In analyzing Total All Reflux episodes, Physician 1 and Physician 2 significantly differed from each other (p=0.008) but did not differ when compared to the computer. The variability in analysis of NREA lead to a change in diagnostic management in 21% of patients when comparing computer analysis versus physician. Moreover, 12% of patients had a change in management when comparing between physicians. Finally, the correlation between symptoms differed in 3% of physician-physician interpretations versus 10% of computer-physician interpretations. Conclusion: Impedance testing analysis is subject to marked variability between physicians and computer software. As such, unlike the finite score for pH monitoring, impedance is prone to interpretation error leading to differences
SSAT Abstracts
S-1022
in diagnosis and symptom correlation. This variability should be taken into consideration by clinicians when evaluating impedance results.
Robotic Heller Myotomy and Dor Fundoplication With Real-Time Functional Lumen Imaging Probe Hassanain Jassim, Jon Gould Achalasia is a well-known, but rare esophageal motility disorder caused by aperistalsis of the esophageal body and a failure of relaxation of the lower esophageal sphincter. We present a case of a 68 year old female who underwent a robotic Heller Myotomy with Dor Fundoplication. In addition, real-time esophageal distensibility was recorded using a functional lumen imaging probe at three time points: pre-myotomy, post-myotomy, and post-fundoplication. The video demonstrates key points in the operation, as well as realtime images from the imaging probe and intraoperative endoscopy. Lastly, data from our small series of three patients is graphically illustrated. 531 Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome Hugh G. Auchincloss, Peter J. Fagenholz, Ozanan Meireles A 21 year-old man presented with abdominal pain, vomiting and jaundice occurring 4 months after a motor vehicle accident that had left him a C6 paraplegic. In the interim he had lost 40lbs and now had a BMI of 19. On exam his abdomen was distended. His jaundice resolved with nasogastric decompression. CT scan demonstrated dilation of the stomach and proximal duodenum with a transition point at the crossing of the superior mesenteric artery. The SMA formed a 25 degree angle with the aorta, consistent with SMA syndrome. He was brought to the operating room for a laparoscopic duodenojejunostomy. His postoperative course was unremarkable and he was able to return to spinal cord rehabilitation.
618 Laparoscopic Revision Fundoplication of Transoral Fundoplication Reginald Bell Transoral fundoplication creates a full-thickness fusion of the distal esophagus to the fundus using small H-shaped polypropylene fasteners. With laparoscopic revision surgery there is potential for leak related to the treatment of these full-thickness fasteners. There have been reports that laparoscopic revision of a TF is associated with complications of postoperative leak and abscess. These complications a due to tension on or difficulties treating the fasteners, or unfamiliarity with the surgical changes of TF. This video illustrates a systematic approach to laparoscopic revision that has been used in over 25 procedures without any adverse outcome.
532 Turnbull-Cutait Pull Through for Recto-Vaginal Fistula Joseph Garvin, Jean Ashburn, Feza H. Remzi
619
This video demonstrates the utility of the Turnbull-Cutait abdominoperineal colonic pull through in the management of a complex recto-vaginal fistula. The patient presented with a fistula having previously undergone a low anterior resection for rectal cancer with preoperative chemoradiotherapy. A symptomatic vaginal fistula developed following closure of defunctioning ileostomy. We demonstrate the techniques used in this procedure including colonic mobilization, excision of phlegmon, mucosectomy, excision of scar tissue, staged placement of the anal sutures, tissue placement in order to prevent recurrence and acceptance of a degree of ectropion in order to prevent retraction and stricture.
The Significance of Signet Ring Cell Histology in Early Esophageal Adenocarcinoma Stephanie G. Worrell, Steven R. DeMeester, Joseph D. Dixon, Christina L. Greene, Daniel S. Oh, Jeffrey A. Hagen Background: Signet ring cell (SRC) histology is thought to confer a worse prognosis for gastric and esophageal cancers and the appropriateness of endoscopic therapy for superficial adenocarcinoma of the esophagus with SRC histology is controversial. Our aim was to evaluate the impact of SRC histology on lymph node metastasis and survival in patients with early esophageal adenocarcinoma. Methods: A retrospective chart review was performed of all patients with esophageal or gastroesophageal junction adenocarcinoma who underwent primary esophagectomy for a pT1-2 tumor that was ≤5cm in size from 4/1990 to 5/2012. Patient characteristics and survival were compared based on the presence or absence of SRC histology. Results: There were 200 patients that met inclusion criteria, 16 (8%) had SRC histology and 184 were non-SRC. Esophagectomy consisted of en bloc transthoracic (n=98), transhiatal (n=64), or vagal-sparing (n=38). There was no difference in type of esophagectomy between groups. Patient demographics, tumor characteristics, and survival are compared in the Table. Patients with SRC were younger and more likely to have involved nodes. All 4 patients with pT1a SRC tumors were N0 compared to 97 of 99 patients (98%) with nonSRC histology. In patients with T1b or T2 lesions, those with SRC histology were more likely to have lymph node metastases [7/12 (58%) for SRC versus 26/85 (31%) for nonSRC, p=0.09]. In addition, T1b or T2 patients with SRC histology were more likely to have N2-3 disease (SRC 58% versus 15% for non-SRC, p=0.002). Overall 5 year and disease specific survival were equivalent between groups. Conclusions: Intramucosal (T1a) adenocarcinoma with or without SRC histology has a low risk of lymph node metastases and endoscopic resection can be considered in these patients. However, deeper invasion with SRC histology was associated with a significantly increased risk of lymph node metastases compared to similar invasion without SRC histology. Further, patients with SRC histology were more likely to have multiple (N2-3) involved nodes. Neoadjuvant therapy prior to surgical resection is recommended for T1b or deeper lesions that show SRC histology.
533
SSAT Abstracts
Arterial Approach Distal Pancreatectomy Yi Miao Survival outcome after standard distal pancreatectomy (DP) for left-sided pancreatic adenocarcinoma is poor, which may be attribute to both the disease nature and the surgical procedure. Accordingly, several efforts could be taken to deal with this problem. One of our practice is to adopt an arterial approach for DP, which emphasize the dissection of superior mesenteric artery (SMA) and celiac trunk (CT) in the early stage of the procedure, and also deepens the retroperitoneal dissection plane beyond the Gerota fascia. Our technique could provide the best chance to achieve a negative margin and lymph node clearance after DP, hence improving the survival of the patients. 617 More Art Than Science: Impedance Analysis Prone to Interpretation Error Thomas Ciecierega, Benjamin L. Gordon, Anna Aronova, Carl V. Crawford, Rasa Zarnegar Background: Esophageal pH monitoring is the gold standard for diagnosis of acid reflux, and with the advent of the DeMeester score interpretation can be made with relative ease. However, impedance monitoring to evaluate for all reflux does not have a standardized scale, which can confound interpretation between observers. We aim to determine the interobserver variability of 24-hour impedance testing interpretations between physicians and computer software. Methods: Thirty-eight patients that underwent 24-hour impedance monitoring at a tertiary referral center were randomly selected between 2008 and 2013. Two physicians, who routinely use impedance testing, each interpreted raw impedance data generated by the Given Imaging Digitrapper pH-Z Monitoring Test for the same patient cohort. These interpretations were then compared to the computer interpretation of the same cohort. Normalized reflux episode activity (NREA) and reflux symptom association probability were evaluated to determine diagnostic accuracy. Results: NREA interpretations did not significantly differ between each physician and the computer for Total Acid Reflux (p=0.17) or for Total Nonacid Reflux (p=0.21). However, Physician 2 interpreted the number of Total Weakly Acidic Reflux episodes significantly differently than Physician 1 (p=0.0001) and the computer (p=0.006), whereas Physician 1's interpretations where not significantly different from the computer. In analyzing Total All Reflux episodes, Physician 1 and Physician 2 significantly differed from each other (p=0.008) but did not differ when compared to the computer. The variability in analysis of NREA lead to a change in diagnostic management in 21% of patients when comparing computer analysis versus physician. Moreover, 12% of patients had a change in management when comparing between physicians. Finally, the correlation between symptoms differed in 3% of physician-physician interpretations versus 10% of computer-physician interpretations. Conclusion: Impedance testing analysis is subject to marked variability between physicians and computer software. As such, unlike the finite score for pH monitoring, impedance is prone to interpretation error leading to differences
SSAT Abstracts
S-1022