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Does previous botulinum toxin injection or pneumatic dilatation affect surgical outcome of laparoscopic heller myotomy?
GASTROENTEROLOGYVol. 114, No. 4
A1380 SSAT ABSTRACTS • S0031
CLINICAL AND FUNCTIONAL RESULTS OF PRIMARY LAPAROSCOPIC MYOTOMY AND ANTERIOR FUNDOPLICATION FOR ESOPHAGEAL ACHALASIA. L.Bonavina. G.Micheletto. M.Panani. L.Antoniazzi, R.Rosati. A.Se~,alin. G.Marotta. and A.Peracchia. Department of Surgery, University of Milan School of Medicine, Milan, Italy. Long-term results of Heller myotomy and Dor fundoplication have been highly satisfactory. Aim of this study was to verify whether similar results can be achieved laparoscopically. Methods. Between April 1992 and May 1997, 51 patients underwent laparoscopic myotomy and anterior fundoplication for esophageal achalasia. None of them had previously been treated either endoscopically or surgically. There were 32 females and 19 males; the median age was 37 yrs (range 9-67 ). The cardia was not mobilized except in patients with sigmoid esophagus. The myotomy was carried out for at least 5 cm on the esophagus and 1.5 cm on the gastric side. Results. The median operative time was 100 minutes (range 60-200). Postoperative complications occurred in 2 patients and consisted of bleeding from an acute gastric ulcer and from a port site, respectively. The median hospital stay was 4 days (range 3-8). After a median follow-up of 22 months (range 6-65), the mean dysphagia score decreased from 2.2 to 0.3. The mean esophageal diameter on standard barium swallow study decreased from 4.0 to 2.5 cm (p<0.04). Lower esophageal sphincter (LES) pressure decreased from 30.6 to 11.3 mmHg (p<0.0001); LES residual pressure decreased from 14.6 to 2.9 mmHg (p<0.0001). Radionuclide esophageal activity at 1 and 10 minutes decreased from 88.5% to 23.2% and from 84.2% to 9.7%, respectively (p<0.0001). Abnormal gastroesophageal reflux was documented by 24-hour esophageal pH monitoring in one patient (I/10 tested, 10%) in whom the cardia was mobilized to reduce in the abdomen a sigmoid esophagus. Conclusions. Laparoscopic myotomy combined with anterior fundoplication is a safe and effective procedure. Cardia mobilization may increase the risk of postoperative gastroesophageal reflux. S0032
DOES PREVIOUS BOTULINUM TOXIN INJECTION OR PNEUMATIC DILATATION AFFECT SURGICAL OUTCOME OF LAPAROSCOPIC HELLER MYOTOMY? L.Bonavina. R.Incarbone. M.Pa~,ani. L.Antoniazzi. A.Peracchia. Department of Surgery, University of Milan, Milan, Italy. Aim of this study was to assess surgical outcome in patients undergoing laparoscopic Heller myotomy after unsuccessful endoscopic treatment, compared to patients having primary surgery. Materials and methods. Since 1992, 75 patients with manometrically proven achalasia underwent laparoscopic myotomy and anterior fundoplication. The first twenty cases were excluded from the study as considered part of the learning curve. Dysphagia was graded as: 1-occasional, 2-once a month, 3-once a week, 4-twice a week, 5-dally. Thirty-five patients with a mean dysphagia score of 4.5 + 0.8 had primary surgery (PS), and 20 patients with a mean dysphagia score of 4.7 -+ 07 had surgery after ineffectual pneumatic dilation (PD) (n.15), or botulinum toxin injection (Botox) (u. 5). Preoperative lower esophageal sphincter pressure and residual radionuclide activity at 1 and 10 min. were similar in both groups. Operative time, intraoperative complications, postoperative symptoms, and results of esophageal manometry and transit scintigraphy were compared. Results. There were no conversions to open procedure. Median operative time was 100 - 44 min. in patients having PS, versus 110 -+ 34 min. in the PD and Botox group. There was 1 intraoperative mucosal tear in the PS group (3%) compared to 3 tears in the PD group and 1 in the Botox group (20%). All tears were treated laparoscopically. Median follow-up was 23 months (range 1-44). Four patients of the PS group (12%) complained postoperative dysphagia (score 2.5 -+ 1.3), compared to 4 patients of the PD group and 2 patients of the Botox group (30%) (score 2.7 -+ 1.5). Results of manometry and scintigraphy did not significantly differ between the two groups. All patients regained body weight. Conclusion. Patients previously treated by PD or Botox undergoing Heller myotomy have an increased risk of intraoperative mucosal perforation and postoperative dysphagia than patients undergoing primary surgery. • S0033 PRESUMED MALIGNANT BILIARY OBSTRUCTION DESPITE A NORMAL CT" DATA TO SUPPORT PANCREATICODUODENECTOMY (PD). M Bouvet. R Bold. J Lee. P Pisters. J Abbruzzese. I Raiiman. C Chamsan~avei. DB Evans. The University of Texas M. D. Anderson Cancer Center, Houston, TX. INTRODUCTION: The absence of a clear mass on CT in patients with suspected periampullary or pancreatic cancer often results in multiple unnecessary attempts at preoperative or intraoperative biopsy and diagnostic confusion on the part of patients and physicians. We, therefore, sought to define clinical, radiologic and endoscopic factors which may distinguish benign from malignant causes of extrahepatic biliary obstmction in patients without a definitive pancreatic mass on high-quality CT. METHODS: 192 patients underwent PD for biopsy proven or suspected periampullary carcinoma from 1990 to 1997. 34 of these 192 patients had suspected malignant biliary obstruction without an identifiable pancreatic mass on CT. Clinical factors and ERCP findings were correlated with permanent-section histologic diagnosis.
RESULTS: Final pathology was benign in 10 patients and malignant in 24. Seven of 10 (70%) patients who underwent PD for benign disease had either a history of acute pancreatitis or alcohol abuse, or a long biliary stricture (>2.5 cm). These findings were present in only 5 of 24 (21%) patients with malignancy (p=0.006, Chi-squared). 12 of 24 patients with malignancy had an ampullary mass seen endoscopically. The remaining 12 patients with malignancy were compared to the 10 patients with benign disease: Benign Malignant (n = 10) (n = 12) Age (median) 65 67 Gender (male:female) 7:3 6:6 Alcohol abuse 3 (30%) 1 (8%) History of pancreatitis 2 (20%) 0 (0%) Diabetes 2 (20%) 3 (25%) Stricture length > 2.5 cm** 5 of 6 (83%) 1 of 9 (11%) *Chi-squared, **stricture length not available on all patients.
p
value* NS NS 0.18 0.10 NS 0.09
CONCLUSIONS: 12 of 22 patients (55%) had a malignant cause of biliary obstruction despite a normal ampulla and a normal CT. In the absence of a long stricture on ERCP, a benign etiology for biliary obstruction is very unlikely; data critically important for surgeons counseling such patients prior to planned PD. S0034
SURGICAL RESECTION FOR ESOPHAGEAL CARCINOMA: THE MIAMI EXPERIENCE. Michael J Boyle. Dido Franceschi. David Wrubel. Yung Nguven. David S Robinson. Frederick L Moffat. Alan S Livingstone. University of Miami, Department of Surgery, Miami, Florida. Surgical resection as the sole treatment modality for esophageal carcinoma has historically been associated with poor survival rates. Improved survival has been reported over the past ten years using varied neoadjuvant chemoradiation protocols. This study evaluates the outcome of patients undergoing surgery for esophageal carcinoma at the University of Miami/Jackson Memorial Hospital, between July 1991 and June 1996. Of 155 patients receiving treatment for esophageal carcinoma, 72 underwent esophageal resection (46%). There were 51 males and 21 females with a median age of 62.5 years (range = 42-82). Esophagectomy was transhiatal in 44 (61%), transthoracic in 24 (33%), transabdominal in two (3%) and thoraco-abdominal in 2 patients (3%). Histology was equally distributed between adenocarcinoma (36 patients; 50%) and squamous cell carcinoma (36 patients; 50%). Pathological stage distribution consisted of 6 Stage 0 (8%), 10 Stage I (14%), 23 Stage II (32%), 31 Stage III (43%), and 2 Stage IV (3%) lesions. All survivors were followed for a minimum of one year.
No of Patients Median Survival - mouths (range)
Surgery alone Neoadjuvant5-FU Neoadjuvant P based chemotx, chemo-radiation value (Group 1) (Group 2) (Group 3)** 44 (61%) 18 (25%) 9 (12.5%) 24 (0-61) 26 (3-73) 2 (0.1-50") < 0.01
3 Year Survival 42% 42% 22% < 0.01 5 Year Survival 28% 21% 0%* < 0.01 *Compared with Groups 1 and 2. One patient received pre-op radiation alone (1.5%) - not shown. **Four peri-operative deaths in group 3 (44%).
Of 28 patients receiving any form of neoadjuvant therapy only one patient had a pathological complete response (CR)(3.5%). The overall median survival was 20.5 months (range=0-73). Overall cumulative survival rates were 39% at three years and 18% at five years. The best predictor of survival was pathological stage. The table illustrates survival according to treatment group. Analysis by stage failed to indicate any improved survival in Group 2 over Group 1. These results indicate that surgical resection continues to be an important treatment modality for esophageal carcinoma. Improved surgical outcomes compared to historical controls may be due to technical advances and better post-operative care. Neoadjuvant chemotherapy in our experience failed to improve these survival rates. Pre-opemtive chemoradiation was associated with a high peri-operative mortality rate and poor patient outcome. Chemotherapy regimens with higher CRs may further improve these survival rates. S0035
SURVEY OF VITAMIN AND MINERAL SUPPLEMENTATION A F r E R GASTRIC AND BILIOPANCREATIC BYPASS FOR MORBID OBESITY. RE. Brolin. M. Leune. UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ. The purpose of this study was to determine whether the practice patterns of bariatric surgeons correlated with published data regarding the incidence and severity of metabolic deficiencies after gastric (GB) and biliopancreatic (BP) bypass. One hundred nine (109) surgeons completed a questionnaire to determine patterns for use of supplements and frequency of lab tests. Regarding supplements routinely prescribed after GB, 96% gave multivitamins (MV), 63% gave Fe, 49% gave B-12 whereas after BP 96% gave MV, 67% gave Fe, 42% gave B-12, 97% gave Ca++, 63% gave fat
A1380 SSAT ABSTRACTS • S0031
CLINICAL AND FUNCTIONAL RESULTS OF PRIMARY LAPAROSCOPIC MYOTOMY AND ANTERIOR FUNDOPLICATION FOR ESOPHAGEAL ACHALASIA. L.Bonavina. G.Micheletto. M.Panani. L.Antoniazzi, R.Rosati. A.Se~,alin. G.Marotta. and A.Peracchia. Department of Surgery, University of Milan School of Medicine, Milan, Italy. Long-term results of Heller myotomy and Dor fundoplication have been highly satisfactory. Aim of this study was to verify whether similar results can be achieved laparoscopically. Methods. Between April 1992 and May 1997, 51 patients underwent laparoscopic myotomy and anterior fundoplication for esophageal achalasia. None of them had previously been treated either endoscopically or surgically. There were 32 females and 19 males; the median age was 37 yrs (range 9-67 ). The cardia was not mobilized except in patients with sigmoid esophagus. The myotomy was carried out for at least 5 cm on the esophagus and 1.5 cm on the gastric side. Results. The median operative time was 100 minutes (range 60-200). Postoperative complications occurred in 2 patients and consisted of bleeding from an acute gastric ulcer and from a port site, respectively. The median hospital stay was 4 days (range 3-8). After a median follow-up of 22 months (range 6-65), the mean dysphagia score decreased from 2.2 to 0.3. The mean esophageal diameter on standard barium swallow study decreased from 4.0 to 2.5 cm (p<0.04). Lower esophageal sphincter (LES) pressure decreased from 30.6 to 11.3 mmHg (p<0.0001); LES residual pressure decreased from 14.6 to 2.9 mmHg (p<0.0001). Radionuclide esophageal activity at 1 and 10 minutes decreased from 88.5% to 23.2% and from 84.2% to 9.7%, respectively (p<0.0001). Abnormal gastroesophageal reflux was documented by 24-hour esophageal pH monitoring in one patient (I/10 tested, 10%) in whom the cardia was mobilized to reduce in the abdomen a sigmoid esophagus. Conclusions. Laparoscopic myotomy combined with anterior fundoplication is a safe and effective procedure. Cardia mobilization may increase the risk of postoperative gastroesophageal reflux. S0032
DOES PREVIOUS BOTULINUM TOXIN INJECTION OR PNEUMATIC DILATATION AFFECT SURGICAL OUTCOME OF LAPAROSCOPIC HELLER MYOTOMY? L.Bonavina. R.Incarbone. M.Pa~,ani. L.Antoniazzi. A.Peracchia. Department of Surgery, University of Milan, Milan, Italy. Aim of this study was to assess surgical outcome in patients undergoing laparoscopic Heller myotomy after unsuccessful endoscopic treatment, compared to patients having primary surgery. Materials and methods. Since 1992, 75 patients with manometrically proven achalasia underwent laparoscopic myotomy and anterior fundoplication. The first twenty cases were excluded from the study as considered part of the learning curve. Dysphagia was graded as: 1-occasional, 2-once a month, 3-once a week, 4-twice a week, 5-dally. Thirty-five patients with a mean dysphagia score of 4.5 + 0.8 had primary surgery (PS), and 20 patients with a mean dysphagia score of 4.7 -+ 07 had surgery after ineffectual pneumatic dilation (PD) (n.15), or botulinum toxin injection (Botox) (u. 5). Preoperative lower esophageal sphincter pressure and residual radionuclide activity at 1 and 10 min. were similar in both groups. Operative time, intraoperative complications, postoperative symptoms, and results of esophageal manometry and transit scintigraphy were compared. Results. There were no conversions to open procedure. Median operative time was 100 - 44 min. in patients having PS, versus 110 -+ 34 min. in the PD and Botox group. There was 1 intraoperative mucosal tear in the PS group (3%) compared to 3 tears in the PD group and 1 in the Botox group (20%). All tears were treated laparoscopically. Median follow-up was 23 months (range 1-44). Four patients of the PS group (12%) complained postoperative dysphagia (score 2.5 -+ 1.3), compared to 4 patients of the PD group and 2 patients of the Botox group (30%) (score 2.7 -+ 1.5). Results of manometry and scintigraphy did not significantly differ between the two groups. All patients regained body weight. Conclusion. Patients previously treated by PD or Botox undergoing Heller myotomy have an increased risk of intraoperative mucosal perforation and postoperative dysphagia than patients undergoing primary surgery. • S0033 PRESUMED MALIGNANT BILIARY OBSTRUCTION DESPITE A NORMAL CT" DATA TO SUPPORT PANCREATICODUODENECTOMY (PD). M Bouvet. R Bold. J Lee. P Pisters. J Abbruzzese. I Raiiman. C Chamsan~avei. DB Evans. The University of Texas M. D. Anderson Cancer Center, Houston, TX. INTRODUCTION: The absence of a clear mass on CT in patients with suspected periampullary or pancreatic cancer often results in multiple unnecessary attempts at preoperative or intraoperative biopsy and diagnostic confusion on the part of patients and physicians. We, therefore, sought to define clinical, radiologic and endoscopic factors which may distinguish benign from malignant causes of extrahepatic biliary obstmction in patients without a definitive pancreatic mass on high-quality CT. METHODS: 192 patients underwent PD for biopsy proven or suspected periampullary carcinoma from 1990 to 1997. 34 of these 192 patients had suspected malignant biliary obstruction without an identifiable pancreatic mass on CT. Clinical factors and ERCP findings were correlated with permanent-section histologic diagnosis.
RESULTS: Final pathology was benign in 10 patients and malignant in 24. Seven of 10 (70%) patients who underwent PD for benign disease had either a history of acute pancreatitis or alcohol abuse, or a long biliary stricture (>2.5 cm). These findings were present in only 5 of 24 (21%) patients with malignancy (p=0.006, Chi-squared). 12 of 24 patients with malignancy had an ampullary mass seen endoscopically. The remaining 12 patients with malignancy were compared to the 10 patients with benign disease: Benign Malignant (n = 10) (n = 12) Age (median) 65 67 Gender (male:female) 7:3 6:6 Alcohol abuse 3 (30%) 1 (8%) History of pancreatitis 2 (20%) 0 (0%) Diabetes 2 (20%) 3 (25%) Stricture length > 2.5 cm** 5 of 6 (83%) 1 of 9 (11%) *Chi-squared, **stricture length not available on all patients.
p
value* NS NS 0.18 0.10 NS 0.09
CONCLUSIONS: 12 of 22 patients (55%) had a malignant cause of biliary obstruction despite a normal ampulla and a normal CT. In the absence of a long stricture on ERCP, a benign etiology for biliary obstruction is very unlikely; data critically important for surgeons counseling such patients prior to planned PD. S0034
SURGICAL RESECTION FOR ESOPHAGEAL CARCINOMA: THE MIAMI EXPERIENCE. Michael J Boyle. Dido Franceschi. David Wrubel. Yung Nguven. David S Robinson. Frederick L Moffat. Alan S Livingstone. University of Miami, Department of Surgery, Miami, Florida. Surgical resection as the sole treatment modality for esophageal carcinoma has historically been associated with poor survival rates. Improved survival has been reported over the past ten years using varied neoadjuvant chemoradiation protocols. This study evaluates the outcome of patients undergoing surgery for esophageal carcinoma at the University of Miami/Jackson Memorial Hospital, between July 1991 and June 1996. Of 155 patients receiving treatment for esophageal carcinoma, 72 underwent esophageal resection (46%). There were 51 males and 21 females with a median age of 62.5 years (range = 42-82). Esophagectomy was transhiatal in 44 (61%), transthoracic in 24 (33%), transabdominal in two (3%) and thoraco-abdominal in 2 patients (3%). Histology was equally distributed between adenocarcinoma (36 patients; 50%) and squamous cell carcinoma (36 patients; 50%). Pathological stage distribution consisted of 6 Stage 0 (8%), 10 Stage I (14%), 23 Stage II (32%), 31 Stage III (43%), and 2 Stage IV (3%) lesions. All survivors were followed for a minimum of one year.
No of Patients Median Survival - mouths (range)
Surgery alone Neoadjuvant5-FU Neoadjuvant P based chemotx, chemo-radiation value (Group 1) (Group 2) (Group 3)** 44 (61%) 18 (25%) 9 (12.5%) 24 (0-61) 26 (3-73) 2 (0.1-50") < 0.01
3 Year Survival 42% 42% 22% < 0.01 5 Year Survival 28% 21% 0%* < 0.01 *Compared with Groups 1 and 2. One patient received pre-op radiation alone (1.5%) - not shown. **Four peri-operative deaths in group 3 (44%).
Of 28 patients receiving any form of neoadjuvant therapy only one patient had a pathological complete response (CR)(3.5%). The overall median survival was 20.5 months (range=0-73). Overall cumulative survival rates were 39% at three years and 18% at five years. The best predictor of survival was pathological stage. The table illustrates survival according to treatment group. Analysis by stage failed to indicate any improved survival in Group 2 over Group 1. These results indicate that surgical resection continues to be an important treatment modality for esophageal carcinoma. Improved surgical outcomes compared to historical controls may be due to technical advances and better post-operative care. Neoadjuvant chemotherapy in our experience failed to improve these survival rates. Pre-opemtive chemoradiation was associated with a high peri-operative mortality rate and poor patient outcome. Chemotherapy regimens with higher CRs may further improve these survival rates. S0035
SURVEY OF VITAMIN AND MINERAL SUPPLEMENTATION A F r E R GASTRIC AND BILIOPANCREATIC BYPASS FOR MORBID OBESITY. RE. Brolin. M. Leune. UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ. The purpose of this study was to determine whether the practice patterns of bariatric surgeons correlated with published data regarding the incidence and severity of metabolic deficiencies after gastric (GB) and biliopancreatic (BP) bypass. One hundred nine (109) surgeons completed a questionnaire to determine patterns for use of supplements and frequency of lab tests. Regarding supplements routinely prescribed after GB, 96% gave multivitamins (MV), 63% gave Fe, 49% gave B-12 whereas after BP 96% gave MV, 67% gave Fe, 42% gave B-12, 97% gave Ca++, 63% gave fat