- Email: [email protected]
M1526 Outcomes Following Esophagogastrectomy in Octogenarians
M1525 Acid Reflux to the Proximal Esophagus Predicts Postoperative Success in Patients with Laryngopharyngeal Reflux Disease Carlos Godinez, Stephen M. Kavic, George T. Fantry, Paul F. Castellanos, J. Scott Roth, F Jacob Seagull, Adrian E. Park Background: Acid reflux to the proximal esophagus and oropharynx is reasonably assumed to play a role in the etiology of atypical symptoms of reflux disease. To date, little published data exists to confirm this relationship. Similarly, the role of laparoscopic Nissen fundoplication (LNF) as therapy for this condition remains unproven over the long term. We theorized that symptoms of laryngopharyngeal reflux disease (LPR) could be correlated to documented episodes of proximal acid reflux, and that LNF would improve or relieve these symptoms. Methods: One hundred and forty-three patients were diagnosed with LPR based upon clinical evaluation, 24 hour esophageal pH probe monitor, and Reflux Symptom Index (RSI) score. pH probe data was analyzed for total number of proximal reflux episodes (defined as pH < 4.0 in the proximal esophagus), and correlation of symptom occurrence with proximal reflux episodes. Patients who underwent operation then completed validated symptom assessment instruments at multiple time points postoperatively. Results: Since July 2002, 114 patients have undergone LNF for laryngopharyngeal reflux at our institution. Patients were followed for up to 3 years (mean follow-up 11.5 months). pH probe data was available for analysis on 45 patients. Eighteen patients (40%) reported symptoms in association with proximal reflux. Following LNF, Reflux Symptom Index score improved most significantly in patients experiencing five or more symptomatic proximal reflux episodes, compared to those experiencing four or fewer (p=0.045). Further, patients whose absolute number of proximal reflux episodes exceeded thirty in a 24 hour period, regardless of symptom correlation, also had greater improvement in postoperative RSI scores (p=0.032). Conclusions: Full-height acid reflux episodes do not uniformly correspond to symptom occurrence in patients with LPR. However, patients experiencing five or more symptomatic proximal reflux episodes in a 24 hour period report greater improvement in atypical symptoms following LNF. LNF is an effective therapy for LPR in carefully selected patients.
*Total expense and expense per month were calculated within 3 years after diagnosis in USD **REPI was calculated by the ratio of survival time benefit divided by the ratio of expense per month M1528 Incorporation of Biologic Mesh Into Crural Closure Decreases Complications and Recurrence of Paraesophageal Hernias Tayyab S. Diwan, Michael Ujiki, Yashodhan S. Khajanchee, Christy M. Dunst, Lee L. Swanstrom
M1526
SSAT Abstracts
Outcomes Following Esophagogastrectomy in Octogenarians Sebastian A. Defranchi, Francis C. Nichols, Claude Deschamps, Mark S. Allen, Stephen D. Cassivi, Dennis A. Wigle, K.Robert Shen
Introduction In 1973, Allison reported a 49% recurrence rate in 421 paraesophageal hernia (PEH) cases followed over 22 years. A more recent study shows a recurrence rate of 30% following a laparoscopic repair without mesh. The placement of mesh has been shown to decrease the PEH recurrence to less than 7% in some studies. Typical synthetic mesh are easy to use but have an unacceptable rate of erosion into the esophagus. Biologic mesh have recently gained favor as an alternative for crural reconstruction of PEH. In a recent randomized, prospective study by Oelschlager, recurrence rates decreased from 25 to 9% with the use of biologic mesh. However, a simple method for placing and securing the mesh to the diaphram has never been described. Methods that have been suggested include sutures, tacks, and staples, but risk complications of mesh migration, diaphragmatic injury, and pericardial injury as well as increased cost. We have employed a technique of crural incorporation (CI) of the biologic mesh into the closure of the diaphragmatic hiatus. We hypothesize that this method of crural repair will decrease the rate of hernia recurrence and avoid the cost and complications of other mesh placement techniques. Methods The pre-operative and post-operative data from 35 patients operated on from December 2005 to May 2007 was analyzed, including pre- and post-op EGD, manometry, and UGI. All patients were pre-operatively diagnosed with PEH using one or all of the tests formerly mentioned. A structured systems assessment tool was also administered to all patients pre- and postoperatively. All pts underwent PEH repair with CI. Biologic mesh was incorporated into the crural closure using pledgeted zero polyester suture in a horizontal mattress stitch. Mean follow-up was 6.1 months (range 1-16 months). Results Pre-operatively, 60% of pts had GERD symptoms, 42% pulmonary symptoms (SOB, cough), and 25% had chest pain. Postoperatively 100% of pts had resolution of their pre-op symptoms. 5/35 (14%) of pts were found to have post-operative dysphagia. Twenty-one pts had post-op studies (egd, manometry, or UGI). No patients were found to have recurrence of their PEH. No intra-operative complications were noted. Discussion The use of biologic mesh has been demonstrated to decrease recurrence rates following PEH repair. The safest and most efficient method of mesh placement has not been defined. Our method of PEH repair with CI decreases the rate of mesh complications and the rate of recurrence while utilizing no extra suture or staples, while providing excellent apposition of mesh to the underlying crura and securely closing the hiatus.
Background: Conflicting information with regards to morbidity and mortality has been reported for esophagogastrectomy in octogenarians. Methods: From our prospectively maintained database, all patients 80-years of age and older who underwent esophagogastrectomy at our institution between January 1999 and December 2005 were identified and their records reviewed. Results: There were 34 patients (30 men and 4 women). Median age was 81.8 years (range: 80 to 86 years). Twenty-eight patients (82%) were symptomatic at presentation. Most common were dysphagia in 17 patients (50%) and bleeding in 8 (23%). Comorbdities included hypertension in 22 patients (64%), coronary artery disease in 14 (41%), cardiac arrhythmias in 6 (17%), and diabetes and renal failure in 4 each (11%). Histopathology was adenocarcinoma in 30 patients (88%) and squamous cell in 3 (8%). One patient (2%) had end-stage achalasia without malignancy. Four patients (11%) received neoadjuvant chemoradiation therapy. The type of esophagogastrectomy included Ivor Lewis in 19 patients (56%), transhiatal in 11 (32%), and McKeown in 4 (12%). Pathologic stage was 0 or I in 12 patients (35%), II in 12 (35%), and stage III in 10 (29%). Operative mortality occurred in 2 patients (5.9%). Complications occurred in 24 patients (70%)and included: pulmonary in 11 (32%), atrial fibrillation in 10 (29%), aspiration in 6 (21%), and anastomotic leak in 5 (15%). Only 1 patient with anastomotic leak required reoperation. Median hospitalization was 11.5 days (range: 6 to 83 days). Overall morbidity was more common in patients with a prior cardiac history, patients whose BMI was > 30, or patients who had a McKeown procedure. In particular, pulmonary complications were more common in patients who had a history of major cardiac disease, or underwent a McKeown procedure. One-,two-, three-, and five-year survivals were 63%, 38%, and 30%, and 15% respectively. Conclusion: Esophagogastrectomy in octogenarians can be performed with low mortality but has high morbidity. Increasing morbidity is associated with a history of major cardiac disease, BMI > 30, and performance of the McKeown esophagogastrectomy procedure. M1527 Analyzing Treatment Costs for Esophageal Cancer Patients At Different Stages Chih-Cheng Hsieh, Ching-Wen Chien Background: Esophageal cancer (EC) is a complex disease. Poor treatment results and high medical expense make it unpopular in cost-effectiveness analyses. At present, the main treatment for EC is surgical or non-surgical treatment. The aim of this study is to compare relative performance in terms of survival time and medical expenses of the 2 treatments for EC patients at different stages. This Result can be used to assist clinical decision making. Materials and Methods: Charge & clinical data of 356 EC patients treated between 2000/1 to 2003/6 were collected. Patients were divided into 2 groups—surgical & non-surgical groups. Survival time, total expense, expense per month and relative expense performance index (REPI) for 2 treatments were calculated and compared between patients at different stages. Results: The survival time and total expense in surgical group were longer and higher than in non-surgical treatment at all stages. Expense per month of EC patients at stage I, II & III were not significantly different between 2 groups. The expense per month in surgical group is significantly more than non-surgical group only for patients at stage IV. The REPI for patients at stage III was the highest and for patients at stage IV was lowest among four stages. Conclusions: From the perspective of survival time and REPI, patients at early stage of EC, even stage III, surgical treatment was a better treatment than non-surgical treatment. But, for EC patients at stage IV, surgical treatment has a low REPI which suggests that surgical treatment may need further evaluation if medical expenses were included in clinical consideration.
SSAT Abstracts
M1529 New Techniques for Endoscopic (Laparoscopic and Thoracoscopic) Esophagectomy of Esophageal Cancer, Ropeway Technique for Dissection Along with the Nerve and Double-Gloving Method of HALS for Reconstruction Hitoshi Satodate, Haruhiro Inoue, Shin-ei Kudo INTRODUCTION: The concept of three-field lymph node dissection for esophageal cancer was developed by Japanese surgeons and now the three-field esophagectomy is in the mainstream of the esophageal cancer surgery in Japan, and also in the various countries. With advent of minimal access surgery, a myriad of different approaches have been devised and studied in recent years. Thoracoscopic esophageal mobilization is becoming popular approaches. METHODS: Hand-assisted laparoscopic surgery (HALS) for gastric conduit preparation, modified radical cervical node dissection and cervical esophagogastrostomy followed by thoracoscopic esophagectomy through the right chest is the authors practice. Recently we added two new methods toward complete and safe lymph node dissection. One is for excision of the nodes along both recurrent laryngeal nerves as they course through the mediastinum to the neck. Both recurrent nerves are taped after the neck dissection, and the tapes are extracted thoracic cavity during the thoracoscopic procedure. Then the tapes are retracted by the forceps and nodes along to the recurrent nerves are thoroughly excised.
A-866
*Total expense and expense per month were calculated within 3 years after diagnosis in USD **REPI was calculated by the ratio of survival time benefit divided by the ratio of expense per month M1528 Incorporation of Biologic Mesh Into Crural Closure Decreases Complications and Recurrence of Paraesophageal Hernias Tayyab S. Diwan, Michael Ujiki, Yashodhan S. Khajanchee, Christy M. Dunst, Lee L. Swanstrom
M1526
SSAT Abstracts
Outcomes Following Esophagogastrectomy in Octogenarians Sebastian A. Defranchi, Francis C. Nichols, Claude Deschamps, Mark S. Allen, Stephen D. Cassivi, Dennis A. Wigle, K.Robert Shen
Introduction In 1973, Allison reported a 49% recurrence rate in 421 paraesophageal hernia (PEH) cases followed over 22 years. A more recent study shows a recurrence rate of 30% following a laparoscopic repair without mesh. The placement of mesh has been shown to decrease the PEH recurrence to less than 7% in some studies. Typical synthetic mesh are easy to use but have an unacceptable rate of erosion into the esophagus. Biologic mesh have recently gained favor as an alternative for crural reconstruction of PEH. In a recent randomized, prospective study by Oelschlager, recurrence rates decreased from 25 to 9% with the use of biologic mesh. However, a simple method for placing and securing the mesh to the diaphram has never been described. Methods that have been suggested include sutures, tacks, and staples, but risk complications of mesh migration, diaphragmatic injury, and pericardial injury as well as increased cost. We have employed a technique of crural incorporation (CI) of the biologic mesh into the closure of the diaphragmatic hiatus. We hypothesize that this method of crural repair will decrease the rate of hernia recurrence and avoid the cost and complications of other mesh placement techniques. Methods The pre-operative and post-operative data from 35 patients operated on from December 2005 to May 2007 was analyzed, including pre- and post-op EGD, manometry, and UGI. All patients were pre-operatively diagnosed with PEH using one or all of the tests formerly mentioned. A structured systems assessment tool was also administered to all patients pre- and postoperatively. All pts underwent PEH repair with CI. Biologic mesh was incorporated into the crural closure using pledgeted zero polyester suture in a horizontal mattress stitch. Mean follow-up was 6.1 months (range 1-16 months). Results Pre-operatively, 60% of pts had GERD symptoms, 42% pulmonary symptoms (SOB, cough), and 25% had chest pain. Postoperatively 100% of pts had resolution of their pre-op symptoms. 5/35 (14%) of pts were found to have post-operative dysphagia. Twenty-one pts had post-op studies (egd, manometry, or UGI). No patients were found to have recurrence of their PEH. No intra-operative complications were noted. Discussion The use of biologic mesh has been demonstrated to decrease recurrence rates following PEH repair. The safest and most efficient method of mesh placement has not been defined. Our method of PEH repair with CI decreases the rate of mesh complications and the rate of recurrence while utilizing no extra suture or staples, while providing excellent apposition of mesh to the underlying crura and securely closing the hiatus.
Background: Conflicting information with regards to morbidity and mortality has been reported for esophagogastrectomy in octogenarians. Methods: From our prospectively maintained database, all patients 80-years of age and older who underwent esophagogastrectomy at our institution between January 1999 and December 2005 were identified and their records reviewed. Results: There were 34 patients (30 men and 4 women). Median age was 81.8 years (range: 80 to 86 years). Twenty-eight patients (82%) were symptomatic at presentation. Most common were dysphagia in 17 patients (50%) and bleeding in 8 (23%). Comorbdities included hypertension in 22 patients (64%), coronary artery disease in 14 (41%), cardiac arrhythmias in 6 (17%), and diabetes and renal failure in 4 each (11%). Histopathology was adenocarcinoma in 30 patients (88%) and squamous cell in 3 (8%). One patient (2%) had end-stage achalasia without malignancy. Four patients (11%) received neoadjuvant chemoradiation therapy. The type of esophagogastrectomy included Ivor Lewis in 19 patients (56%), transhiatal in 11 (32%), and McKeown in 4 (12%). Pathologic stage was 0 or I in 12 patients (35%), II in 12 (35%), and stage III in 10 (29%). Operative mortality occurred in 2 patients (5.9%). Complications occurred in 24 patients (70%)and included: pulmonary in 11 (32%), atrial fibrillation in 10 (29%), aspiration in 6 (21%), and anastomotic leak in 5 (15%). Only 1 patient with anastomotic leak required reoperation. Median hospitalization was 11.5 days (range: 6 to 83 days). Overall morbidity was more common in patients with a prior cardiac history, patients whose BMI was > 30, or patients who had a McKeown procedure. In particular, pulmonary complications were more common in patients who had a history of major cardiac disease, or underwent a McKeown procedure. One-,two-, three-, and five-year survivals were 63%, 38%, and 30%, and 15% respectively. Conclusion: Esophagogastrectomy in octogenarians can be performed with low mortality but has high morbidity. Increasing morbidity is associated with a history of major cardiac disease, BMI > 30, and performance of the McKeown esophagogastrectomy procedure. M1527 Analyzing Treatment Costs for Esophageal Cancer Patients At Different Stages Chih-Cheng Hsieh, Ching-Wen Chien Background: Esophageal cancer (EC) is a complex disease. Poor treatment results and high medical expense make it unpopular in cost-effectiveness analyses. At present, the main treatment for EC is surgical or non-surgical treatment. The aim of this study is to compare relative performance in terms of survival time and medical expenses of the 2 treatments for EC patients at different stages. This Result can be used to assist clinical decision making. Materials and Methods: Charge & clinical data of 356 EC patients treated between 2000/1 to 2003/6 were collected. Patients were divided into 2 groups—surgical & non-surgical groups. Survival time, total expense, expense per month and relative expense performance index (REPI) for 2 treatments were calculated and compared between patients at different stages. Results: The survival time and total expense in surgical group were longer and higher than in non-surgical treatment at all stages. Expense per month of EC patients at stage I, II & III were not significantly different between 2 groups. The expense per month in surgical group is significantly more than non-surgical group only for patients at stage IV. The REPI for patients at stage III was the highest and for patients at stage IV was lowest among four stages. Conclusions: From the perspective of survival time and REPI, patients at early stage of EC, even stage III, surgical treatment was a better treatment than non-surgical treatment. But, for EC patients at stage IV, surgical treatment has a low REPI which suggests that surgical treatment may need further evaluation if medical expenses were included in clinical consideration.
SSAT Abstracts
M1529 New Techniques for Endoscopic (Laparoscopic and Thoracoscopic) Esophagectomy of Esophageal Cancer, Ropeway Technique for Dissection Along with the Nerve and Double-Gloving Method of HALS for Reconstruction Hitoshi Satodate, Haruhiro Inoue, Shin-ei Kudo INTRODUCTION: The concept of three-field lymph node dissection for esophageal cancer was developed by Japanese surgeons and now the three-field esophagectomy is in the mainstream of the esophageal cancer surgery in Japan, and also in the various countries. With advent of minimal access surgery, a myriad of different approaches have been devised and studied in recent years. Thoracoscopic esophageal mobilization is becoming popular approaches. METHODS: Hand-assisted laparoscopic surgery (HALS) for gastric conduit preparation, modified radical cervical node dissection and cervical esophagogastrostomy followed by thoracoscopic esophagectomy through the right chest is the authors practice. Recently we added two new methods toward complete and safe lymph node dissection. One is for excision of the nodes along both recurrent laryngeal nerves as they course through the mediastinum to the neck. Both recurrent nerves are taped after the neck dissection, and the tapes are extracted thoracic cavity during the thoracoscopic procedure. Then the tapes are retracted by the forceps and nodes along to the recurrent nerves are thoroughly excised.
A-866