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Mo1799 Limitations of EUS and CT for Preoperative Staging of Gastric Cancer
Mo1800
CI, Confidence Interval; ASA, American Society of Anesthiologists *Compared to ASA 1 and 2.
Gastrointestinal Stromal Tumors Outcomes in Afro-Caribbean Immigrants Are Impacted by Social and Economic Status Francesco Serafini, Rebecca M. Miller, Thomas Mcintyre, Muthukumar Muthusamy
Mo1798
Introduction: Previous studies have reported that outcomes of patients with Gastrointestinal Stromal Tumors (GIST) are not impacted by racial disparities. In this study, we characterized the clinical features and outcomes of GIST tumors in a homogeneous immigrant AfroCaribbean population with indices of low socio-economic status. Subsequently, we compared our results with SEER data and with a large homogeneous European population. Methods: We reviewed our Afro-Caribbean patients with GIST treated from 01/2002 to 07/2013. Low socio-economic status was assigned for uninsured and Medicaid patients. Measured outcomes were risk class according to Fletcher-NIH consensus criteria, rate of metastasis, resectability, and disease-free survival. Comparisons were made using Fisher's Exact Test and Columns Proportions Tests. Statistical significance was accepted at p<0.05. Results: We identified 52 patients with GIST, of which 37 were Afro-Caribbean. 84% had Medicaid (51%) or were uninsured (33%). Mean age was 65 years (39-86), stomach was the primary site in 76%. Bleeding was present in 86% and pain in 65% of patients. Metastases were found in 36% of patients at presentation, compared to 24% in the SEER (p=0.3), 11% in the Swedish (p= 0.001) studies. Resection was undertaken in 78% compared to 81% in SEER data and 86% Swedish studies (p =NS). Three year disease-free survival was 56% compared to 79% in the SEER data (p<.05). Conclusions: Our Afro-Caribbean patients presented with more advanced disease, and despite aggressive treatment, they experienced worse outcomes compared to other ethnicities. Racial diversities and socio-economic status are important determinant of outcomes in patients with GIST.
SSAT Abstracts
Daikenchuto (DKT) Helps Improve Postoperative Functional Gastrointestinal Disorder After Total Gastrectomy in Patients With Gastric Cancer: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial(JFMC421002) Keisuke Koeda, Go Wakabayashi, Mitsuo Shimada, Kohichiro Ishida, Takashi Kaiho, Yuko Kitagawa, Junichi Satamoto, Norio Shiraishi, Satoshi Morita, Masaki Kitajima, Shigetoyo Saji, Seigo Kitano Background and Aim Prolonged postoperative paralytic ileus and/or adhesive intestinal obstruction remain serious and inevitable consequences in certain number of cases after abdominal surgery. Intestinal ileus results in not only protracted hospital stay, but also deteriorates quality of life of the patients. Daikenchuto (DKT), a traditional herbal medicine (Kampo), has widely been used to improve abdominal symptoms by accelerating bowel motility. In this study, we examined the efficacy and safety of DKT for prevention of ileus and associated gastrointestinal symptoms after total gastrectomy by a double-blind placebocontrolled randomized phase II clinical trial. Methods Two hundred forty-five gastric cancer patients who underwent total gastrectomy at 40 Japanese institutions from January 2011 to December 2012 were enrolled. Patients received either DKT (15.0 g/day) or matching placebo from postoperative day (POD) 1 to POD12. Primary endpoints were time to first passage of flatus, time to first bowel movement (BM), and frequency of BM. Secondary endpoints included quality of life, C reactive protein level, symptoms of severe gastrointestinal problems (i.e., abdominal pain, bloating, nausea and vomiting), and the incidence of postoperative ileus. Quality of life was evaluated at baseline, POD3 and POD12. Symptoms of gastrointestinal dysfunction and C reactive protein level were also assessed at baseline, POD1, POD5, and POD12. Results One hundred ninety-five patients (DKT, n=96; placebo, n=99) were included in per protocol set analysis. Significant differences were not found between the groups in terms of patient background characteristics (age, sex, body mass index, operation time, intraoperative bleeding, and tumor stage). The median time to first BM was shorter in the DKT group than in the placebo group [97.4 h (95% CI, 90.0-114.1) vs. 113.9 h (95% CI, 96.5-119.1); p=0.051, Wilcoxon test]. In patients with high medication adherence, the median time to first BM was also shorter in the DKT group than in the placebo group [93.8 h (95% CI, 87.9-105.3) vs. 115.1 h (95% CI, 95.2-123.8); p=0.014, generalized Wilcoxon test]. Significantly fewer patients in the DKT group had two or more symptoms of gastrointestinal dysfunction than those in the placebo group on POD12 (p =0.026, Fisher's exact test). Other outcome measures such as time to first flatus, frequency of BM, quality of life, C reactive protein level, and the incidence of postoperative ileus did not show significant differences between the groups. None of the patients developed serious adverse drug reactions during the study. Conclusion DKT administration during the immediate postoperative period appears to promote and improves early recovery of postoperative bowel function and is presumed to prevent postoperative ileus after total gastrectomy for patients with gastric cancer.
Mo1801 Primary Sleeve Gastrectomy Compared to Sleeve Gastrectomy As Revisional Surgery Allison M. Barrett, Kim T. Vu, Kulmeet K. Sandhu, Edward H. Phillips, Scott A. Cunneen, Miguel Burch Introduction: The laparoscopic adjustable gastric band (LAGB) can be revised to laparoscopic sleeve gastrectomy (LSG) due to insufficient weight loss, patient intolerance, or complications. Little is known about the weight-loss outcomes in this population when directly compared to patients undergoing primary sleeve gastrectomy. Objective: To compare weight loss between patients undergoing primary LSG compared to those undergoing single-stage revision from LAGB to LSG, and to assess for complications. Methods: Retrospective analysis was performed on patients who underwent single-stage revision from LAGB to LSG between 2009 and 2013 (revision group). A cohort of matched patients who underwent primary LSG was used for comparison (control group). All patients underwent surgery at the same academic medical center by the same surgeons. Patients were followed for six months postoperatively and evaluated for weight loss and complications. Results: The revision group included 24 patients, with a matched cohort of 48 patients in the control group. There was no difference between the groups with respect to age and the presence of comorbidities. Preoperative BMI was 41.8 in the revision group and 42.6 in the control group (p=0.55). Average OR time was 154 minutes for the revision group and 114 minutes for the control group (p=0.002). Intraoperative blood loss was equivalent. Length of stay was 3.2 days in the revision group and 2.5 days in the control group (p=0.005). There were no reoperations or emergency visits within 30 days of surgery in either group. At three months, BMI was 35.15 in the revision group and 35.03 in the control group (p=0.90) with percent excess weight loss (%EWL) of 32.64 and 35.64 respectively (p=0.21). At six months postoperatively, BMI was 33.61 for the revision group and 32.87 for the control group (p=0.57), with %EWL of 40.94 and 48.68 respectively (p=0.03). Average change in BMI was 7.90 in the revision group and 9.69 in the control group (p=0.06). Conclusion: Single-stage revision from LAGB to LSG can be performed safely and with only a minor increase in length of stay compared to primary LSG. At six months postoperatively, there is a trend toward improved weight loss following primary LSG compared to revision from LAGB to LSG.
Mo1799 Limitations of EUS and CT for Preoperative Staging of Gastric Cancer Mark Fairweather, Kunal Jajoo, Sainani I. Nisha, Monica M. Bertagnolli, Jiping Wang Background: Neoadjuvant therapy has been recommended for locally advanced gastric cancer patients (stage IB-IIIC, AJCC 7th edition). Accurate preoperative staging is critical for the implementation of this recommendation. This study was to determine the accuracy of endoscopic ultrasound (EUS) and CT imaging in evaluating depth of tumor invasion (T stage) and lymph node status (N stage) for gastric cancer patients. Methods: Between 2000 and 2013, 49 gastric adenocarcinoma patients who underwent preoperative staging by EUS followed by a radical gastrectomy with curative intent were included. CT scans of adequate quality available in 25 patients were reviewed by a radiologist blinded to the EUS and pathology results. The results of preoperative EUS/CT staging were compared with surgical pathologic staging to determine the accuracy of the imaging results. Results: The accuracy of EUS in identifying each individual T and N stage was 41.0% and 42.9% respectively. The accuracy in differentiating locally advanced from early (stage 0-IA) disease was 77.6%. For each individual T and N stage, the accuracy of CT imaging was 4.0% and 56% respectively. CT scan had low accuracy in differentiating locally advanced from early disease (44.0%). When combining EUS and CT staging, the accuracy of identifying early vs. locally advanced disease increased to 76%. Conclusion: EUS and CT imaging have suboptimal performance to identify each individual T and N stage although EUS had moderate accuracy in identifying patients with locally advanced diseases. CT does not improve the staging accuracy when combined with EUS. Efforts are needed to improve the performance of both preoperative staging modalities. Accuracy of preoperative EUS (38/49=77.6%) and CT imaging (15/25=44.0%) in predicting early (0-IA0) and locally advanced (IB-IIIC) disease
SSAT Abstracts
Mo1802 Single Stage Conversion From Gastric Banding to a Stapled Bariatric Procedure: An Analysis of Complications Collin E. Brathwaite, Keneth N. Hall, Owen J. Pyke, Alex Barkan, Joshua R. Karas, Patricia D. Cherasard, Elizabeth Carruthers Introduction: Single stage conversion from gastric banded procedures to other bariatric surgery approaches has been associated with increased rates of strictures and other complications, likely due to scarring and reaction to the foreign body. The objective of this study was to review the experience with this group of patients at our hospital, a Center of Excellence in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Methods: Our prospective database was queried for the 6-year period ending 10/31/2013. Only patients who had a single stage conversion from Adjustable Gastric Banding (AGB) to Roux-En-Y Gastric Bypass (RNY) or Laparoscopic Sleeve Gastrectomy (LSG), performed at our hospital, were included. Outcomes including rates of organ failure, venous thromboembolism (VTE), wound infection, persistent nausea and vomiting (N/V), strictures, staple line leaks and mortality were assessed. Results: Of 1,840 patients having bariatric surgery in the time period, 81 underwent conversion from a banding procedure. We excluded
S-1074
CI, Confidence Interval; ASA, American Society of Anesthiologists *Compared to ASA 1 and 2.
Gastrointestinal Stromal Tumors Outcomes in Afro-Caribbean Immigrants Are Impacted by Social and Economic Status Francesco Serafini, Rebecca M. Miller, Thomas Mcintyre, Muthukumar Muthusamy
Mo1798
Introduction: Previous studies have reported that outcomes of patients with Gastrointestinal Stromal Tumors (GIST) are not impacted by racial disparities. In this study, we characterized the clinical features and outcomes of GIST tumors in a homogeneous immigrant AfroCaribbean population with indices of low socio-economic status. Subsequently, we compared our results with SEER data and with a large homogeneous European population. Methods: We reviewed our Afro-Caribbean patients with GIST treated from 01/2002 to 07/2013. Low socio-economic status was assigned for uninsured and Medicaid patients. Measured outcomes were risk class according to Fletcher-NIH consensus criteria, rate of metastasis, resectability, and disease-free survival. Comparisons were made using Fisher's Exact Test and Columns Proportions Tests. Statistical significance was accepted at p<0.05. Results: We identified 52 patients with GIST, of which 37 were Afro-Caribbean. 84% had Medicaid (51%) or were uninsured (33%). Mean age was 65 years (39-86), stomach was the primary site in 76%. Bleeding was present in 86% and pain in 65% of patients. Metastases were found in 36% of patients at presentation, compared to 24% in the SEER (p=0.3), 11% in the Swedish (p= 0.001) studies. Resection was undertaken in 78% compared to 81% in SEER data and 86% Swedish studies (p =NS). Three year disease-free survival was 56% compared to 79% in the SEER data (p<.05). Conclusions: Our Afro-Caribbean patients presented with more advanced disease, and despite aggressive treatment, they experienced worse outcomes compared to other ethnicities. Racial diversities and socio-economic status are important determinant of outcomes in patients with GIST.
SSAT Abstracts
Daikenchuto (DKT) Helps Improve Postoperative Functional Gastrointestinal Disorder After Total Gastrectomy in Patients With Gastric Cancer: A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial(JFMC421002) Keisuke Koeda, Go Wakabayashi, Mitsuo Shimada, Kohichiro Ishida, Takashi Kaiho, Yuko Kitagawa, Junichi Satamoto, Norio Shiraishi, Satoshi Morita, Masaki Kitajima, Shigetoyo Saji, Seigo Kitano Background and Aim Prolonged postoperative paralytic ileus and/or adhesive intestinal obstruction remain serious and inevitable consequences in certain number of cases after abdominal surgery. Intestinal ileus results in not only protracted hospital stay, but also deteriorates quality of life of the patients. Daikenchuto (DKT), a traditional herbal medicine (Kampo), has widely been used to improve abdominal symptoms by accelerating bowel motility. In this study, we examined the efficacy and safety of DKT for prevention of ileus and associated gastrointestinal symptoms after total gastrectomy by a double-blind placebocontrolled randomized phase II clinical trial. Methods Two hundred forty-five gastric cancer patients who underwent total gastrectomy at 40 Japanese institutions from January 2011 to December 2012 were enrolled. Patients received either DKT (15.0 g/day) or matching placebo from postoperative day (POD) 1 to POD12. Primary endpoints were time to first passage of flatus, time to first bowel movement (BM), and frequency of BM. Secondary endpoints included quality of life, C reactive protein level, symptoms of severe gastrointestinal problems (i.e., abdominal pain, bloating, nausea and vomiting), and the incidence of postoperative ileus. Quality of life was evaluated at baseline, POD3 and POD12. Symptoms of gastrointestinal dysfunction and C reactive protein level were also assessed at baseline, POD1, POD5, and POD12. Results One hundred ninety-five patients (DKT, n=96; placebo, n=99) were included in per protocol set analysis. Significant differences were not found between the groups in terms of patient background characteristics (age, sex, body mass index, operation time, intraoperative bleeding, and tumor stage). The median time to first BM was shorter in the DKT group than in the placebo group [97.4 h (95% CI, 90.0-114.1) vs. 113.9 h (95% CI, 96.5-119.1); p=0.051, Wilcoxon test]. In patients with high medication adherence, the median time to first BM was also shorter in the DKT group than in the placebo group [93.8 h (95% CI, 87.9-105.3) vs. 115.1 h (95% CI, 95.2-123.8); p=0.014, generalized Wilcoxon test]. Significantly fewer patients in the DKT group had two or more symptoms of gastrointestinal dysfunction than those in the placebo group on POD12 (p =0.026, Fisher's exact test). Other outcome measures such as time to first flatus, frequency of BM, quality of life, C reactive protein level, and the incidence of postoperative ileus did not show significant differences between the groups. None of the patients developed serious adverse drug reactions during the study. Conclusion DKT administration during the immediate postoperative period appears to promote and improves early recovery of postoperative bowel function and is presumed to prevent postoperative ileus after total gastrectomy for patients with gastric cancer.
Mo1801 Primary Sleeve Gastrectomy Compared to Sleeve Gastrectomy As Revisional Surgery Allison M. Barrett, Kim T. Vu, Kulmeet K. Sandhu, Edward H. Phillips, Scott A. Cunneen, Miguel Burch Introduction: The laparoscopic adjustable gastric band (LAGB) can be revised to laparoscopic sleeve gastrectomy (LSG) due to insufficient weight loss, patient intolerance, or complications. Little is known about the weight-loss outcomes in this population when directly compared to patients undergoing primary sleeve gastrectomy. Objective: To compare weight loss between patients undergoing primary LSG compared to those undergoing single-stage revision from LAGB to LSG, and to assess for complications. Methods: Retrospective analysis was performed on patients who underwent single-stage revision from LAGB to LSG between 2009 and 2013 (revision group). A cohort of matched patients who underwent primary LSG was used for comparison (control group). All patients underwent surgery at the same academic medical center by the same surgeons. Patients were followed for six months postoperatively and evaluated for weight loss and complications. Results: The revision group included 24 patients, with a matched cohort of 48 patients in the control group. There was no difference between the groups with respect to age and the presence of comorbidities. Preoperative BMI was 41.8 in the revision group and 42.6 in the control group (p=0.55). Average OR time was 154 minutes for the revision group and 114 minutes for the control group (p=0.002). Intraoperative blood loss was equivalent. Length of stay was 3.2 days in the revision group and 2.5 days in the control group (p=0.005). There were no reoperations or emergency visits within 30 days of surgery in either group. At three months, BMI was 35.15 in the revision group and 35.03 in the control group (p=0.90) with percent excess weight loss (%EWL) of 32.64 and 35.64 respectively (p=0.21). At six months postoperatively, BMI was 33.61 for the revision group and 32.87 for the control group (p=0.57), with %EWL of 40.94 and 48.68 respectively (p=0.03). Average change in BMI was 7.90 in the revision group and 9.69 in the control group (p=0.06). Conclusion: Single-stage revision from LAGB to LSG can be performed safely and with only a minor increase in length of stay compared to primary LSG. At six months postoperatively, there is a trend toward improved weight loss following primary LSG compared to revision from LAGB to LSG.
Mo1799 Limitations of EUS and CT for Preoperative Staging of Gastric Cancer Mark Fairweather, Kunal Jajoo, Sainani I. Nisha, Monica M. Bertagnolli, Jiping Wang Background: Neoadjuvant therapy has been recommended for locally advanced gastric cancer patients (stage IB-IIIC, AJCC 7th edition). Accurate preoperative staging is critical for the implementation of this recommendation. This study was to determine the accuracy of endoscopic ultrasound (EUS) and CT imaging in evaluating depth of tumor invasion (T stage) and lymph node status (N stage) for gastric cancer patients. Methods: Between 2000 and 2013, 49 gastric adenocarcinoma patients who underwent preoperative staging by EUS followed by a radical gastrectomy with curative intent were included. CT scans of adequate quality available in 25 patients were reviewed by a radiologist blinded to the EUS and pathology results. The results of preoperative EUS/CT staging were compared with surgical pathologic staging to determine the accuracy of the imaging results. Results: The accuracy of EUS in identifying each individual T and N stage was 41.0% and 42.9% respectively. The accuracy in differentiating locally advanced from early (stage 0-IA) disease was 77.6%. For each individual T and N stage, the accuracy of CT imaging was 4.0% and 56% respectively. CT scan had low accuracy in differentiating locally advanced from early disease (44.0%). When combining EUS and CT staging, the accuracy of identifying early vs. locally advanced disease increased to 76%. Conclusion: EUS and CT imaging have suboptimal performance to identify each individual T and N stage although EUS had moderate accuracy in identifying patients with locally advanced diseases. CT does not improve the staging accuracy when combined with EUS. Efforts are needed to improve the performance of both preoperative staging modalities. Accuracy of preoperative EUS (38/49=77.6%) and CT imaging (15/25=44.0%) in predicting early (0-IA0) and locally advanced (IB-IIIC) disease
SSAT Abstracts
Mo1802 Single Stage Conversion From Gastric Banding to a Stapled Bariatric Procedure: An Analysis of Complications Collin E. Brathwaite, Keneth N. Hall, Owen J. Pyke, Alex Barkan, Joshua R. Karas, Patricia D. Cherasard, Elizabeth Carruthers Introduction: Single stage conversion from gastric banded procedures to other bariatric surgery approaches has been associated with increased rates of strictures and other complications, likely due to scarring and reaction to the foreign body. The objective of this study was to review the experience with this group of patients at our hospital, a Center of Excellence in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP). Methods: Our prospective database was queried for the 6-year period ending 10/31/2013. Only patients who had a single stage conversion from Adjustable Gastric Banding (AGB) to Roux-En-Y Gastric Bypass (RNY) or Laparoscopic Sleeve Gastrectomy (LSG), performed at our hospital, were included. Outcomes including rates of organ failure, venous thromboembolism (VTE), wound infection, persistent nausea and vomiting (N/V), strictures, staple line leaks and mortality were assessed. Results: Of 1,840 patients having bariatric surgery in the time period, 81 underwent conversion from a banding procedure. We excluded
S-1074