- Email: [email protected]
Modeling hospital costs in gastric bypass
procedure. It can be also valuableas a therapeutic option for this group of patients, although a careful approach and appropriate training is advisable 2476 Laparoacopically-Assisted Intestinal Surgery Using the Pfannenstiel Incision Sheila K. Partridge, Richard A. Hodin, Beth israel DeaconessMedical Ctr and Harvard Medical Sch, Boston, MA Compared to standard laparotomy incisions, the pfannenstiel incision has been shown to result in decreasedpain, fewer wound complications, faster recovery, and better cosmesis. However,gastrointestinalsurgeons have rarely used this incision, primarily due to inadequate exposureto intrapedtonealstructures. The ability to mobilizethe bowel laparoscopica,yallows for the possibility of using the pfannenstiel incision for a variety of intestinal operations. Methods: 28 cases (May 1998 to October 2000) were performed in which the pfannenetiel incision was used. The operativetechnique generallyinvolved initial laparoscopicmobilization of the hepatic and/or splenic flexure, thereby bringing the bowel into the operativefield. Data were compiled by review of the medical records and patient quesfionnalre. Results: 11 males and 17 females underwent surgery, the average age being 40 + / - 15 (SD) years. The procedures included Ueocolectomy(20), small bowel resection (3), sigmoid resection (3), total abdominal colectomy (1), and lysis of adhesions (1). 20 patients had Crohn s disease, 8 of whom had complicated disease including fistulae (3 ileovesicle, 5 ileosigmoid) and/or abscess (2) at the time of surgery. There were no conversionsto other taparotomyincisions. The operative time averaged151 + / - 40 minutes, the median length of hospital stay was 4 + / - 1.5 days, with first flatus occurring on day 3 + / - 1.2. Post-operativecomplications included early small bowel obstruction (1) and abscess requiring percutaneousdrainage (2). At follow up, patients reported a median time to return to full activity of 28 + / - 15 days. Narcotic pain medication was required for 5 + / - 5 days after hospital discharge, however 8 patients reported not requiring any pain medicationat home. All patients reported excellent satisfaction with the procedure and the cosmetic result. Conclusions: The laparoscopicallyassisted pfannenstieloperation is feasiblefor a variety of gastrointestinalsurgical procedures, even those involving extensive inflammatory processessuch as abscessand/or fistulae. The technique provides excellent results in regard to overall morbidity and cosmesis and may be a preferred alternativeto the standard midline laparotomy.
bands removed for inadequateweight loss (12%) and all were converted to gastric bypass (GB). Eighteen had bands removed for obstruction (21%), 7 had band revision, 8 were converted to GB, and 3 were removed. Another 3 patients from other surgeons had band replacementfor obstruction, 2 were convertedto GB and one had a band revision. Fivebands of our 85 were removed for infection (6%). Two were infected peri-operatively (1 skin and 1 bowel flora), 1 eroded, and two developedinfections years after band placement.One band was replacedwith resolution of infection, and four had conversion to GB. All three patients who underwent band removal regainedtheir weight. Conversionto GB or band replacement for obstruction resulted in maintenance or improvement of weight loss. Eight of the 10 convertedto GBfor inadequateweight loss, subsequentlylost weight. One died of a pulmonary embolus. Other major complications included 3 strictures requiring post-operative dilations, 2 wound infections, and 4 patients developedseveredepression after conversion to GB. One patient's stricture was treated with glucocorticoids, and developed a severe but reversible neuropethy.Two of the obstructed patients had megaesophagusthat resolvedwith conversion to GB. A laparoscopicapproach was used to convert four of these patients to GB, for 1 band replacement, and for all simple removals. CONCLUSIONS:After gastric banding one-third of the patients required revision, a higher rate than that reported outside the U.S. Conversion to gastric bypass was influenced by insurance coverage and surgeon experience.Outcomes were generally favorable but major complications including death occurred. As experience accumulates, more conversions can be completed laparoscopically.A cost-effective analysis will be required to determine whether this initially less invasive approach is as effective as GB in the U.S. 2479 Risk Assessmentfor Major Complications of Gastric Bypass Surgery Sergio Huerta, UCLA Ctr for Human Nutrition, Los Angeles, CA; Scott Lee, UCLA Sch of Medicine, Los Angeles, CA; David Heber, UCLA Ctr for Human Nutrition, Los Angeles, CA; Edward H. Livingston, VA Greater Los Angeles and UCLA, Los Angeles, CA Background/Objectives:The incidenceof obesity is rapidly increasing resulting in performance of a greeter number of gastric bypass procedures. Despite the high surgical risk the overall complication rate remains low. However, complications do occur and so far no study has prospectively examined a large cohort of patients to determine what preoperative clinical features predict postoperativecomplications. Methods: 548 patients (428 female, 120 Male) were prospectivelyevaluatedfor 10 potential dsk factors: Age, sex, weight, body mass index, history of smoking, hypertension, osteoarthritis, diabetes, and sleep apnea and reV=sional operation. The hospital quality assurance coordinator monitored outcomes for all patients. Pulmonary embolus, evisceration, major anastomotic leak (requiring reoperetion or hospital stay> 10 days), intraabdominalabscessesor sepsis, pneumoniaand death were categorized as the major complications. Data with continuous vadables (age, weight and body mass index) were compared by t-tests. Discrete variables (sex, smoking history, hypertension, osteoarthritis, diabetes,sleep apnea, and revisional operation) were evaluatedby contingency table analysis. Results: 548 patients underwent gastric bypass procedure in the time period between December 1993 and December 1999. There were 19 major complications (3.5%) with nine deaths (1.6%). Maleswere more likely to havecomplicationsthan females (p = .002), and there was a non significant trend for a higher complication rate in diabetics (p =.069). Weight was also an independentrisk factor. The meanweight for patientswithout complications was 333.9-+3.4 and for those with complications397.3-+23.6 (p = 0.015), There were 6 major anastomotic leaks, 5 pulmonary emboli, 2 eviscerations,2 patients developedsepsis with no source identified, 1 severe marginal ulcer, 1 anastomotic obstruction requiring reoperation, 1 bowel obstruction requidng reoperation and 1 portal vein injury. Conclusions: Our gastric bypass patients were larger (mean BM1=53.8 -+ 0.5) than those included in most other seriesyet havecomparablemorbidity and mortality. The major risk factors predicting significant complications were being male and superobesity. In contrast to pdor retrospectiveanalysis, revisional operations did not increase the risk of major postoperative complications. Major complications may be minimized by preoperativemedicallyinducedweight loss prior to gastric bypass surgery for superobesemales.
2477 Laparoscopic Roux-ea-Y Gastric Bypass is More Effective than Laparoscopic Gastric Banding for Weight Loss. Theresa M. Quinn, Michel Gagner, John De Csepel, Stephen Burpce, Todd Francone, Daniel Herron, A/tons Pomp, Mount Sinai Hosp, New York, NY BACKGROUND:Laparoscopicgastric banding (Lap Band) is the most commonly performed morbid obesity operation in Europe. The major benefits of banding are easy reversibility and minimal invasiveness. Laparoscopic Roux-en-Y gastric bypass (RGB) is another effective weight loss procedure. The purpose of this study was to compare the effectiveness (BMI <35 kg/m2) and re-operationrateof Lap Bandwith laparoscopicRGB.METHODS:We analyzed patients undergoing Lap Band (n=80) and RGB (n=73) at a single instttution. RESULTS: In the band group, there were 16 men and 64 women. In the RGB group, there were 14 men and 59 women. The table below compares the preoperativeand postoperativeBMI (kg/m2). Two (2.5%) patientswith the Lap Bandachieveda BM1<35 kg/m2. Two (2.5%) of laparoscopic banding operations were converted to open. Band slippage occurred in 24 % (n=19) of patients necessitatingoperative repair in nine cases, removal in six, and replacementin one. Other complications of the band included erosion (n = 1, 1.3%), port infection (n = 1, 1.3%) and port leak (n = 2, 2.5%). Owingto inadequateweight loss, nine patients (11.3%) underwent a second bariatric operation that included taparoscopic RGB (n = 6), open vertical banded gastroplasty (n=2), and open RGB (n= 1). Overall, twenty-six (33%) of patients with the Lap Band have required re-operation to date. In the laparoscopic RGB group, 56% (n=41) of patients achieved a BM1<35 kg/m2. No operations were converted to open. The wound and intra-abdominal infection rates were 2.7% (n=2) and 1.4% (n=l), respectively. Ten patients (14%) had early anastomotic stricture requiring endoscopic dilation. No RGB patient has requireda revision. CONCLUSIONS:LaparoscopicRGB is more effectivethan laparoscopic gastric banding in producing weight loss that will reduce obesity-relatedmorbidity. Banding has significant complicationsthat required revisionto another badetric operation. RGBcomplications were related to the anastomosis but easily addressed by non-operative means.
2480 Modeling Hospital Costs in Gastric Bypass J Chris Eagon, Donna Marin, Washington Univ, Dept of Surg, St. Louis, MO BACKGROUND:Roux-Ygastric bypass(GB) reducesobesity relatedcomorbidity, but considerable hearth care resources are consumed performing this operation. Greater understanding of the factors influencing operative costs is needed to permit rational cost-benefit analyses by health care providers and insurors. Our aim was to determine to what extent clinical vadables can be used to predict GB hospital costs and to develop a model for these costs. METHODS: From 7/97 through 8•00, 161 patients underwent GB by a single surgeon at a teaching hospital.Clinicalvadableswere age,sex, BMI, and presenceof diabetes,hypertension, sleep apnea, heart failure, lapardscopic approach, and the complications leak, PE, MI, SBO, GI bleed, decubitus wounds, stenosis, wound infection, postop transfusion, and incisional hemia. Total hospital costs (TC) were the summation of fixed and variable costs of individual charge items derived from inpatient billing records. Stepwise multiple regression was used to derive a linear model of TC both with and without TC outliers (5) included. RESULTS:123 women and 38 men underwent GB with an average (mean+_SD)age of 43+8 yrs and BMI of 56-+12 kg/m2, and 40% were laparoscopic. Comorbidities included: DM 25%, HTN 54%, sleepapnea57%, heartfailure 9%. Mortality within 3 months occurred in 1.2%. Complications occurred in 35%, but most occurred in the outpatient setting not reflected in TC. In-hospital complications occurred in 9% including leak 1.2%, MI 1.2%, PE 3%, SBO 12%, GI bleed 2.5%, and decubitus wounds 1.9%. The TC (mean-+SEM) was $14580-+1808 including outliers and $11163-+258 excluding outliers. Regression including outliers yielded a four vadable model including DECUB,MI, leak, and transfusion with an adjusted R2of .60. With outliers excluded,a six variable model yielded an adjusted Wof .43: TC = 7797 + 68*age + 8214"MI + 2958*transfusion + 9669*decubitus + 3529"GI bleed + 3949"SB0 BMI showed colineadty with decubitus wounds and was a significant predictor of TC only when postop complicationswere not included in the model. CONCLUSIONS:SignificantTC variability (43%) can be attributed to patient age and the occurrence of a small number of high cost
Body Mass index (kg/rnz)
Band RGB
Preop
6 mos
12 mos
18 mos
24 mos
49+/-8 50 +/-8
44+/-8 33 +/- 10
41+/-10 28 +/12
40+/-8 32 +/-7
42+/-7 29 +•-3
2478 Treatment Of Poor OutcomesAfter Adjustable Gastric Banding For Morbid Obesity. Louis F. Martin, Louisiana State Univ Sch of Medicine, New Orleans, LA; William J. Raum, Teresa Klainer, Iris Bethancourt, LSU Health Science Ctr, New Orleans, I_A; Kenneth R. Bibbins, Univ of New Orleans, New Odeans, I_A; J P. O'Leary, LSU Health ScienceCtr, New Orleans, LA BACKGROUND:The adjustablegastric band has beentouted as an innovativeand less invasive approach to the treatment of severe obesity. This device is still under evaluation by the FDA. A defined incidence of failure needs to be established. Although the exact rate has not yet been determined, in this report we detail our expedencein recovery of patients who have a less than ideal outcome. METHODS:We report our experiencein 85 adjustablegastric bands placedsince 1995. We havefollowed another20 patientswho had their bandsplacedelsewhere. RESULTS: In our cohort, 28 patients (33%) had bands removed (4 patients twice). Ten had
A-487
complications including decubitus wounds, MI, transfusion, and leak. This analysis can be used to estimate the cost of complications after GB. Larger amounts of health care resources will likely be consumed when performing GB on older patients and on those with larger BMI.
2481 A Prospective Evaluation of Esophagogastreduodenoscopy(EGD) in a Population at increased Risk for Gastric Cancer Stuart G. Marcus, HengheTian, Yvette Lam, Chun T. Wong, Javier Ortega, NYU Sch of Medicine, New York, NY; Elliot Newman, NYU Medical Ctr, New York, NY; Peter Shamamian, SamanthaGarbers, Gerald Villanueva, Herman Yee, NYU Sch of Medicine, New York, NY Background: EGD is not routinely recommendedin the initial evaluationof dyspepsiaalthough gastric cancer may be the underlying etiology. Heliobacter pylori (Hp) infection, gastric ulceration, atrophic gastritis, intestinal metapiasia(IM), and dysplasiaare pre-malignahtlesions of the stomach associatedwith progressionto gastric cancer and may presentwith dyspepsia. The purpose of this study was to prospectivelyanalyzethe utility of EGD in detecting gastric cancer and pro-malignant lesions in the initial evaluationof high risk EastAsian subjects with dyspepsia. Methods: From October 1998 to June 2000, East Asian subjects > 45 years old with dyspepsia were recruited from the local community for an IRB approved gastric cancer screening protocol. We have previously identified this population as having an increasedrisk of gastric cancer. 109 individuals completing history, physical exam, EGD with biopsies, and pathologic review were included. Pro-malignantlesions were analyzedaccording to the status of associated chronic gastritis (active vs. inactive). Results: The median age was 48 years. 49% were male.All were immigrants; 81% from China,7% Korea,6% Vietnam,6% elsewhere. 85% did not speak English. 23% were in the U.S. <5 years, 32% 6-10 years, 45% >10 years. Gross endoscopicfindings were as follows: 20% normal, 74% gastritis, 6% ulcer, 5% esophagitis, 1 subject with esophagealcancer. Histelogic findings were as follows: Of 54 (49.5%) subjects with chronic active gastritis, all were Hp (+), 37% had atrophic gastritis, 50% had IM, none had dysplasla, 81% had healed gastric ulceration or active regenerative mucosa. Of 54 (49.5%) subjects with chronic inactive gastritis, 63% were Hp (+), 63% had atrophic gastritis, 37% had IM, 4% had dysplasia,94% had healedgastric ulceration or active regenerativemucosa. 1 subject without chronic gastritis had atrophy and IM History, physical exam, and status of chronic gastritis were not predictive of pro-malignant changes. Conclusions: Pre-malignantchangesof the stomach are prevalentin this high risk immigrant population. Detailedhistologic analysisof EGD biopsies is the only reliable indicator of pro-malignant changes. To identity those high risk dyspeptic patients with the greatestthreat of progression to gastric cancer, EGD with biopsies is recommendedas an initial test in these individuals. Long term follow-up, including repeat EGD, will determine the clinical implications of these pre-malignant changes.
2482
postoperativeendoscopy.Forty-threerequired dilation. Fifty-five percent (24/43) required only one dilation at an averageof 5.5 weeks postoperatively (range, 3 to 9 weeks); 33% (14/42) underwent 2 dilations, and 12% (5/42) required > 2 dilations (range, 6 -28 weeks) postoperatively. The stricture rate was 11.6% overall: ROB (GJ) 42/290 (14.4%) vs. BPD/DS (DI) 1/80 (1%). Twenty six percent (11/43) of patients with stenosis had undergone previous barlatric surgery. Other features associated with stenosis were intraoperative leak 4/43 (9%) and postoperative therapeutic endoscopy (injection/bicap) for anastomotic bleeding 2/43 (5%). Twelve percent (5/43) of patients with stenosis had beentreated for H. py/ori preoperatively. We detected a margJnaJulcer in one patient with a stricture and in three others without evidence of a stricture (4/370, 1.1%). Dilation was complicated by perforation in 3/43 (7%) with two paBents requiring operative repair (5%). One patient failed dilation and required operative revision. CONCLUSIONS:Gastro-jejunostomy stricture in the Roux-en-Y gastric bypass accounts for nearly all the stenoses in this series, presents early in the postoperative period and is amenableto endoscopictreatment with acceptablemorbidity and no mortality. The stenosis rarely requires operative intervention. Previous bariatric operation markedly increases the risk of anastomotic stricture.
2484 Achieving RO Resection for Locally Advanced Gastric Cancer: Is It Worth the Risk with Multi-Organ Resection? Robert C G Martin II. Memorial Sloan-KetteringCancer Ctr. New York, NY; Murray F. Brenean, David P. Jaques, Dennis Leuog, MSKCC, New York, NY; Martin Karpeh, MSLCC, New York, NY Introduction: In gastric adenocarcinoma,only complete resection (RO) translates into survival benefit. Giventhe potential for increasedmorbidity and mortality from multiple organ resection we asked the question as to whether extended (multiple organ) resection was justified for advanced gastric cancer. Methods: From 7/85 to 7/2000, 2112 patients underwent gastric resection for adenocarcinoma, and were entered and followed in a prospectively recorded database.Four hundred and eighteen patients undergoing primary resection had one or more organs resected in addition to the stomach. Clinicopathologic, operative, and survival data was compared betweenthese groups. Complicationswere categorizedby severity on a scale from 0 to 5; 0 no complication, 1 oral antibiotics, 2 intravenousantibiotics or TPN, 3 operative or intervendonal radiology drainage, 4 enteral diversion, and 5 death. Chi square analysis as well as Logistic Regression method was used to compare and estimate factors significant for complications. Results: Three hundred and thirty-seven patients with a single additional organ resected,63 two organs, and 18 with three organs. Logistic regression identified only the number of organs resected, two or greater, to be predictive of complications (RR 2.0). When excluding minor complications (values 1 and 2), again number of organs resected (RR 3.8) was a significant factor of severecomplications (values3, 4, and 5). Conclusion: Resection of 2 or greater adjacentorgans in advancedgastric adanocarcinomaincreasescomplications, but is associatedwith an equivalent median survival (16.9 men) when compared to patients with one organ resected (16.5 mon).
Conservative Management Of Ingested Foreign Bodica Steven T. Wetland, Michael J. Schurr, Bruce A. Harms, Univ of Wisconsin, Madison, Wl
Owgan
We reviewedthe clinical benefit of hospitalization,esophago-gastmduodenoscopy(EGD),and surgical interventionfor ingestedforeign bodies (FB) in adults. Methods: A lO-year experience is reported. Patient s presenting physical examination,white blood count (WBC), length of stay, number and types of FB ingested, endoscopic interventions, surgical interventions and complications of interventions were reviewed. Results: 75 separatehospital admissions occurred in 22 male prisoners. 256 FB were ingested (avg 3.4 per admit). Patients incurred 281 hospitalizationdays (avg 3.7 days per admit). One presentedwith peritonealsigns. White blood cell counts were less that 10 in 85% (avg 8.3). Only 2 patients had WBC greater than 12. EGD results: 64 EGD s were performed with removal of 79/163 FB (48% success rate). Five patients required general anesthesia due to lack of cooperation. Four complications occurred (6%), one requiring laparotomy. Surgical results: 9 laparotomieswere performed. One was performed for an acute abdomen on admission and one for the developmentof an acute abdomenafter conservativemanagement.One was performed due to an EGD complication. Two were performed to remove metal bezoars. Four additional laparotomies were performed secondaryto surgeon managementpreference.Conservativemanagementresults: In 23 admits managedconservatively,77 of 79 FB passed spontaneously(97%). One required laparotomy. Summary: Of the 256 ingested FB, 79 were removed endoscopically, 71 were removed surgically, and 106 passed spontaneously.Size, shape and number of FB were not predictive of the ability to transit the intestinal tract. Conclusions: Foreign body ingestion is problematic in prisoners. When managed conservatively, most foreign bodies will pass spontaneously. EGD has a high failure rate and is associated with significant complications. Surgical interventions should be reservedfor the acute abdomen or large bezears.
Spbe~only
2483 Early Anastomotic Stricture Requiring EndoscopicDilation After Laparescapic Sariatric Operations Theresa M. Ouinn, Kenneth Miller, John De Csepal,Todd Francone,Anthony Weiss, James George, Daniel Herron, William Inabnet, Alfons Pomp, Michel Canner, Mount Sinai Hosp, New York, NY BACKGROUND:A circular stapled proximal anastomosisfor bafiatric surgery createsa consistent, restricted outlet but can be associatedwith stricture. The purpose of our study was to analyzethe incidence and predictive features of stricture requiring endoscopicdilatation after a circular, stapledanastomosisfor bariatric surgery. METHODS:We analyzed370 consecutive patients undergoing two laparoscopic bariatric operations over a 3.5 year period: Roux-enY gastric bypass (ROB, n=290) and biliopancreatic diversion with duodenal switch (BPD/ DS, n = 80). The proximal anastomosis for these procedures is a gastro-jejunostomy (GJ) and duodeno-ileostomy (DI), respectively. Forty-one patients presented for revision of a previous bariatric surgery. Patients who developed postoperative dysphagia and vomiting and required endoscopic evaluation were identified. RESULTS:Forty-six patients underwent
A-488
Ce4e~olW
Dyer only 2 organs 3oragns NI P~antu
N 1 6 6 3 3 2 8 6 3 1 8 4 1 8
Ilodddity (1&2) (3&4) 5
p
LOS (median)
Survival (median)
23%
12%
4% ns
15days
21.9mon
18%
12%
6% ns
14days
13.4mon
28%
4%
4% ns
14 days
tl.5 mon
29%
16%
2% 0.04
20 days
16.9 rnon
28%
39%
6% 0.01
23days
17.9mon
23%
13%
4%
15 days
16.6 mon
2485
Safety and Efficacy of Postoperative Continuous Positive Airway Pressure (CPAP) to Prevent Pulmonary Complications for Patients Following Upper GastroiMestinal Anastomosis, Sergio Huerta, UCLA Ctr for Human Nutrition, Los Angeles, CA; Scott Lee, UCLA, Los Angeles, CA; David Heber, UCLA Ctr for Human Nutrition, Los Angeles, CA; Robert Shpiner, UCLA Pulmonary Medicine, Los Angeles, CA; Edward H. Livingston, VA Greater Los Angeles and UCLA, Los Angeles, CA Background/Objectives: CPAP is utilized to prevent apneic arrest and/or hypoxia for sleep apnea patients. This modality has not been universally acceptedfor patients following upper intestinal surgery secondary to concerns that pressurized air will inflate the stomach and intestine resulting in anastomotic disruption. This study was performed to assess the safety and efficacy of postoperative CPAP for patients undergoing gastrojejunostomy as part of a gastric bypass procedure.Methods: BetweenDecember1993 and December1999, 548 obese patients were prospectivelyevaluatedfor complications of gastric bypass procedures.Patients with sleep apnea who required CPAP had the device placed immediately following surgery and continued to use CPAPthroughout their hospitalization.Pressure settings were the same as used at home. Major complications were reviewed and catalogued by the hospital OA coordinator. Contingency table analysis was used to determine if CPAP contributed to the incidence of anastomotic leak. Results: Of the 548 patients undergoing gastric bypass 224 had obstructive sleep apnea requiring CPAP. There were 6 major anastomotic leaks, 3 of which occurred in CPAPtreated patients. Contingencytable analysis revealedno statistically significant effect of CPAP use and the incidence of major anastomotic leakage.There were 19 major complications in this series of patients, 5 were pulmonary emboli. Notably, there
bands removed for inadequateweight loss (12%) and all were converted to gastric bypass (GB). Eighteen had bands removed for obstruction (21%), 7 had band revision, 8 were converted to GB, and 3 were removed. Another 3 patients from other surgeons had band replacementfor obstruction, 2 were convertedto GB and one had a band revision. Fivebands of our 85 were removed for infection (6%). Two were infected peri-operatively (1 skin and 1 bowel flora), 1 eroded, and two developedinfections years after band placement.One band was replacedwith resolution of infection, and four had conversion to GB. All three patients who underwent band removal regainedtheir weight. Conversionto GB or band replacement for obstruction resulted in maintenance or improvement of weight loss. Eight of the 10 convertedto GBfor inadequateweight loss, subsequentlylost weight. One died of a pulmonary embolus. Other major complications included 3 strictures requiring post-operative dilations, 2 wound infections, and 4 patients developedseveredepression after conversion to GB. One patient's stricture was treated with glucocorticoids, and developed a severe but reversible neuropethy.Two of the obstructed patients had megaesophagusthat resolvedwith conversion to GB. A laparoscopicapproach was used to convert four of these patients to GB, for 1 band replacement, and for all simple removals. CONCLUSIONS:After gastric banding one-third of the patients required revision, a higher rate than that reported outside the U.S. Conversion to gastric bypass was influenced by insurance coverage and surgeon experience.Outcomes were generally favorable but major complications including death occurred. As experience accumulates, more conversions can be completed laparoscopically.A cost-effective analysis will be required to determine whether this initially less invasive approach is as effective as GB in the U.S. 2479 Risk Assessmentfor Major Complications of Gastric Bypass Surgery Sergio Huerta, UCLA Ctr for Human Nutrition, Los Angeles, CA; Scott Lee, UCLA Sch of Medicine, Los Angeles, CA; David Heber, UCLA Ctr for Human Nutrition, Los Angeles, CA; Edward H. Livingston, VA Greater Los Angeles and UCLA, Los Angeles, CA Background/Objectives:The incidenceof obesity is rapidly increasing resulting in performance of a greeter number of gastric bypass procedures. Despite the high surgical risk the overall complication rate remains low. However, complications do occur and so far no study has prospectively examined a large cohort of patients to determine what preoperative clinical features predict postoperativecomplications. Methods: 548 patients (428 female, 120 Male) were prospectivelyevaluatedfor 10 potential dsk factors: Age, sex, weight, body mass index, history of smoking, hypertension, osteoarthritis, diabetes, and sleep apnea and reV=sional operation. The hospital quality assurance coordinator monitored outcomes for all patients. Pulmonary embolus, evisceration, major anastomotic leak (requiring reoperetion or hospital stay> 10 days), intraabdominalabscessesor sepsis, pneumoniaand death were categorized as the major complications. Data with continuous vadables (age, weight and body mass index) were compared by t-tests. Discrete variables (sex, smoking history, hypertension, osteoarthritis, diabetes,sleep apnea, and revisional operation) were evaluatedby contingency table analysis. Results: 548 patients underwent gastric bypass procedure in the time period between December 1993 and December 1999. There were 19 major complications (3.5%) with nine deaths (1.6%). Maleswere more likely to havecomplicationsthan females (p = .002), and there was a non significant trend for a higher complication rate in diabetics (p =.069). Weight was also an independentrisk factor. The meanweight for patientswithout complications was 333.9-+3.4 and for those with complications397.3-+23.6 (p = 0.015), There were 6 major anastomotic leaks, 5 pulmonary emboli, 2 eviscerations,2 patients developedsepsis with no source identified, 1 severe marginal ulcer, 1 anastomotic obstruction requiring reoperation, 1 bowel obstruction requidng reoperation and 1 portal vein injury. Conclusions: Our gastric bypass patients were larger (mean BM1=53.8 -+ 0.5) than those included in most other seriesyet havecomparablemorbidity and mortality. The major risk factors predicting significant complications were being male and superobesity. In contrast to pdor retrospectiveanalysis, revisional operations did not increase the risk of major postoperative complications. Major complications may be minimized by preoperativemedicallyinducedweight loss prior to gastric bypass surgery for superobesemales.
2477 Laparoscopic Roux-ea-Y Gastric Bypass is More Effective than Laparoscopic Gastric Banding for Weight Loss. Theresa M. Quinn, Michel Gagner, John De Csepel, Stephen Burpce, Todd Francone, Daniel Herron, A/tons Pomp, Mount Sinai Hosp, New York, NY BACKGROUND:Laparoscopicgastric banding (Lap Band) is the most commonly performed morbid obesity operation in Europe. The major benefits of banding are easy reversibility and minimal invasiveness. Laparoscopic Roux-en-Y gastric bypass (RGB) is another effective weight loss procedure. The purpose of this study was to compare the effectiveness (BMI <35 kg/m2) and re-operationrateof Lap Bandwith laparoscopicRGB.METHODS:We analyzed patients undergoing Lap Band (n=80) and RGB (n=73) at a single instttution. RESULTS: In the band group, there were 16 men and 64 women. In the RGB group, there were 14 men and 59 women. The table below compares the preoperativeand postoperativeBMI (kg/m2). Two (2.5%) patientswith the Lap Bandachieveda BM1<35 kg/m2. Two (2.5%) of laparoscopic banding operations were converted to open. Band slippage occurred in 24 % (n=19) of patients necessitatingoperative repair in nine cases, removal in six, and replacementin one. Other complications of the band included erosion (n = 1, 1.3%), port infection (n = 1, 1.3%) and port leak (n = 2, 2.5%). Owingto inadequateweight loss, nine patients (11.3%) underwent a second bariatric operation that included taparoscopic RGB (n = 6), open vertical banded gastroplasty (n=2), and open RGB (n= 1). Overall, twenty-six (33%) of patients with the Lap Band have required re-operation to date. In the laparoscopic RGB group, 56% (n=41) of patients achieved a BM1<35 kg/m2. No operations were converted to open. The wound and intra-abdominal infection rates were 2.7% (n=2) and 1.4% (n=l), respectively. Ten patients (14%) had early anastomotic stricture requiring endoscopic dilation. No RGB patient has requireda revision. CONCLUSIONS:LaparoscopicRGB is more effectivethan laparoscopic gastric banding in producing weight loss that will reduce obesity-relatedmorbidity. Banding has significant complicationsthat required revisionto another badetric operation. RGBcomplications were related to the anastomosis but easily addressed by non-operative means.
2480 Modeling Hospital Costs in Gastric Bypass J Chris Eagon, Donna Marin, Washington Univ, Dept of Surg, St. Louis, MO BACKGROUND:Roux-Ygastric bypass(GB) reducesobesity relatedcomorbidity, but considerable hearth care resources are consumed performing this operation. Greater understanding of the factors influencing operative costs is needed to permit rational cost-benefit analyses by health care providers and insurors. Our aim was to determine to what extent clinical vadables can be used to predict GB hospital costs and to develop a model for these costs. METHODS: From 7/97 through 8•00, 161 patients underwent GB by a single surgeon at a teaching hospital.Clinicalvadableswere age,sex, BMI, and presenceof diabetes,hypertension, sleep apnea, heart failure, lapardscopic approach, and the complications leak, PE, MI, SBO, GI bleed, decubitus wounds, stenosis, wound infection, postop transfusion, and incisional hemia. Total hospital costs (TC) were the summation of fixed and variable costs of individual charge items derived from inpatient billing records. Stepwise multiple regression was used to derive a linear model of TC both with and without TC outliers (5) included. RESULTS:123 women and 38 men underwent GB with an average (mean+_SD)age of 43+8 yrs and BMI of 56-+12 kg/m2, and 40% were laparoscopic. Comorbidities included: DM 25%, HTN 54%, sleepapnea57%, heartfailure 9%. Mortality within 3 months occurred in 1.2%. Complications occurred in 35%, but most occurred in the outpatient setting not reflected in TC. In-hospital complications occurred in 9% including leak 1.2%, MI 1.2%, PE 3%, SBO 12%, GI bleed 2.5%, and decubitus wounds 1.9%. The TC (mean-+SEM) was $14580-+1808 including outliers and $11163-+258 excluding outliers. Regression including outliers yielded a four vadable model including DECUB,MI, leak, and transfusion with an adjusted R2of .60. With outliers excluded,a six variable model yielded an adjusted Wof .43: TC = 7797 + 68*age + 8214"MI + 2958*transfusion + 9669*decubitus + 3529"GI bleed + 3949"SB0 BMI showed colineadty with decubitus wounds and was a significant predictor of TC only when postop complicationswere not included in the model. CONCLUSIONS:SignificantTC variability (43%) can be attributed to patient age and the occurrence of a small number of high cost
Body Mass index (kg/rnz)
Band RGB
Preop
6 mos
12 mos
18 mos
24 mos
49+/-8 50 +/-8
44+/-8 33 +/- 10
41+/-10 28 +/12
40+/-8 32 +/-7
42+/-7 29 +•-3
2478 Treatment Of Poor OutcomesAfter Adjustable Gastric Banding For Morbid Obesity. Louis F. Martin, Louisiana State Univ Sch of Medicine, New Orleans, LA; William J. Raum, Teresa Klainer, Iris Bethancourt, LSU Health Science Ctr, New Orleans, I_A; Kenneth R. Bibbins, Univ of New Orleans, New Odeans, I_A; J P. O'Leary, LSU Health ScienceCtr, New Orleans, LA BACKGROUND:The adjustablegastric band has beentouted as an innovativeand less invasive approach to the treatment of severe obesity. This device is still under evaluation by the FDA. A defined incidence of failure needs to be established. Although the exact rate has not yet been determined, in this report we detail our expedencein recovery of patients who have a less than ideal outcome. METHODS:We report our experiencein 85 adjustablegastric bands placedsince 1995. We havefollowed another20 patientswho had their bandsplacedelsewhere. RESULTS: In our cohort, 28 patients (33%) had bands removed (4 patients twice). Ten had
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complications including decubitus wounds, MI, transfusion, and leak. This analysis can be used to estimate the cost of complications after GB. Larger amounts of health care resources will likely be consumed when performing GB on older patients and on those with larger BMI.
2481 A Prospective Evaluation of Esophagogastreduodenoscopy(EGD) in a Population at increased Risk for Gastric Cancer Stuart G. Marcus, HengheTian, Yvette Lam, Chun T. Wong, Javier Ortega, NYU Sch of Medicine, New York, NY; Elliot Newman, NYU Medical Ctr, New York, NY; Peter Shamamian, SamanthaGarbers, Gerald Villanueva, Herman Yee, NYU Sch of Medicine, New York, NY Background: EGD is not routinely recommendedin the initial evaluationof dyspepsiaalthough gastric cancer may be the underlying etiology. Heliobacter pylori (Hp) infection, gastric ulceration, atrophic gastritis, intestinal metapiasia(IM), and dysplasiaare pre-malignahtlesions of the stomach associatedwith progressionto gastric cancer and may presentwith dyspepsia. The purpose of this study was to prospectivelyanalyzethe utility of EGD in detecting gastric cancer and pro-malignant lesions in the initial evaluationof high risk EastAsian subjects with dyspepsia. Methods: From October 1998 to June 2000, East Asian subjects > 45 years old with dyspepsia were recruited from the local community for an IRB approved gastric cancer screening protocol. We have previously identified this population as having an increasedrisk of gastric cancer. 109 individuals completing history, physical exam, EGD with biopsies, and pathologic review were included. Pro-malignantlesions were analyzedaccording to the status of associated chronic gastritis (active vs. inactive). Results: The median age was 48 years. 49% were male.All were immigrants; 81% from China,7% Korea,6% Vietnam,6% elsewhere. 85% did not speak English. 23% were in the U.S. <5 years, 32% 6-10 years, 45% >10 years. Gross endoscopicfindings were as follows: 20% normal, 74% gastritis, 6% ulcer, 5% esophagitis, 1 subject with esophagealcancer. Histelogic findings were as follows: Of 54 (49.5%) subjects with chronic active gastritis, all were Hp (+), 37% had atrophic gastritis, 50% had IM, none had dysplasla, 81% had healed gastric ulceration or active regenerative mucosa. Of 54 (49.5%) subjects with chronic inactive gastritis, 63% were Hp (+), 63% had atrophic gastritis, 37% had IM, 4% had dysplasia,94% had healedgastric ulceration or active regenerativemucosa. 1 subject without chronic gastritis had atrophy and IM History, physical exam, and status of chronic gastritis were not predictive of pro-malignant changes. Conclusions: Pre-malignantchangesof the stomach are prevalentin this high risk immigrant population. Detailedhistologic analysisof EGD biopsies is the only reliable indicator of pro-malignant changes. To identity those high risk dyspeptic patients with the greatestthreat of progression to gastric cancer, EGD with biopsies is recommendedas an initial test in these individuals. Long term follow-up, including repeat EGD, will determine the clinical implications of these pre-malignant changes.
2482
postoperativeendoscopy.Forty-threerequired dilation. Fifty-five percent (24/43) required only one dilation at an averageof 5.5 weeks postoperatively (range, 3 to 9 weeks); 33% (14/42) underwent 2 dilations, and 12% (5/42) required > 2 dilations (range, 6 -28 weeks) postoperatively. The stricture rate was 11.6% overall: ROB (GJ) 42/290 (14.4%) vs. BPD/DS (DI) 1/80 (1%). Twenty six percent (11/43) of patients with stenosis had undergone previous barlatric surgery. Other features associated with stenosis were intraoperative leak 4/43 (9%) and postoperative therapeutic endoscopy (injection/bicap) for anastomotic bleeding 2/43 (5%). Twelve percent (5/43) of patients with stenosis had beentreated for H. py/ori preoperatively. We detected a margJnaJulcer in one patient with a stricture and in three others without evidence of a stricture (4/370, 1.1%). Dilation was complicated by perforation in 3/43 (7%) with two paBents requiring operative repair (5%). One patient failed dilation and required operative revision. CONCLUSIONS:Gastro-jejunostomy stricture in the Roux-en-Y gastric bypass accounts for nearly all the stenoses in this series, presents early in the postoperative period and is amenableto endoscopictreatment with acceptablemorbidity and no mortality. The stenosis rarely requires operative intervention. Previous bariatric operation markedly increases the risk of anastomotic stricture.
2484 Achieving RO Resection for Locally Advanced Gastric Cancer: Is It Worth the Risk with Multi-Organ Resection? Robert C G Martin II. Memorial Sloan-KetteringCancer Ctr. New York, NY; Murray F. Brenean, David P. Jaques, Dennis Leuog, MSKCC, New York, NY; Martin Karpeh, MSLCC, New York, NY Introduction: In gastric adenocarcinoma,only complete resection (RO) translates into survival benefit. Giventhe potential for increasedmorbidity and mortality from multiple organ resection we asked the question as to whether extended (multiple organ) resection was justified for advanced gastric cancer. Methods: From 7/85 to 7/2000, 2112 patients underwent gastric resection for adenocarcinoma, and were entered and followed in a prospectively recorded database.Four hundred and eighteen patients undergoing primary resection had one or more organs resected in addition to the stomach. Clinicopathologic, operative, and survival data was compared betweenthese groups. Complicationswere categorizedby severity on a scale from 0 to 5; 0 no complication, 1 oral antibiotics, 2 intravenousantibiotics or TPN, 3 operative or intervendonal radiology drainage, 4 enteral diversion, and 5 death. Chi square analysis as well as Logistic Regression method was used to compare and estimate factors significant for complications. Results: Three hundred and thirty-seven patients with a single additional organ resected,63 two organs, and 18 with three organs. Logistic regression identified only the number of organs resected, two or greater, to be predictive of complications (RR 2.0). When excluding minor complications (values 1 and 2), again number of organs resected (RR 3.8) was a significant factor of severecomplications (values3, 4, and 5). Conclusion: Resection of 2 or greater adjacentorgans in advancedgastric adanocarcinomaincreasescomplications, but is associatedwith an equivalent median survival (16.9 men) when compared to patients with one organ resected (16.5 mon).
Conservative Management Of Ingested Foreign Bodica Steven T. Wetland, Michael J. Schurr, Bruce A. Harms, Univ of Wisconsin, Madison, Wl
Owgan
We reviewedthe clinical benefit of hospitalization,esophago-gastmduodenoscopy(EGD),and surgical interventionfor ingestedforeign bodies (FB) in adults. Methods: A lO-year experience is reported. Patient s presenting physical examination,white blood count (WBC), length of stay, number and types of FB ingested, endoscopic interventions, surgical interventions and complications of interventions were reviewed. Results: 75 separatehospital admissions occurred in 22 male prisoners. 256 FB were ingested (avg 3.4 per admit). Patients incurred 281 hospitalizationdays (avg 3.7 days per admit). One presentedwith peritonealsigns. White blood cell counts were less that 10 in 85% (avg 8.3). Only 2 patients had WBC greater than 12. EGD results: 64 EGD s were performed with removal of 79/163 FB (48% success rate). Five patients required general anesthesia due to lack of cooperation. Four complications occurred (6%), one requiring laparotomy. Surgical results: 9 laparotomieswere performed. One was performed for an acute abdomen on admission and one for the developmentof an acute abdomenafter conservativemanagement.One was performed due to an EGD complication. Two were performed to remove metal bezoars. Four additional laparotomies were performed secondaryto surgeon managementpreference.Conservativemanagementresults: In 23 admits managedconservatively,77 of 79 FB passed spontaneously(97%). One required laparotomy. Summary: Of the 256 ingested FB, 79 were removed endoscopically, 71 were removed surgically, and 106 passed spontaneously.Size, shape and number of FB were not predictive of the ability to transit the intestinal tract. Conclusions: Foreign body ingestion is problematic in prisoners. When managed conservatively, most foreign bodies will pass spontaneously. EGD has a high failure rate and is associated with significant complications. Surgical interventions should be reservedfor the acute abdomen or large bezears.
Spbe~only
2483 Early Anastomotic Stricture Requiring EndoscopicDilation After Laparescapic Sariatric Operations Theresa M. Ouinn, Kenneth Miller, John De Csepal,Todd Francone,Anthony Weiss, James George, Daniel Herron, William Inabnet, Alfons Pomp, Michel Canner, Mount Sinai Hosp, New York, NY BACKGROUND:A circular stapled proximal anastomosisfor bafiatric surgery createsa consistent, restricted outlet but can be associatedwith stricture. The purpose of our study was to analyzethe incidence and predictive features of stricture requiring endoscopicdilatation after a circular, stapledanastomosisfor bariatric surgery. METHODS:We analyzed370 consecutive patients undergoing two laparoscopic bariatric operations over a 3.5 year period: Roux-enY gastric bypass (ROB, n=290) and biliopancreatic diversion with duodenal switch (BPD/ DS, n = 80). The proximal anastomosis for these procedures is a gastro-jejunostomy (GJ) and duodeno-ileostomy (DI), respectively. Forty-one patients presented for revision of a previous bariatric surgery. Patients who developed postoperative dysphagia and vomiting and required endoscopic evaluation were identified. RESULTS:Forty-six patients underwent
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Ce4e~olW
Dyer only 2 organs 3oragns NI P~antu
N 1 6 6 3 3 2 8 6 3 1 8 4 1 8
Ilodddity (1&2) (3&4) 5
p
LOS (median)
Survival (median)
23%
12%
4% ns
15days
21.9mon
18%
12%
6% ns
14days
13.4mon
28%
4%
4% ns
14 days
tl.5 mon
29%
16%
2% 0.04
20 days
16.9 rnon
28%
39%
6% 0.01
23days
17.9mon
23%
13%
4%
15 days
16.6 mon
2485
Safety and Efficacy of Postoperative Continuous Positive Airway Pressure (CPAP) to Prevent Pulmonary Complications for Patients Following Upper GastroiMestinal Anastomosis, Sergio Huerta, UCLA Ctr for Human Nutrition, Los Angeles, CA; Scott Lee, UCLA, Los Angeles, CA; David Heber, UCLA Ctr for Human Nutrition, Los Angeles, CA; Robert Shpiner, UCLA Pulmonary Medicine, Los Angeles, CA; Edward H. Livingston, VA Greater Los Angeles and UCLA, Los Angeles, CA Background/Objectives: CPAP is utilized to prevent apneic arrest and/or hypoxia for sleep apnea patients. This modality has not been universally acceptedfor patients following upper intestinal surgery secondary to concerns that pressurized air will inflate the stomach and intestine resulting in anastomotic disruption. This study was performed to assess the safety and efficacy of postoperative CPAP for patients undergoing gastrojejunostomy as part of a gastric bypass procedure.Methods: BetweenDecember1993 and December1999, 548 obese patients were prospectivelyevaluatedfor complications of gastric bypass procedures.Patients with sleep apnea who required CPAP had the device placed immediately following surgery and continued to use CPAPthroughout their hospitalization.Pressure settings were the same as used at home. Major complications were reviewed and catalogued by the hospital OA coordinator. Contingency table analysis was used to determine if CPAP contributed to the incidence of anastomotic leak. Results: Of the 548 patients undergoing gastric bypass 224 had obstructive sleep apnea requiring CPAP. There were 6 major anastomotic leaks, 3 of which occurred in CPAPtreated patients. Contingencytable analysis revealedno statistically significant effect of CPAP use and the incidence of major anastomotic leakage.There were 19 major complications in this series of patients, 5 were pulmonary emboli. Notably, there