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Multiple revisions of esophagogastric fundoplications: Why do they keep failing?
110 _+ 8 to 81 _+ 4 min (p < 0.001). Gastric emptying improved to a similar extent in patients with delayed (n= 11; emptying rate below 30%) and normal preoperative gastric emptying. Vagus nerve function showed postoperative signs of vagus nerve damage (PP peak < 47 pmol/L) in 4 patients (10%). In these 4 patients gastric emptying both before and after operation was not different from patients with normal vagus nerve function. In fact, none of the 41 patients had severely delayed emptying after hemifundoplication. Conclusion: Laparoscopic hemifundoplication affects vagus nerve integrity in 10% of patients but this does not necessarily lead to a delay in gastric emptying. In fact, postoperative gastric emptying improved significantly after operation.
patients. Methods: Data on all patients undergoing foregut surgery are collected prospectively. Patients who have unremitting dysphagia due to identifiable anatomic defects or objectively confirmed recurrent GERD are considered FGF failures and offered redo EGF. Between 1991-2002, 251 patients underwent redo EGF at our institution. Eighteen of these 251 patients (7%) required a second redo operation. Our experience with multiple redo EGF includes these 18, as well as an additional 36 patients who underwent their first redo EGF elsewhere. Overall, 54 patients underwent 2 redos, 5 had 3 redos, and 1 had 4 redos. Herein we report on our 18 patients that underwent both first and subsequent redo procedures at our institution. Results: Findings prompting consideration of second redo EGF included dysphagia (43%), recurrent GERD (48%), PEH (16%), dysmotility (7%), stricture (6%) and new Barrett's changes (1.8%). Many patients had multiple symptoms. Nearly one third presented for their second redo with different findings than those that led to their first redo, suggesting either significant progression of their disease or a new problem resulting from prior operation. Median time from first redo to second redo EGF was 16 months. At second redo surgery, 54% had wrap herniation above the diaphragm, 11% wrap disruption, 26% malpositioned wrap, and 11% a shortened esophagus. Not surprisingly, 19% had more than one operative finding. However, of those patients that had a herniated wrap at first redo, 85% had recurrent wrap hemiation at the time of second redo. There were no mortalities. Operative complications included pneumothorax (1.8%), gastrotomy (28%) and esophagotomy (3.8%). Median hospitalization was 5 days. Surveys obtained at a mean of 32 months after second redo revealed 66% patient satisfaction with results. Conclusions: Multiple failures of esophagngastric fundoplication is an unusual problem. Multiple redo EGF can be safely accomplished, but there is a significant rate of foregut visceral injury. The need for multiple redo EGF is most commonly related to wrap herniation, suggesting careful strategies are needed for managing the esophageal hiatus in the these patients.
M1893 Positron Emission Tomography (PET) Cannot Replace Computed Tomography (CT) and Endoscopic Uhrasonography (EUS) in the Staging of Adenocarcinoma of the Esophagus and the Esophagugastric Junction Jarmo A. Salo, Jari V. Rasdnen, Eero I. Sihvo, Juhani Knuuti Exact preoperative staging of adenocarcnioma of the esophagus and the esophagogastric junction is essential for accurate prognosis and selection of appropnate treatment modalities. The usefulness of PET in staging of esophageal cancer has often been postulated. However, there are no studies concerning solely adenocarcinoma of the esophagus and the esophagogastric junction including a sufficient number of histologically examined lymph nodes. Fortytwo patients with adenocarcinoma of the esophagus and the esophagogastric j unction suitable for radical esophageal resection were prospectively staged with PET, CT and EUS. The results were compared with histologically findings obtained at en-bloc esophagectomy and two-field lymphadenectomy. The total number of dissected lymph nodes was 3123 and the average number per patient was 33 (range 12-51) lymph nodes. The primary tumor was detectable in 35 out of 42 patients using PET (sensitivity 83%)and in 28 patients using CT (sensitivity 67%). In locoregional lymph node metastases the sensitivity of EUS (89%) was significantly higher than that of either CT (47%) or PET (37%), but the specificity was significantly poorer in EUS (54%) than in CT (92%)or in PET (100%). Fifteen (36%) of the 42 patients had metastatic lesions (6 distant lymph nodes and 9 organ metastases). The diagnostic specificity was here 89% in PET, 96% in CT and the diagnostic sensitivity 47% in PET and 33% in CT. The accuracy for metastatic lesions was 74% in PET and 74% in CT The false negative diagnoses of distant metastasis in PET were peritoneal carcinosis in 2 patients, abdominal para-aortic cancer growth in 1, metastatic lymph nodes by celiac artery in 4, and metastases in pancreas in 1. PET showed wrong positive lymph nodes at the jugulum in 3 patients. PET cannot be used as a single staging method of adenocarcinoma of the esophagus and the esophagugastric junction because of low accuracy in staging of paratumoral and distant lymph nodes. However PET detects organ metastases better than CT
M1896 Antireflux surgery in patients with Barrett'sesophagus: What happens when surgery fails? David A. McClusky III, Edward Lin, Rodrigo Gonzalez, Andrew B. Lederman, E. M. Ritter, Vickie Swafford, C. D. Smith Background: Barrett's esophagus represents a serious manifestation of chronic gastroesophageal reflux disease. In work presented at DDW last year, we have shown that antireflux surgery (ARS) is commonly effective in controlling GERD and stabilizing or reversing Barrett's changes. Methods: Patients who have unremitting dysphagia due to identifiable anatomic problems (e.g. wrap herniation or malposition) or objectively confirmed pathologic GERD are considered ARS failures and offered redo ARS. Herein we report our experience in patients with Barrett's esophagus who have ARS failures requiring redo ARS.Results: Between 1991 and 2002, 196 patients with GERD and biopsy confirmed Barrett's underwent primary ARS at our center. With a mean fofiow-up of 2.9 years (_+ 2.3), fourteen patients failed ARS and required subsequent redo ARS (7.1%). Twelve of these (86%) were evaluated and treated within two years of the primary ARS. This ARS failure rate was significantly higher than in patients who underwent ARS for uncomplicated GERD during the same time period (22/1026, 2.1%, p = <0.001). intraoperatively, primary wrap herniation was found in 10/ 14 patients (71%) (1 with associated fundoplication disruption). Three patients had a slipped wrap (21%), and 1 had no observable abnormality. An additional thirty-six patients with Barrett's esophagus had their initial ARS elsewhere and subsequently underwent redo at our center. The pattern of failure in this group was similar to that in those whose initial operation was performed at our center (72% wrap herniation, 17% slipped wrap, 1% no abnormality). In total, three patients underwent Colhs gastroplasty for shortened esophagus. Conclusion: Compared to patients with uncomplicated GERD antireflux surgery in patients with Barrett's esophagus has a high rate of failure requinng redo ARS. This is most likely due to the severity of the GERD and associated changes seen in these patients. Wrap herniation is the most common pattem of failure and esophageal lengthening may be necessary. Because of the complex issues in this subset of GERD patients they may best be cared for in specialized centers.
M1894 Pregnancy and Delivery After Antireflux Surgery: Effects on Gastroesophageal
Reflux Symptoms R0drigo Gonzalez, Steven P Bowers, Vickie Swafford, C. Daniel Smith INTRODUCTION: Concerns have been raised that pregnancy after antireflux surgery (ARS) may predispose to wrap disruption or herniation and adversely affect outcomes. Some surgeons withhold ARS in childbearing age women for fear of this, but outcomes in this population have not been reported. METHODS: Data on all patients undergoing foregut surgery at our center are collected prospecuvely. Between January 1991 and July 2000, 1,238 patients underwent ARS for the management of gastroesophageal reflux disease. Of these, 118 childbearing age women were identified and were asked to complete a detailed foll0w-up questionnaire. Patients with subsequent pregnancies (SP) after ARS were compared to patients without subsequent pregnancies (NP). RESULTS: Ninety-five of the 118 patients (81%) completed the questionnaire at a mean follow-up of 4.9 years. Fifteen patients had 19 subsequent pregnancies after undergoing ARS, and retching and/or vomiting were reported daring 13 of the pregnancies (69%). Long-term outcomes and failure rates were similar in both groups, except more patients in the SP group were satisfied with their ARS (Table 1), Redo ARS rate in this patient population is higher than that in all of our patients (2.5%). CONCLUSIONS: Childbearing age women have higher than expected rates of symptomatic and anatomic fundoplication failure. Subsequent pregnancy does not adversely affect outcomes after ARS, but antireflux surgery should be given careful consideration in childbearing age women due to high failure rates in these patients.
M1897 Elective Esophageal Surgery Consumes More Resources than Elective Surgery of Other Gastrointestinal Sites Srinevas K. Reddy, Hui-Chuan Lai, Laurence Genton, Kenneth A. Kudsk Aim: To budget for expenses related to the rising tide of health care costs, it is essential to identify those patients likely to consume the most resources. This study evaluates hospital and extra-hospital resource utilization in patients undergoing elective GI tract surgery at tertiary referral center. Methods: We reviewed charts of 1003 patients who underwent elective surgery of the esophagus, stomach, pancreas and colon between 1996 and 2001 for length (LOS) and cost of hospital stay, preoperative serum albumin, major post-operatwe complications (infections, organ fhilures, anastomotic leaks, decubitus ulcer, death) and use of home or nursing home (specialty) care after discharge. To focus on those patients who consume the most resources, we then separated patients with long (top quartile) and short LOS (lower 3 quartfles). Results: Patients with esophageal surgery had a significantly longer LOS (15 vs. 8 days) and a higher rate of complications (33% vs. 8%) and use of post-discharge specialty care (40% vs. 21%) than other patients having any other type of surgery(p<0.001). The 25% of patients with longest LOS consumed 39 to 46 % of total hospital resources in all surgical groups. Preoperative albumin negatively correlated with LOS for gasmc (r = -0.62), pancreatic (r = -0.22) and colonic (r = -0.45) procedures (p<0.05) but not for esophageal procedures. Conclusion: Greatest hospital and post-discharge health care resource consumption occurs in patients undergoing procedures on the esophagus compared to other sites. Preoperative albumin predicts LOS for all operative sites except for the esophagus.
Table 1. Antlreflux Surgery Outcomes NP (%) SP (%) Satisfaction 61 (76) 15 (100)1" eonp~aOeal =ymptoms 14 (18) 1 (7) e=trzeonphapal symptom 5 (6) 0 Aatleecn~o0y medication 18 (23) 2 (13) Nooormal pontop, studio= 10 (12) 1 (7) Poqdopmntlve dilations 8 (10) 1 (7) Rode AI~ 9(11} 0 I" F/sher's Exact Test: p
Total (%) 76 (80) 15 (16) 5 (5) 20 (21) 11 (12) 9 (9) 9 (9)~t
M1895 Multiple Revisions of EsophagogastricFundoplications: W h y Do They Keep Failing? Andrew B. Lederman, David A. McClusky [II, Rodrign Gonzalez, E. Matt Ritter, Leena Khaitan, C Daniel Smith Background: Although esophagogastric fundoplication (EGF) has been shown to be an effective procedure for management of GERD and paraesophageal hernia (PEH), there is a small group of patients for whom surgery fails and redo EGF is necessary. A subset of these patients require more than one redo operations Little data are available on these complicated
A-807
SSAT Abstracts
patients. Methods: Data on all patients undergoing foregut surgery are collected prospectively. Patients who have unremitting dysphagia due to identifiable anatomic defects or objectively confirmed recurrent GERD are considered FGF failures and offered redo EGF. Between 1991-2002, 251 patients underwent redo EGF at our institution. Eighteen of these 251 patients (7%) required a second redo operation. Our experience with multiple redo EGF includes these 18, as well as an additional 36 patients who underwent their first redo EGF elsewhere. Overall, 54 patients underwent 2 redos, 5 had 3 redos, and 1 had 4 redos. Herein we report on our 18 patients that underwent both first and subsequent redo procedures at our institution. Results: Findings prompting consideration of second redo EGF included dysphagia (43%), recurrent GERD (48%), PEH (16%), dysmotility (7%), stricture (6%) and new Barrett's changes (1.8%). Many patients had multiple symptoms. Nearly one third presented for their second redo with different findings than those that led to their first redo, suggesting either significant progression of their disease or a new problem resulting from prior operation. Median time from first redo to second redo EGF was 16 months. At second redo surgery, 54% had wrap herniation above the diaphragm, 11% wrap disruption, 26% malpositioned wrap, and 11% a shortened esophagus. Not surprisingly, 19% had more than one operative finding. However, of those patients that had a herniated wrap at first redo, 85% had recurrent wrap hemiation at the time of second redo. There were no mortalities. Operative complications included pneumothorax (1.8%), gastrotomy (28%) and esophagotomy (3.8%). Median hospitalization was 5 days. Surveys obtained at a mean of 32 months after second redo revealed 66% patient satisfaction with results. Conclusions: Multiple failures of esophagngastric fundoplication is an unusual problem. Multiple redo EGF can be safely accomplished, but there is a significant rate of foregut visceral injury. The need for multiple redo EGF is most commonly related to wrap herniation, suggesting careful strategies are needed for managing the esophageal hiatus in the these patients.
M1893 Positron Emission Tomography (PET) Cannot Replace Computed Tomography (CT) and Endoscopic Uhrasonography (EUS) in the Staging of Adenocarcinoma of the Esophagus and the Esophagugastric Junction Jarmo A. Salo, Jari V. Rasdnen, Eero I. Sihvo, Juhani Knuuti Exact preoperative staging of adenocarcnioma of the esophagus and the esophagogastric junction is essential for accurate prognosis and selection of appropnate treatment modalities. The usefulness of PET in staging of esophageal cancer has often been postulated. However, there are no studies concerning solely adenocarcinoma of the esophagus and the esophagogastric junction including a sufficient number of histologically examined lymph nodes. Fortytwo patients with adenocarcinoma of the esophagus and the esophagogastric j unction suitable for radical esophageal resection were prospectively staged with PET, CT and EUS. The results were compared with histologically findings obtained at en-bloc esophagectomy and two-field lymphadenectomy. The total number of dissected lymph nodes was 3123 and the average number per patient was 33 (range 12-51) lymph nodes. The primary tumor was detectable in 35 out of 42 patients using PET (sensitivity 83%)and in 28 patients using CT (sensitivity 67%). In locoregional lymph node metastases the sensitivity of EUS (89%) was significantly higher than that of either CT (47%) or PET (37%), but the specificity was significantly poorer in EUS (54%) than in CT (92%)or in PET (100%). Fifteen (36%) of the 42 patients had metastatic lesions (6 distant lymph nodes and 9 organ metastases). The diagnostic specificity was here 89% in PET, 96% in CT and the diagnostic sensitivity 47% in PET and 33% in CT. The accuracy for metastatic lesions was 74% in PET and 74% in CT The false negative diagnoses of distant metastasis in PET were peritoneal carcinosis in 2 patients, abdominal para-aortic cancer growth in 1, metastatic lymph nodes by celiac artery in 4, and metastases in pancreas in 1. PET showed wrong positive lymph nodes at the jugulum in 3 patients. PET cannot be used as a single staging method of adenocarcinoma of the esophagus and the esophagugastric junction because of low accuracy in staging of paratumoral and distant lymph nodes. However PET detects organ metastases better than CT
M1896 Antireflux surgery in patients with Barrett'sesophagus: What happens when surgery fails? David A. McClusky III, Edward Lin, Rodrigo Gonzalez, Andrew B. Lederman, E. M. Ritter, Vickie Swafford, C. D. Smith Background: Barrett's esophagus represents a serious manifestation of chronic gastroesophageal reflux disease. In work presented at DDW last year, we have shown that antireflux surgery (ARS) is commonly effective in controlling GERD and stabilizing or reversing Barrett's changes. Methods: Patients who have unremitting dysphagia due to identifiable anatomic problems (e.g. wrap herniation or malposition) or objectively confirmed pathologic GERD are considered ARS failures and offered redo ARS. Herein we report our experience in patients with Barrett's esophagus who have ARS failures requiring redo ARS.Results: Between 1991 and 2002, 196 patients with GERD and biopsy confirmed Barrett's underwent primary ARS at our center. With a mean fofiow-up of 2.9 years (_+ 2.3), fourteen patients failed ARS and required subsequent redo ARS (7.1%). Twelve of these (86%) were evaluated and treated within two years of the primary ARS. This ARS failure rate was significantly higher than in patients who underwent ARS for uncomplicated GERD during the same time period (22/1026, 2.1%, p = <0.001). intraoperatively, primary wrap herniation was found in 10/ 14 patients (71%) (1 with associated fundoplication disruption). Three patients had a slipped wrap (21%), and 1 had no observable abnormality. An additional thirty-six patients with Barrett's esophagus had their initial ARS elsewhere and subsequently underwent redo at our center. The pattern of failure in this group was similar to that in those whose initial operation was performed at our center (72% wrap herniation, 17% slipped wrap, 1% no abnormality). In total, three patients underwent Colhs gastroplasty for shortened esophagus. Conclusion: Compared to patients with uncomplicated GERD antireflux surgery in patients with Barrett's esophagus has a high rate of failure requinng redo ARS. This is most likely due to the severity of the GERD and associated changes seen in these patients. Wrap herniation is the most common pattem of failure and esophageal lengthening may be necessary. Because of the complex issues in this subset of GERD patients they may best be cared for in specialized centers.
M1894 Pregnancy and Delivery After Antireflux Surgery: Effects on Gastroesophageal
Reflux Symptoms R0drigo Gonzalez, Steven P Bowers, Vickie Swafford, C. Daniel Smith INTRODUCTION: Concerns have been raised that pregnancy after antireflux surgery (ARS) may predispose to wrap disruption or herniation and adversely affect outcomes. Some surgeons withhold ARS in childbearing age women for fear of this, but outcomes in this population have not been reported. METHODS: Data on all patients undergoing foregut surgery at our center are collected prospecuvely. Between January 1991 and July 2000, 1,238 patients underwent ARS for the management of gastroesophageal reflux disease. Of these, 118 childbearing age women were identified and were asked to complete a detailed foll0w-up questionnaire. Patients with subsequent pregnancies (SP) after ARS were compared to patients without subsequent pregnancies (NP). RESULTS: Ninety-five of the 118 patients (81%) completed the questionnaire at a mean follow-up of 4.9 years. Fifteen patients had 19 subsequent pregnancies after undergoing ARS, and retching and/or vomiting were reported daring 13 of the pregnancies (69%). Long-term outcomes and failure rates were similar in both groups, except more patients in the SP group were satisfied with their ARS (Table 1), Redo ARS rate in this patient population is higher than that in all of our patients (2.5%). CONCLUSIONS: Childbearing age women have higher than expected rates of symptomatic and anatomic fundoplication failure. Subsequent pregnancy does not adversely affect outcomes after ARS, but antireflux surgery should be given careful consideration in childbearing age women due to high failure rates in these patients.
M1897 Elective Esophageal Surgery Consumes More Resources than Elective Surgery of Other Gastrointestinal Sites Srinevas K. Reddy, Hui-Chuan Lai, Laurence Genton, Kenneth A. Kudsk Aim: To budget for expenses related to the rising tide of health care costs, it is essential to identify those patients likely to consume the most resources. This study evaluates hospital and extra-hospital resource utilization in patients undergoing elective GI tract surgery at tertiary referral center. Methods: We reviewed charts of 1003 patients who underwent elective surgery of the esophagus, stomach, pancreas and colon between 1996 and 2001 for length (LOS) and cost of hospital stay, preoperative serum albumin, major post-operatwe complications (infections, organ fhilures, anastomotic leaks, decubitus ulcer, death) and use of home or nursing home (specialty) care after discharge. To focus on those patients who consume the most resources, we then separated patients with long (top quartile) and short LOS (lower 3 quartfles). Results: Patients with esophageal surgery had a significantly longer LOS (15 vs. 8 days) and a higher rate of complications (33% vs. 8%) and use of post-discharge specialty care (40% vs. 21%) than other patients having any other type of surgery(p<0.001). The 25% of patients with longest LOS consumed 39 to 46 % of total hospital resources in all surgical groups. Preoperative albumin negatively correlated with LOS for gasmc (r = -0.62), pancreatic (r = -0.22) and colonic (r = -0.45) procedures (p<0.05) but not for esophageal procedures. Conclusion: Greatest hospital and post-discharge health care resource consumption occurs in patients undergoing procedures on the esophagus compared to other sites. Preoperative albumin predicts LOS for all operative sites except for the esophagus.
Table 1. Antlreflux Surgery Outcomes NP (%) SP (%) Satisfaction 61 (76) 15 (100)1" eonp~aOeal =ymptoms 14 (18) 1 (7) e=trzeonphapal symptom 5 (6) 0 Aatleecn~o0y medication 18 (23) 2 (13) Nooormal pontop, studio= 10 (12) 1 (7) Poqdopmntlve dilations 8 (10) 1 (7) Rode AI~ 9(11} 0 I" F/sher's Exact Test: p
Total (%) 76 (80) 15 (16) 5 (5) 20 (21) 11 (12) 9 (9) 9 (9)~t
M1895 Multiple Revisions of EsophagogastricFundoplications: W h y Do They Keep Failing? Andrew B. Lederman, David A. McClusky [II, Rodrign Gonzalez, E. Matt Ritter, Leena Khaitan, C Daniel Smith Background: Although esophagogastric fundoplication (EGF) has been shown to be an effective procedure for management of GERD and paraesophageal hernia (PEH), there is a small group of patients for whom surgery fails and redo EGF is necessary. A subset of these patients require more than one redo operations Little data are available on these complicated
A-807
SSAT Abstracts