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Obesity Does Not Affect Outcomes in Gastro-Esophageal Cancer
has been questioned. We hypothesize that the ramp bolus pressure (RBP) may be a better determinant of the need to tailor the type of fundoplication. The aim of this study was to determine normal values for the RBP in asymptomatic subjects and in patients before and after a Nissen fundoplication. Methods: The ramp bolus pressure (RBP) was determined by measuring the mean pressure preceding the upstroke of the contraction wave 5cm above the lower esophageal sphincter (LES) (Figure). We measured the RBP in 53 asymptomatic volunteers and 37 patients with reflux symptoms before and after a Nissen fundoplication. All of the reflux patients had an excellent outcome and none had dysphagia at the time of postoperative evaluation. Results: A RBP was present in 97% of normal subjects and 100% of patients. The mean (SD) amplitude of the RBP in normal subjects was 6.8 (3.7) mmHg. The RBP in reflux patients was significantly lower than that in normal subjects [3.6 (7.0) mmHg, p<0.003]. After Nissen fundoplication, the RBP increased to 12.0 (3.2) mmHg and was significantly greater than the preoperative values (p<0.0001). The 95th percentile value for RBP in normal subjects was 10.4 mmHg and after Nissen fundoplication was 20.0 mmHg. Conclusion: The ramp bolus pressure is a frequent manometric finding that indicates the degree of outflow resistance in the LES region. This amplitude increases after a Nissen Fundoplication. These findings suggest that a contraction amplitude above 20mmHg is necessary to overcome the resistance of a Nissen fundoplication and this threshold may be a better determinant of the need to tailor the type of fundoplication performed.
with a similar median age of 66 and 64 years, respectively. Neoadjuvant chemo/radiotherapy was administered to 20 (36%) and 19 (46%) patients respectively. All MIE were performed either in a 3-field, prone VATS technique (N=48), or a 2-field, laparoscopic extra-pleural technique (N=8). Open esophagectomy included trans-thoracic techniques: Ivor-Lewis (N= 10), thoracoabdominal approach with cervical incision (N=11), and 3-field esophagectomy (N=8) and extra-pleural transhiatal technique (N=12). Using the Charlson Comorbidity Index, the MIE group had 3 patients categorized as low-risk, 41 as moderate-risk and 12 as high-risk while the open group had 33 moderate-risk and 8 high-risk patients. Postoperative complications were stratified using the Clavien Classification Scale, with minor complications classified as Class 1-2 and major complications as Class 3-5. Results: Average operative time for the MIE trans-thoracic was 333 minutes; for the MIE extra-pleural was 291 minutes, for the open trans-thoracic was 215 minutes and open extra-pleural was 192 minutes. Postoperative complications occurred in 42 MIE patients and 21 open patients; these were major in 19 (34%) MIE and 17 (41%) open (p=0.53). The predominant in-hospital complications were cardiac, mainly arrhythmias (32% vs. 41%, P=0.40), pulmonary (34% vs. 44%, P=0.40), and leaks (11% vs. 10%, P=1.00). Postoperative 30-day mortalities were 4% in the MIE group and 7% in the open group (P=0.65). Median length of stay was 8 days (range 5-51 days) for the MIE, 9 days (range 6-38 days) for the open technique. When looking at trans-thoracic versus extra-pleural techniques, there were significant differences in major complications (43% vs. 11%, P=0.013), pulmonary complications (43% vs. 17%, P=0.032), hoarseness (4% vs. 22%, P=0.027) and wound infections (4% vs. 22%, P=0.027). Conclusions: This series shows no differences in major complications and mortality between MIE and open esophagectomies in similar patient groups. If the pleural cavity is violated, regardless of approach, there are higher risks of pulmonary complications. Avoiding the pleural cavity however may increase the risk of hoarseness and wound infections. Mo1606
BACKGROUND: Obesity is a growing epidemic in the United States. The CDC estimates that 25.6% of all adults in the US have a Body Mass Index (BMI) > 30. Obesity and its associated comorbidities have been shown to increase risk for perioperative complications. The purpose of this study was to compare the rate of complication in normal vs. obese patients undergoing esophageal anastomosis following oncologic resection. METHODS: We reviewed our prospective 350 patient esophageal-gastric database and found 166 esophageal anastomoses performed for esophageal and gastric cancer from 1994 to 2009, 157 with BMI data. With informed consent and IRB approval, we compared clinical, pathologic, and outcomes data in the perioperative period between patients with BMI ≥ 30 and BMI < 30. We then evaluated the presence of complication, severity of complication as indicated by the 5 point Clavien grading scale, and overall survival. Statistical correlations were calculated with Chi-Square (Monte-Carlo), independent T-test, Kaplan-Meier, and log-rank analyses as appropriate. RESULTS: Of the 157 patients reviewed with a median age of 62 (range 17 - 84);120 (76.4%) were men, 37 women, 40 were Obese (25.5%) and 117 were not Obese (74.5%). Of these 157 patients, 62 (39.4%) had neoadjuvant chemotherapy with 59 (37.5%) adjuvant treatment. No statistically significant difference was seen between the obese and non-obese patients regarding development of perioperative complication (72.5% vs. 62.4%, p = .268, 95% CI .198 - .377), grade of complication (p = .471, 95% CI .393 - .549), or anastomotic leak (25% vs. 20.5%, p = .745, 95% CI .687-.813). Intraoperative variables also showed no significant difference including: estimated blood loss (EBL) (p = .985), need for transfusion (P=.863), number of units transfused (p=.522), number of nodes collected on lymphadenectomy (p = .420). There was a decreased incidence of positive margin after resection in the Obese (2.5%) than non-Obese (12.0%) (p = .079, 95% CI = .075 - .180). In the superobese (BMI > 35), there was a significant trend toward greater intraoperative transfusion (4.5 vs. 2.4 units, p=.006) and increased mean number of positive lymph nodes on (8.9 vs. 3.9, p = .024). There was no difference in overall survival in the Obese with median of 16 months (range 0-180 months) and non-Obese 16.5 months (range = 0 - 180 months), (p=.968). CONCLUSIONS: Obesity does not affect rate of complication, grade of complication, or rate of anastomotic leak, or overall survival in patients undergoing esophageal anastomosis for oncologic resection. Further investigation is needed to determine the effect of obesity on margin positive resection as a function of procedure-limiting body habitus. Clinical Outcomes After Esophagectomy Stratified by BMI > 30
Mo1604 Chemoradiotherapy or Pharyngo-Laryngo-Esophagectomy for Cervical Esophageal Squamous Cancer Shirley Y. Liu, Philip W. Chiu, Anthony Y. Teoh, Man Yee Yung, Candice C. Lam, Simon K. Wong, Enders K. Ng INTRODUCTION: Cervical esophageal squamous cell carcinoma (SCC) is primarily treated by either concurrent chemoradiotherapy (CRT) or pharyngo-laryngo-esophagectomy (PLO). Literature evidence directly comparing CRT to PLO for curative intent is lacking. Although laryngeal preservation in CRT is more preferred, whether CRT can produce comparable disease control and survival over PLO is yet to be elucidated. METHOD: This study aims to compare the recurrence rate and overall survival after CRT and PLO for cervical esophageal cancer. A retrospective comparison was conducted on consecutive patients receiving either definitive CRT or PLO in Prince of Wales Hospital. RESULTS: Between January 1998 and June 2010 (12.5 years inclusive), 57 patients (47 males and 10 females) with mean age of 61.4 ± 8.0 years received curative treatment for cervical esophageal cancer. Forty patients (70.1%) received definitive CRT while 17 patients (30.9%) underwent PLO with either gastric (94.1%) or colonic transposition (5.9%). Clinical AJCC stage I, II and III diseases were confirmed in 0 (0%), 9 (22.5%) and 31 (77.5%) patients in CRT group while those in PLO group were 0 (0%), 4 (23.5%) and 13 (76.5%) patients respectively. Both groups were comparable for age, gender, ASA class and clinical stage. In CRT group, all patients completed two courses of chemotherapy (infusional 5-fluorouracil plus cisplatin) and radiotherapy (dosage 50-60Gy). Complete tumor response was observed in 21 patients (52.5%). Of the remaining 19 treatment failure patients, 5 (12.5%) underwent salvage PLO, 1 (2.5%) refused salvage surgery, and 13 (32.5%) had distant metastasis upon re-staging. In PLO group, the operative morbidity and mortality rates were 70.5% and 11.7% respectively. Three patients (17.6%) had positive margin involvement requiring postoperative adjuvant radiotherapy. In a median follow-up of 14.4 (range 1.2 - 109.9) months, there was no difference in local recurrence rate (42.5% vs. 52.9%, P=0.469) and distant recurrence rate (32.5% vs. 29.4%, P=0.819) between CRT and PLO groups. The overall survival in CRT group was 17.1 (95% C.I. 11.2 - 22.1) months while that of PLO group was 14.4 (95% C.I. 7.8 - 22.9) months. Their difference was not statistically significant (P=0.943, log rank test). CONCLUSION: Despite a relatively high local treatment failure risk, the tumor recurrence rate and overall survival of CRT were comparable to PLO for patients with cervical esophageal cancer. Mo1605 Trans-Thoracic Approaches to Esophagectomy Associated With Higher Morbidity Ross F. Goldberg, Steven P. Bowers, Michael Parker, John Stauffer, Michael G. Heckman, Colleen S. Thomas, Horacio J. Asbun, John A. Odell, C. Daniel Smith Introduction: Esophagectomy is performed through various approaches, both open and minimally invasive (MIE). This study's aim is to review the perioperative outcomes after all types of esophagectomy while quantifying patients' preoperative comorbidities. Methods and Procedures: We retrospectively reviewed the charts of 97 patients who underwent either MIE (N=56) or open esophagectomy (N=41) between January 2007 and August 2010. Indications for esophagectomy included adenocarcinoma (N=73), squamous cell carcinoma (N=11), Barrett's with high-grade dysplasia (N=8), end-stage achalasia (N=3), mesh erosion (N=1) and leiomyoma (N=1). In both groups males predominated (MIE:86%, open:83%)
S-1033
SSAT Abstracts
SSAT Abstracts
Obesity Does Not Affect Outcomes in Gastro-Esophageal Cancer Russell Farmer, Kelly M. McMasters, Charles R. Scoggins, Robert C. Martin
Mo1608 The Impact of Delayed Gastric Emptying on Outcome of Nissen Fundoplication in GERD Patients Weisheng Chen, Steven R. DeMeester, Shahin Ayazi, Gaurav Sharma, Joerg Zehetner, Kimbely S. Grant, Florian Augustin, Daniel S. Oh, John C. Lipham, Jeffrey A. Hagen, Tom R. DeMeester Background: Symptoms of delayed gastric emptying are common in patients with gastroesophageal reflux disease (GERD). The aim of this study was to compare symptomatic outcome after Nissen fundoplication in patients with and without delayed gastric emptying symptoms (DGES). Patients and methods: Records from 650 patients who had a primary Nissen fundoplication for proven GERD from 2002-2008 were reviewed, and patients with symptoms of delayed gastric emptying (nausea, early or prolonged satiety) were identified. A comparison group of age and sex matched patients who had primary antireflux surgery during the same period for proven GERD but without symptoms of delayed gastric emptying was also identified. Outcome after surgery was compared between groups, and a favorable symptomatic outcome was defined as either complete relief of all preoperative symptoms without troublesome new symptoms, or residual symptoms occurring less than once a month. Results: Preoperative symptoms of delayed gastric emptying were present in 140 patients: 60 had a normal gastric emptying study (DGES: Normal study), 31 had either an abnormal gastric emptying study (n=22) or retained food in the stomach on endoscopy after an overnight fast (n=9) (DGES: Abnormal study), and 49 had no gastric emptying study performed (DGES: No study). The comparison group (No DGES) consisted of 140 patients. A Nissen fundoplication was performed in all patients, and in 17 of 31 patients in the DGES: Abnormal study group a gastric drainage procedure was added. Demographic data, preoperative pH and manometry values, and mean follow up were similar between groups. Delayed gastric emptying symptoms were relieved in 91% of patients, but a favorable surgical outcome was significantly less likely in patients with DGES [Table]. The majority of unsatisfactory results in DGES patients were due to persistent symptoms of delayed gastric emptying. Relief of reflux symptoms was similar. The addition of a drainage procedure did not increase the likelihood of a favorable surgical outcome (70.6% vs. 71.4%, p=1). Conclusions: Patients with GERD and delayed gastric emptying symptoms are less likely to have a favorable symptomatic outcome after Nissen fundoplication compared to GERD patients without delayed gastric emptying symptoms, despite similar relief of reflux symptoms. The addition of a drainage procedure in patients with proven delayed gastric emptying did not improve the symptomatic outcome.
Overall Survival Following Esophageal Anastomosis: BMI < 30 vs. BMI > 30 Mo1607
SSAT Abstracts
Defining the Learning Curve of Laparo-Endoscopic Single Site (Less) Heller Myotomy Sharona B. Ross, Tony J. Kurian, Kenneth Luberice, Natalie Donn, Harold Paul, Melissa Rosas, Chinyere P. Okpaleke, Alexander S. Rosemurgy Introduction: Initial outcomes suggest Laparo-Endoscopic Single Site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. Methods: 100 patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored utilizing a Likert scale (0=never/not bothersome to 10=always/very bothersome). Symptom resolution, additional trocar placements, and complications were compared among patient quartiles. Median data are presented. Results: Preoperative frequency/severity scores were: dysphagia=10/8, regurgitation=8/6, heartburn=2/2. Additional trocars were placed in 11 patients (11%), of whom 81% were in the first two quartiles; placement of additional trocars decreased in successive quartiles (p<0.05). Esophagotomy/gastrotomy occurred in 3 patients. Postoperative complications occurred in 9%, none specific to Heller myotomy (Table). No conversions to open operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia=2/0, regurgitation=0/0, heartburn=0/0; scores were similar and less than before myotomy across all quartiles, p<0.001(Figure). There were no apparent scars, except where an additional trocar was placed. Conclusions: LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar, without inducing reflux. Placement of additional trocars primarily occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, as proficiency is quickly attained. 25- Patient Quartiles
Mo1609 A Tailored Surgical Approach to Esophago-Gastric Junction Cancers: Can We Maximize Complete Resection Without Increasing Morbidity? Frank Schwenter, Sara Najmeh, Lorenzo E. Ferri Background: The primary goal in surgery for esophago-gastric junction(EGJ) cancers is to obtain a complete resection (R0), as this is the strongest predictor of survival. The published rate of complete resection is only approx. 70% and the optimal surgical approach to achieve R0 is controversial. We sought to determine the influence of an approach tailored to patient and tumor characteristics on complete resection and post-operative outcomes. Methods: A prospectively entered database on all upper GI cancer resections at a single institution (20052010) was accessed for EGJ tumors (Type I, II, III). Patient demographics, operative and tumor characteristics, short term outcomes, and margin status (proximal/distal/radial) were compared between patients undergoing one of three operative approaches (Ivor-Lewis (IL): Left Thoraco-abdominal (LTA): Trans-abdominal (TA)). Operative approach was tailored to pt and tumor (EGD+CT) characteristics with a view to maximize complete resection whilst minimizing morbidity. Data presented as median (range). Mann Whitney U or Fishers Exact test determined significance (*p<0.05). Results: Of 241 pts in the database, 60 patients underwent resection of EGJ tumors (I/II/III = 12/22/26). IL was performed in 31 (EGJ I/II/ III = 10/17/4), LTA in 13 (EGJ I/II/III = 1/1/11), and TA in 16 (EGJ I/II/III = 1/4/11). TA pts were older (IL 63y (24-82): LTA 62 (27-80): TA 73y (38-82))*. TA (7.2cm(1-11)) and LTA (9.8cm(4-14)) had larger tumors than IL (4.1cm(0.4-8.3))*. Post-op pulmonary complications(IL 10/31 LTA 1/13 TA 4/16), anastomotic leak (IL 4/31 LTA 1/13 TA 1/16), LOS (IL 11d: LTA 10d: TA 10d), and mortality (IL 2/31: LTA 0/13: LTA 0/16) did not differ between groups. Lymph node retrieval was higher in IL (IL 37(8-66):LTA 25(7-64): TA 25 (4-40))*, but complete resection was achieved in 57/60 (95%) and did not differ between groups. Conclusions: A tailored approach to cancers of the EGJ based on patient and tumor characteristics is feasible, is associated with a high complete resection rate, and does not increase morbidity. Mo1610 Utilization and Morbidity Associated With Routine Placement of a Feeding Jejunostomy at the Time of Gastro-Esophageal Resection Omar H. Llaguna, Hong Jin Kim, Karyn B. Stitzenberg, Benjamin F. Calvo, Michael O. Meyers Background: The purpose of the study was to evaluate the utilization and morbidity associated with feeding jejunostomy tubes (JT) placed at the time of gastro-esophageal (GE) resection. Methods: Under IRB approval a prospective database of patients undergoing GE resection
SSAT Abstracts
S-1034
with a similar median age of 66 and 64 years, respectively. Neoadjuvant chemo/radiotherapy was administered to 20 (36%) and 19 (46%) patients respectively. All MIE were performed either in a 3-field, prone VATS technique (N=48), or a 2-field, laparoscopic extra-pleural technique (N=8). Open esophagectomy included trans-thoracic techniques: Ivor-Lewis (N= 10), thoracoabdominal approach with cervical incision (N=11), and 3-field esophagectomy (N=8) and extra-pleural transhiatal technique (N=12). Using the Charlson Comorbidity Index, the MIE group had 3 patients categorized as low-risk, 41 as moderate-risk and 12 as high-risk while the open group had 33 moderate-risk and 8 high-risk patients. Postoperative complications were stratified using the Clavien Classification Scale, with minor complications classified as Class 1-2 and major complications as Class 3-5. Results: Average operative time for the MIE trans-thoracic was 333 minutes; for the MIE extra-pleural was 291 minutes, for the open trans-thoracic was 215 minutes and open extra-pleural was 192 minutes. Postoperative complications occurred in 42 MIE patients and 21 open patients; these were major in 19 (34%) MIE and 17 (41%) open (p=0.53). The predominant in-hospital complications were cardiac, mainly arrhythmias (32% vs. 41%, P=0.40), pulmonary (34% vs. 44%, P=0.40), and leaks (11% vs. 10%, P=1.00). Postoperative 30-day mortalities were 4% in the MIE group and 7% in the open group (P=0.65). Median length of stay was 8 days (range 5-51 days) for the MIE, 9 days (range 6-38 days) for the open technique. When looking at trans-thoracic versus extra-pleural techniques, there were significant differences in major complications (43% vs. 11%, P=0.013), pulmonary complications (43% vs. 17%, P=0.032), hoarseness (4% vs. 22%, P=0.027) and wound infections (4% vs. 22%, P=0.027). Conclusions: This series shows no differences in major complications and mortality between MIE and open esophagectomies in similar patient groups. If the pleural cavity is violated, regardless of approach, there are higher risks of pulmonary complications. Avoiding the pleural cavity however may increase the risk of hoarseness and wound infections. Mo1606
BACKGROUND: Obesity is a growing epidemic in the United States. The CDC estimates that 25.6% of all adults in the US have a Body Mass Index (BMI) > 30. Obesity and its associated comorbidities have been shown to increase risk for perioperative complications. The purpose of this study was to compare the rate of complication in normal vs. obese patients undergoing esophageal anastomosis following oncologic resection. METHODS: We reviewed our prospective 350 patient esophageal-gastric database and found 166 esophageal anastomoses performed for esophageal and gastric cancer from 1994 to 2009, 157 with BMI data. With informed consent and IRB approval, we compared clinical, pathologic, and outcomes data in the perioperative period between patients with BMI ≥ 30 and BMI < 30. We then evaluated the presence of complication, severity of complication as indicated by the 5 point Clavien grading scale, and overall survival. Statistical correlations were calculated with Chi-Square (Monte-Carlo), independent T-test, Kaplan-Meier, and log-rank analyses as appropriate. RESULTS: Of the 157 patients reviewed with a median age of 62 (range 17 - 84);120 (76.4%) were men, 37 women, 40 were Obese (25.5%) and 117 were not Obese (74.5%). Of these 157 patients, 62 (39.4%) had neoadjuvant chemotherapy with 59 (37.5%) adjuvant treatment. No statistically significant difference was seen between the obese and non-obese patients regarding development of perioperative complication (72.5% vs. 62.4%, p = .268, 95% CI .198 - .377), grade of complication (p = .471, 95% CI .393 - .549), or anastomotic leak (25% vs. 20.5%, p = .745, 95% CI .687-.813). Intraoperative variables also showed no significant difference including: estimated blood loss (EBL) (p = .985), need for transfusion (P=.863), number of units transfused (p=.522), number of nodes collected on lymphadenectomy (p = .420). There was a decreased incidence of positive margin after resection in the Obese (2.5%) than non-Obese (12.0%) (p = .079, 95% CI = .075 - .180). In the superobese (BMI > 35), there was a significant trend toward greater intraoperative transfusion (4.5 vs. 2.4 units, p=.006) and increased mean number of positive lymph nodes on (8.9 vs. 3.9, p = .024). There was no difference in overall survival in the Obese with median of 16 months (range 0-180 months) and non-Obese 16.5 months (range = 0 - 180 months), (p=.968). CONCLUSIONS: Obesity does not affect rate of complication, grade of complication, or rate of anastomotic leak, or overall survival in patients undergoing esophageal anastomosis for oncologic resection. Further investigation is needed to determine the effect of obesity on margin positive resection as a function of procedure-limiting body habitus. Clinical Outcomes After Esophagectomy Stratified by BMI > 30
Mo1604 Chemoradiotherapy or Pharyngo-Laryngo-Esophagectomy for Cervical Esophageal Squamous Cancer Shirley Y. Liu, Philip W. Chiu, Anthony Y. Teoh, Man Yee Yung, Candice C. Lam, Simon K. Wong, Enders K. Ng INTRODUCTION: Cervical esophageal squamous cell carcinoma (SCC) is primarily treated by either concurrent chemoradiotherapy (CRT) or pharyngo-laryngo-esophagectomy (PLO). Literature evidence directly comparing CRT to PLO for curative intent is lacking. Although laryngeal preservation in CRT is more preferred, whether CRT can produce comparable disease control and survival over PLO is yet to be elucidated. METHOD: This study aims to compare the recurrence rate and overall survival after CRT and PLO for cervical esophageal cancer. A retrospective comparison was conducted on consecutive patients receiving either definitive CRT or PLO in Prince of Wales Hospital. RESULTS: Between January 1998 and June 2010 (12.5 years inclusive), 57 patients (47 males and 10 females) with mean age of 61.4 ± 8.0 years received curative treatment for cervical esophageal cancer. Forty patients (70.1%) received definitive CRT while 17 patients (30.9%) underwent PLO with either gastric (94.1%) or colonic transposition (5.9%). Clinical AJCC stage I, II and III diseases were confirmed in 0 (0%), 9 (22.5%) and 31 (77.5%) patients in CRT group while those in PLO group were 0 (0%), 4 (23.5%) and 13 (76.5%) patients respectively. Both groups were comparable for age, gender, ASA class and clinical stage. In CRT group, all patients completed two courses of chemotherapy (infusional 5-fluorouracil plus cisplatin) and radiotherapy (dosage 50-60Gy). Complete tumor response was observed in 21 patients (52.5%). Of the remaining 19 treatment failure patients, 5 (12.5%) underwent salvage PLO, 1 (2.5%) refused salvage surgery, and 13 (32.5%) had distant metastasis upon re-staging. In PLO group, the operative morbidity and mortality rates were 70.5% and 11.7% respectively. Three patients (17.6%) had positive margin involvement requiring postoperative adjuvant radiotherapy. In a median follow-up of 14.4 (range 1.2 - 109.9) months, there was no difference in local recurrence rate (42.5% vs. 52.9%, P=0.469) and distant recurrence rate (32.5% vs. 29.4%, P=0.819) between CRT and PLO groups. The overall survival in CRT group was 17.1 (95% C.I. 11.2 - 22.1) months while that of PLO group was 14.4 (95% C.I. 7.8 - 22.9) months. Their difference was not statistically significant (P=0.943, log rank test). CONCLUSION: Despite a relatively high local treatment failure risk, the tumor recurrence rate and overall survival of CRT were comparable to PLO for patients with cervical esophageal cancer. Mo1605 Trans-Thoracic Approaches to Esophagectomy Associated With Higher Morbidity Ross F. Goldberg, Steven P. Bowers, Michael Parker, John Stauffer, Michael G. Heckman, Colleen S. Thomas, Horacio J. Asbun, John A. Odell, C. Daniel Smith Introduction: Esophagectomy is performed through various approaches, both open and minimally invasive (MIE). This study's aim is to review the perioperative outcomes after all types of esophagectomy while quantifying patients' preoperative comorbidities. Methods and Procedures: We retrospectively reviewed the charts of 97 patients who underwent either MIE (N=56) or open esophagectomy (N=41) between January 2007 and August 2010. Indications for esophagectomy included adenocarcinoma (N=73), squamous cell carcinoma (N=11), Barrett's with high-grade dysplasia (N=8), end-stage achalasia (N=3), mesh erosion (N=1) and leiomyoma (N=1). In both groups males predominated (MIE:86%, open:83%)
S-1033
SSAT Abstracts
SSAT Abstracts
Obesity Does Not Affect Outcomes in Gastro-Esophageal Cancer Russell Farmer, Kelly M. McMasters, Charles R. Scoggins, Robert C. Martin
Mo1608 The Impact of Delayed Gastric Emptying on Outcome of Nissen Fundoplication in GERD Patients Weisheng Chen, Steven R. DeMeester, Shahin Ayazi, Gaurav Sharma, Joerg Zehetner, Kimbely S. Grant, Florian Augustin, Daniel S. Oh, John C. Lipham, Jeffrey A. Hagen, Tom R. DeMeester Background: Symptoms of delayed gastric emptying are common in patients with gastroesophageal reflux disease (GERD). The aim of this study was to compare symptomatic outcome after Nissen fundoplication in patients with and without delayed gastric emptying symptoms (DGES). Patients and methods: Records from 650 patients who had a primary Nissen fundoplication for proven GERD from 2002-2008 were reviewed, and patients with symptoms of delayed gastric emptying (nausea, early or prolonged satiety) were identified. A comparison group of age and sex matched patients who had primary antireflux surgery during the same period for proven GERD but without symptoms of delayed gastric emptying was also identified. Outcome after surgery was compared between groups, and a favorable symptomatic outcome was defined as either complete relief of all preoperative symptoms without troublesome new symptoms, or residual symptoms occurring less than once a month. Results: Preoperative symptoms of delayed gastric emptying were present in 140 patients: 60 had a normal gastric emptying study (DGES: Normal study), 31 had either an abnormal gastric emptying study (n=22) or retained food in the stomach on endoscopy after an overnight fast (n=9) (DGES: Abnormal study), and 49 had no gastric emptying study performed (DGES: No study). The comparison group (No DGES) consisted of 140 patients. A Nissen fundoplication was performed in all patients, and in 17 of 31 patients in the DGES: Abnormal study group a gastric drainage procedure was added. Demographic data, preoperative pH and manometry values, and mean follow up were similar between groups. Delayed gastric emptying symptoms were relieved in 91% of patients, but a favorable surgical outcome was significantly less likely in patients with DGES [Table]. The majority of unsatisfactory results in DGES patients were due to persistent symptoms of delayed gastric emptying. Relief of reflux symptoms was similar. The addition of a drainage procedure did not increase the likelihood of a favorable surgical outcome (70.6% vs. 71.4%, p=1). Conclusions: Patients with GERD and delayed gastric emptying symptoms are less likely to have a favorable symptomatic outcome after Nissen fundoplication compared to GERD patients without delayed gastric emptying symptoms, despite similar relief of reflux symptoms. The addition of a drainage procedure in patients with proven delayed gastric emptying did not improve the symptomatic outcome.
Overall Survival Following Esophageal Anastomosis: BMI < 30 vs. BMI > 30 Mo1607
SSAT Abstracts
Defining the Learning Curve of Laparo-Endoscopic Single Site (Less) Heller Myotomy Sharona B. Ross, Tony J. Kurian, Kenneth Luberice, Natalie Donn, Harold Paul, Melissa Rosas, Chinyere P. Okpaleke, Alexander S. Rosemurgy Introduction: Initial outcomes suggest Laparo-Endoscopic Single Site (LESS) Heller myotomy with anterior fundoplication provides safe, efficacious, and cosmetically superior outcomes relative to conventional laparoscopy. This study was undertaken to define the learning curve of LESS Heller myotomy with anterior fundoplication. Methods: 100 patients underwent LESS Heller myotomy with anterior fundoplication. Symptom frequency and severity were scored utilizing a Likert scale (0=never/not bothersome to 10=always/very bothersome). Symptom resolution, additional trocar placements, and complications were compared among patient quartiles. Median data are presented. Results: Preoperative frequency/severity scores were: dysphagia=10/8, regurgitation=8/6, heartburn=2/2. Additional trocars were placed in 11 patients (11%), of whom 81% were in the first two quartiles; placement of additional trocars decreased in successive quartiles (p<0.05). Esophagotomy/gastrotomy occurred in 3 patients. Postoperative complications occurred in 9%, none specific to Heller myotomy (Table). No conversions to open operations occurred. Length of stay was 1 day. Postoperative frequency/severity scores were: dysphagia=2/0, regurgitation=0/0, heartburn=0/0; scores were similar and less than before myotomy across all quartiles, p<0.001(Figure). There were no apparent scars, except where an additional trocar was placed. Conclusions: LESS Heller myotomy with anterior fundoplication well palliates symptoms of achalasia with no apparent scar, without inducing reflux. Placement of additional trocars primarily occurred early in the experience. For surgeons proficient with the conventional laparoscopic approach, the learning curve of LESS Heller myotomy with anterior fundoplication is short and safe, as proficiency is quickly attained. 25- Patient Quartiles
Mo1609 A Tailored Surgical Approach to Esophago-Gastric Junction Cancers: Can We Maximize Complete Resection Without Increasing Morbidity? Frank Schwenter, Sara Najmeh, Lorenzo E. Ferri Background: The primary goal in surgery for esophago-gastric junction(EGJ) cancers is to obtain a complete resection (R0), as this is the strongest predictor of survival. The published rate of complete resection is only approx. 70% and the optimal surgical approach to achieve R0 is controversial. We sought to determine the influence of an approach tailored to patient and tumor characteristics on complete resection and post-operative outcomes. Methods: A prospectively entered database on all upper GI cancer resections at a single institution (20052010) was accessed for EGJ tumors (Type I, II, III). Patient demographics, operative and tumor characteristics, short term outcomes, and margin status (proximal/distal/radial) were compared between patients undergoing one of three operative approaches (Ivor-Lewis (IL): Left Thoraco-abdominal (LTA): Trans-abdominal (TA)). Operative approach was tailored to pt and tumor (EGD+CT) characteristics with a view to maximize complete resection whilst minimizing morbidity. Data presented as median (range). Mann Whitney U or Fishers Exact test determined significance (*p<0.05). Results: Of 241 pts in the database, 60 patients underwent resection of EGJ tumors (I/II/III = 12/22/26). IL was performed in 31 (EGJ I/II/ III = 10/17/4), LTA in 13 (EGJ I/II/III = 1/1/11), and TA in 16 (EGJ I/II/III = 1/4/11). TA pts were older (IL 63y (24-82): LTA 62 (27-80): TA 73y (38-82))*. TA (7.2cm(1-11)) and LTA (9.8cm(4-14)) had larger tumors than IL (4.1cm(0.4-8.3))*. Post-op pulmonary complications(IL 10/31 LTA 1/13 TA 4/16), anastomotic leak (IL 4/31 LTA 1/13 TA 1/16), LOS (IL 11d: LTA 10d: TA 10d), and mortality (IL 2/31: LTA 0/13: LTA 0/16) did not differ between groups. Lymph node retrieval was higher in IL (IL 37(8-66):LTA 25(7-64): TA 25 (4-40))*, but complete resection was achieved in 57/60 (95%) and did not differ between groups. Conclusions: A tailored approach to cancers of the EGJ based on patient and tumor characteristics is feasible, is associated with a high complete resection rate, and does not increase morbidity. Mo1610 Utilization and Morbidity Associated With Routine Placement of a Feeding Jejunostomy at the Time of Gastro-Esophageal Resection Omar H. Llaguna, Hong Jin Kim, Karyn B. Stitzenberg, Benjamin F. Calvo, Michael O. Meyers Background: The purpose of the study was to evaluate the utilization and morbidity associated with feeding jejunostomy tubes (JT) placed at the time of gastro-esophageal (GE) resection. Methods: Under IRB approval a prospective database of patients undergoing GE resection
SSAT Abstracts
S-1034