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Su1674 Laparoscopic Sleeve Gastrectomy As a Revision From Laparoscopic Adjustable Gastric Band - One Year Results
banding. Complications were analyzed during a 90-day post-operative window. Cardiopulmonary complications included DVT/PE, myocardial infarction, arrhythmia, and cerebrovascular accident. Non-cardiopulmonary complications included anastomotic leak / intraabdominal abscess, bowel obstruction, pneumonia, bleeding, and ulcer / stricture. Pre-op biochemical cardiac risk values, demographics, and anthropometric features were collected prospectively Pre-op biochemical risk factors were matched to post-operative values to calculate percent change. Continuous variables were analyzed by student t-test. P-values ≤ 0.05 were considered significant. All analyses were performed using Stata/SE statistica software, release 12. Results Of 12 preoperative characteristics included in the regression model, HDL ≤ 40 (OR 2.40, 95% CI (1.11 - 5.19)), high-sensitivity C-reactive protein ≥ 11 (OR 2.22, 95% CI (1.05 - 4.67)), Age ≥ 50 (OR 2.72, 95% CI (1.31 - 5.63)), and BMI ≥ 50 (OR 2.31, 95% CI (1.12 - 4.76)) were found to be significant predictors of cardiopulmonary complication. Furthermore, these features were not found to be significant predictors of non-cardiopulmonary complication. At 12 months after surgery, those experiencing a cardiopulmonary complication had a 9% improvement in HDL compared to 23% improvements in those experiencing a non-cardiopulmonary complication or no complication at all. Individual t-tests comparing cardiopulmonary complication to non-cardiopulmonary complication and no complication were all significant. A logistic regression was used to show that incidence of a cardiopulmonary complication, baseline HDL ≤40, age ≥ 50, and BMI ≥ 50 are all individual predictors for a negative percent change in HDL at 12 months. Conclusion HDL, hs-C-reactive protein, age, and BMI were all found to be significant predictors of cardiopulmonary complication. HDL, which is cardio-protective, showed reduced post-op improvement in patients with cardiopulmonary complications at 1 year. This study clearly identifies factors that influence a patient's risk of cardiopulmonary complication after bariatric surgery.
Su1672 Predictors of Lymph Node Involvement in T1 Gastric Carcinoma Rima Ahmad, Benjamin H. Schmidt, Nicole J. Look Hong, Jonathan D. Schoenfeld, Jennifer Y. Wo, Eunice L. Kwak, Lawrence S. Blaszkowsky, David P. Ryan, Ted Hong, David W. Rattner, John T. Mullen Background: The application of endoscopic and local resections for early gastric cancers is limited by the presence of regional lymph node (LN) metastases. We sought to determine the incidence and predictors of LN metastases in patients with early gastric cancer. Methods: A total of 71 patients with pT1 gastric adenocarcinoma underwent radical surgery without neoadjuvant therapy at our institution between 1995 and 2011. Preoperative endoscopic ultrasound (EUS) staging was performed on 17 patients. Clinicopathologic factors predicting regional LN metastases were analyzed. Results: LN metastases were present in 2 of 28 (7.1%) T1a tumors and 14 of 43 (32.6%) T1b tumors, for an overall rate of nodal positivity of 23%. The median number of examined LN for the entire cohort was 15, including 20 for LN-positive patients and 15 for LN-negative patients. On univariate analysis, the presence of submucosal tumor invasion (p=0.012), lymphovascular invasion (LVI) (p ,0.001), and positive nodal status by EUS (p,0.001) were significant predictors of LN metastasis. Tumor size, site, degree of differentiation, and perineural invasion status did not predict LN metastasis. The presence of LVI was the only factor that significantly predicted LN metastasis on multivariate analysis, as well as a significantly worse 5-year disease-specific survival. T1a tumors without LVI had a 4.3% rate of positive LN, whereas T1b tumors with LVI had a 64.3% rate of positive LN. Conclusions: T1 gastric cancers limited to the mucosa, without evidence of LVI, and N0 on EUS can be safely considered for limited resection. However, given an unacceptably high incidence of LN metastasis, any T1 gastric cancer with submucosal invasion, LVI, or N+ by EUS should undergo radical resection with lymphadenectomy.
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Long Term Recurrence and Survival Rates in Gastrointestinal Stromal Tumours (GISTs) Treated by Minimally Invasive Surgery Evangelos S. Photi, Helen Stubbings, Laszlo Igali, Edward Cheong, Allan Clark, Michael P. Lewis Introduction: Gastrointestinal Stromal Tumours (GISTs) are the most frequently occurring sarcoma of the GI tract. Current treatment usually involves resection of the tumour with consideration of adjuvant imatinib, depending on the risk of recurrence. Complete R0 resection is an important aspect of surgery though the surgical or pathological margin required is unclear. Laparoscopic resection is used increasingly for these tumours. We aimed to examine the risk of recurrence, both local and metastatic, after laparoscopic resection with a macroscopic 10mm margin. Risk of relapse can be estimated based on Miettinen and Lasota criteria and this can also be used to guide frequency of clinical follow-up and imaging. Methods: From the upper GI tumour database we identified primary non-metastatic GISTs of the upper GI tract treated by laparoscopic local resection. Cases were then graded for risk of progression based on histopathological findings using criteria such as tumour size, location within the GI tract and number of mitoses. This produced 5 risk groups: high, moderate, low, very low and no risk of progressive disease. Time to event was then calculated for each patient, the event being either death due to GIST, GIST recurrence (as evidenced on follow up CT abdomen/pelvis), or being recurrence free up to the end of the study. Results: A total of 90 patients with primary upper gastrointestinal GISTs were identified from March 2000 to October 2012. The site of occurrence was gastric in 77 cases, small bowel in 11 cases, duodenal in 1 case and oesophageal in 1 case. Patients underwent surgical resection via a laparoscopic approach where possible with a standard local resection margin of 10mm (R0). Follow up was for a mean of 4.5 years. Three patients in the high risk group who died of disease developed distant metastases (two patients with liver and one with peritoneal disease). Two other patients in the same group developed recurrence (one patient with liver and one with ileum/bladder metastases) but remain alive. One patient in the moderate risk group died of omental metastases. Two other patients developed liver metastases, one of whom died of thyroid cancer whilst on imatinib therapy and the other remains alive on imatinib therapy The low and very low risk groups had a 10 year progression free survival of 100% with no incidences of GIST related death. Conclusion: A 10mm surgical margin results in no local recurrence at up to 10 years. The low distant recurrence rate suggests that these tumours can safely be treated laparoscopically with an R0 resection using a surgical margin of 10mm. Distant recurrence is relatively low even in the high risk group for such tumours. GIST related deaths and recurrences for each risk group.
Background: Laparoscopic adjustable gastric banding (LAGB) is known to have a considerable revisional surgery rate, reported from 10% to 40+%. Mechanical complications such as band slip, esophageal dilation or development of a hiatal hernia can lead to symptoms of GERD, dysphagia, and epigastric pain; weight loss failure/regain are also prevalent factors that lead patients to seek surgical revision. Weight loss data for conversion to sleeve gastrectomy is sparse. We present our initial series of patients who have undergone revision from LAGB to laparoscopic sleeve gastrectomy (LSG). Methods: A prospectively maintained clinical database was reviewed retrospectively. Data were reviewed for the period August 2010 to August 2012. Data collected included indication for revision, and degree of weight reduction. Indications for revision included slipped LAGB, epigastric pain, dysphagia, GERD, emesis, and weight loss failure or weight regain. All candidates met NIH criteria for bariatric surgery. Patients underwent laparoscopic gastric band removal and conversion to sleeve gastrectomy either in one or two stages. Operative technique was similar in all cases. Results: Twenty patients (17 female, 3 male) underwent revision from LAGB to LSG between August 2010 to August 2012 by two surgeons (MB and BS). A one-stage procedure was done in 14 patients (70%), while two-stage procedure was done in 6 patients (30%). Mean preoperative weight and BMI before the original LAGB placement were 281.7 (220-373) lb and 46.70 (39.01-56.57) kg/m2, respectively. Mean weight, BMI and % excess weight loss (%EWL) at the nadir of the LAGB were 220.77 (156-322) lb, 37.33 (30.63-51.75) kg/m2, and 43.55% (13.95-66.60) respectively. The average interval between LAGB placement and LSG was 4.79 (1.74-7.71) years. Mean preoperative weight and BMI before conversion to LSG were 261.3 (197-360) lb and 42.62 (35.07-54.96) kg/m2, respectively. Mean %EWL was 21.41%, 31.82%, and 39.02% at 3, 6, and 12 months, respectively. Data was available for 9, 14, and 15 patients at the 3, 6, and 12 month time points, respectively. There were no mortalities. Discussion: Our data indicates that revisional surgery from LAGB to LSG at one year averages 39.02% EWL (range 0% to 70.92%). Published data for primary LSG have shown results of approximately 60% EWL (ranges reported approximately 30% to 80%) at one year. Our preliminary data suggests that weight loss after conversion from LAGB to LSG may not result in weight loss equivalent to primary LSG. This relatively small number of patients does not allow comment as to the etiology of the relatively poor weight loss seen here, although factors such as nadir weight loss achieved with the band, interval between banding and sleeve (one or two stage), preoperative LSG weight, or others, may provide insight as more data becomes available. Su1794 Effect of Instrument Type on Transanal Endoscopic Microsurgery (TEM) Learning Curves Ezra N. Teitelbaum, Fahd O. Arafat, Brittany Lapin, Anne M. Boller Background: The transanal endoscopic microsurgery (TEM) proctoscope is used to resect benign and early-stage malignant rectal tumors, and has received recent attention as a potential platform for transanal natural orifice surgery. No study has evaluated the effectiveness of different instrumentation types for TEM surgery. We tested whether learning curves for surgical novices using a TEM proctoscope would be improved with the use of scissors with shaft articulation. Additionally, we compared TEM and laparoscopic learning curves for the same task. Methods: Medical students were randomized into three study groups: laparoscopic (LAP), TEM rigid (TEM-R), and TEM articulating (TEM-A). All groups completed the Fundamentals of Laparoscopic Surgery (FLS) circle-cut task 10 times. The LAP group completed the task using an FLS box-trainer and a standard laparoscopic grasper and rigid laparoscopic scissors. The TEM-R group completed the task using the same instruments but through a TEM proctoscope within a custom TEM box-trainer. The TEM-A group completed the tasks using the same grasper but with scissors capable of shaft articulation up to 85 degrees. Outcomes were the standard FLS metrics of time and error (deviation as a percentage of total circle area). Instrument switches between hands and TEM position adjustments were
S-1087
SSAT Abstracts
SSAT Abstracts
Laparoscopic Sleeve Gastrectomy As a Revision From Laparoscopic Adjustable Gastric Band - One Year Results Melissa Bagloo, Beth Schrope
Su1672 Predictors of Lymph Node Involvement in T1 Gastric Carcinoma Rima Ahmad, Benjamin H. Schmidt, Nicole J. Look Hong, Jonathan D. Schoenfeld, Jennifer Y. Wo, Eunice L. Kwak, Lawrence S. Blaszkowsky, David P. Ryan, Ted Hong, David W. Rattner, John T. Mullen Background: The application of endoscopic and local resections for early gastric cancers is limited by the presence of regional lymph node (LN) metastases. We sought to determine the incidence and predictors of LN metastases in patients with early gastric cancer. Methods: A total of 71 patients with pT1 gastric adenocarcinoma underwent radical surgery without neoadjuvant therapy at our institution between 1995 and 2011. Preoperative endoscopic ultrasound (EUS) staging was performed on 17 patients. Clinicopathologic factors predicting regional LN metastases were analyzed. Results: LN metastases were present in 2 of 28 (7.1%) T1a tumors and 14 of 43 (32.6%) T1b tumors, for an overall rate of nodal positivity of 23%. The median number of examined LN for the entire cohort was 15, including 20 for LN-positive patients and 15 for LN-negative patients. On univariate analysis, the presence of submucosal tumor invasion (p=0.012), lymphovascular invasion (LVI) (p ,0.001), and positive nodal status by EUS (p,0.001) were significant predictors of LN metastasis. Tumor size, site, degree of differentiation, and perineural invasion status did not predict LN metastasis. The presence of LVI was the only factor that significantly predicted LN metastasis on multivariate analysis, as well as a significantly worse 5-year disease-specific survival. T1a tumors without LVI had a 4.3% rate of positive LN, whereas T1b tumors with LVI had a 64.3% rate of positive LN. Conclusions: T1 gastric cancers limited to the mucosa, without evidence of LVI, and N0 on EUS can be safely considered for limited resection. However, given an unacceptably high incidence of LN metastasis, any T1 gastric cancer with submucosal invasion, LVI, or N+ by EUS should undergo radical resection with lymphadenectomy.
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Long Term Recurrence and Survival Rates in Gastrointestinal Stromal Tumours (GISTs) Treated by Minimally Invasive Surgery Evangelos S. Photi, Helen Stubbings, Laszlo Igali, Edward Cheong, Allan Clark, Michael P. Lewis Introduction: Gastrointestinal Stromal Tumours (GISTs) are the most frequently occurring sarcoma of the GI tract. Current treatment usually involves resection of the tumour with consideration of adjuvant imatinib, depending on the risk of recurrence. Complete R0 resection is an important aspect of surgery though the surgical or pathological margin required is unclear. Laparoscopic resection is used increasingly for these tumours. We aimed to examine the risk of recurrence, both local and metastatic, after laparoscopic resection with a macroscopic 10mm margin. Risk of relapse can be estimated based on Miettinen and Lasota criteria and this can also be used to guide frequency of clinical follow-up and imaging. Methods: From the upper GI tumour database we identified primary non-metastatic GISTs of the upper GI tract treated by laparoscopic local resection. Cases were then graded for risk of progression based on histopathological findings using criteria such as tumour size, location within the GI tract and number of mitoses. This produced 5 risk groups: high, moderate, low, very low and no risk of progressive disease. Time to event was then calculated for each patient, the event being either death due to GIST, GIST recurrence (as evidenced on follow up CT abdomen/pelvis), or being recurrence free up to the end of the study. Results: A total of 90 patients with primary upper gastrointestinal GISTs were identified from March 2000 to October 2012. The site of occurrence was gastric in 77 cases, small bowel in 11 cases, duodenal in 1 case and oesophageal in 1 case. Patients underwent surgical resection via a laparoscopic approach where possible with a standard local resection margin of 10mm (R0). Follow up was for a mean of 4.5 years. Three patients in the high risk group who died of disease developed distant metastases (two patients with liver and one with peritoneal disease). Two other patients in the same group developed recurrence (one patient with liver and one with ileum/bladder metastases) but remain alive. One patient in the moderate risk group died of omental metastases. Two other patients developed liver metastases, one of whom died of thyroid cancer whilst on imatinib therapy and the other remains alive on imatinib therapy The low and very low risk groups had a 10 year progression free survival of 100% with no incidences of GIST related death. Conclusion: A 10mm surgical margin results in no local recurrence at up to 10 years. The low distant recurrence rate suggests that these tumours can safely be treated laparoscopically with an R0 resection using a surgical margin of 10mm. Distant recurrence is relatively low even in the high risk group for such tumours. GIST related deaths and recurrences for each risk group.
Background: Laparoscopic adjustable gastric banding (LAGB) is known to have a considerable revisional surgery rate, reported from 10% to 40+%. Mechanical complications such as band slip, esophageal dilation or development of a hiatal hernia can lead to symptoms of GERD, dysphagia, and epigastric pain; weight loss failure/regain are also prevalent factors that lead patients to seek surgical revision. Weight loss data for conversion to sleeve gastrectomy is sparse. We present our initial series of patients who have undergone revision from LAGB to laparoscopic sleeve gastrectomy (LSG). Methods: A prospectively maintained clinical database was reviewed retrospectively. Data were reviewed for the period August 2010 to August 2012. Data collected included indication for revision, and degree of weight reduction. Indications for revision included slipped LAGB, epigastric pain, dysphagia, GERD, emesis, and weight loss failure or weight regain. All candidates met NIH criteria for bariatric surgery. Patients underwent laparoscopic gastric band removal and conversion to sleeve gastrectomy either in one or two stages. Operative technique was similar in all cases. Results: Twenty patients (17 female, 3 male) underwent revision from LAGB to LSG between August 2010 to August 2012 by two surgeons (MB and BS). A one-stage procedure was done in 14 patients (70%), while two-stage procedure was done in 6 patients (30%). Mean preoperative weight and BMI before the original LAGB placement were 281.7 (220-373) lb and 46.70 (39.01-56.57) kg/m2, respectively. Mean weight, BMI and % excess weight loss (%EWL) at the nadir of the LAGB were 220.77 (156-322) lb, 37.33 (30.63-51.75) kg/m2, and 43.55% (13.95-66.60) respectively. The average interval between LAGB placement and LSG was 4.79 (1.74-7.71) years. Mean preoperative weight and BMI before conversion to LSG were 261.3 (197-360) lb and 42.62 (35.07-54.96) kg/m2, respectively. Mean %EWL was 21.41%, 31.82%, and 39.02% at 3, 6, and 12 months, respectively. Data was available for 9, 14, and 15 patients at the 3, 6, and 12 month time points, respectively. There were no mortalities. Discussion: Our data indicates that revisional surgery from LAGB to LSG at one year averages 39.02% EWL (range 0% to 70.92%). Published data for primary LSG have shown results of approximately 60% EWL (ranges reported approximately 30% to 80%) at one year. Our preliminary data suggests that weight loss after conversion from LAGB to LSG may not result in weight loss equivalent to primary LSG. This relatively small number of patients does not allow comment as to the etiology of the relatively poor weight loss seen here, although factors such as nadir weight loss achieved with the band, interval between banding and sleeve (one or two stage), preoperative LSG weight, or others, may provide insight as more data becomes available. Su1794 Effect of Instrument Type on Transanal Endoscopic Microsurgery (TEM) Learning Curves Ezra N. Teitelbaum, Fahd O. Arafat, Brittany Lapin, Anne M. Boller Background: The transanal endoscopic microsurgery (TEM) proctoscope is used to resect benign and early-stage malignant rectal tumors, and has received recent attention as a potential platform for transanal natural orifice surgery. No study has evaluated the effectiveness of different instrumentation types for TEM surgery. We tested whether learning curves for surgical novices using a TEM proctoscope would be improved with the use of scissors with shaft articulation. Additionally, we compared TEM and laparoscopic learning curves for the same task. Methods: Medical students were randomized into three study groups: laparoscopic (LAP), TEM rigid (TEM-R), and TEM articulating (TEM-A). All groups completed the Fundamentals of Laparoscopic Surgery (FLS) circle-cut task 10 times. The LAP group completed the task using an FLS box-trainer and a standard laparoscopic grasper and rigid laparoscopic scissors. The TEM-R group completed the task using the same instruments but through a TEM proctoscope within a custom TEM box-trainer. The TEM-A group completed the tasks using the same grasper but with scissors capable of shaft articulation up to 85 degrees. Outcomes were the standard FLS metrics of time and error (deviation as a percentage of total circle area). Instrument switches between hands and TEM position adjustments were
S-1087
SSAT Abstracts
SSAT Abstracts
Laparoscopic Sleeve Gastrectomy As a Revision From Laparoscopic Adjustable Gastric Band - One Year Results Melissa Bagloo, Beth Schrope