Surg Endosc (2016) 30:S211–S263 DOI 10.1007/s00464-016-4770-8

and Other Interventional Techniques

2016 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA, 16–19 March 2016 Oral Presentations

Ó Springer Science+Business Media New York 2016



Total Retroperitoneoscopic Living Donor Nephrectomy: Implementation at the First German Center

Learning Curves and Surgical Outcomes for Laparoscopic Ventral Mesh Rectopexy: Cumulative Sum Curve Analysis

Marty Zdichavsky, MD1, Martina Guthoff, MD2, Nils Heyne, MD2, Pranjal Modi, MD3, Jessica Lange, MD1, Alfred Konigsrainer, MD1, Silvio Nadalin, MD1, 1Department of General, Visceral and Transplant Surgery, University Hospital Tubingen, 2Department of Internal Medicine, Division of Endocrinology, Diabetology, Vascular Disease, Nephrology and Clinical Chemistry, University Hospital Tubingen, 3Department of Urology, Dr. HL Trivedi Institute of Transplantation Sciences, Asarwa, Ahmedabad, Gujarat, India

P Pucher1, A Clarke2, M Lamparelli1, 1Dorset County Hospital, 2 Poole General Hospital

Introduction: Since laparoscopic living donor nephrectomy is well established in specific centers the purpose of this trial was to inaugurate a program for fully retroperitoneoscopic kidney donation according to Modi’s technique in our institution of transplant surgery. Methods and Procedures: Different techniques for living donor nephrectomies were studied and compared. At the first European Workshop for retroperitoneoscopic donor nephrectomies at the Royal Liverpool University Hospital in England in 2014, the fully retroperitoneoscopic kidney donation was the most convincing one for us in terms of safety, feasibility and technical aspects. In July 2015 three total retroperitoneoscopic living donor nephrectomies could be performed in our institution in attendance of Prof. P. Modi having the most experience in this procedure. Results: The first three retroperitoneoscopic donor nephrectomies were successfully performed without any complications. One right and two left kidneys were retrieved using a three trocar technique for the left side and one additional trocar for the right side. Organ harvesting was performed through an inguinal incision that was created just before renal vessel dissection and closed after organ harvesting. Mean operative time was 164 min. Organs were instantly implanted in another operating room. Postoperative course was uneventful for all donors. Donors’ satisfaction was very good in all three cases. All recipients could be discharged with a good kidney function. Mean recipient’s serum creatinine was 1.4 mg/dl on day 7 and 1.3 mg/dl on day 21, respectively. Conclusion: Fully retroperitoneoscopic living donor nephrectomies could be implemented in our institution and performed without complications and a high level of patient’s satisfaction.

Background: Laparoscopic ventral mesh rectopexy (VMR) is an effective and well recognised treatment for symptoms of obstructive defecation in the context of rectal prolapse and recto-rectal intussusception. Uptake of the procedure has been increasing due to superior outcomes compared to traditional transanal procedures for prolapse. However, due to the technical complexity of VMR, a significant learning curve must be expected in the adoption of this procedure. The implications on patient safety, outcomes, and resources must be considered. Methods: A retrospective analysis of a prospectively maintained database from two district general hospitals was conducted, with inclusion of all cases performed by two surgeons since first adoption of the procedure in 2007 to the present. Operative time, length of stay, and in-hospital complications were evaluated, with learning curves assessed using cumulative sum curves. Results: 267 patients underwent VMR during the study period and were included for analysis. The mean operative duration was 108 ± 31 minutes, length of stay was 1.6 ± 2.6 days. In-hospital mortality was 2.8 %, with 0 % mortality. Cumulative sum curve analysis suggested a learning curve of between 28–35 cases based on operative times and length of stay. No significant learning curve was seen for morbidity or mortality. Conclusion: VMR is an effective and safe treatment for rectal prolapse. Despite a moderate learning curve for operative time and length of stay, no negative effects on patient safety, morbidity, or mortality were seen. Surgeons in this study were proctored during the adoption process by another surgeon experienced in VMR; this may contribute to increased safety and abbreviated learning curve.



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What is the Value of the SAGES/AORN MIS Checklist? A Multiinstitutional Practical Assessment

Year Trends in Incidence and Indications for Laparoscopic Cholecystectomy, the NY State Experience

Emily Benham, MD1, William Richardson, MD2, Henry Lin, MD3, Jonathan Dort, MD4, Dimitrios Stefanidis, MD, PhD1, 1Carolinas Healthcare System, Charlotte, NC, 2Ochsner Clinic, New Orleans, LA, 3Naval Hospital Camp LeJeune, NC, 4Inova Fairfax Medical Campus, Falls Church, VA

Vamsi V Alli, MD, Jie Yang, PhD, Jianjin Xu, Andrew T Bates, MD, Aurora D Pryor, MD, Mark A Talamini, Dana A Telem, Stony Brook Medicine

Background: Surgical safety checklists reduce perioperative complications and mortality. Given that minimally invasive surgery (MIS) is dependent on technology and vulnerable to problems introduced by equipment failure, SAGES and AORN have partnered to create a MIS checklist to optimize case flow and minimize errors and frustration. The aim of this project was to evaluate the effectiveness of the SAGES/AORN MIS Surgery Checklist in preventing disruptions that lead to case delays and determine its ease of use. Methods: After IRB approval, the checklist was implemented across four institutions by members of the SAGES quality, safety, and outcomes committee. The checklist was completed by the operating team during MIS procedures; given potential conflicts with existing preoperative checklists, the MIS checklist could be completed before or after the case. To assess its effectiveness, we recorded how often the checklist identified problems and how frequently each of the 45 checklist items were not completed. The perceived usefulness (1 = not useful, 5 = very useful), ease of use (1 = very easy, 5 = very difficult), and frustration (1 = no frustration, 5 = extreme frustration) associated with the checklist use were rated on a 5 point Likert scale by the surgeon. We assessed any differences dependent on timing of checklist completion (before or after surgery). Results: The checklist was performed during both basic and complex MIS procedures (n = 111) with an average duration of 76.1 ± 59.8 minutes. When used before the procedure (n = 36) the checklist identified missing items in 7 cases (19.44 %). When used after the procedure (n = 58) the checklist identified missing items in 13 cases (22.41 %) that caused an average case delay of 3.4 ± 4.6 minutes. The most frequently missed checklist items included preoperative preference card review (13.5 %), verifying readiness of the carbon dioxide insufflator (9.0 %), and verifying availability of the Veress needle (3.6 %). The checklist took an average 3.9 ± 2.6 minutes to complete with its usefulness rated as 2.3 ± 1.7, ease of use as 1.7 ± 1.2, and frustration as 1.1 ± 1.2. Conclusion: The SAGES/AORN MIS checklist identified problems in 23 % of total cases that led to preventable delays. The checklist was easy to complete and not frustrating, indicating that preoperative use of the checklist could improve operative flow. This study also identified which checklist items were most useful which may help abbreviate the checklist, minimizing the frustration and time taken to complete it while maximizing its utility. These promising attributes of the SAGES/AORN MIS checklist should be further explored in future larger scale studies.


Background: In the 30 years since the first laparoscopic cholecystectomy, we have seen modifications in technique, evolution of instruments and streamlined postoperative management. Continued experience and comfort with laparoscopic cholecystectomy has led to its entry into the ambulatory arena. We asked whether this migration to an outpatient setting combined with increased penetrance of laparoscopy has had any impact on the indications for cholecystectomy over time. Methods: The New York State Planning and Research Cooperative System (NY SPARCS) longitudinal administrative database was utilized to identify patients who underwent cholecystectomy between 1995 & 2013. ICD-9 and CPT procedure codes were extracted corresponding to laparoscopic and open cholecystectomy and associated primary diagnostic codes. Data was analyzed as relative change in incidence (normalized to 1000 cholecystectomy patients) for respective diagnoses. An increase in state population of 7.85 % was used to correct for population growth, according to US Census data. Results: From 1995 to 2013, 711,406 patients underwent cholecystectomy in NY State, of which 637,308 (89.58 %) underwent laparoscopic cholecystectomy. The overall incidence of cholecystectomy has not increased (1.23 % increase with a commensurate population increase of 7.85 %). The distribution of indications for cholecystectomy during this time was: 65 % for acute calculus cholecystitis (n = 130,661), 11 % for biliary colic (n = 22,436), 7 % for acalculus cholecystitis (n = 13,813), 3 % for gallstone pancreatitis (n = 5,853), and 1 % for biliary dyskinesia (n = 2,951). While acute calculus cholecystitis as an indication declined by 20 % (p \ 0.0001) over 19 years, other primary diagnoses increased in incidence as follows: biliary colic (+54.96 %, p = 0.0013), acalculus cholecystitis (+94.24 %, p \ 0.0001), gallstone pancreatitis (+107.48 %, p \ 0.0001), and biliary dyskinesia (+331.74 %, p \ 0.0001). Ambulatory cholecystectomy has increased dramatically, with only 0.12 % of cholecystectomies being performed as outpatient in 1995 but increased by 382 fold to 45.94 % in 2013. Conclusion: An increase in operative volumes in response to the adoption of laparoscopic cholecystectomy was not borne out in our series. A shift in the distribution of diagnoses may reflect that patients with symptomatic cholelithiasis are undergoing operations earlier in their disease course, prior to the development of acute calculus cholecystitis. In addition, we observed a marked increase in the proportion of operations performed for other indications, most notably with biliary dyskinesia demonstrating a 332 fold change over the 19 year span of this study.

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Force Comparison for Transfascial Penetration of Commercially Available Suture Passers

Impact of a Responsive Insertion Technology (RIT) on Reducing Discomfort During Colonoscopy – Randomized Clinical Trial

Alexander J Shope, BS, Joshua S Winder, MD, Jonathon Bliggenstorfer, BS, Randy S Haluck, MD, Eric M Pauli, MD, Penn State Hershey Medical Center

Artur Pasternak, MD, PhD, Miroslaw Szura, MD, PhD, Rafal Solecki, MD, PhD, Andrzej Matyja, MD, PhD, Professor, 1st Department of General, Oncological and GI Surgery, Jagiellonian University Medical College, Krakow, Poland

Background: Transfascial suture passers (TSPs) are a common open and laparoscopic tool used to assist in port site closure or mesh securement. Commercially available TSPs have a wide array of distal tip configurations, mechanical actions, and shaft diameters. We assessed the insertion force of various TSPs in a novel ex-vivo porcine model. We hypothesized that TSPs with smaller diameter and a closed distal tip would require less insertion force. Methods: A custom designed support structure held a 3D-printed platform (Fortus 400mc, Statasys) suspended from a digital tensiometer. Uniform sections of porcine abdominal wall including skin, subcutaneous fat, and rectus muscle were sequentially secured to the platform. Nine TSPs were tested: Novapass straight and curved (Cook Inc), Gore suture passer (W.L. Gore), Weck-EFx (Teleflex Medical), Omniclose (Unimax), Artisan Port Closer (Artisan Medical), Carter-Thomason (Cooper Surgical), Endo-Close (Covidien), and a Reverdin needle (Amity Impex). After a standard skin incision, TSPs were passed through the abdominal wall at three locations both without and with 0 prolene suture under the following scenarios: native abdominal wall and abdominal wall with underlay ePTFE or composite ePTFE/polypropylene mesh. Insertion force was recorded in Newtons (N) ± standard deviation. Results: Force measurements can be seen in Table 1. When passed without suture through the abdominal wall, smaller diameter TSPs required less force [1.50 N ± 0.17 for 1.52 mm diameter compared to 9.68 N ± 1.5 for 2.82 mm diameter (p = 0.00072)]. When passing through mesh or while holding suture, diameter was not the only contributor to force; distal tip design and suture holding location played a contributory role. Through composite mesh, the solid tipped Gore TSP required less force than the hollow tipped Unimax [3.87 N ± 0.25 vs 7.88 N ± 0.20 (p = 0.00026)]. However, through the same mesh while holding suture, Unimax TSP required less force that the Gore [8.57 N ± 0.83 vs 13.67 N ± 2.70 (p = 0.035)]. Overall, smaller diameter TSPs required less force than the larger TSPs when passed through ePTFE empty [Gore 2.95 N ± 0.83 vs. Carter-Thomason 16.07 N ± 2.10 (p = 0.0005)] or through ePTFE mesh with suture [Gore 8.37 N ± 2.59 vs. Carter-Thomason 19.12 N ± 1.10 (p = 0.003)]. Conclusions: When passed without suture through the native abdominal wall, TSP diameter plays the greatest role in the force required for transfascial penetration. When passed through the abdominal wall/underlay mesh or passed while holding a suture, the distal tip shape, the mechanism of suture holding and the shaft diameter all contribute to the forces necessary for transfascial penetration. These factors should be considered when choosing a TSP for intraoperative use.

In many countries, colonoscopies for colorectal cancer screening, due to the costs are performed without sedation. Changes in the structure of the endoscopes are designed to facilitate the colonoscopic examination, shorten the time and improve the imaging of the intestinal lumen. Variable stiffness of the endoscope and recently introduced responsive insertion technology (RIT) are aimed to ease colonoscope insertion and reduce discomfort and pain during examination. The aim of the study is to analyze the frequency of auxiliary maneuvers during endoscopy depending on the structure of endoscopic armor tube, and a subjective assessment of patient discomfort during the examination. Material and Methods: The analysis included 647 patients who underwent complete colonoscopy in the screening program. All colonoscopies were performed without sedation. Olympus series 180 and 190 endoscopes equipped with a magnetic positioning system were used. Group I included patients who were examined using variable stiffness endoscopes and group II included patients examined using variable stiffness endoscopes with RIT. Main objective was to evaluate the cecal intubation time, the rate of loop formation, the need to change the patient position, the requirement to apply manual pressure to different areas of the abdomen and degree of discomfort and pain on a VAS. number, NCT01688557 Results: Group I consisted of 329 patients and group II - 318. The mean age of the patients was 58.4 years (SD ± 4.21). Both groups were compared in terms of age, sex, BMI and frequency of previous abdominal procedures. The mean cecal intubation time was 209 seconds in group I and 224 seconds in group II (p \ 0.05). Increased loop formation was observed on endoscope insertion in group II (1.7 vs 1.35) (p \ 0.05), and required more manual pressures to the abdomen (2.2 vs. 1.7) (p = 0.001). In group I, there was less discomfort and pain graded on a VAS - 2.3, in group II - 2.6. Conclusions: The implementation of responsive insertion technology facilitated shortening of the cecal intubation time. Modified structure of the endoscope made the colonoscopic examination easier by reducing loop formation on insertion with subsequent lower rate of auxiliary maneuvers.

Table 1 .



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Transoral Fundoplication Offers Durable Symptomatic Control for Chronic GERD: 3-Year Final Report from the Tempo Randomized Trial with a Crossover Arm

Predictive Factors for the Migration of Endoscopic SelfExpanding Metal Stents Placed in the Foregut

Karim S Trad, MD1, Mark A Fox, MD2, Gilbert Simoni, MD3, Ahmad B Shughoury, MD4, Mamoon Raza, MD5, Jeffrey A Heise, MD6, Daniel G Turgeon, MD1, Peter G Mavrelis, MD4, William E Barnes, MD7, 1The George Washington University School of Medicine and Health Sciences, Washington, DC, 2Crossville Medical Group, Crossville, TN, 3Advanced Gastroenterology, Inc, Thousand Oaks, CA, 4St. Mary Medical Center, Hobart, IN, 5Indiana Medical Research, Elkhart, IN, 6Hancock Regional Hospital, Greenfield, IN, 7Livingston Hospital and Healthcare Services, Inc, CAH, Salem, KY Background: Three previously published randomized controlled studies have demonstrated the short-term (up to 12 months) efficacy and safety of transoral esophagogastric fundoplication (TF) performed with the EsophyX device in eliminating troublesome gastroesophageal reflux symptoms and improving quality of life (QOL) in a sub-set of patients with chronic GERD. The aim of this study was to assess the durability of these outcomes at 36 months follow-up. Methods: The TEMPO trial (TIF EsophyX vs Medical PPI Open Label Trial) was conducted in 7 US sites. Between June and August 2012, chronic GERD patients with small (\2 cm) or absent hiatal hernias and who suffered from troublesome symptoms while on PPI therapy for at least six months and with abnormal esophageal acid exposure (C5.3 %, 48-hour pH-metry) were randomized either to TF group (n = 40) or to PPI group (n = 23). Following evaluation at six months, all remaining PPI patients (n = 21) elected to undergo crossover to TF. During the course of the study, 11 patients (6 TF, 2 PPI and 3 PPI-crossover patients) were lost to follow-up. Therefore, for the purpose of this work, the patient population comprised of the original TF patients (n = 34) at 3 year follow-up and the crossover patients (n = 18) at 30-month follow-up. GERD symptoms were assessed with 3 validated instruments: GERD Health-related Quality of Life (GERD-HRQL), Reflux Symptom Index (RSI) and Reflux Disease Questionnaire (RDQ). EGD (esophagogastroduodenoscopy) and 48-hour pH-metry were used for objective assessment. Two patients who underwent revisional laparoscopic procedures (1 Nissen, 1 Dor) were included in this analysis. Results: At the end of study, 38/54 (70 %) patients were off daily PPIs. Elimination of troublesome regurgitation was reported by 39/43 (91 %) of patients. Atypical symptom control was supported by improvement in the mean RSI score from 21.9 ± 9.0 on PPIs before TIF to 4.2 ± 7.3, p \ 0.001. The RSI score was normalized (B13) in 40/46 (87 %) of patients. The GERD-HRQL score improved from 26.3 ± 9.3 on PPIs before TF to 5.4 ± 8.4, p \ 0.001, indicating control of typical symptoms and improvement in QOL. The total GERD-HRQL and RSI scores between 12-month and the end of study remained stable (p [ 0.05). The number of reflux episodes was reduced from 172 ± 84 to 107 ± 72, p \ 0.001. Mean total % time pH \ 4 was improved from 10.2 to 7.8, p = 0.017. Esophagitis was healed in 20/23 (87 %) of patients. Conclusion: This study demonstrates that TF can be used to achieve long-term control of chronic GERD symptoms, healing esophagitis and improvement in esophageal acid exposure.


Jordan Singer, Amir H Aryaie, MD, Mojtaba Fayezizadeh, MD, John Lash, Jeffrey Marks, MD, Case Western Reserve University/ University Hospitals Case Medical Center Introduction: With recent advancements in endoscopy, self-expandable metal stents (SEMS) have been used to treat gastrointestinal leaks, perforations, and strictures. Stent migration frequently complicates management and often requires additional treatments to reach resolution. Our study aims to determine predictive factors for stent migration. Methods: Consecutive patients who received a SEMS with or without fixation after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, type of surgery, rate of stent migration, and type of stent (fully covered, partially covered, and uncovered) was collected. Rate of stent migration were compared between those fixated vs. non-fixated. Results: 214 consecutive stent placements for leak after foregut surgery, foregut stricture, and foregut perforation were included. Average duration of stent placement was 50.5 (range 0–358) days. 43 (19 %) stents migrated after the procedure. Of those that migrated, 33 stents (15 %) were removed and 27 (13 %) required another stent placement. 11 (5 %) procedures utilized stent fixation and 203 (95 %) did not incorporate fixation of the stents. Fixation techniques included endoscopic clips (9 %), endoscopic sutures (73 %), and transnasal sutures (18 %). Rate of stent migration was not different between those with and those without fixation (36 % vs. 19 % respectively, p = 0.2). 134 (63 %) procedures used a fully covered stent, 36 (17 %) used a partially covered stent, and 44 (20 %) used an uncovered stent. Rate of migration was significantly higher in procedures involving fully covered stents (30 %, vs. 3 %, vs. 5 %, respectively (p \ 0.001). Migration occurred mostly after esophagectomy, gastric bypass, and gastrojejunostomy (50 %, 50 %, and 25 % respectively). Conclusion: A big challenge with the use of SEMS in the treatment of gastrointestinal leaks, perforation and strictures is stent migration. The use of stent fixation did not appear to be associated with prevention of stent migration while the use of stent covering and type of surgery was predictive of the risk of migration.

S009 Is EGD Reporting Adequate: A Review of Reports from 100 Referring Gastroenterologists Joshua A Boys, MD, Beina Azadgoli, BS, Matthew Martinez, BS, Daniel S Oh, MD, Jeffrey A Hagen, MD, Steven R DeMeester, University of Southern California, Keck School of Medicine, Los Angeles, California Introduction: Esophagogastroduodenoscopy (EGD) is commonly performed in patients with symptoms of gastroesophageal reflux disease (GERD). A report that includes relevant landmarks and findings is important for communication with referring physicians and to document a patient’s baseline status. Pertinent findings include: the presence of esophagitis or a columnar lined esophagus (CLE), the locations of the squamocolumnar junction (SCJ), gastroesophageal junction (GEJ), and crural impression and the type of a hiatal hernia if present. Our aim was to evaluate how commonly these pertinent findings were described in patients being evaluated for GERD. Methods: A retrospective review was performed of consecutive EGD reports in patients referred to our center from 2012–2015. To avoid multiple reports from a single endoscopist, we used only the first report encountered from an endoscopist. Reports were reviewed for a description of pertinent findings. Results: We reviewed 100 EGD reports from different endoscopists in 100 individual patients. Esophagitis was reported in 33 patients, but was graded only 14 (42 %). The LA and Savory–Miller classifications were used equally. The esophagitis was characterized as erosive by 15 % of endoscopists. A CLE was documented in 28 patients, but the length was reported in only 16 (57 %), and no report used the Prague classification system. A hiatal hernia was present in 61 patients, but it was measured by only 31 (51 %). In the remainder it was subjectively described. The type of hiatal hernia, sliding versus paraesophageal, was classified in only 26 % of patients. One or more biopsies were taken in 93 patients. Biopsies were taken from the stomach alone in 19, esophagus/GEJ in 20 and both locations in 48 patients. The location of the biopsy was not documented in 7 % of patients. In 12 patients undergoing surveillance for known Barrett’s esophagus, a Seattle biopsy protocol was used in only 1 patient. Conclusion: Grading systems for esophagitis or a CLE when present were reported by only 28 % of endoscopists. The size and type of hiatal hernia were reported by only 13 % of endoscopists. Routine use of an established grading system, measurement of a hiatal hernia size and a description of the type of hernia would be beneficial to improve communication between endoscopists and other physicians. Further, these descriptions are invaluable to allow assessment of treatment response or disease progression in a patient.

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Should Surgeons Perform more Diagnostic and Screening Colonoscopies? A Comparison of Endoscopic Localization Error Rate Between Operating Surgeons and Referring Endoscopists in Colorectal Cancer

Is Current Surgery Resident and GI Fellow Training Adequate to Pass FES?

Arash Azin, MD, Fady Saleh, MD, MPH, Andrew Yuen, MD, Michelle Cleghorn, MSc, Timothy Jackson, MD, MPH, Allan Okrainec, MDCM, MHPE, Fayez A Quereshy, MD, MBA, University of Toronto Introduction: Colonoscopy for colorectal cancer (CRC) has been shown to have a localization error rate as high as 21 %. Such errors can have substantial clinical consequences especially in laparoscopic surgery. The primary objective of this study is to determine if initial diagnostic colonoscopic examination performed by the operating surgeon compared to non-operating referring endoscopists are associated with lower endoscopic localization errors. Methods: A retrospective chart review of all patients who underwent elective surgical resection for CRC at a large tertiary academic hospital between January 2006 and August 2014 was performed. The primary exposure of interest was the operator of the initial endoscopy: 1) patients who had their initial endoscopy by the same surgeon who conducted the definitive operation (operating surgeon group), and 2) patients that had their initial endoscopy by a referring gastroenterologist or general surgeon (non-operating endoscopist group). The primary outcome was localization error; categorized as a difference in at least one anatomic segment between initial endoscopy and final operative location. Multivariable logistic regression was used to control for predictors of localization error and to provide an adjusted comparison of odds ratio (OR) of localization error rate between the operating surgeon group and non-operating endoscopist group. Results: 557 patients were identified, 81 patients had their initial endoscopy completed by the operating surgeon, and 476 patients by a non-operating endoscopist. Initial diagnostic colonoscopy performed by the operating surgeon compared to nonoperating endoscopist demonstrated statistically significant lower operative localization error rate (1.2 % vs. 9.0 %, p = 0.016), shorter mean time from endoscopy to OR (52.3 days vs. 76.4 days, p = 0.015), higher tattoo localization rate (32.1 % vs. 21.0 %, p = 0.027), and lower repeat endoscopy rate (8.6 % vs. 40.8 %, p \ 0.001). Initial endoscopy performed by the operating surgeon was protective against error in both univariate, OR = 7.94 [95 % Confidence Interval (CI): 1.08–58.52; p = 0.016] and multivariate analysis, OR = 8.31 (95 % CI: 1.12–63.37; p = 0.040). Conclusion: This study demonstrates that diagnostic colonoscopies performed by an operating surgeon are independently associated with a lower localization error rate. Further research exploring the factors influencing localization accuracy and explaining why operating surgeons have lower error rates relative to non-operating endoscopists is necessary to understand differences in care.

Aimee K Gardner, PhD1, Daniel J Scott, MD1, Ross E Willis, PhD2, Kent Van Sickle, MD2, Michael S Truitt, MD3, John Uecker, MD4, Jeffrey M Marks, MD5, Brian J Dunkin, MD6, 1University of Texas Southwestern Medical Center at Dallas, 2University of Texas Health Sciences Center San Antonio, 3Dallas Methodist Hospital, 4University of Texas Southwestern Medical Center at Austin, 5Case Western Reserve University, 6Houston Methodist Hospital Background: Beginning in 2018, all graduates in General Surgery residency programs will be required to pass the Fundamentals of Endoscopic Surgery (FES) examination as part of the ABS Fundamentals of Endoscopy Curriculum (FEC). The purpose of this study was to assess the adequacy of current surgical residency and Gastroenterology (GI) fellowship flexible endoscopy training as measured by performance on the FES examination. Methods: Fifth-year general surgery residents and GI fellows across five institutions were invited to complete the FES examination. All general surgery residents had met ACMGE/ABS case volume requirements as well as additional institution-specific requirements for endoscopy, including some or all of the following: didactic modules, simulator training, and dedicated rotations. All participants completed FES testing at the end of their respective academic year. Procedure volumes were obtained from ACGME case logs. Curricular components for each specialty and institution were recorded. Results: Twenty-three PGY5 residents and 16 GI Fellows completed the examination. Average case numbers for PGY5 s were 79.0 ± 26.9 colonoscopies and 46.3 ± 12.6 EGDs. First-year GI Fellows (N = 7) reported 118.1 ± 68.4 colonoscopies and 156.4 ± 92.0 EGDs. Second-year fellows (N = 3) reported 462.0 ± 307.0 colonoscopies and 411.0 ± 260.1 EGDs. Third-year fellows (N = 6) reported 480.17 ± 67.1 colonoscopies and 365.5 ± 44.7 EGDs. The overall pass rate for all participants was 79.5 %, with 69.6 % of residents and 93.8 % of fellows passing both the cognitive and skills components. For surgery residents, pass rates were 78.3 % for manual skills and 82.6 % for cognitive. On the skills examination, Task 2 (loop reduction) was associated with the lowest performance. Data indicated no significant correlation between cognitive and skills scores. Experience with colonoscopy cases significantly correlated with skills scores (r = .44, p \ .05), whereas EGD cases revealed no significant correlations. Receiver operating characteristics (ROC) curves were examined among the resident cohort. The minimum number of cases associated with passing FES the skills component was 101. Significant variability existed in curricular components across institutions. Conclusions: These data suggest that current flexible endoscopy training may not be sufficient for all trainees to pass the examination. Implementing additional components of the FEC may prove beneficial in achieving more uniform pass rates on the FES examination.



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Probe Based Confocal Laser Endomicroscopy: The New Standard for the Surveillance of Barrett’s Esophagus?

Outcomes in Patients with Over One-Year Follow-Up After Peroral Endoscopic Myotomy (POEM)

Thomas T Wang, MD, William F Buitrago, MD, PhD, Philip Leggett, MD, University of Texas Health Science Center at Houston

Marc A Ward, MD1, Matt E Gitelis, BA2, Lava Y Patel2, Yalini Vigneswaran1, Joann Carbray2, Michael B Ujiki, MD2, 1University of Chicago Hospitals Department of Surgery, 2NorthShore University HealthSystem Department of Surgery

Introduction: Probe-based confocal laser endomicroscopy (pCLE) is one of several emerging technologies that offers unique advantages over conventional endoscopy in the surveillance and treatment of Barrett’s esophagus. The goal of this study is to validate the use of pCLE in guiding the surveillance and treatment of Barrett’s esophagus. Methods: In our single-institution prospective study, 22 patients who presented with reflux symptoms were selected to undergo endoscopy with pCLE. Inclusion criteria were adults with reflux symptoms regardless of PPI use, prior diagnosis of Barrett’s esophagus, or prior EGD findings. Exclusion criteria were patients under the age of 18 and patients whose insurance would not reimburse for the procedure. For each patient, standard white light endoscopy was performed followed by the application of pCLE imaging regardless of endoscopic findings. pCLE images of the gastroesophageal junction were obtained and recorded. Afterwards 4 quadrant biopsies were taken at the same level that was imaged. Images obtained by pCLE were reviewed at the end of each procedure. The pCLE diagnosis of Barrett’s esophagus was defined as the presence of intestinal metaplasia and goblet cells. The presence of dysplasia was determined using validated imaging criteria. Results: The incidence of Barrett’s esophagus diagnosed using pCLE (n = 9, 41 %) was greater than the incidence found by Seattle protocol (n = 4, 18 %). The negative predictive value of Seattle protocol using pCLE as the standard for Barrett’s esophagus detection was 53.9 %. Regarding the diagnosis of dysplasia, the detection rate of dysplasia positivity was higher when using pCLE criteria (n = 3, 13.6 %) compared to Seattle protocol (n = 1, 4.5 %). The discordance was due to the fact that two patients were diagnosed as indeterminate for dysplasia by histologic analysis. Conclusions: Results of this study support the existing literature that there is improved detection rates of Barrett’s esophagus using pCLE, which provides a larger area of diagnostic coverage. Furthermore a secondary benefit found by this study is that by utilizing pCLE to obtain more information regarding mucosal microarchitecture, a diagnosis of dysplasia may be made with greater confidence. In this study results from our ongoing experience with pCLE technology has led directly to a change in clinical management in 32 % of our patients. Those patients with Barrett’s esophagus missed by traditional 4-quadrant biopsy surveillance will undergo shorter surveillance intervals. Patients with pathology indeterminate for dysplasia yet positive for dysplasia on pCLE will receive radiofrequency ablation therapy.


Introduction: Peroral endoscopic myotomy is a promising therapy in the treatment of achalasia. The study was designed to report outcomes, including quality of life, in patients with at least one-year follow-up. Methods: Patients from an institutional review board-approved protocol underwent POEM and were followed prospectively. Health-related quality of life (HRQOL) was measured preoperatively and 1 year postoperatively using Short Form 36 Health Survey Version 2 (SF-36v2). Comparisons were made with patients from a prospective database who underwent laparoscopic Heller myotomy over the same period. Paired t tests were used to determine statistical significance. Results: We analyzed 41 consecutive POEM patients with at least one-year followup. Mean age was 63 +/- 17.9 years and 61 % were male. Chicago Classification included 12 Type I, 16 Type II, and 9 Type III. Twenty-eight previous esophageal interventions were performed in these patients including 13 botox injections, 16 pneumatic dilations, and 7 LHM. Significant improvements in quality of life between baseline and 1 year were found in role limitations due to physical health (81.8 +/- 25.8 vs 65.9 +/- 31.6, p = 0.002) and social functioning (83 +/- 19.1 vs 64.6 +/- 31.3, p = 0.002). In addition, the reflux severity index (RSI) was significantly decreased at one-year (8.0 +/- 7.8 vs 23.5 +/- 11.1, p \ 0.002) with most improvement found in decreased symptoms related to GERD and dysphagia. When compared to 24 patients who underwent LHM, there was no difference in average Eckardt scores (0.9 +/- 1.6 vs 1.0 +/- 1.3, p [ 0.05) or incidence of PPI use (65 % vs 61 %, p = 0.75). However, when looking at just type III patients, POEM patients had a higher remission rate (100 % vs 62.5 %) and significantly lower post-operative Eckardt scores at 1 year (1.1 vs 3.1, p \ 0.05). The average myotomy length of type III achalasia patients undergoing POEM was 18.6 cm (+/-6.9) compared to 10.3 cm (+/-1.0) in LHM patients (p \ 0.01), which may have contributed to this difference. Conclusion: POEM provides a significant quality of life benefit at one year while having similar relief of dysphagia and post-operative PPI use compared to LHM. Type III achalasia patients may have better outcomes with POEM compared to LHM.

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Poem is a Cost-Effective Procedure: Cost-Utility Analysis of Endoscopic and Surgical Treatment Options in the Management of Achalasia

Short-Term Outcomes of Self-Expanding Metal Stent Placement as a Bridge to Surgery for Acute Colorectal Cancer Obstruction

Heidi J Miller, MD, MPH, Ruel Neupane, BS, Mojtaba Fayezizadeh, MD, Arnab Majumder, MD, Jeffrey M Marks, MD, FACS, FASGE, UH Case Medical Center Introduction: Peroral Endoscopic Myotomy (POEM) is a safe and effective treatment for achalasia with few contraindications and the added benefit of an endoscopic, minimally invasive approach. Alternative treatments include Laparoscopic Heller Myotomy (LHM) along with endoscopic treatments including Pneumatic Dilation (PD) and onabotulinumtoxina injections (BI). We evaluate the economics and cost-effectiveness of treating achalasia. Methods: We performed an analysis of charges for POEM, LHM, PD and BI performed at our institution from 2011–2013. The Consumer Price Index inflation calculator was used to bring charges equivalent to 2015 USD. Cost-effectiveness was calculated based on institutional charges, number of interventions required for best results for dilations and injections, and efficacy reported in current literature. Incremental cost effectiveness ratio (ICER) was calculated by a cost-utility analysis using quality-adjusted life year (QALY) gained, defined as a symptom-free year in a patient with achalasia. Results: The average number of interventions required is 2.3 dilations or 2 injections for efficacies of 80 % and 61 % respectively, with charges of $12,427 for PD and $12,440 for BI. Charges were $38,552 for LHM and $40,585 for POEM with efficacies of 90 %. Annual cost per cure over a period of three years for POEM, BI and PD are $15,032, $51,834 and $4,931 respectively. PD remains cost-effective over the course of 5 years when compared to POEM, however these calculations do not account for the cost of complications or secondary procedures required due to failure of pneumatic dilations. POEM becomes more cost-effective than BI at 2 years. ICER ($/QALY) for POEM vs BI is $24,264 at 2 years, $11,442 at 3 years and $7906 at 4 years. An accepted benchmark for the value of care is $50,000 per QALY, therefore at year two, POEM has reached incremental cost effectiveness based on quality adjusted life years over BI. Conclusion: POEM clearly becomes more cost-effective than BI after 2 years post procedure due to high failure rates of the relatively economical BI intervention. There are additional costs after BI and PD as the majority of patients will require either LHM or POEM within 2 years of BI and PD. Therefore these should be reserved for patients who are unable to tolerate general anesthesia or have life expectancy less than 3 years. From an economic standpoint, POEM should be considered equivalent to LHM and superior to BI or PD as standard treatment for achalasia.

Yoshihisa Saida, MD, Toshiyuki Enomoto, MD, Emiko Takeshita, MD, Kazuhiro Takabayashi, MD, Sayaka Nagao, MD, Yoichi Nakamura, MD, Miwa Katagiri, MD, Ryohei Watanabe, MD, Yasushi Nagaoka, MD, Manabu Watanabe, MD, Koji Asai, MD, Natsuya Katada, MD, Shinya Kusachi, MD, Department of Surgery, Toho University Ohashi Medical Center Aim: The aim of this study was to evaluate the short-term outcomes of self-expanding metal stent (SEMS) insertion as a bridge to surgery (BTS) in patients presenting with acute colorectal cancer obstruction. Methods: All patients with acute colorectal cancer obstruction who underwent endoscopic SEMS placement with a guide wire under radiographic guidance and utilizing colonoscopy, as a BTS between 1993 and September 2015 were reviewed and included in the study. Results: A total of 215 patients underwent EMS placement for colorectal stenosis during the period, those included 147 BTS, 60 palliative purpose cases for unresectable malignant diseases and 8 benign strictures. In 147 BTS cases, 88 M and 59F; mean age 67 were included. The BTS was able to be successfully performed in 137 cases (successful rate: 93 %). Complications at the time of insertion were; 4 perforation cases in sigmoid colon and rectosigmoid (3 %) and 4 migration in Transverse, descending, sigmoid colon and rectum (3 %). The surgery enabled 99 % of total case to EMS insertion of bridge to surgery. The duration of preoperative EMS placement was 3–27 days (mean: 8 days). No intraoperative mortality and morbidity, or postoperative mortality were observed. Postoperative morbidities included 4 wound infection, 2 ileus, 1 abdominal abscess and 3 leakages. These results are considered to be relatively favorable. The rate of stoma creation after BTS was 7 %, which is lower than the rate of 67 % from the cases that EMS could not be placed. Circumferentially obstructive colorectal cancer often gives us difficult preoperative treatment, risk of contaminated operation and the need for secondary operation. But EMS enables us to obtain wider lumen to decrease the pressure of proximal intestine. It also enables us to inspect proximal intestine and to perform elective surgery after preoperative mechanical preparation. So, SEMS for BTS has been effectively used. Conclusions: In our experience, SEMS placement as a BTS is a safe and effective strategy for the treatment of patients with acute colorectal cancer obstruction.



Surg Endosc (2016) 30:S211–S263



Preventing Anastomotic Complications: Early Results of Laparoscopic Gastric Devascularization Two Weeks Before Minimally Invasive Esophagectomy

Does the Type of Intraoperative Pyloric Procedure During Minimally-Invasive Esophagectomy Predict the Need for Postoperative Endoscopic Interventions?

David S Strosberg, MD, Jennifer S Schwartz, MD, Maelee Yang, BS, Robert E Merritt, MD, Kyle A Perry, MD, The Ohio State University Wexner Medical Center

Danica Giugliano, MD, Adam C Berger, MD, Hanna Meidl, Michael J Pucci, MD, Ernest L Rosato, MD, Talar Tatarian, MD, Scott Keith, PhD, Nathaniel R Evans, MD, Francesco Palazzo, MD, Thomas Jefferson University Hospital

Introduction: Anastomotic complications resulting from ischemic changes in the gastric fundus remain a major cause of surgical morbidity following esophagectomy with gastric pull-up reconstruction. Laparoscopic gastric devascularization (LGD) proposes an innovative method to improve gastric conduit perfusion and improve anastomotic healing to date. Clinical studies with LGD performed 4 to 7 days before esophagectomy have produced inconsistent results; however, preclinical studies suggest that a longer ischemic conditioning time may be required to achieve the desired changes in gastric perfusion. This study reports our early experience with LGD performed two weeks prior to minimally invasive esophagectomy (MIE) with intrathoracic anastomosis. Methods: We performed a retrospective review of all patients who underwent LGD prior to minimally invasive Ivor-Lewis esophagectomy between August 2014 and July 2015 at a large academic medical center. LGD included staging laparoscopy with mobilization of the stomach including division of the short gastric vessels, left gastric artery and coronary vein, and posterior gastric attachments. Patient data are maintained in a prospectively collected, IRB approved database, and variables of interest for this study included patient demographics, comorbid conditions, clinical stage, use of neoadjuvant chemoradiation, perioperative events, length of hospital stay, 60-day readmission and complications. Results: Thirty patients underwent LGD prior to minimally invasive Ivor-Lewis esophagectomy, and 21 (70 %) received neoadjuvant chemoradiation. LGD was performed a median of 14.5 (9–42) days prior to esophagectomy. Median operative time was 39 (18–56) minutes, and median length of stay was 0 (0–1) days. There were no complications or readmissions following LGD. MIE was completed laparoscopically in 93 % of patients; two patients required conversion to an open procedure due to mediastinal inflammation following neoadjuvant chemoradiation. Five patients (17 %) were readmitted within 60 days of surgery: 1 (3 %) patient with an anastomotic leak, 2 (7 %) with pneumonia, and 2 (7 %) with post-operative nausea and vomiting. One patient (3 %) expired following an anastomotic leak that required reoperation, and no patients developed an anastomotic stricture during the study period. Conclusions: LGD with delayed esophageal resection and reconstruction can be safely performed 2 weeks prior to MIE with minimal morbidity. The low rate of anastomotic leak (3 %) and absence of anastomotic strictures in this series suggests that this approach may successfully improve gastroesophageal anastomotic healing and reduce the rate of anastomotic complications reported with single stage approaches. However, larger comparative studies are required to directly compare the outcomes of this approach to those of single-stage Ivor-Lewis esophagectomy.

Introduction: The aim of this study was to compare intraoperative pyloric interventions and the rates of postoperative endoscopic interventions within the first six months following minimally invasive esophagectomy (MIE). Intraoperative pyloric procedures are commonly performed during esophagectomies to reduce the rate of postoperative gastric conduit dysfunction. These procedures include pyloroplasty (PP), pyloromyotomy (PM), and pyloric botox injections (BI). Despite these interventions, some patients experience postoperative symptoms of conduit dysfunction that warrant further endoscopic interventions. Methods and Procedures: We queried our IRB-approved prospective foregut database to identify patients who underwent MIE (minimally-invasive 3-hole esophagectomy or minimally-invasive Ivor-Lewis esophagectomy) for esophageal carcinoma from January 2008 to January 2015 and who had six months of follow-up. Intraoperative pyloric procedure type was noted and the patients were grouped as ‘‘none’’, ‘‘PP’’, ‘‘PM’’ or ‘‘BI’’. The types and rates of endoscopic interventions after surgery were reviewed and compared using pairwise comparisons. Significance was established at p \ 0.05. Results: There were 146 patients who underwent a MIE for esophageal carcinoma. The majority (n = 113, 76.9 %) underwent a 3-hole MIE. Table 1 shows the types of pyloric procedures and types of endoscopic interventions. Postoperative endoscopic interventions were performed on a total of 38 patients (26.0 %). Twenty-eight patients (19.2 %) had anastomotic dilations and 16 patients (11.0 %) had pyloric interventions (pyloric dilation and/or botox injection), with 6 of these patients requiring both anastomotic and pyloric interventions. The BI group was most likely to require any type of postoperative intervention (n = 13, 31.7 %) and was most likely to require a pyloric intervention (n = 8, 19.5 %). By contrast, the percentage of patients requiring pyloric intervention was 7.9 % (n = 3) for PM, 6.8 % (n = 4) for PP, and 12.5 % (n = 1) in the ‘‘none’’ group. Though not statistically significant, patients receiving intraoperative botox injections tended to require further pyloric interventions. Conclusions: Which intraoperative pyloric intervention is the most effective during MIE remains unclear. Our data show that the patients who received botox injection to the pylorus demonstrated a trend toward requiring a higher number of secondary interventions. Further research is needed to determine if the choice of intraoperative pyloric procedure type significantly affects quality of life, morbidity, and overall prognosis in these patients.

Table 1 .


Surg Endosc (2016) 30:S211–S263




Minimally-Invasive Duodenojejunostomy for Superior Mesenteric Artery Syndrome: Intermediate Follow Up Results of a Rare Operation

A 5-Item Frailty Index Based on NSQIP Data Correlates with Morbidity and Mortality Following Paraesopahgeal Hernia Repair

Julietta Chang, MD1, Mena Boules, MD1, John Rodriguez, MD1, R Matthew Walsh, MD1, Raul Rosenthal, MD2, Matthew Kroh, MD1, 1 Cleveland Clinic Institution, 2Cleveland Clinic Florida

Munyaradzi Chimukangara, MD1, Matthew Frelich, MS1, Matthew Bosler, BA1, Lisa Rein, MS2, Aniko Szabo, PhD2, Jon Gould, MD1, 1 Medical College of Wisconsin, Surgery, 2Medical College of Wisconsin, Biostatistics

Introduction: Superior mesenteric artery syndrome (SMAS) is a rare condition caused by partial obstruction of the 3rd portion of the duodenum by the SMA anteriorly and aorta posteriorly resulting in abdominal pain, bilious emesis, and bloating symptoms. Contrast radiography, CT scan, and sometimes endoscopy confirm diagnosis. Laparoscopic duodenojejunostomy has been described as a safe and feasible surgical intervention with favorable short-term outcomes. However, descriptions of intermediate outcomes are lacking in the literature. Methods and Procedures: A retrospective chart review was performed on patients who underwent minimally-invasive duodenojejunostomy for SMAS from March 2005 to August 2015 at our healthcare system. We analyzed patients’ presentations, work-up, surgical therapy, short-term and intermediate (6 month or greater) outcomes. Results: Of 26 patients who underwent minimally invasive duodenojejunostomy for SMAS at the Cleveland Clinic, 18 were 6 months or more out from the initial procedure. Mean age was 30.0 with 4 men and 14 women. Patients’ diagnosis was made by clinical presentation, elimination of other diagnoses, and radiographic confirmation. Mean weight loss preoperatively was 7.0 kg. 14 of 18 patients had other comorbid conditions. 16 patients underwent laparoscopic duodenojejunostomy; 2 underwent robotic duodenojejunostomy. There were no intraoperative complications. Postoperatively, 2 patients developed prolonged ileus. 1 underwent exploratory laparotomy and washout for presumed leak but none was identified. 3 patients were readmitted within 30 days; 2 for intolerance to enteral intake with dehydration, and 1 for abdominal pain related to an anastomotic stricture which was successfully dilated endoscopically. The average and median length of follow up was 29.6 months and 22.5 months, respectively. Patients gained an average of 2.2 kg with an increase in body mass index of from 19.6 m/kg2 to 20.3 m/kg2. 9 of 18 patients reported an improvement in symptoms, while only 3 reported resolution. 5 continued to be severely symptomatic. 3 required long-term parenteral nutrition. 1 was diagnosed with intestinal dysmotility and underwent a feeding jejunostomy tube placement. Another was diagnosed with gastroparesis and underwent a laparoscopic gastric electric stimulator placement and pyloroplasty. None suffered from symptoms of blind loop syndrome like new-onset bloating, diarrhea, or greasy stools. There were no mortalities. Conclusions: Duodenojejunostomy is the most common surgical intervention in management of SMAS. Laparoscopic duodenojejunostomy is associated with less morbidity in the perioperative period. Our intermediate follow-up reveals moderate improvement and infrequent resolution of preoperative symptomatology. Patients had a modest average weight gain postoperatively. This may suggest that different preoperative work-up and treatment is indicated.

Introduction: Frailty is a measure of physiologic reserve associated with increased vulnerability to adverse outcomes following surgery in the elderly. The ‘accumulating deficits’ model of assessing frailty has been applied to the ACS NSQIP database, and an 11-item modified frailty index (mFI) has been developed and validated. Unfortunately, many of the 11 variables in this mFI are often missing from the NSQIP data, significantly decreasing the sample size for less commonly performed procedures. We developed a condensed 5-point frailty index based on the larger 11-point scale to assess the relationship between frailty and outcomes in patients undergoing paraesophageal hernia (PEH) repair. Methods: The NSQIP database was queried for ICD-9 and CPT codes associated with PEH repair. The NSQIP participant use files for the years 2011–2013 were utilized. Only subjects C60 years old were included. Frailty was assessed based on the number of variables mapped to the 5-point frailty index (0, 1, 2, C3 items present). Outcomes were 30-day mortality, Clavien-Dindo Grade C3 complications, discharge destination, and readmissions. Multivariate logistic regression was used to determine the relationship between frailty and outcomes. Results: Of the 4434 eligible patients, 3711 records were included in the final analysis (84 %). Excluded patients were missing 1 or more variables in the 5-point frailty index. Additional analysis revealed that using the 11-point mFI, only 885 patients (20 %) would have been included based on missing data. Clavien-Dindo Grade C3 complications were 5.9 %, mortality 1.2 %, readmission 7.6 %, and 8.7 % of patients were discharged to a facility other than home. The 5-point frailty index was significantly correlated with complications [p \ 0.0001], mortality [p \ 0.0007], discharge to a facility other than home [p \ 0.0001], and readmissions [p \ 0.0184]. Conclusions: Frailty, as assessed by a condensed 5-point frailty index is significantly correlated with adverse outcomes in patients undergoing PEH repair. When compared to the original 11-point mFI, the utilization of the 5-point index allows for a significantly increased sample size and a cohort that is likely more representative of the study group of interest (84 % vs. 20 % of otherwise eligible patients). Further study is necessary to determine if the condensed 5-point mFI is a valid measure of frailty.



Surg Endosc (2016) 30:S211–S263



The Impact of Crural Closure Versus Fundoplication During Nissen Fundoplication as Measured by EndoflipÒ Parameters

Autologous Augmentation of Hiatal Hernia Repair with Filtered Platelet Concentrate Improves Tissue Remodeling in a Swine Model

Andreas M Schneider, MD, Daniel D Bradley, MD, Brian E Louie, MD, Alexander S Farivar, MD, Ralph W Aye, MD, Swedish Medical Center Cancer Institute Introduction: The two main components of Nissen Fundoplication (NF) are hiatal closure and creation of the fundoplication. Both contribute toward the repair but their individual influence remains controversial. We hypothesized that crural closure plays a significant and underappreciated role. We aimed to determine each separate influence on Diameter - minimum (Dmin), Cross-Sectional Area (CSA), Distensibility (Dist) and Compliance (Comp) as measured by EndoflipÒ during the repair. Methods: Randomized controlled prospective study. Patients included had documented gastroesophageal reflux disease, hiatal hernia \5 cm, intact peristalsis and normal distal contractile integral. Patients were randomized to either hiatal closure followed by fundoplication (Group 1) or fundoplication followed by hiatal closure (Group 2). EndoflipÒ measurements were performed at predetermined critical steps throughout the procedure - pre dissection, after dissection, after the first and after the second component of the repair. Results: A total of 16 patients, predominantly women (87.5 %) were randomized. The groups were comparable in BMI and hiatal hernia size. There was a trend toward impact of hiatal closure in both groups. Between dissection and completion of the procedure, Group 1 had a decrease in all parameters but this did not reach statistical significance. By comparison Group 2 had a significant decrease in all parameters (Table 1; Fig. 1). Conclusion: Both hiatal closure and fundoplication decrease the diameter, crosssectional surface area, distensibility and compliance. When hiatal closure is followed by fundoplication the decrease appears less in comparison. Unopposed hiatal closure significantly amplifies the reduction in diameter, cross-sectional surface area, distensibility and compliance; thus, underlining its significance during Nissen repair.

Table 1 . Mean

Group 1 (n = 7) (p-value)

Dmin Pre– Post

7.8 +/- 2.1

CSA Pre– Post

55 +/- 28.7 40 +/- 19.4

0.28 58.6 +/- 25.5 31.7 +/- 14.5 0.017

Dist Pre– Post

1.9 +/- 1.4

1.5 +/- 0.6

0.41 2.2 +/- 1.2

Comp Pre– Post

53 +/- 30

33 +/- 25.6

0.45 60 +/- 29.9

Fig. 1 .


Group 2 (n = 9) (p-value)

7.03 +/- 1.6 0.46 8.4 +/- 1.9

6.2 +/- 1.3

0.9 +/- 0.5



28.3 +/- 21.6 0.007

Maria S Altieri, Gabriel Pagnotti, PhD, Angelique Corthals, MD, Kenneth Shroyer, MD, PhD, Aurora Pryor, MD, Rashid Kikhia, MD, Mark Talamini, MD, Dana A Telem, MD, Stony Brook University Hospital Introduction: Autologous augmentation of wound remodeling with platelet concentrate is a burgeoning field with promising results. Filtered plasma concentrate (fPC) is comprised of growth factors essential during the proliferative phase of wound healing. fPC stimulates fibroblast proliferation making it an ideal catalyst to increase collagen synthesis and deposition. We hypothesized that the addition of fPC to an acellular biologic graft would improve crural healing and tissue remodeling in hiatal hernia repair. Methods: Sixteen healthy Yorkshire male pigs were divided into three groups: Hiatus repair (HR) (n = 5), HR with biologic graft (n = 5), and HR with biologic graft and fPC (n = 6). All surgeries were performed in a standardized fashion by a single surgeon. For the fPC group, 60 mL of blood was drawn prior to procedure and processed sterilely through a point-of-care blood filtration system. The graft was saturated with 6 mL fPC for 30 minutes based on prior kinetic studies to maximize adherence. 1 mL was reserved for platelet count and functional analysis. Animals were euthanized at 8-weeks and the distal esophagus with hiatus was harvested enblock. A blinded histopathologist graded tissue for collagen deposition and vascularization at the graft-hiatal interface. Tensile strength testing was performed with the Teststar IIs (MTS), coupled with a strain extensometer (Epsilon). Samples were pre-loaded to 1 N and deformed at a constant rate of 0.2 mm/s. Analysis was performed via one-way analysis of variance. Results: On gross examination, no animal had hiatal hypertrophy or esophageal kinking or obstruction. Animals in the fPC group had significantly increased mean collagen deposition (3.3 +/- 1.2 vs 1.8 +/- 1.3, 1.5 +/- 1.1, p = 0.04) compared to HR alone and HR + biologic graft. Vascular deposition did not differ between groups (p = 0.9). A trend towards increased ultimate strength, defined as the force resulting in tissue failure, was 10.4 +/- 9.0 in the fPC group compared to 3.7 +/- 3.5 and 5.3 +/- 4.4 in HR and HR + biologic graft groups, respectively (p = 0.17). Aspirate analysis revealed a mean platelet count of 3 million platelets/ 1 mL of aspirate. Conclusion: Autologous augmentation of a biologic graft with fPC significantly increased collagen deposition at the hiatus. No evidence of excessive hiatal hypertrophy was grossly or microscopically appreciated. A trend towards increased ultimate strength of the fPC group was also demonstrated. Use of autologous fPC appears a safe and promising adjunct to wound remodeling and healing in a swine model. Planning is underway for human trials.

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Impact of Standard Pressure and Low Pressure Pneumoperitoneum in Shoulder Pain Following Laparoscopic Cholecystectomy: A Double Blind Randomized Controlled Trial

Predictive Factors of Macroscopic Serosal Invasion in Gastric Cancer: Candidates for Intraperitoneal Chemotherapy

Hemanga K Bhattacharjee, MS, Virinder Bansal, MS, Azarudeen Jalaludeen, Subodh Kumar, MS, Asuri Krishna, MS, Rajeshwari Subramaniam, MD, Rashmi Ramachandran, MD, Mahesh Misra, MS, All India Institute of Medical Sciences Background: Laparoscopic cholecystectomy (LC) is the standard of care for gallstone disease. 30–60 % of patients following LC suffer from shoulder pain in the immediate post-operative period. Exact mechanism of shoulder pain following LC is not well elucidated. This double blind randomized study is designed to evaluate the incidence and severity of shoulder pain following LC at low pressure and standard pressure pneumoperitoneum. Materials and Methods: The study was conducted in a tertiary care referral hospital from November 2014 to September 2015. Consecutive patients undergoing LC for gallstone disease who met the inclusion criteria were enrolled. Sample size calculated was 80. 40 patients were randomized to Standard Pressure Laparoscopic Cholecystectomy (Group I - Pressure of 14 mmHg) and 40 to Low Pressure Laparoscopic Cholecystectomy (Group II- Pressure of 9 -10 mmHg). Randomisation was done using computer generated random numbers, divided into blocks of eight. Sealed envelopes were used to conceal allocation. Data were collected in concurrence with CONSORT guidelines. Primary outcome measured was incidence of shoulder pain and its severity on Visual Analogue Scale (VAS) at 4, 8, 24 hours and 7 days after LC. Secondary outcomes measured were duration of surgery, technical difficulty during LC, intra-operative variation in heart rate and blood pressure and post-operative abdominal pain. The patient and the resident who measured the pain were blinded about the allocated group. Results: A total of 170 LC were performed and 80 were randomised. All patients received the allocated treatment. There was no conversion to open surgery or major bile duct injury on either group. 23 patients (57.5 %) in Group I and 9 patients (22.5 %) in Group II had shoulder pain. This difference was statistically significant (p = 0.001). The severity of pain (VAS score, mean ± SD) at 4 hrs, 8 hrs, 24 hrs and 7 days following surgery were 0.125 ± 0.79, 1.8 ± 2.64, 2.35 ± 2.63 and 0, respectively in Group I and 0.125 ± 0.79, 0.7 ± 1.92, 0.925 ± 1.87 and 0 respectively in Group II. The difference was significant at 8 and 12 hrs after surgery (p = 0.009, 0.005). The difference in procedural time, technical difficulty, intraoperative variations in heart rate and blood pressure and post-operative abdominal pain were not significant. Conclusion: Laparoscopic cholecystectomy with intra-abdominal pressure of 9–10 mmHg significantly reduces the incidence and severity of post-operative shoulder pain. Performing LC at a lower intra-abdominal pressure is safe and effective.

Seonmi Hwangbo, MD, Oh Kyoung Kwon, MD, Wansik Yu, MD, FACS, Gastric Cancer Center, Kyungpook National University Medical Center Introduction: The aim of this study is to investigate the predictive factors of macroscopic serosal invasion in gastric cancer and to determine suitable candidates for intraperitoneal chemotherapy. Macroscopic serosal invasion is one of the most important risk factors for the peritoneal recurrence of gastric cancer and is a good criterion for the use of adjuvant intraperitoneal chemotherapy. However, in clinical practice, many patients still hesitate or refuse to receive intraperitoneal chemotherapy despite the reported survival benefit. Methods and Procedures: The clinical data of 680 patients who underwent surgery with clinical diagnosis of advanced gastric cancer between January 2011 and December 2014 were reviewed. Multiple stepwise logistic regression analysis was used to determine factors associated with macroscopic serosal invasion. Results: Macroscopic serosal invasion was found in 223 (32.8 %) patients during laparotomy. The patients with macroscopic serosal invasion had significantly worse outcomes than those without macroscopic serosal invasion (overall survival (OS): 36.5 vs. 47.2 months, p \ 0.001; disease-free survival (DFS): 37.0 vs. 48.3 months, p \ 0.001). In univariate analyses, macroscopic serosal invasion were significantly associated with CEA level (p \ 0.001), CA 19-9 level (p \ 0.001), macroscopic type (p \ 0.001), differentiation (p = 0.001), longitudinal location (p \ 0.001), and circumferential location (p \ 0.001). Multivariate analysis showed that CEA level [7 ng/mL [hazard ratio (HR) 4.018; 95 % confidence interval (CI) 2.089–7.728; p \ 0.001), CA 19-9 level[37 U/mL (HR 1.906; 95 % CI 1.076–3.375; p = 0.027), macroscopic type 3 or 4 (HR 2.193; 95 % CI 1.481–3.247; p \ 0.001), undifferentiated histology (HR 1.456; 95 % CI 1.001–2.118; p = 0.049), tumors involving more than 2 portions in longitudinal location (HR 2.771; 95 % CI 1.538–4.991; p = 0.001), and tumors with circumferential involvement (HR 2.618; 95 % CI 1.319–5.197; p = 0.006) were significant predictive factors for macroscopic serosal invasion. Conclusion: Patients with CEA level [7 ng/mL, CA 19-9 level [37 U/mL, macroscopic type 3 or 4, tumors involving more than 2 portions in longitudinal location, and tumors with circumferential involvement may be suitable candidates for intraperitoneal chemotherapy because of the high possibility of macroscopic serosal invasion. Physicians need to make efforts to improve the compliance to intraperitoneal chemotherapy through adequate education of those patients.



Surg Endosc (2016) 30:S211–S263



Or Fire Virtual Training Simulator: Design and Face Validity 1



Denis Dorozhkin , Daniel B Jones , Steven D Schwaitzberg , Stephanie B Jones4, Caroline L Cao5, Jaisa Olasky6, Marcos Molina2, Steven Henriques2, Jinling Wang5, Jeff Flinn5, Suvranu De1, 1Center for Modeling, Simulation and Imaging in Medicine (CeMSIM), Rensselaer Polytechnic Institute, Troy, NY, USA, 2Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA, 3Department of Surgery, University at Buffalo, The State University of New York, Buffalo, NY, USA, 4 Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA, 5Department of Biomedical, Industrial and Human Factors Engineering, Wright State University, Dayton, OH, USA, 6Department of Surgery, Mount Auburn Hospital, 300 Mount Auburn Street Suite 407, Cambridge, MA, USA Introduction: The Virtual Electrosurgical Skill Trainer (VEST) is being developed as a tool for training surgeons the safe operation of electrosurgery tools in both open and minimally invasive surgery. This training includes a dedicated team-training module that focuses on operating room (OR) fire prevention and response. The module was developed to allow trainees as well as practicing surgeons, anesthesiologists, and nurses to interact with a virtual OR environment that includes anesthesia apparatus, electrosurgical equipment, a virtual patient, and a fire extinguisher. Wearing a head mounted display, participants demonstrate knowledge of potential fire hazards by correctly identifying the ‘fire triangle’ elements and then successfully containing an OR fire caused by an oxygen (O2) enriched environment under the surgical drape. Within these virtual reality (VR) scenarios, trainees learn to react appropriately to a simulated fire emergency. An initial set of validation studies, targeted at establishing the face validity of the virtual OR fire simulator, was undertaken at the 2015 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) conference. Methods and Procedure: Forty nine subjects (n = 49) with varying electrosurgical experience participated in this Institutional Review Board (IRB) approved study. The subjects were asked to complete the OR fire training/prevention sequence in the VEST simulator. The subjects were then asked to answer a subjective preference questionnaire, focused on the usefulness and fidelity of the simulator. Results: On a 5-point scale, 12 out of 13 questions were rated at the mean value of 3 or greater (92 %). Five questions were rated above 4 (38 %), particularly those focusing on simulator effectiveness and its usefulness in OR fire safety training. 33 of the 49 participants (67 %) chose the virtual OR fire trainer over the traditional training methods, such as a textbook or an animal model. Conclusions: Training for OR fire emergencies in fully-immersive virtual reality environments may be the ideal training modality, and the VEST OR fire trainer was developed for this task. The results of this study indicate a high level of importance associated with the virtual reality electrosurgical trainer by the participating physicians. The face validity of the OR fire training module of the VEST simulator was successfully established on many aspects of the simulation.


Totally Laparoscopic and Hand-Assisted Laparoscopic Major Liver Resection: An 8-Year Single Institution Experience Edwin O Onkendi, MBChB, John A Stauffer, MD, Steven P Bowers, MD, Justin H Nguyen, MD, Horacio J Asbun, MD, Mayo Clinic Introduction: Minimally invasive major liver surgery (MIMLS) in increasingly being performed in tertiary centers. Two main approaches utilized are hand-assisted laparoscopic surgery (HALS) and totally laparoscopic surgery (TLS). Our aim was to review our 8-year experience with MIMLS and associated perioperative outcomes. Methods and Procedures: At our institution, MIS liver resection was formally introduced in January 2007, initially using the HALS approach. Since then, the use of TLS approach has increased. We retrospectively reviewed our prospectively maintained hepatobiliary resection database to assess our 8-year experience with MIS liver resection thus far, focusing on major liver resection defined as resection of C3 liver segments. The TLS and HALS approaches were comparatively analyzed, specifically assessing the effect of totally laparoscopic major liver resection on outcomes. Results: From 1/2007 to 12/014, 387 patients underwent open and MIS liver surgery. Of these, 262 patients (68 %) underwent MIS major and minor liver surgery. From this latter group, 55 patients (21 %) who underwent MIMLS comprised our study group. Mean age was 60.2 ± 13.6 years, with 27 patients (49 %) being male. Forty-three patients (78 %) had malignant disease, with colorectal cancer metastases being the most common malignant tumor resected (51 %). Overall, 64 % of patients underwent MIS right hepatectomy, 29 % had left hepatectomy, and 7 % underwent central and extended right hepatectomy. Use of TLS approach significantly doubled (51.9 % from 25 %, p = 0.029) over the two halves of the 8 years, with an associated decrease in the HALS approach (75 % to 48 %, p = 0.029). Overall conversion rate to open resection was 20 %, with need for complex biliary reconstruction being the commonest reason for conversion from laparoscopic to open. Median operating time was 270 minutes (105–839). Median estimated blood loss was 600 (0–13300), with 29 % of patients requiring pRBC transfusion in the OR and 15 % requiring transfusion postoperatively. Mean malignant tumor size was 6.5 ± 4.2 cm. R0 resection margin rate was 100 %, with average closest negative margin of 7 ± 5 mm. Mean hospital stay was 6.4 ± 3.5 days; reoperation rate was 1.8 %. Overall major morbidity (Clavien grade III-V) was 18.2 %. Liver-specific morbidity was 20 %; including bile leak in 11 %, post-hepatectomy hemorrhage in 9 % and post-hepatectomy liver failure in 3.6 %. Overall 90-day mortality was 3.6 %. Conclusions: MIMLS is feasible and safe with an adequate R0 resection. A tendency to a totally laparoscopic approach was present in the second half of the study period without a significant change in the outcomes.

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Predicting Opportunities to Increase Utilization of Laparoscopy for Colon Cancer

ERCP in the Diagnosis and Treatment of Life -Threatining Biliary Obstruction Caused by Fascioliasis: Experience of 5 Cases

Deborah S Keller, MS, MD1, Niraj Parikh, MS2, Nina Ferraris, MD1, Irlna Tantchou, MD3, Matt Schultzel, DO3, Eric M Haas, MD, FACS, FASCRS4, 1Colorectal Surgical Associates, 2Medtronic, 3University of Texas Medical Center at Houston, 4Colorectal Surgical Associates; Houston Methodist Hospital; University of Texas Medical Center at Houston

Kemal Dolay, MD1, Engin Hatipoglu, MD2, Fatma Umit Malya, MD1, Adem Akcakaya, MD1, 1Bezmialem Vakif University General Surgery Department, 2Cerrahpasa University General Surgery Department

Background: Despite proven safety and efficacy, rates of laparoscopic surgery for colon cancer remain low in the United States. Given the known clinical and financial benefits, investigation of the root causes of underutilization and methods to increase laparoscopy are warranted. Our goal was to develop a predictive model of the factors that impact use of laparoscopic surgery for colon cancer. Methods: The Premier Perspective national inpatient database was reviewed from 2010–2014 to identify patients with colon cancer who underwent elective colorectal resection. Patients were identified by ICD-9 diagnosis code, then stratified into open or laparoscopic approaches by ICD-9 procedure codes. Patient, hospital, and surgeon demographics were evaluated. An adjusted multivariate logistic regression model was used to identify variables predictive of use of laparoscopy for colon cancer. Results: 24,245 patients were included in the analysis- 12,523 (52 %) laparoscopic and 11,722 (48 %) open. General surgeons performed the majority of all procedures (77.99 % open, 71.60 % laparoscopic). The overall use of laparoscopy significantly increased from 48.94 % to 52.03 % over the study period (p \ 0.0001). From the regression model, patients with private insurance were more likely to have a laparoscopic procedure (OR 1.089, 95 % CI [1.004, 1.181], p = 0.0388). Obesity had no effect on utilization. Higher volume surgeons (OR 3.518, 95 % CI [2.796, 4.428], p \ 0.0001) were more likely to approach colon cancer laparoscopically. Colorectal surgeons were 32 % more likely to approach a case laparoscopically than general surgeons (OR 1.315, 95 % CI [1.222, 1.415], p \ 0.0001). Compared to higher volume hospitals (500 + beds), lower volume hospitals were 22 % (less than 100 beds), 15 % (100–249 beds) and 19 % (250–499 beds) less likely to approach colon cancer laparoscopically. Teaching hospitals were also 21 % less likely to perform colon cancer cases through a laparoscopic approach (OR 0.787, 95 % CI [0.738, 0.839], p \ 0.0001). Conclusions: There are patient, provider and hospital characteristics that can be identified preoperatively to predict who will undergo laparoscopic surgery for colon cancer. These results have implications for regionalization and increasing teaching of minimally invasive surgery. Recognizing and addressing these variables could increase use of laparoscopy, with its clinical and financial benefits.

Introduction: Fasciola hepatica is one of the endemic parasites in Turkey. Biliary fascioliasis is rarely asymptomatic and in many cases; biliary obstruction and inflammation usually occur in chronic infections. Because of technical limitations, images obtained by US, CT or MRCP are of lesser significance when compared to the ones taken by ERCP. For that reason, the gold standard for evaluation of the bile ducts in these patients is still ERCP. Even though the medical treatment seems adequate in the acute period, endoscopic techniques may be necessary in the chronic period for cases with biliary obstruction. Here we report five cases of fascioliasis presented with findings of acute cholangitis and biliary pancreatitis. Methods and Procedures: Here we present 5 cases of biliary fascioliasis. All of our patients were referrals from other centers, with probable diagnosis of pancreatitis due to choledocholithiasis and they were sent to our hospital for further evaluation with ERCP. Following radiaologic evaluation Endoscopic retrograde cholangiopancreatography (ERCP) was performed as a next step. Results: ERCP allowed both diagnosis and treatment in all cases. During the ERCP procedure, linear filling defects in the distal common bile duct were revealed. After sufficient endoscopic sphincterotomy procedure, baloon catheter and Dormia basket catheter was used to extract live parasites. In 3 patients baloon catheter was not enough to extract the parasite, and dormia basket was used in a half open position to capture the parasite. We prescribed Triclabendazol (Egaten 250; Novartis, Switzerland) single dose 10 mg/kg to all our patients. In all of our patients, the physical findings and jaundice regressed, 3 days after ERCP procedure. The lab values progressively decreased in 10 days. In one of our cases, during the ERCP procedure the lesion occupying the liver was thought to be similar to a dead Fasciola hepatica parasite. In this patient, there was a stricture of a short segment in the proximal common bile duct. After endoscopic sphincterotomy and parasite extraction, baloon dilatation was performed and a 6 cm 10F stent was placed. In the control ERCP that was performed three months later, no pathology could be observed, and her stent was extracted. No extra findings were observed in the 6 month and 1-year follow-up controls Conclusions: Biliary fascioliasis may present with different clinical aspects. The most serious presentations are acute cholangitis or pancreatitis which can threaten life. In those cases ERCP has a crucial role both in diagnosis and treatment.

S028 Gastric Bypass Procedure for the Type 2 Diabetes Patients with BMI \ 28 kg/m2 Ke Gong, Nengwei Zhang, Bin Zhu, Dexiao Du, Dongdong Zhang, Zhen Zhang, Jirun Peng, Beijing Shijitan Hospital, Capital Medical University, Beijing, China Objectives: To evaluate the Gastric bypass (GBP) procedure for the patients who suffered from type 2 diabetes (T2DM) with BMI \ 28 kg/m2. Methods: Thirty-one suffering from T2DM were selected to undergo GBP surgery were enrolled at Beijing Shijitan Hospital, Capital Medical University between November 2012 to September 2014. The fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c), C-peptide, fasting insulin (FINS) and glucagon-like peptide-1 (GLP-1) of all patients were measured before and at 1, 6 months after surgery. The results were analyzed. Results: 31 patients suffered from T2DM underwent GBP surgery successfully (a mean age of 46 years), 14 were male and 17 were female, Among them, 7 patients had hypertriglyceridemia (HTG). The patients were followed up for 6 months. No major complications. The average body mass index (BMI) was 26.5 ± 1.7 kg/m2 before surgery and 21.9 ± 2.4 kg/m2 at 6 month after surgery, which was statistically decreased at 6 months after surgery compared with that before surgery (P \ 0.05). The average levels of FPG, HbA1c, C-peptide, FINS of all patients were statistically decreased at 1,6 months after surgery respectively compared to those before surgery (all P \ 0.05). However, the mean GLP-1 of all patients was (2.6 ± 2.5 pmol/L) before surgery, and was (3.9 ± 1.7 pmol/L, 4.8 ± 1.8 pmol/L) at 1,6 months after surgery respectively, the mean GLP-1 of all patients were statistically increased after surgery compared to those before surgery (all P \ 0.05). At 6 months after surgery, 22 patients (71.0 %) achieved complete remission of T2DM with HbA1c \ 6.5 %, and stopped taking diabetic medications, 7 patients (22.6 %) gained partial remission of T2DM with 6.5 % B HbA1c \ 7.0 %, and 2 patients (6.5 %) 3.84 % got no remission of T2DM. The mean serum triglyceride in of 7 patients with HTG was decreased statistically at 6 months after surgery compared to that before surgery (3.04 ± 3.71 mmol/L vs 1.45 ± 1.08 mmol/L). Conclusions: This research shows that GBP procedure is safe and effective for the patients who suffered from T2DM with BMI \ 28 kg/m2, and the patients with hypertriglyceridemia were greatly improved. Moreover, the further studies with larger samples and long term follow-up are needed.



Surg Endosc (2016) 30:S211–S263



Is Bariatric Surgery Safe in the Elderly Population?

After 48 Consecutive Endoscopic Gastrojejunal Revisions for Weight Gain Following Roux-en-Y Gastric Bypass: What Have We Learned?

Federico Perez Quirante, MD, Lisandro Montorfano, MD, Rajmohan Rammohan, MD, Nisha Dhanabalsamy, MD, Alex Ordonez, MD, Aaron Lee, MD, Abraham Abdemur, MD, Emanuele Lo Menzo, MD, PhD, FACS, FASMBS, Samuel Szomstein, MD, FACS, FASMBS, Raul J Rosenthal, MD, FACS, FASMBS, Cleveland Clinic Florida Background: The aim of our study is to report the outcomes of bariatric surgery in patients over 65 years of age at our Institution. Methods: A retrospective review of a prospectively collected database of the patients who underwent bariatric surgery at our institution from December 2010 to November 2014 was performed. The data analyzed included age, preoperative body mass index, post-operative complications, and comorbidities. Results: Of the 1139 patients identified 981 were younger than 65 years of age and 158 were older than 65 years of age. Of these patients there was a significant difference in the gender ratio, 42 % of the [65 were males in comparison to 31 % males in the under 65 group (p = 0.004). Caucasian represented the majority of our patients 52 % in the cohort less than 65, but 85 % in the cohort over 65 (p \ 0.001). The over 65 patients had a lower preoperative BMI (Mean = 39 – Range 37–44) than younger patients (Mean = 42 – Range 38–48) (p \ 0.001). In the [65 group there were a higher incidence of comorbidities when compared to the \65 group. In particular the statistically significant differences were in Hypertension (p \ 0.001), Sleep apnea (p \ 0.001), CAD (p \ 0.001), Heart failure (p \ 0.001), Myocardial infarction (p \ 0.001), Diabetes II (p = 0.035), Dyslipidemia (p \ 0.001), Hyperlipidemia (p \ 0.001), Hypercholesterolemia. No difference however was found in the presence of GERD (p = 0.051) or history of DVT/PE (P = 0.2) When the rate of each procedure was analyzed (LSG, LRYGB, LGB, Revisions) significant difference was found in the [65 group with 22 % of them undergoing revisional surgery when compared to 14 % for \65 (p = 0.017). Also, elderly patients stayed on average one day more after their surgery (LOS = 3 days, p = 0.037) But no significant difference were found in the rate of readmission (12 % vs. 11 %) (p = 0.7), wound infection (2 % vs. 4 %) (p = 0.28), obstruction (2 % vs. 4 %) (p = 0.24), jejunal ulcer (2 % vs. 3 %) (p = 0.69), gastric ulcer (2 % vs. 3 %) (p = 0.15), nausea (15 % vs. 13 %) (p = 0.49), vomiting (13 % vs. 9 %) (p = 0.18), abscess (3 % vs. 4 %) (p = 0.5), dehydration (6 % vs. 7 %) (p = 0.68) and new GERD (6 % vs. 4 %) (p = 0.4). Only the incidence of fistulas was higher in the [65 group (4 % vs. 2 %) (p = 0.039) Conclusion: Elderly patients present for surgery significantly sicker in terms of comorbidities than the younger population. However age seems to represent no risk for surgical complications after a bariatric surgery. Revisional surgery is more prevalent in elderly patients and this explains the higher incidence of fistulae.

Lava Y Patel, MD, Thomas J Stringer, BA, Matthew E Gitelis, BS, John G Linn, MD, Woody Denham, MD, Liz Farwell, APN, Stephen Haggerty, MD, Michael B Ujiki, MD, NorthShore University HealthSystem Background: Endoscopic gastrojejunal revision (EGJR) is a novel procedure for patients seeking a minimally invasive treatment option for weight gain in the years following a Roux-en-Y gastric bypass (RYGB). Several studies have demonstrated the procedure to be effective at reversing weight gain and achieving modest weight loss outcomes. There is minimal data however regarding how to perform the procedure most effectively and what factors may predict good outcomes. We present our experience with 48 consecutive EGJR cases using a full-thickness suturing device. Methods: Institutional review board-approved retrospective study of 48 consecutive EGJR cases between June 2012 and September 2015. Adjusted linear regression models were constructed to predict weight loss postoperatively. Analyzed predictors included preoperative body mass index (BMI), percent reduction of the gastrojejunal (GJ) anastomosis, final diameter of the GJ anastomosis, endoscopic suturing technique (interrupted vs purse-string), experience level of the surgeon, and weight regain from nadir. Results: All data are presented as mean ± standard deviation unless otherwise stated. Mean age was 50.8 ± 11.1 years and 92 % were female. Prior to EGJR, patients regained an average of 52.4 ± 28.8 lbs from their weight loss nadir and had a mean body mass index of 41.3 ± 6.9 kg/m2. The average procedure time was 50 ± 25 minutes. Three patients underwent redo EGJR at an average of 2.3 years following the original revision procedure. A linear regression model showed that preoperative BMI (estimate ± se: 0.26 ± 0.12, p \ .05), percent reduction of the GJ anastomosis (0.23 ± 0.09, p \ .05), and weight regain from nadir (0.13 ± 0.05, p \ .05) could significantly predict postoperative weight loss at 6 weeks postoperatively (p \ .01). At 3 months postop, only percent reduction in the GJ anastomosis (0.35 ± 0.15, p \ .05) remained a significant predictor. These relationships remained intact after controlling for patient-reported compliance with the suggested diet and exercise program. Patients who had the interrupted suture technique reported the sensation of restriction 68 % vs purse-string technique 100 % at 3 weeks postop. There were no complications (Table 1). Conclusion: Several factors contribute to increased weight loss after EGJR including the preoperative BMI profile of the patient, the amount of weight regain experienced from nadir, and the intraoperative percent reduction of the GJ anastomosis. Purse-string suture technique demonstrated an increased sensation of restriction postoperatively.

Table 1 Weight loss outcomes


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Comparative Effectiveness of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy in Super Obese Patients

Regression of Renal Dysfunction in Long Term Follow-Up After Roux-en-Y Gastric Bypass

Adam Celio, MD1, Qiang Wu, PhD2, Kevin Kasten, MD1, Mark Manwaring, MD1, William Chapman, MD1, Walter Pories, MD1, Konstantinos Spaniolas, MD1, 1Department of Surgery, Brody School of Medicine at East Carolina University, 2Department of Biostatistics, College of Allied Health Sciences at East Carolina University

Jaclyn Chen, MD1, Rouzbeh Mostaedi, MD2, Blythe P DurbinJohnson3, Mohamed R Ali, MD1, Angelo M De Mattos, MD1, Roger K Low, MD1, 1University of California, Davis Health System, 2Kaiser Permanente Health System, 3University of California, Davis

Introduction: The disproportionate increase of the super-obese (SO) patient is a hidden component of the current obesity pandemic. SO is associated with a greater burden of obesity related comorbidities, with BMI itself a strong predictor of mortality. The best bariatric operation for this group should be based on safety and efficacy in this specific patient population. The aim of this study is to assess the comparative effectiveness of the two most common bariatric procedures in the SO. Methods and Procedures: The Bariatric Outcomes Longitudinal Database (Surgical Review Corporation; Raleigh, NC) from 2005–2012 was used for this study. We compared SO patients (BMI [ 50) undergoing laparoscopic Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). A stepwise logistic regression model was used to calculate a propensity score and adjust for patient demographics and comorbidities. Data is presented as mean (standard deviation) or weighted percentage where the weight is defined as the inverse of the propensity score of the group assigned. Results: We identified 50,987 SO patients who underwent RYGB (N = 42,119, 82.6 %) or SG (N = 8,868, 17.4 %). RYGB patients had higher adjusted rates of 30 day mortality (0.3 % vs 0.2 % p = 0.042), reoperation (4.0 % vs 2.4 %, p \ 0.001), and readmission (6.9 % vs 5.5 % p \ 0.001) compared to SG patients but no difference in overall complications (11.5 % vs 11.1 % p = 0.250). Similar differences were seen with 90 day outcomes, including higher overall complications (16.0 % vs 13.7 % p \ 0.001), reoperation (6.7 % vs 3.2 % p \ 0.001), readmission (9.2 % vs 6.6 % p \ 0.001), strictures (2.4 % vs 0.6 % p \ 0.001), and ulcers (0.9 % vs 0.1 % p \ 0.001). Percent of total weight loss (TWL) was significantly higher for SO patients who underwent RYGB compared to SG at 3 months (14.1 % vs 13.1 % p \ 0.001), 6 months (25.2 % vs 22.4 % p \ 0.001), and 12 months (34.5 % (6.7) vs 29.7 % (1.8), p \ 0.001). The comorbidity resolution and improvement at 3 months, 6 months, and 12 months is shown in Figs. 1 and 2; all differences are statistically significant (p \ 0.001) except OSA resolution at 12 months follow-up. Conclusion: There are significant differences in comorbidity resolution and postoperative safety between RYGB and SG in the SO population. Significantly more RYGB patients developed complications and required readmission. However, RYGB is considerably more effective in controlling obesity related comorbidities within the first year after surgery. TWL differences were statistically significant but clinically small. Our results favor performance of RYGB in SO patients of appropriate risk.

Morbidly obese patients develop pathologic renal hyperfiltration indicated by higher than normal glomerular filtration rate (GFR). Short term (6–24 months) outcomes after Roux-en-Y gastric bypass (RYGB) have shown either no worsening or decrease in GFR, trending towards normal. We hypothesize that renal hyperfiltration resolves after RYGB with long term ([ 24 months) stability. Demographic and comorbidity data were prospectively collected on 1,196 patients who underwent RYGB at a single academic institution from 2002–2012. GFR and serum creatinine (sCr) were examined preoperatively and postoperatively at 2-, 6-, 12-months, and annually up to 10-years. GFR was calculated using the CockcroftGault equation with adjustments for age, gender, and lean body weight. The changes from baseline over time in GFR and sCr were compared between patient subgroups [body mass index (BMI), age, chronic kidney disease (CKD), percentage excess weight loss (%EWL)], using linear mixed effects models. The estimated change from baseline GFR was measured by the geometric mean ratio (time point/baseline). The majority of the study group were women (n = 1046, 87.5 %). The mean and median follow-up was 5.1- and 5.0-years, respectively. Women for all BMI categories showed significant decreases from baseline GFR (BMI 30.0–39.9 = 0.92; BMI 40.0–49.9 = 0.88; BMI 50.0–59.9 = 0.84; BMI C 60.0 = 0.85). In men, GFR did not change significantly for any BMI category; however, sCr showed significant decreases for BMI 40.0–49.9 (0.96) and BMI 50.0–59.9 (0.91). Women for all age groups showed significant decreases from baseline GFR (\40-years = 0.86; 40–59years = 0.89; C60-years = 0.94). In men, there was no significant change from baseline GFR or sCr for the \40- and C60-years groups, while there was a GFR increase (1.05, p = 0.026) and sCr decrease (0.94, p \ 0.001) for the 40–59-years group. Women with CKD stage 2 showed no significant change from baseline GFR and decreases from baseline sCr (0.83, p \ 0.001), and men showed increases from baseline GFR (1.19, p \ 0.001) and decreases from baseline sCr (0.86, p \ 0.001). Women with CKD stage C3 showed increases from baseline GFR (1.11, p = 0.024) and decreases from baseline sCr (0.74, p \ 0.001). Women with %EWL C 50 % had greater decreases from baseline GFR compared to %EWL \ 50 % (0.89, p \ 0.001 vs 0.95, p \ 0.001). Men with %EWL C 50 % showed increases from baseline GFR (1.08, p \ 0.001) and decreases from baseline sCr (0.94, p = 0.001). Renal hyperfiltration significantly improves in morbidly obese patients who underwent RYGB with long term stabilization of renal function. Patients with CKD stage 2 and C3 showed significant regression in renal dysfunction.

Fig. 1 Comorbidity resolution

Fig. 2 Comorbidity improvement



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Magnetic Duodenal-Ileal Bypass (DIPASS): Feasibility Pilot Trial 1


Claire E Graves, MD , Elisabeth J Leeflang, MD , Hilary B Gallogly, MD2, Dillon Kwiat, BS1, Sarah Umetsu, MD, PhD1, Corey Iqbal, MD3, Kullada O Pichakron, MD4, James Graham, BS2, Peter Havel, DVM, PhD2, Stanley Rogers, MD, FACS1, Michael Harrison, MD, FACS1, 1University of California San Francisco, 2University of California Davis, 3University of Missouri-Kansas City School of Medicine, 4David Grant Medical Center, Travis Air Force Base Introduction: Bariatric surgery, such as gastric bypass, decreases insulin resistance in patients with type 2 diabetes mellitus. One proposed weight-independent mechanism involves ‘‘upregulation’’ of ileal incretin secretion in response to expedited delivery of nutrients and digestive enzymes to the distal ileum. We hypothesize that Magnetic Duodenal-Ileal Bypass (DIPASS), a magnetic compression anastomosis created between the distal duodenum and distal ileum, is a feasible procedure that may reproduce similar effects to more invasive bariatric surgeries. Methods: Yucatan mini pigs (n = 12) were fed a high-fat diet for 3 months. Baseline intravenous glucose tolerance tests (IVGTT) were performed in the 12 fatfed pigs and one farm pig (as normal control). 8 randomly-selected fat-fed animals underwent the DIPASS procedure using either 23 mm (n = 3) or 17 mm diameter (n = 5) magnets. 4 animals underwent sham operation. We assigned 2 DIPASS and 1 sham animal to be sacrificed at 2, 4, 8, or 12 weeks, at which points we measured plasma glucose and insulin following IVGTT (n = 8), as well as Glucagon-like peptide-1 (GLP-1), Peptide YY (PYY), bile acids, and lipids. Animals were euthanized and the anastomoses dissected and fixed for histology. Results: At baseline, the fat-fed pigs were visibly obese, glucose intolerant (peak glucose at 5 and 10 minutes during IVGTT was 502 and 426 mg/dL versus 353 and 309 mg/dL), and exhibited elevated insulin secretion (average insulin AUC normalized to weight 1846.9 ± 1149.2 lU/mL*min versus 297.39 lU/mL*min), suggestive of insulin resistance (Fig. 1). No intraoperative adverse events occurred, and all anastomoses were well-formed with burst pressures[90 mm Hg. While two animals with 23 mm magnets lost excessive weight by 4–6 weeks (48 ± 3 %), only moderate weight-loss occurred in pigs with 17 mm magnets (17 ± 13 %). Fasting GLP-1 increased in DIPASS pigs, but remained stable in the sham group (Fig. 2). Serum LDL, total cholesterol, and triglyceride levels trended lower in the DIPASS group. All pigs showed decreased insulin secretion following IVGTT throughout the study, suggestive of improvement in insulin resistance, with similar rates of improvement in both groups. Conclusions: Magnetic DIPASS is a novel procedure that may provide a minimallyinvasive, outpatient therapy for type 2 diabetes mellitus. This study demonstrates the procedure is safe and feasible in a swine model, and shows trends in lipid and incretin levels that suggest it may mimic some effects of more invasive bariatric procedures. Further studies are necessary to validate its efficacy.

Fig. 1 .

Fig. 2 .


The Effect of Component Separation Technique on Quality of Life (QOL) and Surgical Outcomes in Complex Open Ventral Hernia Repair (OVHR) Laurel J Blair, MD, Tiffany C Cox, MD, Ciara R Huntington, MD, Steven A Groene, MD, Tanushree Prasad, MA, Amy E Lincourt, PhD, MBA, Kent W Kercher, MD, FACS, B. Todd Heniford, MD, FACS, Vedra A Augenstein, MD, FACS, Carolinas Medical Center Introduction: The type of component separation may affect outcomes following OVHR. In this study, outcomes including QOL of patients undergoing OVHR were evaluated based on the utilization of transversus abdominis release (TAR), posterior rectus sheath release (PRSR) alone, or in combination with external oblique release (EOR + PRSR). Methods: A prospective, single institution study following open ventral hernia repair involving component separation was performed from May 2005 to April 2015. Self-reported QOL outcomes were obtained preoperatively and at 1, 6, and 12 months postoperatively using the Carolinas Comfort Scale (CCS). A CCS of 2 (mild but bothersome discomfort) or greater was considered symptomatic. Comorbidities, complications, outcomes, and CCS scores were reviewed. Univariate group comparisons were performed using chi-square and Wilcoxon two-sample tests with statistical significance set at p \ 0.05. Results: During the study period, 298 OVHRs with CST met inclusion criteria. Demographics included: average age-56.9 ± 11.8 years, BMI-33.7 ± 7.5 kg m2, 52 % female, 67 % at least one prior hernia repair, and average defect size279.1 ± 224.7 cm2. Preoperative discomfort (82 % vs 74 % vs 78 %, p = 0.73) and movement limitation (94 % vs 70 % vs 78 %, p = 0.09) in TAR, PRSR and EOR + PRSR respectively were similar. Average follow up was [15 months. At 1, 6, and 12 months post-operatively, there was no difference in reported CCS pain scores, movement limitation, or mesh sensation among the groups (p [ 0.05). Comparing OVHR patients outcomes by CST type, TAR was associated with decreased wound infections compared to others (3.2 % vs. 16.5 % vs. 19.1 %, p \ 0.05) however, recurrence rates were similar (0 % vs. 1.7 % vs. 7.1 %, p [ 0.05). Eighty percent of patients who recurred had been repaired with a biologic mesh secondary to contaminated field during hernia repair. The other two recurrences were one which occurred superior to the mesh and one who developed a wound infection postoperatively. Mesh infection rates were low (0 % vs. 1.9 % vs. 3.4 %, p [ 0.05) and were statistically equivalent among all three techniques. Conclusion: While QOL is not impacted by type of component separation on short or long-term follow up, the TAR may provide benefits such as decreased wound infection rates.

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Preoperative Chemical Component Relaxation Using Botulinum Toxin A: Enabling Laparoscopic Repair of Complex Ventral Hernia

Characterization of Ventral Hernia Repair Using Shear Wave Elastography



Kristen E Elstner, MBBS , Anita S Jacombs, MBBS, PhD , John W Read, FRANZCR3, Anthony N Dardano, FACS4, Peter Cosman, FRACS1, Michael Edye, FRACS5, Omar Rodriguez, MBBS6, Nabeel Ibrahim, FRACS6, 1Macquarie University Hospital, Sydney, Australia, 2Faculty of Medicine & Health Sciences, Macquarie University, Australia, 3Castlereagh Imaging, St Leonards, Australia, 4 Boca Raton Regional Hospital, Boca Raton, Florida USA, 5Professor of Surgery and Chair, University of Western Sydney, 6Hernia Institute Australia, Edgecliff, Australia Introduction: The operative management of large, complex ventral hernia is a significant challenge, despite recent advances in surgical techniques. Recurrence rates after complex ventral hernia repair remain high, and increase with each failed attempt. We report initial outcomes of preoperative abdominal wall chemical component relaxation using Botulinum Toxin A (BTA) to induce prolonged flaccid paralysis, in order to facilitate laparoscopic repair of complex ventral hernia. Methods: This was a prospective evaluation of 27 patients presenting with complex incisional or traumatic ventral hernia, with minimum linear defects (or sum of multiple defects) measuring 5 cm or greater, as measured on abdominal CT imaging. Patients were administered ultrasound-guided BTA injections bilaterally to all three layers of the lateral abdominal wall musculature prior to elective hernia repair. Injections were performed in a single outpatient session, 1–4 weeks preoperatively, according to pre-determined positions on the antero-lateral abdominal wall. Serial non-contrast abdominal CT imaging was obtained pre- and post-BTA injection to measure change in fascial defect size, and abdominal wall muscle belly thickness and length. All hernias were successfully repaired between January 2013 and August 2015. Results: 27 patients received preoperative BTA injections, which were well tolerated with no complications. Mean age was 58 years (range 36 – 84 years), with a mean BMI of 31 kg/m2 (range 22 – 46). Hernia defects ranged from 5 x 9 cm to 24 x 27 cm. Comparison of pre-BTA and post-BTA abdominal CT imaging demonstrated a significant increase in mean length of the lateral abdominal wall from 15.7 cm preBTA to 19.9 cm post-BTA (p \ 0.0001), with a mean unstretched length gain of 4.2 cm/side (range 0 – 11.7 cm/side). All hernias were repaired laparoscopically or laparoscopic-assisted using mesh, with no post-operative complications arising from raised intra-abdominal pressure, wound dehiscence, or early recurrence. Median length of hospital stay was 10 days. Conclusion: Chemical component relaxation using BTA is a safe and effective technique in the preoperative preparation of patients undergoing elective complex ventral hernia repair. This technique lengthens and relaxes laterally retracted abdominal muscles and enables laparoscopic closure of large fascial defects. The prolonged duration of action of BTA reduces lateral traction forces on the healing wound, thereby minimizing risk of early post-operative complications such as early hernia recurrence. Further long term follow-up is required, but early data is encouraging.

Joseph S Fernandez-Moure, MD, MS1, Anuj Chaudhry, PhD2, Jeffrey L Van Eps, MD1, P. S Shajudeen2, Fernando Cabrera, MD3, Rafaella Righetti, PhD2, Brian J Dunkin, MD, FACS1, 1Houston Methodist Hospital, Department of Surgery, 2Texas A&M, Department of Electrical and Computer Engineering, 3Houston Methodist Research Institute, Depart of Regenerative and Biomimetic Medicine Introduction: In the United States, over 300,000 hernia repairs are performed annually. To assess the integrity of repair, imaging modalities like computed tomography (CT) or ultrasound (US) are used. However, either modality properly characterizes the hernia prior to repair or is capable of reliably identifying the mesh after repair. Shear Wave Elastography (SWE) is an evolving US technique capable of simultaneous real-time imaging and mechanical property analysis. This modality can be utilized in 3D to visually reconstruct a defect or repair. In this study, we sought to demonstrate the utility of 2D and 3D SWE to characterize ventral hernias prior to and after repair using PatietexTM or StratticeTM mesh in a rat model of chronic hernia repair. We hypothesize that, using SWE, one can obtain a preoperative reconstruction of a hernia and, after repair, identify the mesh and characterize its stiffness based on Young’s Modulus. Methods: Tissue mimicking gelatin-agar phantoms were embedded with ParietexTM or StratticeTM and assessed by SWE. Following this, twenty Lewis rats underwent hernia creation. At 30 days, 16 rats underwent underlay repair with ParietexTM or StratticeTM. After 4 weeks, animals were euthanized, underwent SWE, and stiffness measured. Stiffness measurements were made from a center point in the hernia. 3D reconstructions of the hernia pre- and post-repair were performed using in-house image processing algorithms via Image-vis 3D software. Results: ParietexTM and StratticeTM mesh demonstrated clearly identifiable elastograms in phantoms gels that corresponded to US B-mode imaging with Young’s modulus of 98 ± 6.7 KPa and 46 ± 4.4 KPa, respectively. In vivo, SWE was capable of accurate and real time assessment and diagnosis of the hernia defect. Young’s modulus of ParietexTM and StratticeTM mesh in vivo were respectively 92 ± 3.6 KPa and 42 ± 3.1 KPa. SWE was capable of accurate 3D reconstruction of the hernia defect pre- and post-repair. Discussion: In this study we show the feasibility of using ultrasound SWE to detect ventral hernias and evaluate mesh repair in-vivo. Our results indicate that the presence of a hernia and repair can be reliably visualized by 2D SWE and reconstructed in 3D to provide more spatial information regarding the hernia itself, the contour of the mesh, and the position of the mesh. SWE can be done at the bedside and eliminates exposure to radiation with no loss of diagnostic accuracy. This represents a new modality for the ‘‘in office’’ characterization of incisional hernias or mesh repair for the practicing herniologist.



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The Effect of Tobacco Use on Outcomes of Laparoscopic and Open Ventral Hernia Repairs: A Review of the NSQIP Dataset

Comparison of Ventral Hernia in Patients Undergoing Single Incision Versus Standard Multiport Laparoscopic Colectomy

John C Kubasiak, MD, Mackenzie Landin, MD, Scott Schimpke, MD, Jennifer Poirier, PhD, Jonathan A Myers, MD, Benjamin R Veenstra, MD, Keith W Millikan, MD, Minh B Luu, MD, Rush University Medical Center Introduction: Tobacco smoking is a known risk factor for complications after major surgical procedures. The full effect of tobacco use on these complications has not been studied over large populations for ventral hernia repairs. This effect is more important as the pre-operative conditioning and optimization of patients is adopted. We sought to use the prospectively collected ACS-NSQIP dataset to evaluate respiratory and infectious complications for patients undergoing both laparoscopic and open ventral hernia repairs. Methods: The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic ventral hernia repairs, by primary procedure CPT codes, between years 2009–2012. Smoking use was registered as defined by the ACS-NSQIP, as both a current smoker (within the prior 12 months) or as a history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate postoperative complications for 30-day morbidity and mortality by smoking status while adjusting for preoperative risk factors. Results: A total of 72,350 patients met inclusion; the majority of cases were open, 82 %, compared to laparoscopic 18 %. Sex was evenly distributed with 58 % female and 42 % male. More current smokers existed in the open vs laparoscopic cohort (p = .0001). There was a similar distribution of patients with any history of smoking favoring open (p = .01). When using Fisher’s exact test, there were significantly more respiratory complications (p = .0003) and infectious complications (p = 1.2 9 10-6). When controlling for sex, age, and type of surgery, using logistic regression, there were associations between smoking in the prior 12 months and respiratory complications, including pneumonia (p = 3.4 9 10-15), re-intubation (p = 9.0 9 10-12), and failure to wean (p = 5.7 9 10-11). Similar associations were seen on logistic regression if a patient ever smoked; including pneumonia (p = 3.4 9 10-15), re-intubation (p = 6.9 9 10-14), and failure to wean (p = 1.8 9 10-10). Conclusion: Smoking tobacco, both current and historical use, leads to an increase in both respiratory and infectious complications. As more centers try to pre-operatively condition patients for elective hernia repairs it is important to note that patients may never return to the baseline outcomes of patients who never smoked.

S038 What is the BMI Threshold for Repairing a Ventral Hernia? Luise I Pernar, MD1, Claire H Pernar, MPH2, Bryan V Dieffenbach, MD1, David C Brooks1, Douglas S Smink1, Ali Tavakkoli, MD1, 1 Brigham and Women’s Hospital, 2Harvard School of Public Health Introduction: Overweight and obese patients are often asked to lose weight prior to attempts at ventral hernia repair (VHR). Improved short as well as long term outcomes are cited as reasons behind this strategy; however, limited long term success of non-surgical weight loss means that this strategy mostly influences short term outcomes. Therefore, it is critical to know at what body mass index (BMI) threshold postoperative complications increase in order to properly counsel patients. Methods and Procedures: All patients who underwent VHR at our institution between 2002 and 2015 captured in the NSQIP database were included. The primary outcome was defined as having any (C1) of 18 captured postoperative complications. Patients were divided into five groups based on BMI: group 1 (\25 kg/m2); 2 (25–29.99 kg/m2); 3 (30 to 34.99 kg/m2); 4 (35–39.99 kg/m2); and 5 (C40 kg/m2). Multivariable logistic regression was performed to evaluate the association between BMI categories and postoperative complication, adjusting for age, gender, race, current smoking status, history of severe COPD, presence of ascites within 30 days of surgery, diabetes mellitus, and steroid or other immunosuppressant use. Results: 67 of 922 patients (7.3 %) had at least one postoperative complication following VHR; patients in BMI group 5 were most likely to experience a complication: 5.6 % of patients in group 1 had a complication, 5.7 % in group 2, 6.2 % in group 3, 6.5 % in group 4, and 16.5 % in group 5. The adjusted risk of complications among patients with BMI C 40 kg/m2 was 3.2 times greater compared to patients with BMI \ 25 kg/m2 (OR 3.2; 95 % CI = 1.4–7.4). No significant differences in risk of postoperative complications were observed for groups 2, 3, or 4 compared to group 1. BMI category was significantly associated with undergoing recurrent versus initial VHR, with 28 % of patients in BMI group 5 having a recurrent repair compared to 14 % in patients in BMI group 1 (p = 0.03) Conclusions: After VHR, complications are most likely to occur in patients with BMI [ 40 kg/m2. This subset of patients also had a significantly higher risk of undergoing surgery for a recurrent hernia, suggesting that this group of patients are likely to experience adverse outcomes after VHR and should be counseled to undergo bariatric surgery prior to attempts at VHR. VHR at lower BMIs appears appropriate and delaying therapy to achieve pre-operative weight loss will likely offer no advantage.


Awais Ashfaq, MD, Kian Ahmadieh, Adil A Shah, MD, Alyssa B Chapital, MD, PhD, FACS, Daniel J Johnson, MD, FACS, Kristi L Harold, MD, FACS, Mayo Clinic Introduction: Single incision laparoscopic surgery (SILS) is thought to reduce both incisional trauma and postoperative pain. Use of SILS has gained widespread interest in colectomies as there has been no reported difference in morbidity compared to standard multiport laparoscopic (ML) colectomies. However, hernia rates comparing both approaches have never been reported. The aim of this study was to compare the rates of ventral hernia (VH) in patients undergoing SILS versus ML. Methods: All patients undergoing SILS and ML colectomies were entered into an IRB approved database from January 2010 to June 2014. The primary endpoint was the incidence of ventral hernia and secondary end points included type of hernia repair, operative time, length of hospital stay, recurrence and complications. Results: A total of 406 patients (SILS = 51, 13 %; ML = 355, 87 %), male (n = 32, 53 %), underwent colectomies during the study period. Mean age at VH diagnosis was 66 ± 13 years (SILS = 67 ± 14; ML = 66 ± 13). There was no statistically significant difference in the observed comorbidities in the two groups (SILS vs ML). Most common surgical procedure was laparoscopic right hemicolectomy (n = 24, 40 %) followed by sigmoidectomy (n = 19, 31.7 %). Most common indication for operation was polyp/cancer (n = 33, 55 %) followed by diverticulitis (n = 18, 30 %). Mean time to diagnose VH after laparoscopic colectomy (SILS = 9 ± 4, ML = 14 ± 11 months; p = 0.014) and incidence of VH (SILS = 11, 21.6 %; ML = 49, 13.8 %; p \ 0.001) were statistically significant. A total of 26 (43 %) patients (SILS = 5, 19 %; ML = 21, 81 %) underwent VH repair. Out of these, 19 (73 %) were done laparoscopically (SILS = 3, 16 %; ML = 16, 84 %). Mean size of hernia defect was 57 (1–625) cm2 (SILS = 64 ± 90, ML = 27 ± 18; p = 0.064). There was no statistically significant difference between lengths of hospital stay, recurrences, surgical site infection, fascial dehiscence, bowel injury and other morbidities. Mean length of follow up was 21 ± 16 months (SILS = 30 ± 9; ML = 20 ± 16 months). Conclusion: Incidence of VH is higher in SILS compared to ML colectomies. Laparoscopic repair of VH after colectomies (SILS/ML) is feasible with minimal complications in both groups. Further prospective multi-institutional studies are needed to better study the risk of VH in SILS patients.

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Intraoperative Ercp for Management of Cholecystocholedocholithiasis

A Policy of Universal Cholecystectomy for Acute Cholecystitis Validating the Tokyo Guidelines 2013 –A Single Centre Experience

Ahmed Elgeidie, Ehab Abdellattif, Gamal Elebidy, Yussef Elmahdy, gastroenterology surgical center Background: Common bile duct stones (CBDS) are frequently diagnosed in patients with gallbladder stones (GBS). There is an agreement that these CBDS should be removed to prevent subsequent complications. The introduction of minimally invasive techniques in management of biliary problems added new procedures for treating such patients with cholecysto-choledocholithiasis (CCL). Aim of Work: This study presents the results of intraoperative ERCP during laparoscopic cholecystectomy (LC) as a single-session minimally invasive procedure for management of patients who have GBS and concurrent preoperatively diagnosed CBDS. Patients and Methods: The data base of patients presented to our center by CCL who were treated by LC and intraoperative ERCP was collected and analyzed. CBDS were diagnosed using clinical data, laboratory tests and abdominal sonogram. Magnetic resonance cholangiography (MRC) was requested for doubtful cases. The study included patients who were operated between October 2007 and May 2015. In the first cases ERCP was done using Rendez-vous technique but in late cases we modified the technique to perform standard ERCP immediately after completion of LC under the same anesthesia. Preoperative, intraoperative and postoperative data were recorded, analyzed and reported. Data reported include success/failure rate, complications, conversion to open surgery, operative details and incidence of residual CBDS. Results: The study was conducted on 346 patients who had CCL. The mean age was 24.7 years and 298 of them were females. The most common presentation was abdominal pain (91.6 %) and jaundice (62 %). The mean serum bilirubin level was 2.4 mg/dL. Fifteen patients were excluded and intraoperative ERCP was not done due to negative intraoperative cholangiogram results in 10 patients and conversion to open surgery in 5 patients due to acute cholecystitis (n = 4) and intraoperative bleeding (n = 1). Intraoperative ERCP was tried in the remaining 331 patients. Operative time ranged between 35 and 90 min with a mean of 47.4 min. the mean hospital stay was 1.4 (1–8) days. Failure of CBD clearance was reported in 12 patients (3.6 %) with a success rate of 96.4 %. There was no mortality. Complications were reported in 13 patients in the form of bleeding papillotomy (n = 4), mild pancreatitis (n = 3), transient hyperamylasemia (n = 3), internal hemorrhage (n = 1), incisional hernia (n = 1), and cystic duct leakage (n = 1). 30-day follow up was possible in 142 patients and there was no evidence of residual CBDS. Conclusion: Intraoperative ERCP during LC is a safe and effective option for management of CCL.

Vinoban Amirthalingam1, Low Jee Keem2, Sameer Padmakumar Junnakar2, Winston Woon2, Vishalkumar Shelat2, 1Ministry of Health Holdings Singapore, 2Tan Tock Seng Hospital, Division of General Surgery - HPB Background: Early cholecystectomy is the current accepted standard of care for surgically fit patients with grade 1 and selected grade 2 cholecystitis based on Tokyo Guidelines 2013 (TG13). For selected grade 2 and grade 3 cholecystitis it is recommended for early gallbladder drainage followed by interval cholecystectomy. Our aim of our study is that early cholecystectomy is safe and feasible in all 3 grades of cholecystitis. We propose the policy of universal cholecystectomy independent of TG13 grading. Methods: Patients diagnosed with acute cholecystitis over a 14 month period were identified with the health records department from January 2014 to February 2015. Over that period 149 patients underwent emergency cholecystectomy on admission for acute cholecystitis. The patients were divided into the three grades of cholecystitis: Grade 1 (n = 84), Grade 2 (n = 49), and Grade 3 (n = 16) using the grading and severity from Tokyo Guidelines 2013. The results for this group were analysed with demographics, hospital stay, clinical symptoms, laboratory results, imaging, operative findings, length of hospital stay. Results: Of the 149 patients who underwent emergency cholecystectomy 82 were male (55 %). 84 patients were identified with grade 1 cholecystitis. 83 patients (98.8 %) underwent emergency cholecystectomy and 1 patient (1.2 %) underwent percutaneous drainage followed by emergency surgery. Median length of stay was 2 days (1–11) and median operative time was 113 minutes (35–310). There were 2 readmissions (2.4 %) with fever and no complications such as organ injury, CBD injury and bleeding post-surgery. 65 patients were identified with grade 2 or 3 acute cholecystitis. 6 underwent percutaneous drainage followed by emergency cholecystectomy in the same admission, 59 underwent emergency cholecystectomy. Of the 65 patients that underwent surgery: laparoscopic cholecystectomy (n = 55), open cholecystectomy (n = 1), laparoscopic subtotal cholecystectomy (n = 5), conversion to open (n = 3), and 1 hepatico-jejunostomy repair (n = 1). Average length of post-operative stay was 4 days (1–28) and average operative time was 129 minutes (90–298). There was 1 complication (CBD injury) and 1 readmission for ileus. Similar surgical outcomes were observed between the 2 groups, showing early emergency cholecystectomy should be recommended for all grades of acute cholecystitis. Conclusion: Universal cholecystectomy policy is safe and feasible in all severity grades of acute cholecystitis.



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What is the Fate of the Cholecystostomy Tube Following Percutaneous Cholecystostomy?

Histopathological Examination of Specimen Following Cholecystectomy: Are We Accepting Resect and Discard?

Mena Boules, MD, Mario Farias-Kovac, MD, Daniel Guerron, MD, David Schechtman, MD, Michael Samotowka, MD, Gordon McLennan, MD, R. Matthew Walsh, MD, Gareth Morris-Stiff, MD, Cleveland Clinic

Sean M Wrenn, MD, Wasef Abu-Jaish, MD, FACS, University of Vermont Medical Center

Introduction: Cholecystectomy is the preferred management option for acute cholecystitis, with percutaneous cholecystostomy (PC) considered a viable option in high-risk patients. The aim of this study was to evaluate the efficacy and outcomes of PC in a tertiary referral center. Methods: We retrospectively reviewed all patients that had undergone PC from 2000 to 2012. Data collected included baseline demographics, co-morbidities, details of PC placement and management, and post-procedure outcomes. Additionally, we calculated the age adjusted Charlson comorbidity index (CCI) for all patients. Results: A total of 183 patients received a PC consisting of 88 (48 %) females, and 95 (52 %) males. The mean age and CCI were 68.0 ± 14.3 years, and 5.4 ± 2.2 respectively. A total of 68 (37 %) patients underwent cholecystectomy after a mean duration of 118 ± 110 days following PC. Mean age, and CCI of cholecystectomy patients were 63.0 ± 14.5 years, and 4.4 ± 2.6 respectively, both of which were significantly less (p \ 0.0001) than the remainder of the patients. 19 (28 %) patients underwent early (\30 days) cholecystectomies, and 49 (72 %) patients that underwent late ([30 days) cholecystectomy. Surgical indications for all patients include calculous cholecystitis (n = 37, 54 %), acalculus cholecystitis (n = 26, 38 %), gangrenous (n = 3, 4 %), and gallbladder obstruction (n = 2, 2.8 %). 38 (56 %) patients underwent a laparoscopic approach, and the remaining 30 (44 %) patients underwent primary open procedures. In addition to those having PC removed at time of cholecystectomy 55 patients had elective removal of their PC. The mean age and CCI was 70 ± 14.0 years, and 5.8 ± 2.8 respectively. Only 9 (16 %) patients had recurrence of symptoms post-PC removal. Mean age, and CCI of patients with recurrence was 68 ± 17.5 years, and 5.2 ± 3.0 respectively. 5/9 (55.5 %) patients underwent cholecystectomy (n = 3 laparoscopic; n = 2 open primary), 2 (22 %) received a second PC, and the remaining 2 (22 %) patients underwent ERCP with sphincterotomy for relief of extra-biliary complications (pancreatitis, jaundice). For 60 patients, PC was definitive therapy for their cholecystitis. This group was significantly older (Mean age: 72.3 ± 13 years) and had higher CCIs (Mean CCI: 6.4 ± 2.25), which were significantly less (p \ 0.05) than the operated or tube removal groups. Conclusion: After stabilization of acute medical conditions 37 % of patients underwent cholecystectomy, and 30 % had planned removal of the PC with only 16 % requiring further intervention. For frail patients not suitable for cholecystectomy, PC is an effective therapy.

Introduction: Cholecystectomy is one of the most commonly performed general surgery procedures in the United States. It is most frequently performed for benign biliary disease such as biliary colic or cholecystitis, however resected specimens are frequently sent for histopathological analysis due to the perceived risk of incidental gallbladder carcinoma (iGBC). We sought to determine the incidence of iGBC in our population, a community-academic hybrid medical center, and whether surgeons need to send specimens for further analysis if no preoperative or intraoperative suspicion for malignancy is present. Methods: We performed a large single-center retrospective analysis of all gallbladder specimens sent for analysis to the department of Pathology between 2009–2014. Exclusion criteria included preoperative suspicion for malignancy or polyp, and non-biliary indications for gallbladder resection (such as trauma). The pathological results were tabulated, including both common and rare findings. Results: A total of 2,153 pathology reports spanning from 2009–2014 were reviewed. After exclusion criteria, a total n of 1,984 were included in data analysis. The population of patients was 29 % male and 71 % female, with a median age of 48.5. The incidence of iGBC was 0.25 % (95 % Confidence Interval 0.03, 0.47), and dysplasia was 0.70 % (95 % CI 0.33, 1.07). The most common pathological findings included chronic cholecystitis in 89 % (95 % CI 87.6, 90.3) and cholelithiasis in 81 % (95 % CI 79.2, 82.7) of specimens (Table 1). Conclusions: The incidence of significant pathological findings resulting in necessary change in clinical management is extremely low in our subject population. The historical dogma mandating histopathological evaluation of all gallbladder specimens may need to be reexamined, particularly in populations at low-risk for gallbladder carcinoma.

Table 1 Baseline characteristics of included patients


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Optimal Timing for Laparoscopic Cholecystectomy After Percutaneous Transhepatic Gallbladder Drainage

Development of a Novel Murine Model for Treatment of Infected Mesh Scenarios

Takeshi Gocho, MD, Takeyuki Misawa, MD, PhD, Yuichi Nakaseko, MD, Yuki Takano, MD, Koichiro Haruki, Kenei Furukawa, MD, PhD, Masaru Kanehira, MD, Shinji Onda, MD, Taro Sakamoto, MD, Ryota Saito, MD, PhD, Hiroaki Shiba, MD, PhD, Yasuro Futagawa, MD, PhD, Yuichi Ishida, MD, PhD, Katsuhiko Yanaga, MD, PhD, Jikei University School of Medicine

Arnab Majumder, Clayton Petro, MD, Lijia Liu, MD, Mojtaba Fayezizadeh, MD, Kasim Aydogdu, MD, Yuri W Novitsky, MD, FACS, Department of Surgery, University Hospitals Case Medical Center, Cleveland, OH

Background and Objective: According to TG13 (Updated Tokyo Guidelines for acute cholangitis and acute cholecystitis), percutaneous transhepatic gallbladder drainage (PTGBD) is recommended for patients with severe acute cholecystitis and moderate acute cholecystitis without response to initial medical treatment. For patients after PTGBD, we usually plan laparoscopic cholecystectomy (LC) more than 30 days after PTGBD. However, the optimal timing of LC after PTGBD remains controversial. The aim of this study was to assess the optimal timing of LC after PTGBD. Patients and Methods: Between January 2006 and March 2015, we attempted LC for 83 patients after PTGBD at Jikeu Univ. Hospital and Kashiwa Hospital (age 32–82 [mean 66] years, M:F = 58:25. We divided such patients into two groups according to the interval between PTGBD and LC (O30 group; more than 30 days, U30 group; within 30 days) and evaluated the patients’ clinical background, operative factors, conversion rate to open surgery (CR), complications, length of postoperative hospital stay (HS) and overall treatment period (OTP: from PTGBD to discharge after LC). Results: In two groups (O30 group vs. U30 group), age (years old, median) (65.5 vs. 66, p = 0.2558), sex ( %, male) (70.1 % vs. 66.7 %, p = 0.7853), operative time (min, median) (160 vs. 157.5, p = 0.4980), intraoperative blood loss (g, median) (5 vs. 50, p = 0.5606), CR (23 % vs. 33 %, p = 0.3273) and HS (days, median) (4 vs. 7.5, p = 0.4980) were similar. However, OTP was longer in O30 group than in U30 group (days, median) (88 vs. 20, p \ 0.0001). There was no bile duct injury in either group. Conclusion: Early LC after PTGBD can shorten the overall treatment period without increasing CR or bile duct injury.


Introduction: Despite advances in hernia surgery, mesh infection remains a significant challenge. Indications regarding repair after removal of a previously infected prosthesis remain unclear. Although patients in these circumstances may receive biologic implants or staged primary repair with deferred definitive reconstruction, neither may be ideal management. While various animal models have simulated contamination by direct inoculation of implants with bacteria, there remains a paucity in literature which truly simulates a field following mesh infection and removal. We aimed to develop a murine model to mimic this complex scenario to allow for further testing of various implants and coatings. Materials and Methods: Thirty-six female CL57BL/6 J mice underwent open implantation of a 0.7 9 0.7 cm piece of polyester mesh in the dorsal-subcutaneous position. Wounds were closed and subsequently inoculated with 0.1 mL of 104 GFP labeled MSSA. After two weeks the infected mesh was removed and the cavity was copiously irrigated with saline. Mice were split into four groups: with three groups receiving new polyester, polypropylene, and biologic mesh and remaining as nonmesh controls. Mice were survived for another two weeks and underwent necropsy. Gross infection was evaluated at two and four weeks. Tissue homogenization and direct plating to recover GFP MSSA was completed at four weeks. Results: At two weeks all mice were noted to have gross mesh infection. One animal died due to overwhelming infection and wound breakdown. At four weeks, 5/6 (83 %) control mice who did not have a second mesh implantation had full clearance of their wounds. In contrast 9/9 (100 %) mice with re-implantation of Parietex were noted to have pus and recovery of GFP MSSA on plating. This was also observed in 90 % of mice with polypropylene mesh and 100 % of those with biologic mesh. Conclusion: Our novel murine model demonstrates that mesh re-implantation after infected mesh removal results in infection of the newly placed prosthesis, regardless of the material characteristic or type. This model lays foundation for development and investigation of implants for treatment strategies following infected mesh removal.

Doxycycline Alters Collagen Composition Following Ventral Hernia Repair Crystal Totten, Instructor, of, Surgery, Job C Tharappel, PhD, John S Roth, Professor, of, Surgery, University of Kentucky Introduction: Doxycycline, a nonspecific metalloproteinase (MMP) inhibitor, has been previously demonstrated to impact the strength of the polypropylene (PP) mesh repaired hernia as well as increase deposition of Collagen 1 and 3 in the repair sites. The impact of doxycycline upon hernia repair with porcine acellular dermal matrices has not previously been studied. The current study evaluates the impact of doxycycline administration upon hernia repair with polypropylene mesh and a porcine acellular dermal matrix. Methods: 400 gram Sprague Dawley rats were acclimated and subsequently underwent laparotomy with creation of a midline ventral hernia (VH). 27 days following hernia creation, animals were randomly assigned to four groups of 8 animals and underwent hernia repair with an intraperitoneal underlay with either PP or porcine acellular dermal matrix (PADM). Groups were assigned to administration of daily normal saline (NS) or doxycycline 10 mg/kg daily (D) via oral gavage for 8 weeks beginning 24 hours prior to hernia repair. The animals were euthanized at 8 weeks and underwent tensiometric testing of the abdominal wall, western blot analyses for collagen sub-types and matrix metalloproteinases. Results: 32 animals underwent successful hernia creation and repair with either PADM or PP. All PP implanted animals survived 8 weeks and 13 PADM implanted animals survived 8 weeks (8 PADM-D, 5 PADM-S). There were no differences in the tensiometric strengths of the mesh to fascial interface between groups. Densitometric counts in PADM-D groups demonstrated increased Collagen 1 compared to PP-S (PADM-D [1286.5] PADM-S [906.9], PP-S [700.4], P = 0.037) and decreased Collagen 3 compared to PP-S (PADM-D [7446.9], PADM-S [8507.6], PP-S [11297.1], p = .01). Collagen 3 expression was reduced in PP-D compared to PADM-S (12177.6 vs. 14562.0, p = .04). There were no differences in Collagen 1 or Collagen 3 expression between PP-D and PP-S. MMP-9 levels were increased in PADM-D (PP-S vs. PADM-D, p = 0.04) while MMP-2 levels were similar between PADM-D and PADM-S, respectively. Conclusion: Collagen 1 deposition at the mesh to fascial interface is enhanced following administration of doxycycline in ventral hernia repairs with porcine acellular dermal matrices. Doxycycline administration may have implications for enhancing outcomes following hernia repair.



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Long-Term Incidence of Contralateral Primary Hernia Repair Following Unilateral Inguinal Hernia Repair in a Cohort of 50,220 Patients

Risks of Subsequent Abdominal Operations After Laparoscopic Ventral Hernia Repair

Richard Zheng, MD1, Jie Yang, PhD2, Hao Chen2, Maria S Altieri, MD2, Andrew T Bates, MD2, Aurora D Pryor, MD2, Mark Talamini, MD2, Dana A Telem, MD2, 1Jefferson University Hospital, 2Stony Brook University Hospital Background: Occult or asymptomatic contralateral inguinal hernias are present in many patients at the time of initial inguinal hernia repair. While many may eventually necessitate repair, data on long-term follow-up are sparse. The purpose of this study was to assess long-term rates and risk factors for contralateral inguinal hernia repair following unilateral inguinal hernia repair. Methods: Using New York Statewide Planning and Research Collaborative (SPARCS) administrative data, 50,220 adult patients who underwent non-recurrent inguinal herniorrhaphy during 2002–2003 in New York State were identified. Of these, 49,956 patients had open unilateral inguinal hernia repair. ICD-9 codes and CPT codes were used to identify patients. Patients were followed for 10-years subsequent to their operation to assess for contralateral repair. ‘‘Loss to follow-up’’ was defined patients without inpatient or outpatient files after 1/1/2007, which was the average timing of contralateral repair. Patient risk factors were assessed and compared using descriptive univariate statistics. Significant variables were then analyzed via multivariable regression models. Results: For adult patients having primary unilateral herniorrhaphy, 3364 patients (6.73 %) had contralateral repair during the follow-up period. After excluding ‘‘loss of follow-up’’ patients, the contralateral repair rate was 10.3 %. Contralateral hernia repairs first occurred at a mean of 3.9 +/- 3.5 years and a median of 2.5 years after the initial surgery. Risk factors included age [45 years (OR 1.7[1.4–2.0], p \ 0.001), male gender (OR 2.2 [1.9–2.6], p \ 0.0001) and white race (OR 1.6 [1.1–2.4], p \ 0.001). Factors associated with significantly decreased likelihood for repair included: congestive heart failure (OR 0.6 [0.4–0.9], p = 0.01), diabetes (OR 0.7 [0.5–0.8], 0.02), neurological disorders (OR 0.6 [0.4–0.9], p = 0.02), obesity (OR 0.3 [0.1–0.8], p = 0.01) and alcohol abuse (OR 0.2 [0.03–0.8], p = 0.03). Conclusion: The ten-year probability of necessitating a contralateral inguinal hernia repair is significant. This study assessed incidence of hernia repair, not incidence of hernia diagnosis. As such, hernias that were not repaired could not be assessed. Patients more likely to require repair were those who were older, white and male. Those less likely to undergo repair had significant comorbid conditions including heart failure, diabetes, neurological disorders, obesity and alcohol abuse. One interpretation is that the decreased incidence of repair in this population is due to their underlying health status and suitability for operative intervention. Data depicts the time period prior to adoption of laparoscopy and highlights a key benefit of this approach over open. Based on this data an argument for laparoscopy with routine contralateral inspection in higher risk patients can be made.


Puraj P Patel, DO, Michael W Love, MD, Jeremy A Warren, MD, William S Cobb, MD, Joesph A Ewing, MS, Alfredo M Carbonell, DO, Greenville Health System Laparoscopic ventral hernia repair (LVHR) is well accepted, however, the rate of patients requiring future abdominal operations is not well understood. This study identifies the common characteristics of LVHR patients undergoing reoperation and its attendant sequelae. A review of a prospectively maintained database at a hernia referral center identified patients who underwent LVHR between 2005 and 2014. Furthermore, a retrospective review identified LVHR patients who underwent subsequent abdominal operations. Outcomes of those reoperations were collected. Data are presented as a mean with ranges. A total of 757 patients underwent LVHR, with 24 conversions to open repair. Of the remaining 733 patients, age was 56.5 years, BMI 33.9 kg/m2, hernia size 115 cm2 (range 1–660 cm2), mesh size 411 cm2 (range 17.7–1360 cm2), operative time 143 minutes, and length of stay 3.6 days. Mesh used was ePTFE (57 %), barrier polyester (35 %), and barrier polypropylene (8 %). After a mean follow up of 19.4 months, overall recurrence rate was 8.46 %. Subsequent abdominal operations were performed in 17 % (125 patients); 21 % of these patients required greater than two subsequent operations. Mean time from index hernia repair to reoperation was 5.5 years. The most common indication for reoperation was recurrent hernia (36 patients, 28.8 %), followed by hepatopancreaticobiliary (19 patients, 15.2 %), infected mesh removal (19 patients, 15.2 %), bowel obstruction (18 patients, 14.4 %), gynecologic (10 patients, 8 %), colorectal (8 patients, 6.4 %), bariatric (5 patients, 4 %), trauma (1 patient, 0.8 %), and other (9 patients, 7.2 %). Overall, 2.5 % developed a mesh infection (n = 19; ePTFE 15, polyester 2, polypropylene 2); all of whom required mesh removal. Only 53 % underwent a subsequent hernia repair. Fifteen percent of patients who developed mesh infections, had a subsequent abdominal operation between their index hernia repair and development of the mesh infection. At the time of reoperation for bowel obstruction, the incidence of enterotomy or unplanned bowel resection (EBR), as a direct result of mesh-bowel adhesions was 27 % (n = 5: polyester 3, ePTFE 2). No other indication for reoperation resulted in EBR. In a large consecutive series of LVHR, the rate of abdominal reoperation was 17 %, and appears to increase with time. A reoperation for bowel obstruction carries an increased risk of EBR as a direct result of mesh-bowel adhesions. Surgeons should strongly consider, and discuss with patients the potential morbidity of future abdominal surgery prior to offering an intraperitoneal mesh hernia repair.

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Outcomes of Concomitant Ventral Hernia Repair Performed During Bariatric Surgery

Hospital Costs Associated with Patient Comorbid Risks, Operative Variables and Postoperative Complications in Ventral Hernia Repair: A Ventral Hernia Repair Hospital Cost Primer

Gautam Sharma, MD, Mena Boules, MD, Suriya Punchai, MD, Dvir Froylich, MD, Stacy Brethauer, MD, Phillip Schauer, MD, Kevin ElHayek, MD, John Rodriguez, MD, Matthew Kroh, MD, Cleveland Clinic Foundation Introduction: Currently there is no consensus on management of ventral hernias encountered during bariatric surgery. This study aims to evaluate the incidence and outcomes of concomitant ventral hernia repair (VHR) during bariatric surgery (BS) at our institution. Methods: Patients who had concomitant VHR repair during bariatric surgery from 2004 to 2015 were identified. Data collected included baseline demographics, comorbidities, perioperative parameters, surgical approach, and postoperative outcomes. Parameters were analyzed using Wilcoxon rank-sum test for continuous variables and Chi-square test for categorical variables. Results: A total of 103 (1.0 % of all bariatric cases) patients underwent concomitant VHR during the study period. Sixty-five (63 %) patients were female; mean age was 53.5 ± 9.8 years and mean BMI was 49.7 ± 10.0 kg/m2. Baseline comorbidities included: hypertension (n = 85, 83 %), type 2 diabetes (n = 68, 66 %), hyperlipidemia (n = 64, 62 %), obstructive sleep apnea (n = 56, 54 %) and reflux disease (n = 33, 32 %). 23/103 (22.3 %) had a prior VHR. 61 (59 %) patients underwent Roux-en-Y gastric bypass (RYGB), 38 (37 %) sleeve gastrectomy and 4 patients underwent adjustable gastric banding. 69/103 (67 %) patients had a previous abdominal surgery. Of the concomitant VHR, 90 (87.4 %) were completed Laparoscopically, 10 (9.7 %) patients were converted to open surgery and 3 (3.0 %) patients underwent primary open procedures. Technique included primary suture closure in 68 (66.0 %), and mesh repair in 35. Of the 35 mesh implants, 22 were biologic, 7 were synthetic, and 6 synthetic absorbable. Mean operative duration and estimated blood loss was 217 ± 66.5 minutes and 94 ± 70.4 mL respectively. Early post-operative complications (\30 days) were reported in 12 (11.6 %) patients, with superficial wound infection (n = 8),, bowel obstruction (n = 2), mesh infection (n = 1), marginal ulcer (n = 1), DVT (n = 1), pneumonia (n = 1), enterotomy (n = 1) Hernia recurrence was reported in 2 patients (2 %) in the early post-op period and in 12 patients (12 %) as a late ([ 30 days) complication, at a mean duration of 205 ± 169.4 days from the primary procedure. Recurrent VHR was performed in 10/14 patients. At 12 months follow-up, mean BMI and % excess weight loss (%EWL) were 36.5 ± 9.4 kg/m2, and 59.4 ± 26.1 % respectively. Conclusion: Ventral hernia is a common finding in patients undergoing bariatric surgery. Both primary suture repair and mesh repair result in acceptable results, both in terms of recurrence and peri-operative complications.

J. Scott Roth, MD1, Ranjan Ragulojan, BSc2, Daniel L Davenport, PhD, MBA3, 1University of Kentucky Division of General Surgery, 2 University of Kentucky College of Medicine, 3University of Kentucky Department of Surgery Introduction: Ventral and incisional hernia repair (VHR) is a common general surgical procedure with a significant incidence of postoperative complications and readmissions. Federal and private insurers are targeting increased ‘‘value’’ through both improved outcomes and reduced costs. However, cost data in clinically relevant terms is still rare. This study aims to identify VHR costs associated with clinically relevant factors in order to facilitate strategies by surgeons to enhance the value of VHR. Methods: This retrospective study of 385 consecutive VHRs matched the pre-, periand postoperative data from a single site’s ACS NSQIP database with hospital costs from the cost accounting system. Operating room (ORC), total admission (AdmitC), and 90-day post discharge (90PDC) costs were analyzed relative to the NSQIP clinical variables using non-parametric tests. Results: Median ORC were $6,900 (interquartile range $5,600–$10,000); AdmitC, $10,700 ($7,500–$18,600); and 90PDC, $0 ($0–$800). Female gender, age, ASA class, hypertension and preoperative open wound were associated with both increased ORC and AdmitC; COPD with increased AdmitC. ASA class and chronic steroid use were predictive of 90PDC. Operative variables associated with both increased ORC and AdmitC included inpatient surgery, open approach, recurrent hernia, wound class, operative duration, concomitant procedure, mesh size, biologic mesh, number of mesh pieces, and transfusion within 72 h of operation. Of these, wound class only was associated with 90PDC. Obesity, diabetes, smoking, emergent status, incarcerated hernia and transfer status were not associated with any costs. Inpatient occurrence of any of the NSQIP complications was associated with increased AdmitC, with organ space infections, sepsis, and prolonged mechanical ventilation conferring the largest increases. Post-discharge occurrence of wound infection/dehiscence, UTI or sepsis all increased 90PDC. Patients with post-discharge ED visits had a median increase of $2,600 in 90PDC; readmissions $7,700; outpatient surgery, $4,200; and imaging/lab visits, $600. Conclusions: Value assessment of hospitals performing VHR will need to adequately adjust for numerous pre- and perioperative cost drivers. Reducing complications will likely reduce costs, particularly reducing wound, urinary tract and systemic infections. Elevated ASA class, steroid use and wound class predict 90PDC and could be used to target patients needing additional post-discharge care. An appreciation of these factors associated with hernia repair costs may be useful in guiding surgeon practice to provide the greatest value in hernia procedures.



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A Novel Methodology for In Vivo Endoscopic Phenotyping of Colorectal Cancer Based on Real Time Analysis of The Mucosal Lipidome: A Prospective Observational Study of the iKnife

SAGES 6-Step Protocol for Minimizing Bile Duct Injuries: A Single Center Experience

Jl Alexander1, J Balog1, A Scott1, L Gildea1, A Speller1, L Muirhead1, O Golf1, K Veselkov1, J Kinross1, S Rasheed2, J Teare1, P Tekkis2, A Darzi1, Z Takats1, 1Imperial College London, 2Royal Marsden Hospital Introduction: Rapid Evaporative Ionization Mass Spectrometry (REIMS) provides the operating surgeon with tumour phenotypic data in near real time based on analysis of the mucosal lipidome.(1) This study determined the accuracy of REIMS for detecting established histological biomarkers of poor prognostic outcome in colorectal cancer. Methods: This was a prospective, observational multi-centred cohort study. Patients undergoing elective surgical resection for colorectal cancer were recruited at St. Mary’s Hospital London and The Royal Marsden Hospital, UK. Ex-vivo analysis was performed on resected tumour tissue using a standard electrosurgery handpiece using monopolar diathermy on cutting mode (ValleylabTM) with aspiration of the electrosurgical aerosol to a Xevo G2-S iKnife QTof mass spectrometer (Waters Corporation). Histological examination was carried out for validation purposes. Multivariate analysis was performed using principal component analysis and linear discriminant analysis. Classification of each individual tissue type was performed using leave-one-patient-out cross-validation and receiver operating curves (ROC) were generated. Results: 28 consecutive patients were recruited (12 male, median age 71, range 35–89). REIMS was able to distinguish the histopathological tissue type (Adenoma, adenocarcinoma, mucinous, GIST or signet ring) with 80.4 % overall accuracy. It was able to diagnose well or moderately differentiated tumours with a sensitivity of 89.5 % and a specificity of 65.9 %, ROC AUC = 0.90. The AUC for Lymph node micrometastases, Extra Mural Vascular Invasion (EMVI), and tumour budding was 0.80, 0.86 and 0.84 respectively. Distinction of tissue histology was possible based on differences in membrane lipid ratios. Increases in glycerophospholipids (p = 0.0027), and triacylglycerols (p = 0.0004) were seen in healthy mucosa and an increased prostaglandin D2 was found in malignant tissue (p = 0.0002). Conclusion: REIMS can accurately establish histological features of poor prognostic outcome in colorectal cancer based on chemical analysis of the mucosal lipidome. This technology could assist in the real time assessment of colorectal tumours during endoscopic and surgical resections. We have developed a modified endoscopic snare to allow deployment of this technology in vivo, and a clinical study is now underway. 1. Balog J, Sasi-Szabo L, Kinross J, Lewis MR, Muirhead LJ, Veselkov K, et al. Intraoperative tissue identification using rapid evaporative ionization mass spectrometry. Science translational medicine. 2013;5(194):194ra93.


Tushar C Barot, MD, MPH, Alexander Canales, MD, Jorge Irving, MD, Stephen W Unger, MD, Mount Sinai Medical Center Introduction: Over 750,000 Laparoscopic Cholecystectomies (LC) are performed yearly in US. Benefits are reduced pain, wound infection and length of stay (LOS) with LC compared to open operation. One of the devastating complication of LC is bile duct injury, occurring in about 0.3 % procedures leading to significant morbidity. In 2014 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) launched 6-step protocol to minimize these injuries. Our surgery department has adapted and implemented this protocol as a part of our quality improvement initiative beginning of February 2015. We performed a retrospective analysis to evaluate the feasibility and efficacy of this protocol. Methods: After IRB approval, study period from November 2014 to July 2015 was reviewed retrospectively for patients undergoing LC, including cases three months before and six months following implementation of 6-step protocol. The parameters were age, sex, BMI, Inpatient status, LoS, and peri-operative complications. In addition to that we also collected data on adherence to SAGES 6-steps protocol namely critical view of safety (CVS), Intra-op timeout, recognizing aberrant anatomy, use of intra-op cholangiogram (IOC), conversion to open and getting assistance if needed. A statistical analysis was performed using SPSS 22. A chi-square test, student’s t-test and descriptive frequency analysis performed on the data comparing parameters before and after initiation of SAGES protocol. Results: Total 173 cases matched study criteria, including 70 males (40.5 %) and 103 females (59.5 %) with mean age 56 years (22–92). Mean BMI was 28.45 (17.34–56.09), LoS was 3.52 days (0–31). No statistically significant difference was found between two groups in age, sex, BMI or LoS. Statistically significant difference was found in following three SAGES parameters after implementation of protocol. The visualization of CVS increased from 57.10 % to 95.10 % (p = 0.0001), Intra-op timeout increased from 0 % to 12.6 % (p = 0.001), and recognition of aberrant anatomy increased from 1.4 % to 8.7 % (p = 0.039). No difference was observed in use of IOC (71.4 % to 68.9 %, p = 0.429), conversion to open (0 % to 2.9 %, p = 0.209), or getting assistance (1.4 % to 0 %, p = 0.405). Statistically significant reduction was observed in Intra-op complications (5.7 % to 0 %, p = 0.025). Conclusion: After implementation of 6 step protocol we have seen statistically significant improvement in surgeons’ adherence to protocol and resulting reduction in complication rate. With continued efforts to increase the awareness and use of the SAGES six-step protocol amongst surgeons; we hope to see reproducible reduction in morbidity and mortality related to CBD injuries from LC.

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A Prospective, International, Multi-institution Study Evaluating Type of Fixation and Number of Tacks Affecting Quality of Life (QOL) After Ventral Hernia Repair (VHR)

Impact of Prior Interventions on Outcomes During Per Oral Endoscopic Myotomy

Tiffany C Cox, MD, Laurel J Blair, MD, Ciara R Huntington, MD, Tanushree Prasad, MA, Vedra A Augenstein, MD, FACS, B. Todd Heniford, MD, FACS, Carolinas Medical Center Background: QOL becomes a major aspect of discussion with patients to determine when to perform VHR and one of the major indices defining successful outcome. Herein, we identify if fixation method, tack type, or number of tacks used impact QOL after VHR. Methods: A prospective study of VHR patients was performed via the International Hernia Mesh Registry. Anonymous, self-reported, quality of life (QOL) data utilizing the Carolinas Comfort Scale (CCS) was recorded preoperatively, and 1, 6, and 12-months postoperatively. Pain was identified as a score of C2 (mild but bothersome to severe). Univariate and logistic regression analyses were performed individually for LVHR and OVHR including patient demographics, mesh used, suture fixation, type of tacks, number of tacks, glue, combinations of fixation, and no fixation. Predictors were included in multivariable models using backwards elimination with retention criterion of p \ 0.15. Goodness-of-fit of the model was tested using Hosmer–Lemeshow test. A value of C70 % for the area under the curve (AUC) was considered most accurate diagnostically after internal validation. Results: A total of 950 patients underwent VHR between 2007–2015:443 laparoscopic (LVHR) and 507 open (OVHR). The patients had an average age of 57.2 ± 12.8 years, 52.6 % were female, 17.1 % were active smokers, and 12.9 % used pain medications preoperatively. Preoperative pain (CCS score C 2) were reported by 54.9 % of patients. For OVHR, in cases with suture fixation alone, this was protective against postoperative pain at 6-months (odds ratio (OR):0.5, 95 %confidence interval (CI): 0.2–1.1, p = 0.08); no other fixation factors affected QOL for OVHR at any other time-points. For LVHR, independent protective fixation factors against pain at 1-month included fixation with less than 40 tacks (OR: 0.4, CI: 0.1–0.8, p = 0.01) even if combined with suture fixation (OR: 0.6, CI: 0.4–1.0, p = 0.05). The final logistic regression model had an AUC of 0.70 and after internal validation corrected to 0.66. When we further analyzed number of tacks impacting pain at 1-month, there was further significant difference if C60 tacks were used (OR: 2.8, CI: 1.3–6.2, p = 0.01). Comparison of absorbable versus non-absorbable, if \20 tacks were used, there was an increase in postoperative pain at 1-month for absorbable tacks (OR: 3.9, CI: 1.3–11.9, p = 0.02), but otherwise no difference existed among tack type. Despite method of fixation, no difference existed in rates of postoperative complications such as seroma, hematoma, abdominal wall complications, or recurrence (p [ 0.05). Conclusions: Reducing the number of tacks to\40 for LVHR lessens the rate of short term pain at 1-month. While suture fixation alone is a protective factor for pain at 6-months in OVHR, no method of fixation increases rates of chronic pain at 1-year after surgery.

S054 Volume and Outcomes Relationship in Laparoscopic Diaphragmatic Hernia Repair

Andreas M Schneider, MD, Brian E Louie, MD, Drew B Schembre, MD, Ralph W Aye, MD, Swedish Medical Center Cancer Institute Introduction: Per Oral Endoscopic Myotomy (POEM) for achalasia is performed by accessing the submucosal space of the esophagus. This space may be impacted by prior interventions such as injections of Botulinum toxin, balloon dilations or previous myotomy. There is uncertainty if these interventions make myotomy more difficult to perform and thus may deter surgeons from POEM during their early experience. We sought to determine the impact of prior interventions on our early POEM experience. Methods: Prospective study of consecutive patients undergoing POEM from July 2014 to September 2015. Patients were grouped apriori according to their anticipated complexity: Group I - No prior interventions; Group II - Prior interventions such as Botulinum injections and/or dilations, Group III - Sigmoidal esophagus, prior esophageal surgery or myotomy. We compared procedure length, subjective outcomes, inadvertent mucosotomy rates and other complications between groups. Results: A total of 29 patients underwent POEM for Achalasia Type I (n = 7), Type II (n = 14), Type III (n = 5) and other dysmotility disorders (n = 3). In Group II, 6 patients had balloon dilations and submucosal injections performed, 4 patients had dilation alone. Group III had 2 prior myotomies and one prior esophageal atresia repair. Group I and II were comparable in operative time and mucosotomy rates (I = 4, II = 1 and III = 1), but Group III had longer operative times (I = 141.1 mins, II = 141.2 mins, III = 256.7 mins, p \ 0.0001). One patient in Group 1 required a stent for 24 hrs to cover a mucosotomy and one patient in Group III underwent laparoscopic re-myotomy without symptom relief. At short term follow up, all groups (Table 1) had significant improvement of their Eckhardt scores and improved QOLRAD scores. Conclusion: Prior interventions with Botulinum or dilations did not seem to impact operative times or mucosotomy rates during our early POEM experience. Patients with sigmoid esophagi or prior myotomy required nearly double the operative time. Patients in all groups had significant improvement of their symptoms and improved quality of life.

Table 1 . Group I (n = 12) Eckhardt Pre–Post

Group II (n = 10)

Group III (n = 7)






















Matthew D Whealon, MD, Juan J Blondet, MD, Michael J Phelan, PhD, Ninh T Nguyen, MD, UC Irvine Introduction: There is no published data regarding the relationship between hospital volume and outcomes in patients undergoing laparoscopic diaphragmatic hernia repair. We hypothesize that centers performing high case volume have improved outcomes compared to low volume centers. Materials and Methods: We reviewed the National Inpatient Sample (NIS) database between 2008 and 2012 of adults with the diagnosis of Diaphragmatic Hernia (ICD-9 code 5533) who underwent elective laparoscopic repair of diaphragmatic Hernia (5371) and/or Nissen fundoplication (4467). Pediatric, emergent, and open cases were excluded. Main outcome measures include in-hospital mortality, serious morbidity, length of stay, and the association between case volume and in-hospital mortality. Results: During the study period, a total of 31,228 laparoscopic diaphragmatic hernia operations were performed. The overall in-hospital mortality was 0.14 %. Risk factors for mortality were age older than 60 years (OR 5.05 (2.38–10.76), 95 % CI; p \ 0.0002) and renal failure (OR 6.26 (2.48–15.78), 98 % CI; p \ 0.0009). Risk factors for serious morbidity were age older than 60 years (OR 2.14 (1.63–2.82), 95 % CI; p \ 0.0001), renal failure (OR 5.01 (3.11–8.07), 95 % CI; p \ 0.0001), and congestive heart failure (OR 5.77 (3.67–9.07), 95 % CI; p \ 0.0001). There was an inverse relationship between higher hospital case volume and lower mortality with an annual threshold volume of 10 cases per year. Using this threshold volume, low volume hospital (£10 cases) has a significantly higher mortality compares to high volume hospitals (0.23 % vs 0.12 %, respectively). Conclusions: Laparoscopic diaphragmatic hernia repair is associated with low in-hospital mortality. Significant risk factors for in-hospital mortality and serious morbidity were older age, renal failure, and congestive heart failure. There is an inverse association between the centers’ case volume and mortality with an annual threshold case volume of 10 cases.



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Evolving Techniques for Management of Anastomotic Leak After Esophageal Resection: A Single Center Experience

Feasibility and Functional Outcomes of Laparoscopic Proximal Gastrectomy with Double Tract Reconstruction for Proximal Gastric Cancer: Comparative Study with Conventional Laparoscopic Total Gastrectomy

Steven S Cheung, MD, Brian G Biggerstaff, MD, Pulkesh Bhatia, MBBS, Carrie Bertolloti, APRN, Pradeep K Pallati, MBBS, Kalyana C Nandipati, MBBS, Sumeet K Mittal, MBBS, Creighton University Background: Anastomotic leaks significantly increase morbidity and mortality following esophageal resections. Endoscopic techniques continue to evolve as viable alternatives to operative intervention. This study compares features and outcomes between conservative, endoscopic, and operative management of anastomotic leaks. Methods: After Institutional board review approval retrospective review of a prospectively maintained database was done to identify patients who had anastomotic leak after an esophageal resection. The charts were reviewed and data pertaining to demographics, type of procedure (open, minimally invasive, or hybrid), procedural indication, leak location (cervical, thoracic, or abdominal), management style (conservative, endoscopic, or operative), leak characteristics, and outcomes (complications, reoperations, mortality, ICU duration, and length of stay) extracted. Results: The anastomotic leak rate is 9.4 % during the study period with direct mortality rate of 6.9 % (n = 2). The leak rate for cervical, thoracic, and abdominal anastomosis were 8.4 %, 13.2 % and 5.6 % respectively. Conservative management was utilized for 13 patients, most commonly for cervical leaks. In almost all cases, the leak was identified on initial swallow study prior to initiation of oral diet. There was one death in this cohort due to gastric conduit necrosis and resultant aortic fistula. Endoscopic management was used for 12 patients, most commonly for intra-thoracic anastomosis. Leaks were less likely to be contained and identified later compared to cervical leaks. Endoscopic techniques include stent placement (n = 11) and endoscopic vacuum assisted closure (n = 2). Most patients required multiple endoscopic washouts during their hospital course (58.3 %). Re-operative intervention was needed in 4 patients, performed exclusively for thoracic leaks. One patient developed gastro-bronchial fistula resulting in mortality. Strictures requiring balloon dilation were most common in conservatively managed patients (46.2 %,) compared to endoscopic and operative management (33.3 % and 0.0 % respectively). The only fistula occurred in an operatively managed patient. ICU duration and overall length of stay were significantly shorter for conservatively managed patients compared to endoscopic or operative management (p \ 0.05). No statistical significance was not reached between endoscopic and operative management in our cohort. Conclusions: Endoscopic techniques are an effective alternative to operative intervention in management of complicated anastomotic leaks following esophagectomy. While this strategy may require intensive repeat periodic endoscopic washouts, it avoids morbidity of major re-operation.


Young Kyu Park, PhD, Mi Ran Jung, PhD, Seong Yeob Ryu, PhD, Oh Jeong, PhD, Chonnam National university Hwasun Hospital Introduction: Laparoscopic proximal gastrectomy (LPG) with double tract reconstruction (DTR) is an attractive treatment option for proximal gastric cancer when considering the advantages of a function preservation, including improved nutrition and a decreased incidence of postopertive reflux esophagitis. The aim of this study was to assess the feasibility of LPG with DTR and to compare the functional outcomes of LPG with laparoscopic total gastrectomy (LTG). Methods: Between November 2011 and August 2015, 158 patients with proximal gastric cancer underwent LPG (n = 24) or LTG (n = 134) at our institution. Patients were indicated for LPG if they were diagnosed with cT1N0M0 and LTG was indicated for the patients with cT1N0, T1N1 and T2N0 gastric cancer. We reviewed their medical records from our prospectively collected gastric cancer database. The clinicopathological characteristics and functional outcomes were compared between two groups. Results: There was no significant differences in demographic and pathologic characteristics. Though the operative time was longer in LPG group (303 ± 54 vs. 262 ± 78 min, p = 0.013), the postoperative 30-days complication rate was not significantly different between two groups (20.8 % vs. 16.4 %, p = 0.565). The incidences of endoscopic findings of reflux esophagitis (0 % vs. 3.7 %, p = 1.000) and reflux symptoms (4.8 % vs. 10.9 %, p = 0.694) were similar in both groups. LPG group had a significantly better serum Vitamin B12 levels at the first postoperative year than LTG group (420 ± 289 vs. 253 ± 133, p = 0.028). The body weight loss during postoperative 1 year was also significantly lower in LPG group (6.4 ± 3.3 vs. 8.7 ± 4.5 kg, p = 0.023). Conclusion: In the study, the LPG with DTR is a technically feasible and showed comparable incidence of postoperative reflux esophagitis to the LTG. Moreover, LPG is preferred over LTG in terms of postoperative nutritional status at first year. Therefore, LPG with DTR would be a good alternative procedure for proximal gastric cancer. A large scaled randomized trial is needed to validate the functional benefits of LPG.

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Mesh at the Hiatus in Revisional Surgery for Failed Fundoplication: A Case–Control Evaluation

Predicting Magnetic Sphincter Augmentation Failure

Rana M Higgins, MD, Matthew E Bosler, BA, Max Schumm, BS, Matthew J Frelich, MS, Jon C Gould, MD, Medical College of Wisconsin

Jessica L Reynolds, MD1, Stephanie Doggett, MS, PAC2, Vincent Mguyen, BS2, Nikolai A Bildzukewicz, MD1, F P Buckley III, MD2, John C Lipham, MD1, 1University of Southern California Keck Medical Center, 2Scott & White Healthcare

Introduction: Laparoscopic revisional surgery for failed fundoplication has an increased morbidity compared to primary surgery. In an attempt to minimize recurrence, many surgeons will place hiatal mesh, although effectiveness has been debated. There is also controversy surrounding the safety of hiatal mesh, especially for future operations. We sought to determine the impact of pre-existing hiatal mesh on morbidity of revisional surgery for failed fundoplication. Methods: A retrospective review was conducted of 104 patients with prior revisional antireflux surgery between 2010–2015. Fourteen patients (13.5 %) had previous operations with hiatal mesh. Revisional procedures performed were reoperative Nissen (n = 6), conversion of Nissen to Toupet (n = 3), and Roux-en-Y gastric bypass (n = 5). These 14 cases were matched 1:2 with 28 randomly selected control patients from the database who underwent revisional surgery without mesh, paired based on number of previous revision attempts and operation type. Perioperative outcomes included intraoperative perforation, readmission, morbidity, operative time and length of stay. Statistical analysis was performed using Fisher’s exact tests for categorical and unpaired t-tests for continuous variables with significance p \ 0.05. Results: There were no statistically significant differences in perioperative morbidity in patients with or without prior hiatal mesh in revisional antireflux surgery (Table 1). The mean number of prior operative attempts in the mesh group was 1.6 compared to 1.5 in the no mesh group (p = 0.65). Among patients with prior mesh, there was no difference in 30-day morbidity between biologic (n = 5) and synthetic (n = 9) mesh (p = 0.58). Conclusion: In the hands of experienced surgeons, hiatal mesh does not have an impact on morbidity or operative time. While this retrospective analysis cannot address the controversy of mesh and recurrence, we do feel that mesh at the hiatus does not increase the morbidity of reoperative procedures. Revisional surgery for failed fundoplication remains a complex intervention best taken on by surgeons with expertise in reoperative foregut and bariatric surgery.

Introduction: MSA was approved for the treatment of uncomplicated GERD by the FDA in 2012 and over 5000 procedures have been done throughout the world. Studies to date have consistently shown a failure rate of around 20 %. The aim of our study was to identify preoperative variables that may predict failure. Methods and Procedures: Retrospective study of all patients undergoing MSA at 3 institutions by 3 surgeons from 6/2007–6/2015. MSA failure was defined as positive pH study, esophagitis any grade, GERD-HRQL [10, or the use of daily PPIs. Patients underwent post-operative EGD and pH studies at the discretion of the surgeon based on symptoms. Results: 243 patients underwent MSA, 138/105 M/F, median age 53 (19–87). Mean follow up was 7.7 months (1–63). Failure was seen in 65 (26.7 %) patients. Of the 65 failures, 45 had a GERD-HRQL [10, 36 had daily PPI use, 26 patients had EGDs which showed 2 patients with esophagitis, and 10 patients had pH testing with 3 positive DeMeester scores. There was no significant difference in any of the preoperative variables tested (Table 1). Failures did not have a higher incidence of hiatal hernias, larger hiatal hernias, or a significant difference in hiatal hernia repairs compared to successes. We also found no difference in preoperative supine reflux in the 146/243 (60 %) of patients with that data available. Four patients had the device explanted; 1 for persistent Barrett’s (converted to Nissen), 1 for gastroparesis (underwent subtotal gastrectomy), 1 patient who had failure of the device and had a revision with a smaller device, and 1 patient was converted to a Dor fundoplication for severe dysphagia and odynophagia. There were no erosions or migrations. Conclusion: We have shown that there is not a higher risk of MSA failure for any of the variables typically associated with complicated GERD, including high grade esophagitis, Barrett’s esophagus, and large hiatal hernia. Furthermore, we have demonstrated in a large series of patients that even with a very broad definition of failure, MSA continues to have a high success rate even when used in individuals with complicated GERD and therefore should not be restricted to patients with uncomplicated disease.

Table 1 Perioperative outcomes in patients with/without prior hiatal mesh

Table 1 Comparison of preoperative variable in patients who failed MSA and those that did not

Prior mesh (n = 14) Without mesh (n = 28) p-value Intraoperative perforation 1 (7 %)



30-day readmission




30-day morbidity

3 (21.4 %)

7 (25 %)


Operative time

232.9 minutes

258.0 minutes


Length of stay

2.93 days

4.21 days




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Role of Endoscopic Ultrasound in Diagnosis and Staging of Carcinoma Gall Bladder

Using Transthoracic Trocars for Laparoscopic Resection of Subphrenic Hepatic Tumors

Ranjith Kumar Ramasamy, MS, Thakur D Yadav, MS, Vikas Gupta, MCH, Rakesh Kochhar, DM, Saroj K Sinha, DM, Ashim Das, MD, PGIMER

Takeaki Ishizawa, MD, PhD, FACS, Hirofumi Ichida, MD, PhD, Masayuki Tanaka, MD, PhD, Muga Terasawa, MD, Genki Watanabe, MD, Yoshinori Takeda, MD, Ryota Matsuki, MD, Masaru Matsumura, MD, Taigo Hata, MD, Yoshihiro Mise, MD, PhD, Yosuke Inoue, MD, PhD, Yu Takahashi, MD, PhD, Akio Saiura, MD, PhD, Cancer Institute Hospital, Japanese Foundation for Cancer Research

Introduction: Staging is the strongest prognostic factor for Gallbladder carcinoma. Traditionally Contrast enhanced computed tomography (CECT) is the gold standard test to assess the resectability. But the role of CECT in picking up the tumour spread in the hepatoduodenal ligament has been limited. Role of endoscopic ultrasound in the evaluation of periampullary tumour, carcinoma head of pancreas, lower CBD carcinoma were well established. Very limited experience has been reported in the literature regarding the role of endoscopic ultrasound in carcinoma gallbladder. we aimed this study to assess the role of endoscopic ultrasound in diagnosis and staging of carcinoma gall bladder Materials and Methods: 25 patients (20 females) with mean age 53.2 ± 11.84 years with the diagnosis of CaGB who met the inclusion criteria were enrolled into the study. 12 were operated in which the HPR reports were collected and compared with their corresponding EUS and CT finding. In the remaining 13 inoperable patients EUS finding was compared with CT finding. Results: Among the operated patients sensitivity and positive predictive value of EUS in detecting T1, T2, T3, N0, N1 nodes were (100 % & 100 %), (100 % & 100 %), (83.3 & 83.3 %)-(87.5 % & 77.8 %), (66.7 % & 100.0 %) respectively compared to CT which had-(100 % & 50 %), 0 %, (66.7 % & 66.7 %) (87.5 % & 77.8 %), (66.7 % & 66.7 %) respectively. EUS has a high sensitivity and positive predictive value when compared to CT in T staging with a P value of 0.001. Significant association between EUS and HPR was noted compared to CT in T staging. In N1 nodal staging it had similar sensitivity but a high positive predictive value when compared to CT This may be useful as patients with N1 positivity has significantly worse survival. N2 nodal involvement assessment couldn’t be done as these patients were not operated, and so histopathological correlation couldn’t be made. No association was noted between the two tests in the inoperable patients. Conclusion: EUS is useful in the staging of gallbladder carcinoma.

Introduction: Laparoscopic resection for right subphrenic hepatic tumors only with abdominal trocars often needs full mobilization of the right liver to obtain sufficient field of view and working space, even for small subcapsular tumors. Methods and Procedures: Patients were placed in the left lateral decubitus position with the right arm suspended (Fig. 1A). In addition to three or four abdominal trocars, two balloon-tipped trocars, one 12 mm (caudal side) and one 5 mm (cranial side), were deployed through the diaphragm in this order, following identification of lower edge of the lung with the use of ultrasonography from patient’s body surface (Fig. 1B). When these intercostal trocars were placed, respiration movement of the lung edge was also identified by laparoscope and the cranial side of the diaphragm was compressed with the forceps introduced through the abdominal trocar, to exclude the lung from the pleural space around the trocar sites. The 5 mm cranial trocar was used by operator’s left hand and the 12 mm caudal one was used as a camera port (Fig. 1C). Hepatic transection line was determined by using intraoperative ulstrasonography and indocyanine green-fluorescence imaging, following minimal mobilization of the liver. Hepatic parenchyma was dissected with bipolar forceps and vessel sealing systems under intermittent inflow occlusion. When the transthoracic trocars were removed after hepatectomy, the incisions on the diaphragm were sutured. Prophylactic chest drain was not used. Results: Transthoracic trocars were used in 12 laparoscopic hepatectomies for hepatic tumors located in Couinaud’s segment 7 (4 nodules) or segment 8 (8 nodules). The maximum diameter of the lesions and the width of the surgical margin were 12 (6–21) mm and 10 (1–15) mm, respectively (median [range]). The operation time and the amount of blood loss were respectively 205 (109–317) minutes and 65 (25–310) mL. The postoperative hospital stay was 9 (6–19) days. No postoperative complications associated with transthoracic trocars occurred.

Fig. 1 A Placement of transthoracic trocars (TT). TTs are deployed through the diaphragm following identification of lower lung edge with the use of laparoscope and ultrasonography. B Body position and trocar placement. Patients are placedin the left lateral decubitus position. basically, two ballon-tipped trocar, one 12 mm and one 5 mm, are placed. C Tumor identification and resection. A colorectal liver metastasis, visualized in green by indocyanine-green fluorescence imaging, can be identified just beneath the tip of laparoscope and operator’s forcipes, facilitating hemispherical limited resection of the liver. RHV indicates the right hepatic vein Conclusions: Placement of transthoracic trocars is safe and facilitates laparoscopic resection for subphrenic hepatic tumors.


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Validation of Difficulty Scoring System for Laparoscopic Liver Resection In Patients Underwent Laparoscopic Left Lateral Sectionectomy

Is Laparoscopic Pancreaticoduodenectomy Associated with Improved Outcomes for Pancreatic Cancer?

Jai Young Cho, PhD, FACS, Ho-Seong Han, Yoo-Seok Yoon, YoungRok Choi, Jae Yool Jang, Hanlim Choi, Jae Seong Jang, Seong Uk Kwon, Chami Im, Department of Surgery, Seoul National University Bundang Hospital Background: Recently, a novel difficulty scoring system (DSS) using the extent of liver resection, tumor location, liver function, tumor size, and tumor proximity to major vessels was developed to assess the difficulty of various laparoscopic hepatectomy procedures. However, even in laparoscopic left lateral sectionectomy (LLS), operative difficulties vary according to the severity and diagnosis of disease. We validated DSS in all patients underwent laparoscopic LLS. Methods: We reviewed the clinical data of 106 patients who underwent laparoscopic LLS for tumor (n = 72) between July 2003 and July 2013 and validated the DSS to surgical outcomes. Additionally, the data of LLS for hepatolithiasis (n = 34) was also evaluated. Results: The DSS score ranged from 3 to 7 in laparoscopic LLS for tumors, and mean blood loss (P = 0.005) and the rate of complication grade (P = 0.015) were different according to the scores. When we applied DSS to all patients underwent laparoscopic LLC, the mean hospital day (P = 0.002), operation time (P = 0.018), and the rate of complications (P = 0.025) were longer in IHD stone group than tumor group. After we modify DSS with additional 2 score for IHD stones (‘‘diagnosis’’ variable), modified DSS discriminated better intraoperative results according to the scores. Conclusions: Operation difficulty varies even in LLS and modified DSS outperformed original DSS when we added diagnosis variable.

John A Stauffer, MD2, Alessandro Coppola, MD1, Kabir Mody, MD2, Elizabeth Johnson, MD2, Horacio J Asbun, MD2, 2Mayo Clinic Florida, 1Universita Cattolica del Sacro Cuore, Rome, Italy Introduction: Pancreaticoduodenectomy is the only treatment that offers a chance for cure in patients with pancreatic ductal adenocarcinoma (PDAC) of the head of the pancreas. In recent years, laparoscopic pancreaticoduodenectomy (LPD) has been introduced as a feasible alternative to open pancreaticoduodenectomy (OPD) when performed by experienced surgeons. This study reviews and compares perioperative results and long term survival of patients undergoing LPD versus OPD at a single institution over a 20 year time period. Methods: From 1995–2014, 612 patients underwent PD and 252 patients were found to have PDAC. These latter patients were reviewed and divided into two groups: OPD (n = 194) and LPD (n = 58). LPD was introduced in November 2008 and performed simultaneous to OPD within the remaining time period. 90-day perioperative outcomes and long term survival were analyzed. Results: Patient demographics were well matched (Table 1). Operative time was significantly longer with LPD but blood loss and transfusion rate were decreased. Postoperative complications, ICU stay, and overall hospital stay was similar. OPD was associated with larger tumor size; LPD was associated with greater lymph node harvest and lower lymph node ratio. LPD was performed by hand assist method and converted to open in 3 (5.2 %) and 14 (24.1 %) patients respectively. Neoadjuvant therapy was performed in 17 (8.8 %) and 4 (6.9 %) patients for OPD and LPD respectively. The estimated median survival was 20.3 months and 17.9 months for OPD and LPD respectively. Long term survival was similar for the two groups at all points through 5 years. Conclusion: LPD provides similar short term outcomes and long term survival of OPD in the treatment of PDAC.

S063 Effective Stepwise Training and Procedure-Standardization for Young Surgeons to Perform Laparoscopic Left Hepatectomy Mitsuo Shimada, MD, Satoru Imura, MD, Yuji Morine, MD, Tetsuya Ikemoto, MD, Yu Saito, MD, Shinichiro Yamada, MD, Hiroki Teraoku, MD, Masato Yoshikawa, MD, Chie Takasu, MD, Tokushima University

Table 1 Postoperative outcomes (90 day) for 252 patients undergoing open pancreaticoduodenectomy (OPD) or laparoscopic pancreaticoduodenectomy (LPD) for pancreatic ductal adenocarcinoma

Introduction: Laparoscopic hepatectomy remains to be one of the most difficult procedures for young surgeons. We have recently developed a new training method and procedure-standardization for young surgeons to perform laparoscopic left hepatectomy (Lap-LHx). The aim of this study is to clarify the effect of our method for young surgeons to perform Lap-LHx. Methods: Standardization of Lap-LHx: After mobilization of left lobe, left 1st Glissonean pedicle is encircled using the Arantius’ ligament approach by Cho et al. (Asian J Endosc Surg. 2012). Briefly, after division of the Arantius’ ligament, a space between the left Glissonean pedicle and the liver parenchyma made by retracting the caudal stump of the ligament was used to encircle the left Glissonean pedicle. After marking a demarcation line, parenchymal dissection is performed under the Pringle maneuver, principally using CUSA. The common trunk of middle and left hepatic vein is encircled in case of hybrid method. Training method: 1st step, training of fundamental procedures using a dry box; 2nd step, detailed preoperative simulation using a Vincent 3-D software for each patients; 3rd step, practices in OR and self-assessment including understanding anatomies and completion grade of each procedure using a original score sheet, and feedback by both mentors and Professor. 23 patients who underwent Lap-LHx included in this study were divided into 2 groups, young (non-board certified) surgeons (n = 9) and senior (board certified) surgeons (n = 14). Results: As for short-term outcome of all Lap-LHx, mean blood loss and operative time were 203 g and 327 min., respectively. Only one patient suffered from a superficial SSI. Regarding the comparison between young and senior surgeons, blood loss and operative time in young surgeon group (336 min. and 194 g) were similar to those in senior surgeon group (322 min. and 208 g). Conclusion: Our procedure standardization of Lap-LHx and stepwise training could enable young surgeons to perform Lap-LHx surely and safely.



Surg Endosc (2016) 30:S211–S263



Analysis of Learning Curve for Laparoscopic Pancreaticoduodenectomy

Measuring Intra-operative Decision-Making During Laparoscopic Cholecystectomy: Validity Evidence for a Novel Interactive Web-Based Assessment Tool

Yiping Mou, MD, FACS1, Chao Lu, MS2, Weiwei Jin, MD2, Xiaowu Xu, MD1, Renchao Zhang, MD1, Jiafei Yan3, Yucheng Zhou1, Chaojie Huang1, Jiayu Zhou, MD2, Ronggao Chen2, Jingrui Wang2, 1 Department of Gastrointestinal and Pancreatic Surgery, Zhejiang Provincial People’s Hospital, 2School of medicine, Zhejiang University, 3Department of general surgery, Sir Run Run Shaw Hospital Background: Interest in laparoscopic pancreaticoduodenectomy (LPD) keeps on growing, while reports of large series of this procedure is still limited to a few highly specialized centers. Moreover, few of them analyzed the learning curve of LPD. This study aims to assess the overall clinical outcomes and changes during different learning period of this procedure in our institution. Methods: All data of 120 patients who underwent LPD between September 2012 and July 2015 in our institution were reviewed retrospectively, including demographic data, operative time, blood loss, morbidity, mortality, length of hospital stay (LOS). All patients were divided into 4 groups in order: Group A (the first 30 patients), Group B (the second 30 patients), Group C (the third 30 patients), Group D (the last 30 patients). The overall clinical outcomes and changes during different learning period were analyzed. Results: Among 120 patients, 111 of them underwent totally LPD, 9 patients underwent laparoscopic assisted pancreaticoduodenectomy (LAPD). 23(19.2 %) patients had a history of abdominal surgery. Pathologic examination confirmed pancreatic ductal adenocarcinoma in 36 patients, ampulla of Vater carcinoma in 31 patients, distal bile duct carcinoma in 14 patients, and other diseases in 39 patients. The mean operative time was 355.81 ± 57.55 min, mean blood loss was 177.74 ± 152.64 ml. 42(35 %) patients developed postoperative complications with no mortality. The average LOS was 17.01 ± 9.83 d. With accumulating experience of the surgeon, the mean overall operative time tends to decrease from 370.17 ± 52.83 min in Group A to 342 ± 73.10 min in Group D. Moreover, mean operative time of pancreatojejunostomy and choledochojejunostomy also tends to decrease from 55 ± 8.72 min, 39.8 ± 11.68 min in Group A to 43.57 ± 7.62 min, 27.67 ± 11.81 min in Group D respectively. Meanwhile, the clinical outcomes tend to get better. Mean blood loss, morbidity and LOS decreased from 219.33 ± 147.88 ml, 43.3 %, 18.67 ± 10.03 d in Group A to 140 ± 73.60 ml, 23.3 %, 14.38 ± 6.23 d in Group C respectively except for Group D, which expended the operative indications with comparable clinical outcomes with Group C. Conclusions: The laparoscopic pancreaticoduodenectomy procedure is feasible and safe in our center, and it can be applied into routine practice. Clinical outcomes can be improved with accumulating experience for more than 30 operations by overcoming the learning curve. Keywords: Laparoscopic pancreaticoduodenectomy; Learning curve

Amin Madani, MD1, Yusuke Watanabe, MD1, Philip Pucher, MD, PhD2, Elif Bilgic, BSc1, Melina C Vassiliou1, Rajesh Aggarwal, MD, PhD1, Gerald M Fried, MD1, Liane S Feldman, MD1, 1McGill University, 2Imperial College London Introduction: Errors in judgment during laparoscopic cholecystectomy can lead to bile duct injuries. Despite the strong correlations between patient outcomes, expert performance and advanced cognitive skills, current methods to evaluate these complex skills remain subjective, rater- and situation-dependent, and non-systematic. The purpose of this study was to develop objective metrics using a web-based platform, and to obtain validity evidence for their assessment of decision-making during laparoscopic cholecystectomy. Methods and Procedures: An immersive and interactive online learning platform was developed ( Trainees and attending surgeons from 6 institutions completed a 12-item assessment tool. The items were developed to target critical decisions, based on comprehensive cognitive and hierarchical task analyses about achieving a Critical View of Safety. Five items required subjects to draw their answer on the surgical field and accuracy scores were calculated based on an algorithm derived from experts’ responses (Fig. 1). Test-retest reliability, internal consistency, and Spearman’s correlation with self-reported experience, Global Operative Assessment of Laparoscopic Skills (GOALS) score and Objective Performance Rating Scale (OPRS) score were calculated. Scores of novices, intermediates and experts were compared using Analysis Of Variance. Five-point Likert scale questionnaires were administered to evaluate the platform’s usability, feasibility and educational value. Results: Thirty-nine subjects (17 attending surgeons, 22 residents) completed the assessment. There was high test-retest reliability (intraclass correlation coefficient = 0.95; n = 10) and internal consistency (Cronbach’s alpha = 0.87). The assessment tool demonstrated significant differences between novices, intermediates and experts in total exam score (all 12 items; p \ 0.01) and total accuracy score (5 drawing items; p \ 0.01) (Fig. 2). There was a high correlation between total case number and total score (rho = 0.83). Intra-operative assessments were available for 9 residents, with moderate to high correlation between total score and GOALS (rho = 0.63), and between total score and OPRS (rho = 0.87). Most subjects either agreed or strongly agreed that the assessment tool was easy to use (n = 32 (82 %)), facilitates development of intra-operative decision-making (n = 31 (79 %)), and should be integrated into surgical training (n = 31 (79 %)). Conclusion: This study provides validity evidence for a novel web-based interactive platform to objectively assess intra-operative decision-making during laparoscopic cholecystectomy. Given the consequences of bile duct injuries and the importance of advanced cognitive skills, the integration of this tool into surgical training may facilitate the development of expertise and improve patient safety.

Fig. 1 Screenshot of sample user response when asked to identify where they would start dissecting the hepato-cystic triangle

Fig. 2 Mean total score for each group


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S241 Table 1 Overall significant mean difference between blocked (BL) and random (RA) practice orders

Cognitive Load Assessment of Simulated Laparoscopic Surgical Tasks Using Optical Imaging Faiz U Shariff, MD1, Mashaal Syed2, Elizabeth Renza-Stingone, MD1, Hasan Ayaz, PhD2, Andres Castellanos, MD1, D Scott Lind, MD1, Patricia A Shewokis, PhD1, 2School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA, 19104, USA, 1Department of Surgery, College of Medicine, Drexel University, Philadelphia, PA 19102, USA Introduction: We hypothesized that applying cognitive load theory (CLT) to simulation will enhance the retention and transfer of surgical skills. Functional near infrared spectroscopy (fNIR) is a novel, noninvasive neural optical imaging tool that indirectly measures cognitive workload by monitoring the hemodynamics of prefrontal cortex (PFC) activation. To optimize germane load, we applied the contextual interference principle (blocked (BL) and random (RA) practice orders). Intrinsic load was managed by a variation on the simple-to-complex strategy, by comparing the simpler acquisition simulated laparoscopic skills to a more difficult transfer laparoscopic skill. We assessed selected performance metrics and PFC brain activation regions during the retention and transfer of multiple, simulated laparoscopic skills. Methods: Eleven third year medical students acquired three skills on a laparoscopic simulator (Surgical ScienceÒ) and were randomly assigned to either a BL or RA practice orders. Students performed 108 acquisition trials, across three days, of 3 simulated laparascopic skills. A 72-hr retention interval followed skill acquisition, after which 6 retention trials of the acquired skills and 6 transfer trials (2 different simulated laparoscopic tasks) were performed (See Fig. 1). Performance metrics (Global score, Total time and other selected measures) and hemodynamic responses (total hemoglobin) were assessed during skill retention and transfer in four different region of the PFC. Non-parametric randomization tests with 10,000 Monte Carlo samples were used to determine if there were differences between BL vs RA practice orders for each skill separately. The significance criterion for all tests was set at a = 0.05. Results: During retention and transfer, RA performed the surgical skills in significantly less time, had fewer error and had lower change in total Hemoglobin in the right dorsolateral PFC than the BL group (Table 1). Conclusions: We were able to objectively measure cognitive load using fNIR measures of the anterior and dorsolateral PFC hemodynamic response. Compared with BL practice, RA practice resulted in enhanced learning through better performance and less cognitive load for retention and transfer of simulated laparoscopic surgical skills. Application of CLT in this study helped designed an instructional paradigm that managed the intrinsic load and optimized the germane load that lead to enhance learning.

Fig. 1 a Practice schedule of the study subjects. b Hemodynamic monitoring in the Prefrontal Cortex by fNIR and data acquisition while performing the simulated laparoscopic task

S068 ‘Training the Sages Trainers’: A Step Toward Raising the Bar in the Educational Value of The Hands-On Course Experience? Susannah M Wyles1, Erin Schwarz2, Jonathan Dort3, Nabil Tariq4, Tom Cecil5, Mark G Coleman6, John T Paige7, Brian J Dunkin4, 1 UCSF, 2SAGES, 3Inova, VA, 4MITIE, Houston, 5Basingstoke, 6 Derriford, UK, 7LSU Introduction: Hands-on courses are expensive to deliver, are costly for delegates to attend, and thus the educational value should be maximized. There is no prerequisite teaching qualification to mentor on SAGES hands-on courses (SAGES-HOC), just the need to be technically proficient. The Lapco-TT, a teaching course for surgeons, has been delivered successfully in the UK and US, with a demonstrable positive impact on both delegates’ teaching ability and their learners’ learning curves. The aims of this study were to determine if this curriculum could be delivered in a day course to SAGES trainers, and if these trainers could impact the educational experience delegates had at a subsequent SAGES-HOC. Methods and Procedures: Six general surgeons attended the Lapco-TT course. The following day, trainees registered for a SAGES-HOC were split into two groups (A and B). Group A were taught by the Lapco-TT delegates, and Group B by the other SAGES trainers. Opinion surveys (5 point Likert scales) were completed by both the Lapco-TT delegates, and the SAGES-HOC delegates. Furthermore, the TT trainers were assessed by their delegates, by the Lapco-TT faculty and by themselves, using a previously validated teaching assessment (cSTTAR). Mean scores are reported and analyzed (non-parametric test (Mann-Whitney U) for the opinion surveys, and t test for the cSTTAR scores) (p \ 0.05). Results: All 6 Lapco-TT delegates found the TT useful (5), felt that it would influence the way that they taught in the OR (4.83), that their course objectives were met (4.83) and that they would recommend the course to their colleagues (4.83). 10 HOC delegates were taught by the Group A trainers, and 22 by Group B. Delegates in Group A better understood what they were supposed to learn (5 vs. 4.15 [p = 0.046]), and do (5 vs. 4 [p = 0.046]), felt that the session was well organized (5 vs. 4 [p = 0.046]), that time was used effectively (5 vs. 3.9 [p = 0.046]), with sufficient (5 vs. 3.9 [p = 0.028]) and effective feedback regarding their performance on the course (5 vs. 3.95 [p = 0.028]) compared to Group B. Group A trainers were rated significantly higher by their delegates than Group B trainers on the cSTTAR training assessments (p \ 0.0005). Group A trainers rated themselves significantly lower than both the expert observers (p \ 0.0005) and when compared to the Group B trainers’ self-assessment (p \ 0.002). Conclusions: The Lapco-TT course can be delivered effectively over one day to impact the educational experience of learners at a SAGES-HOC. This could help set a new gold standard for the quality of SAGES mentors and thereby increase the value of such SAGES-HOC.



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Increasing Resident Utilization and Recognition of the Critical View of Safety in Laparoscopic Cholecystectomy: A Pilot Study from an Academic Medical Center

Changing Attitudes and Improving Skills: Demonstrating the Value of The Sages Flexible Endoscopy Course for Fellows

Crystal Chen, Francesco Palazzo, Stephen Doane, Jordan Winter, Harish Lavu, Karen Chojnacki, Ernest Rosato, Charles Yeo, Michael Pucci, Thomas Jefferson University Background: Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure; however, it is associated with an increased rate of bile duct injury (BDI). The Critical View of Safety (CVS) provides a secure method of ductal identification to help avoid BDI. CVS is not universally utilized by practicing surgeons and/or taught to surgical residents. We aim to pilot a safe cholecystectomy curriculum to demonstrate that educational interventions could improve resident adherence to and recognition of the CVS during LC. Methods: Forty-three general surgery residents at Thomas Jefferson University Hospital were prospectively studied. Fifty-one consecutive LC cases were recorded during the pre-intervention period, while the residents were blinded to the outcome measured (CVS score). A comprehensive lecture on safe cholecystectomy was given to all residents. Fifty consecutive LC cases were recorded post-intervention, while the residents were empowered to ‘‘time out’’ and document the CVS with a doublet photograph. Two independent surgeons scored the videos and photographs using a 6-point scale previously published by Strasberg. Residents were surveyed pre and post-intervention to determine objective knowledge and self-reported comfort using a 5-point Likert scale. Results: In the 18 week study period, 101 consecutive LCs were adequately captured and included (51 pre-intervention, 50 post-intervention). Patient demographics and clinical data were similar. The mean CVS score improved from 2.3 to 4.3 (p \ 0.001, Table 1). There was strong inter-observer agreement between reviewers. The pre and post-intervention questionnaire response rates were both 86.0 %. A greater number of residents correctly identified all criteria of the CVS post-intervention (41 % to 93 %, p \ 0.001), and offered appropriate bail-out techniques (77 % to 94 %, p \ 0.001). Residents strongly agreed that the CVS education should be included in general surgery residency curriculum (median Likert score = 5.00, IQR = 4.25–5.00). Residents also agreed they are more comfortable with their LC skills after the intervention (4.00, IQR = 3.00–5.00). Conclusion: The combination of focused education and intraoperative time-out significantly improved CVS scores and knowledge during LC in our institution. We strongly believe that increasing resident awareness and adherence to the CVS will ultimately enhance patient safety.

Table 1 . Pre-intervention



Average CVS score




Median CVS score




Cases with CVS score [ 4

8 (15.7 %)

26 (52 %)


Cases with CVS score = 0

5 (10 %)

2 (4 %)



Aimee K Gardner, PhD1, Jeffrey M Marks, MD2, Eric M Pauli, MD3, Arnab Majumder, MD2, Brian J Dunkin, MD4, 1UT Southwestern Medical Center, 2Case Western Reserve University, 3Penn State Hershey Medical Center, 4Houston Methodist Hospital Background: Since 2006, SAGES has sponsored a flexible endoscopy course to help MIS fellows become familiar with GI endoscopes, instruments, GI pathology, and endoscopic options for disease management. The purpose of this study was to examine the effectiveness of the course in improving fellows’ attitudes, confidence, and skills related to implementing endoscopy in practice. Methods: Fellows participated in a two-day course consisting of case presentations, expert panels, and hands-on lab training. Before and after the course, fellows completed a questionnaire assessing demographics, experiences in residency, practice plans, plans to implement flexible endoscopy in practice, and level of confidence performing 15 endoscopic procedures. Half of the fellows were randomly assigned to complete pre and post skills testing using a previously-validated endoscopic targeting model. Results: Fifty-four fellows (90 %; age 33.5 ± 2.8; 58 % male) completed the pre and post questionnaire. All MIS fellowship types were represented. Almost half (48.2 %) reported none or very little flexible endoscopy in their current fellowship. The average prior case volume among those completing an ACGME approved residency (42/54) was 76 upper and 75 lower endoscopies with one third reporting no experience in therapeutic EGD (33 %) or polypectomy (31 %). Intentions to implement flexible endoscopy in practice significantly improved after the course overall (3.72 ± .85 to 3.92 ± .69, p \ .05; 1 = never; 5 = very frequently). Prior to the course, 38.9 % of fellows reported plans to use endoscopy in practice ‘‘occasionally’’ or ‘‘rarely.’’ After, this decreased to 28 % with 72 % planning to implement ‘‘frequently’’ or ‘‘very frequently.’’ The most robust changes in plans to use endoscopy in practice were use in the OR to manage surgical complications (59.3 % to 80.7 %; p \ .05) or to avoid the ‘‘politics’’ of working in the GI suite (5.6 % to 19.3 %, p \ .05). Additionally, mean levels of confidence performing all 15 endoscopic tasks improved significantly after the course. Tasks that moved from a low confidence level to one high enough to be ready to adopt into practice by the majority of fellows included management of non-variceal bleeding, esophageal stenting, and RF ablation of esophageal mucosa. Skills performance for the 27 fellows improved significantly as well, with participants decreasing their time to perform the targeting task by 40 % (222.3 ± 119.8 to 133.0 ± 70.1 seconds; p \ .001) and errors by 49 % (2.90 ± 1.7 to 1.48 ± 1.48; p \ .001). Conclusions: These results indicate that the SAGES flexible endoscopy course increases fellow confidence to implement endoscopic techniques, expands the ways in which they plan to include endoscopy in practice, and enhances their endoscopic skills.

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A Serious Game Skills Competition Increases Voluntary Usage and Proficiency of a Virtual Reality Laparoscopic Simulator During First Year Surgical Residents’ Simulation Curriculum

Cost Analysis of Robotic Versus Laparoscopic General Surgery Procedures

Mostafa H El-Beheiry, BSc, MSc, MD, Greig McCreery, BEsc, MD, Christopher M Schlachta, BSc, MDCM, FRCSC, FACS, CSTAR, London Health Sciences Centre and Department of Surgery, Western University, London, CANADA Introduction: The objective of this study was to assess the effect of a serious game skills competition on voluntary usage of the laparoscopic virtual reality simulator among first year surgical residents’ standard simulation curriculum. Methods: With approval from the local research ethics board, all first year surgical residents attending the surgical foundations simulation training curriculum, between September 2013 and April 2015, at a university based, residency training program, provided informed consent to be included in this study. The class of 2013–14 served as the control cohort and followed the standard curriculum, which included mandatory use and demonstration of proficiency on a virtual reality laparoscopic trainer, peg transfer task. For the 2014–15 competition cohort, the only change introduced was the biweekly and monthly posting of a leader board consisting of the top three, fastest peg transfer times for the same mandated curriculum from the previous cohort. No additional incentive was given. Entry surveys were administered to both groups assessing attitudes towards simulation-based training and competition. Cohorts were each observed for a 5 month period, concluding with the annual deadline for achieving simulator proficiency. Results: There were 24 and 25 residents in the control and competition cohorts respectively. There were no differences in demographics. Half of residents in each cohort felt that simulation-based training was useful. The competition cohort overwhelmingly (76 %) stated that they were not motivated to deliberate practice by competition. Median total simulator usage time was 140 minutes (IQR = 432) in the competition group compared to 96 (IQR = 189) in the control cohort and the competition cohort completed their course requirements significantly earlier than the control cohort (v2 = 6.5, p = 0.01). There was a significantly greater proportion of residents continuing to use the simulator voluntarily after completing their course requirements in the competition cohort (44 % vs 4 %; p = 0.002). Residents in the competition cohort were significantly faster than the control group in skill task completion time (181 ± 71 vs 231 ± 54 sec; p = 0.02) and significantly improved their completion time by 45 ± 63 sec (paired t-test, p = 0.007) from first attempt to best attempt at the task. Conclusion: A simple serious games skills competition increased voluntary usage and performance on a virtual reality laparoscopic simulator, this despite more than half the participants reporting that they are not motivated by a competitive environment. Future directions should endeavor to examine other serious gaming modalities to further engage trainees in simulated skills development.

Rana M Higgins, MD, Matthew J Frelich, MS, Matthew E Bosler, BA, Jon C Gould, MD, Medical College of Wisconsin Introduction: Robotic surgical systems have been used at a rapidly increasing rate in general surgery for procedures that have traditionally been performed laparoscopically. The potential increased cost of a robotic compared to laparoscopic approach is concerning in this era of increased attention to health care costs. In a surgical encounter, a significant portion of total costs is associated with consumable supplies. Our hospital system has invested in a software program that can track costs of consumable surgical supplies by procedure. We sought to determine the differences in cost of consumables with laparoscopic and robotic general surgery procedures. Methods: De-identified procedural cost and equipment utilization data were collected from the Surgical Profitability Compass Procedure Cost Manager System (The Advisory Board Company, Washington DC) for our health care system for laparoscopic and robotic cholecystectomy, hiatal hernia repair and Nissen fundoplication, and inguinal hernia between the years 2013–2015. Outcomes measured were supply cost, length of stay, and case duration. Statistical analysis was performed using t-test for continuous variables and statistical significance defined as p \ 0.05. Results: The total cost of consumable surgical supplies was significantly greater for robotic versus laparoscopic cases for all procedures analyzed (Table 1). Length of stay did not differ by technique. Case duration was similar for laparoscopic and robotic cholecystectomy (75.5 and 83.9 minutes, p = 0.10), but significantly less for laparoscopic versus robotic hiatal hernia repair and Nissen fundoplication (162.1 and 196 minutes, p \ 0.01) and inguinal hernia (81.3 and 124 minutes, p \ 0.01). Conclusion: We found a significantly increased cost of general surgery procedures for our health care system when cases commonly performed laparoscopically are performed robotically. Our analysis is limited in that it included costs associated with consumable surgical supplies. The initial acquisition cost, depreciation, and service contract for the robotic and laparoscopic systems were not included in this analysis. Unless a significant patient-centered clinical outcome advantage can be identified for the robotic approach in these selected general surgery procedures, we believe that the robotic approach is not an effective use of our limited health care dollars.

Table 1 Supply cost robotic versus laparoscopic procedures Cholecystectomy

Hiatal hernia and Nissen fundoplication

Inguinal hernia


$1,712 (n = 37)

$4,124 (n = 21)

$1,954 (n = 12)


$631 (n = 343)

$1,918 (n = 114)

$1,472 (n = 272)







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Outcomes Following Robotic Ventral Hernia Repair: A Study of 21, 565 Patients in the State of New York

Laparoscopic Versus Robotic Colectomy: A National Surgical Quality Improvement Project Analysis

Maria Altieri, MD, MS, Jie Yang, PhD, Aurora Pryor, MD, Jianjin Xu, MD, Andrew Bates, MD, Monica Cramer, MD, Mark Talamini, MD, Dana Telem, MD, Stony Brook

Scott Dolejs, MD, Eugene Ceppa, MD, Benjamin Zarzaur, MD, MPH, Indiana University School Of Medicine

Introduction: With the increase of robotic surgery into areas of general surgery, there is paucity of data assessing its value and outcomes. The purpose of our study is to assess outcomes following robotic ventral hernia repair. Methods: Following appropriate board and state approvals, the New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was used to identify all patients undergoing laparoscopic and robotic ventral hernia repair between 2010–2013. Outcome measures including complications, hospital length of stay (HLOS), 30-day re-admissions, and 30-day emergency department (ED) visits were compared. Chisquared tests were used to compare unadjusted marginal differences for categorical variables between groups. Welch’s ANOVA tests and non-parametric tests, such as KruskalWallis tests or Wilcoxon rank sum tests were used to compare unadjusted marginal differences for continuous variables. Propensity score (PS) analysis was used to estimate the adjusted marginal (population average) differences between patients who underwent robotic-assisted and laparoscopic procedures. P \ 0.05 was considered significant. Results: There were 20,896 laparoscopic and 679 (3.2 %) robotic ventral hernia repairs. Initial univariate analysis demonstrated that patients undergoing robotic ventral hernia (RVH) had worse outcomes in terms of complications (5.85 % vs 2.82 %, p \ .0001), longer HLOS (4.32 vs 2.19 days, p = 0.0023), higher rates in 30-day readmissions (5.62 % vs 3.01 %, p \ 0.0001), and 30-day ED visits (4.29 % vs 3.01 %, p \ .0001) compared with those who underwent laparoscopic ventral hernia (LVH). However, patients undergoing RVH had more co-morbidities (79.97 %) compared to LVH (40.54 %) (p-value \0.0001). Following PS analysis, which accounts for all patient associated variables, there was no difference found in 30-day readmission or 30-day ED visits between RVH and LVH (p = 0.2760 and 0.2043, respectively). Patients undergoing RVH had a significantly shorter HLOS (p \ 0.0001) and lower rate of complications (risk difference between RVH and LVH was estimated to be 5.75 % with 95 % CI = (1.28–10.23 % and p = 0.0134). Conclusion: Following propensity score analysis which corrects for patient selection bias, this study demonstrates that RVH may be advantageous to ventral hernia repair in terms of perioperative complication risk and hospital length of stay. Substratification and more clinically rich data, eg hernia size and characteristics, are needed before determining whom this technique may best benefit.

Introduction: Robotic surgery continues to grow nationwide with reported benefits of faster recovery, less pain, and less physiologic derangement. Studies comparing the outcomes of robotic versus laparoscopic colectomy are limited to small retrospective reviews. The purpose of this study is to determine the differences in 30-day outcomes between robotic and laparoscopic colectomies in a nationally representative sample. Methods and Procedures: The NSQIP colectomy specific participant use file in 2012 and 2013 was used for this study. Adults age 18 and older with CPT codes corresponding to a colectomy with an anastomosis were included. Patients were excluded if the surgeries were not elective or occurred on a hospital day greater than zero. Patients were also excluded if they had a preoperative wound infection, preoperative SIRS or sepsis, preoperative mechanical ventilation, or an ASA class of 5. Patients were stratified based on location of anastomosis (low pelvic versus not). Bivariate data analysis was performed and logistic regression modeling was conducted to calculate risk-adjusted 30-day outcomes. Results: There were a total of 15,488 laparoscopic colectomies (27 % with low pelvic anastomosis and 73 % with other anastomosis) and 575 robotic colectomies (49 % with low pelvic anastomosis and 51 % with other anastomosis). The morbidity and mortality was similar between groups (Table 1). Patients undergoing robotic colectomies had a significantly higher rate of diverting ostomies, which was true in all anastomotic groups (Table 1). Robotic colectomy was associated with a significantly longer operative time (46 mins, P \ 0.0001), but a statistically significantly decreased length of stay (0.5 days, P = 0.01). Conclusions: In a nationally representative sample comparing laparoscopic and robotic colectomies, the overall morbidity and mortality between groups was similar while length of stay was shorter by 0.5 days in the robotic colectomy group. However, robotic colectomies were associated with a two-fold higher rate of diverting ostomies. Thus, any potential advantage of robotic surgery in terms of shorter length of stay is negated by the decreased quality of life for a patient with an ostomy and the need for another operation. The reason for this relationship is unclear. Surgeon factors, patient factors, and technical factors should be considered in future studies.

Table 1 Robotic versus laparoscopic colectomy

S074 Does the Robot Make a Difference? Oncologic Resection in Laparoscopic Versus Robot Assisted Transhiatal Esophagectomy Jeffrey R Watkins, MD, D Rohan Jeyarajah, MD, Methodist Dallas Medical Center Introduction: The aim of this study is to examine the perioperative oncologic outcomes of patients undergoing laparoscopic versus robot-assisted transhiatal esophagectomy. As robotic surgery continues to increase in volume, little is known about robotic oncologic outcomes compared to traditional methods. Methods and Procedures: We identified 36 consecutive patients who underwent laparoscopic and robot-assisted transhiatal esophagectomy for malignant disease over a three-year period. Patients with benign disease or who had a planned open procedure were excluded. Eighteen patients underwent robotic-assisted transhiatal esophagectomy with cervical anastomosis while 18 patients underwent laparoscopic transhiatal esophagectomy. All procedures were performed by a single foregut and thoracic surgeon. Patient charts were reviewed and all relevant data were extracted and evaluated. Statistical analysis was performed. Results: Lymph node yield for both laparoscopic and robot-assisted were similar at 13.9 and 14.28 respectively (p = 0.90). Ninety four percent of each group underwent R0 margins while only 1 patient from each modality had microscopic positive margins on pathology. The type of malignancy was similar for each group with 15 patients in the laparoscopic group undergoing treatment for adenocarcinoma versus 14 for the robot group (p = 0.99). All of the robot patients underwent neoadjuvant chemoradiation while 77 % underwent neoadjuvant therapy in the laparoscopy group (p = 0.23). Clinical and pathologic staging was similar in each group. There was one mortality after laparoscopic surgery in a cirrhotic patient and no mortalities amongst the robot patients (p = 0.99). One patient from each group experienced an anastomotic leak but neither required any further intervention. Patient demographics were similar between both groups with no significant difference in age, gender or BMI. Conclusions: Laparoscopic and robot-assisted trans-hiatal esophagectomy yield similar perioperative oncologic results including lymph node yield and disease-free margins. In the transition from laparoscopic surgery, robotic surgery should be considered non-inferior oncologically when compared to laparoscopy.


OR (95 % CI)



0.8 (0.6–1.0)



0.6 (0.1–4.1)


Ostomy formation

2.2 (1.6–3.0)


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Multi-center Analysis of Robotic Inguinal Hernia Outcomes Across New York State

Laparoscopic Versus Open Inguinal Hernia Repair in the Obese: An American College of Surgeons NSQIP Clinical Outcomes Analysis

Monica Cramer, Jie Yang, PhD, Maria Altieri, MD, Aurora Pryor, Yaqi Xue, Mark Talamini, Dana A Telem, MD, Stony Brook Medicine

Dvir Froylich, MD, Ivy Haskins, MD, Ali Aminian, MD, Zhamak Khorgami, MD, Mena Boules, MD, Stacy Brethauer, MD, Phillip Schauer, MD, Michael Rosen, MD, Cleveland Clinic

Background: Utilization of robotics for inguinal hernia repair is steadily increasing. A major criticism surrounding this technology centers on its adoption outpacing supportive data. Additionally, a uniform benchmark of proficiency is not established with volume serving as a questionable surrogate marker. This study represents one of the first to date assessing outcomes following robotic inguinal hernia as well as the impact of hospital and surgeon volume on outcomes. Methods: Following Institutional Review Board and New York State approval, 19,677 patients who underwent laparoscopic and robotic inguinal hernia (RIH) repair from 2010–2013 were identified. Patients were identified using the New York Statewide Planning and Research Cooperative System (SPARCS) longitudinal administrative database. Chisquared tests compared unadjusted marginal differences for categorical variables and Welch’s ANOVA and non-parametric tests compared unadjusted marginal differences for continuous variables. Propensity score (PS) analysis was used to estimate the adjusted marginal differences. P-values \0.05 were considered significant. Results: In total, 284 patients underwent RIH at 37 institutions (range 1–51 operations). Univariate analysis demonstrated RIH repair had significantly higher rates of perioperative complication (12.7 % vs. 0.9 %, p \ 0.0001), 30-day readmission (6.3 % vs. 1.3 %, p \ 0.0001), 30-day emergency department (ED) utilization (11.3 % and 5.3 %, p \ 0.0001) and longer length of stay (LOS) (2.3 vs. 0.2 days, p \ 0.0001) in relation to laparoscopy. The majority (90 %) of robotic complications were minor and related to digestive issues. A significant discrepancy in population characteristics and comorbidity profile was demonstrated prompting PS analysis. PS analysis demonstrated no significant difference in any clinical outcome metric between procedures: complication (p = 1), readmission (p = 0.7), ED utilization (p = 0.13), and LOS (p = 0.31). Patient outcomes were also compared among cumulative RIH hospital volume classifications: (B10, 11–20 and C21) and surgeon volume classifications (B5, 6–10 and C11). No significant difference in any outcome metric was demonstrated by volume. Hospital volume: complication (9.5 % vs. 12.7 % vs. 14.9 %, p = 0.47), readmission (6.3 % vs. 5.5 % vs. 6.7 %, p = 0.58), and ED utilization (11.6 % vs. 10.9 % vs. 11.2 %, p = 1.0), respectively. Surgeon volume: complication (7.6 % vs. 11.4 % vs. 17.0 %, p = 0.08), readmission (8.6 % vs. 4.6 % vs. 5.2 %, p = 0.58), and ED utilization (13.3 % vs. 11.4 % vs. 9.6 %, p = 0.67). Conclusion: In relation to laparoscopy, robotic surgery did not result in significant outcome differences in terms of complications and perioperative health resource utilization. Hospital and surgeon volume also did not impact patient outcome in this study.

Introduction: The laparoscopic approach to inguinal hernia repair (IHR) has proven beneficial in reducing postoperative pain and facilitating earlier return to normal activity for all patients. Except for indications such as recurrent or bilateral inguinal hernias, there remains a paucity of data that specifically identities patient populations which would benefit most from the laparoscopic approach to IHR. Nevertheless, previous experience has shown that obese patients have increased morbidity following open surgical procedures. The aim of this study, therefore, is to investigate the effect of a laparoscopic versus open approach to IHR on early postoperative morbidity in the obese population using the National Surgical Quality Improvement Database (NSQIP). Methods: All inguinal hernia repairs were identified within the NSQIP database from 2005–2013. Obesity was defined as a body mass index (BMI) C30 kg/m2. Association of obesity with postoperative outcomes in both the open and laparoscopic IHR groups were investigated using the Pearson’s chi-square test, Fisher’s exact test, student t-test, and multivariate logistic regression. Results: A total of 7,326 patients with a BMI C30 kg/m2 underwent IHR from the years 2005–2013; 5,448 patients underwent laparoscopic IHR while 1,878 patients underwent open IHR. A significantly higher rate of superficial surgical site infection (p = 0.01), deep surgical site infection (p = 0.01), wound dehiscence (p \ 0.01), and return to the operating room (p = 0.03) occurred in the open IHR group. There was no statistically significant difference in occurrences of sepsis (p = 0.38), septic shock (p = 0.06), myocardial infarction (p = 1.0), cardiac arrest (p = 0.25), deep venous thrombosis (p = 0.70), pneumonia (p = 0.22) and pulmonary emboli (p = 0.33) between the laparoscopic and open groups. As a preoperative risk factor, increased BMI was associated with an increased risk of postoperative morbidity for all patients (p \ 0.01, 95 % CI: 0.01 (0.0004–0.01)). Conclusions: Increased BMI significantly increases the risk for postoperative morbidity in open IHR. We propose that the ideal approach to IHR for the obese population is laparoscopically. Further studies are needed to investigate the long-term effects of the open and laparoscopic approaches to IHR in the obese population.

S078 A Prospective Randomized Comparison of Testicular Function, Sexual Function and Quality of Life Following Laparoscopic Totally Extra Peritoneal (TEP) and Trans Abdominal Preperitoneal (TAPP) Inguinal Hernia Repair Mahesh C Misra, Prateek Manik, Virinder K Bansal, Krishna Asuri, Rajesh Sagar, Anand Kumar, Subodh Kumar, Atin Kumar, Rajeshwari Subramaniam, All India Institute of Medical Sciences Background: Testicular atrophy following groin hernia repair is a major concern for any male patient. There is very scant literature regarding the impact of inguinal hernia and its mesh repair on testicular function and sexual function following both open and laparoscopic techniques. The present study was designed to compare TAPP and TEP repair in terms of testicular and sexual function, quality of life and chronic groin pain. Methods: The study was conducted from November 2012 to June 2014. 160 patients with uncomplicated groin hernia were randomized to Trans-Abdominal Pre-Peritoneal (TAPP) or Totally Extra-Peritoneal (TEP) techniques. Testicular functions were assessed by measuring testicular volume, testicular hormone levels pre operatively and at 3 months post operatively. Sexual function were assessed using BMSFI and quality of life using WHOQOL BREF scale pre operatively and at 3 months post operatively. Chronic groin pain was evaluated using the VAS scale at 3 months, 6 months and at 1 year Results: The median duration of follow up was 13 months (range 6 months to 18 months) There was no statistically significant difference in terms of chronic groin between the TAPP and TEP repair groups at 3 months (p value 0.06) and 6 months (p value 0.86) follow up. The testicular resistive index and testicular volume did not show any significant change from the pre-operative value to the follow up at 3 months (p value 0.9) in the study population. On further analysis no significant difference was also seen in testicular resistive index and testicular volume at follow up of 3 months as compared to pre-operative value in both TAPP and TEP groups (p value [0.05). There was a statistically significant improvement in the sexual drive score, erectile function and overall satisfaction over a follow up following laparoscopic inguinal hernia repair. However there was no difference between TEP and TAPP group All the domains of Quality of Life in the study population showed a significant improvement at a follow up of 3 months and 6 months. Subgroup analysis of all the domains of Quality of Life in both TAPP and TEP group, showed a similar increment as in the study population (p value \0.001),

Conclusions: Laparoscopic groin hernia repair improves the testicular function, sexual function and quality of life and both TEP and TAPP techniques are comparable with respect to these long term outcomes.



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Laparoscopic Inguinal Hernia Repair Without General Anesthesia

Treatment of Routine Adolescent Inguinal Hernia Vastly Differs Between Pediatric Surgeons and General Surgeons

Mersadies Martin, MS, MD1, Amy Banks-Venegoni, MD2, Erica Kane, MD1, Alexander Knee, MS1, John Romanelli, MD1, David Earle, MD1, 1Baystate Medical Center, Tufts University, 2Spectrum Health Medical Group, Department of Surgery

Nicholas E Bruns, MD1, Ian C Glenn, MD1, Neil L McNinch, MS, RN1, Michael J Rosen, MD2, Todd A Ponsky, MD1, 1Akron Children’s Hospital, 2Cleveland Clinic

Introduction: Literature supporting laparoscopic herniorrhaphy without general anesthesia is almost nonexistent. We believe that in addition to operation type, anesthesia type can also be patient specific. We therefore offered patients the option of choosing local anesthesia with sedation for totally extraperitoneal (TEP) laparoscopic inguinal hernia repair. The purpose of this study was to analyze our experience and describe the lessons learned. Methods: We performed a retrospective, IRB approved study analyzing the experience and outcomes associated with the use of local anesthesia and sedation for laparoscopic TEP repair from 2000–2015. The preperitoneal space was opened with a round balloon dissector placed through an infraumbilical incision with two 5-mm midline ports. A standard CO2 insufflator was used with a set pressure of 10 mmHg. Local anesthetic was used at the incision sites and in the preperitoneal space. Intravenous sedation was controlled by the anesthesia team. All repairs utilized a 10 9 15 cm mesh selectively anchored with permanent spiral tacks. No bladder catheter was utilized. Results: 38 TEP repairs were performed in 33 (86.8 %) males, and 5 (13.2 %) females, age 36–84 (mean 59.79) years. Mean BMI was 26.4 (range: 20.8–35.2). All patients had small hernias on exam (H1–H2; Kingsnorth classification). Permanent spiral tacks were used in 21 (55.3 %) patients, and 23 (60.5 %) repairs were bilateral. Co-morbidities such as cirrhosis, diabetes, hypertension, asthma, obstructive sleep apnea, angina, coronary artery disease, and or COPD were present in 89.5 % of the patients. Median operating time was 73 minutes (range: 40–202) and performed on an elective, outpatient basis. One case was converted to an open approach due to central obesity and intolerance of local anesthesia likely secondary to COPD. No patients required admittance or excessive use of pain medications within the perioperative period. There were no deaths, and one minor complication (hematoma) that required no intervention. Follow up was conducted on 74 % (28/38) of the patients for a mean of 30.5 months (range: 0.3–106.9). There was one recurrence (10 9 15 cm PTFE mesh without fixation), and revision was performed with a TAPP technique using a larger PTFE mesh with fixation. Conclusions: TEP repair with local anesthesia and varying amounts of sedation decreases general anesthesia concerns in those patients with significant co-morbidities that would otherwise need an open inguinal hernia repair. Appropriate patient selection based on motivation to avoid general anesthesia, low BMI body habitus, and small hernia size seems to be the primary reasons for success in this group.


Introduction: We hypothesize that for the same adolescent with an inguinal hernia, the treatment will differ between general surgeons and pediatric surgeons. We aimed to compare the preferences of adult and pediatric general surgeons in managing adolescents by conducting a survey through social media. Methods: A poll was posted on the International Hernia Collaboration Group Facebook page as well as the Facebook page for the authoring pediatric surgeon. The poll gave scenarios of a 16-year-old male with an inguinal hernia and asked surgeons to select one of five listed procedures to repair the hernia: high ligation (open or laparoscopic), mesh repair (open or laparoscopic) or open muscle repair. The four scenarios differed in the diameter of the internal ring (1 cm vs. 4 cm) and the BMI of the patient (20 vs. 35). Fisher’s Exact Test was implemented for statistical analysis. Results: In total, 43 (67 %) adult surgeons and 21 (33 %) pediatric surgeons responded. In the routine adolescent (normal BMI, small defect), 65 % of adult surgeons chose adult-type repairs (mesh or muscle repairs) whereas 86 % of pediatric surgeons chose pediatric-type repairs (high ligation). When the size of the defect increased, 100 % of adult surgeons and 81 % pediatric surgeons selected an adult-type repair, suggesting agreement. When the patient was obese, there was a tendency to prefer laparoscopy. In all patient scenarios, the answers were significantly different between pediatric and adult surgeons (p \ 0.05). Conclusions: For the same routine adolescent inguinal hernia, pediatric surgeons and adult general surgeons choose a different procedure. This finding suggests that further study is needed to determine the optimal treatment for inguinal hernias in adolescents, as the type of practitioner to whom the patient is referred, rather than the disease process itself, currently dictates treatment.

Choice of repair for a routine adolescent inguinal hernia (small defect, normal BMI) Repair type

Adult general surgeon Pediatric (%) (%)

Open high ligation



Laparoscopic high ligation



Open mesh repair



Laparoscopic mesh repair Open muscle repair






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Long Term Patterns and Predictors of Pain Following Laparoscopic Inguinal Hernia Repair: A Patient Centered Analysis

Aberrant Vital Signs are Rare Following Laparoscopic Colectomy and are Indicative of an Anastomotic Leak

Lav Y Patel, Matthew Gitelis, Brittany Lapin, John Linn, Michael Ujiki, Woody Denham, Northshore University Health System Introduction: Laparoscopic inguinal hernia repair (LIHR) has been shown to offer patients the benefit of less pain post-operatively as compared to traditional open techniques. However small, the risk of prolonged post-operative pain may affect patients decision making. The aim of this study is to use patient centered assessment tools to elucidate potential patterns of pain and the predictors of such, up to 2 years post-operatively, in order to guide patient expectations. Methods: We prospectively evaluated 467 patients who underwent totally extra-peritoneal LIHR from March 2009 – June 2015 in an IRB-approved study. Short form-36 (SF36), Surgical Outcomes Measurement System (SOMS) and Carolinas Comfort Scale tools were administered pre- and post-operatively at 3 weeks, 6 months, 1 year and 2 years. Significant pain was determined if a patient indicated mild but bothersome pain or worse. Changes over time were analyzed using ANOVA, tool assessment comparisons were made using Pearson correlation coefficient, and predictors of significant pain were determined by univariate logistic regression models at p \ 0.05. Results: 436 patients underwent a LIHR and completed an assessment tool. Mean age was 60 (± 15) years, with 92 % male. Pain improved significantly over time for all tools (p \ 0.01) although pain was slightly elevated at year 2 on CCS and SOMS. 135 (51 %) patients reported significant pain at 3 weeks, 18 (21 %) at 6 months, 28 (21 %) at 1 year, and 37 (32 %) at 2 years. Reported pain was highly correlated across assessment tools at 3 weeks (p \ 0.01 for all comparisons), but at 6 months, only SOMS and CCS were significantly correlated. Tools did not correlate at 1 year and 2 years. After evaluating several patient and procedure characteristics, only general quality of life measurements were predictive of pain at 6 months, 1 year and 2 year. Conclusions: Our study found reported pain by 51 % of patients at 3 weeks with significant improvement by 6 months. Low quality of life and general health were the only predictors of pain after 6 months. Significant pain is reported at 3 weeks following surgery, but pain after 6 months is unrelated to surgery and due to the patients general health.

Ryan Hendrix, MD1, Larson Erb, MD2, Lucy Greenberg, BS2, Turner Osler, MD2, Neil Hyman, MD3, Edward Borrazzo, MD2, 1University of Massachusetts Medical Center, 2University of Vermont Medical Center, 3University of Chicago Medical Center Introduction: Anastomotic leak is a serious but uncommon complication of gastrointestinal surgery. Early diagnosis remains difficult as patients often fail to present with overt symptomatology. We have previously shown that abnormal vital signs as defined by the American College of Chest Physicians (ACCP) criteria are ubiquitous after bowel resection with anastomosis and therefore of limited value in detecting post-operative leak.* Given the less invasive nature of laparoscopy and its diminished impact on the body’s physiologic response, we sought to challenge these findings specifically in laparoscopy. We hypothesized that vital signs would be less abnormal after laparoscopic operations than after open procedures, and as a result, vital signs would be more predictive of anastomotic leak following laparoscopic colectomy. Methods and Procedures: A retrospective case series evaluating consecutive patients undergoing bowel resection with anastomosis at a tertiary-care academic medical center from July 2009 to June 2014 was performed. Bowel resection cases were identified using CPT codes, and a total of 170,642 vital sign values (HR, RR, Tmax, SBPmin) and 4,868 values WBC count values were retrospectively abstracted from the electronic medical record, representing the complete post-operative course of the entire patient cohort. Using commercially available statistical software, vital signs of patients who developed an anastomotic leak as defined by findings at reoperation or on radiographic imaging were compared to those with uncomplicated clinical courses. Results: A total of 1,059 patients underwent bowel resection during the study period (777 open and 282 laparoscopic). In the laparoscopic group, there were 20 anastomotic leaks (7.1 %). Average vital signs and WBC count were significantly different between uncomplicated cases and those developing an anastomotic leak most notably on postoperative day 3: Tmax (p \ .001), pulse (p \ .0001), SBPmin (p \ .006), respirations (p \ .001), and WBC count (p \ .057). Conclusions: Abnormal vital signs on post-operative day 3 are indicative of an anastomotic leak after laparoscopic colectomy with anastomosis. * J Am Coll Surg. 2014 Jun; 218(6):1195-9.



Long-Term Outcomes by Transanal Total Mesorectal Excision (TATME) for Rectal Cancer

Visceral to Subcutaneous Fat Ratio Predicts Acuity of Diverticulitis

Elizabeth A Myers, DO, Mounica Gummadi, BA, Gerald J Marks, MD, John H Marks, MD, Lankenau Institute for Medical Research

Salvatore Docimo Jr., DO1, Young Lee2, Praveen Chatani2, Ann M Rogers1, Frank J Lacqua3, 1Penn State Hershey Medical Center, 2St. George’s University, 3NYU Lutheran Medical Center

Introduction: The challenge of performing good TME dissection, particularly in the distal 1/3 of the rectum, has spurred interest in new techniques. Robotic surgery has been advocated by some to overcome the technical difficulties of surgery in the distal rectum. More recently a ‘‘new’’ approach, the transanal total mesorectal excision (taTME), has been popularized to address this problem. While great interest in this technique exists, little data of long term outcomes are available. We have been utilizing a taTME approach to facilitate the distal dissection and allow a known distal margin for difficult cases and in the present study, we provide our long-term outcomes using the taTME approach in the management of rectal cancer. Methods and Procedures: From a prospectively maintained rectal cancer database, we identified 379 consecutive rectal cancers treated with sphincter preservation surgery (SPS) through a combined taTME and abdominal approach. Perioperative, pathological, and oncologic outcomes including local recurrence (LR), distant metastasis (DM), and survival were analyzed. Results: 379 patients with rectal cancer underwent taTME with mean follow up of 5.5 years. 91 % of the cancers were in the distal rectum. 70.2 % of patients were men and 52 % of cancers were tethered or fixed on presentation. 97 % received neoadjuvant radiotherapy (mean 5419 cGy, range 3000–8580 cGy; 5-FU based); average time from completion of neoadjuvant therapy to surgery was 10.5 weeks. 182 and 197 patients underwent completion of their operation through open and laparoscopic (Lap) abdominal approaches, respectively. Median blood loss was 400 cc (mean: Open 907 cc, Lap 382 cc). 96 % of TME specimens were complete or near complete, 94 % had a negative circumferential resection margin (CRM), and 98.6 % had a negative distal margin. Overall perioperative morbidity and mortality rates were 18 % and 0.3 %, respectively. Overall LR, DM, and KM5YAS were 7.6 % (Open, 10.8 %; Lap, 4.8 %), 20 % (Open, 18.1 %; Lap 21.2 %), and 89 % (Open, 90 %; Lap, 92 %), respectively. Conclusion: This is the first report of long term data using taTME and shows low risk for local recurrence with an excellent overall survival. Our data with 5 year follow-up supports this approach for rectal cancer, showing that adequate distal and circumferential margins with very good quality TME specimens can be obtained using this technique. While randomized trials will be required to confirm these findings, our long term results support the promising reports of early experiences in the literature.

Introduction: Obesity is increasingly recognized as a risk factor for complicated diverticular disease. As adipose tissue secretes inflammatory cytokines such as tumor necrosis factor-a and interleukin-6, one likely mechanism linking obesity and more severe diverticular disease is chronic inflammation. Evidence suggests an association between visceral fat and complicated diverticular disease. We have applied a quantitative measure of visceral fat content in patients who underwent emergent and elective surgical procedures for diverticulitis. Methods: A retrospective review of all adult diverticulitis patients with an associated CT scan who underwent emergent or elective surgery from 2010 to 2014 was performed with institutional review board approval. Data was collected on demographics, co-morbidities, vital signs, operative findings, complications and length of stay (LOS). Radiologic measurements of adiposity were obtained from preoperative CT scans using Osirix DICOM viewer software. Visceral fat areas (VFA) and subcutaneous fat areas (SFA) were measured from a single axial slice at the level of L4–L5 intervertebral space. The CT attenuation level to delineate the regions of adipose tissue was set using Hounsfield units -190 to – 30. The VFA to SFA ratio (V/S) was calculated. Statistical analysis was performed using Student’s T-test and Fisher’s exact test. Results: Thirty-four patients underwent emergent and 32 patients underwent elective surgery for diverticular disease. The mean age was 66 for the emergent and 57.84 for the elective group. Most patients were Caucasian: (21/34) in the emergent and (16/32) in the elective group. The perinephric, visceral, subcutaneous fat, and V/S ratio for the emergent group was 1.71, 185.22, 338.22, and 0.56 and 1.11, 127.18, 295.28, and 0.46 for the elective group. The difference between the V/S ratio for each group was statistically significant (p = 0.0238). The emergent group had an average LOS of 16.11 days compared to 5.11 for the elective group (p = \0.00001). The complication rate was significantly higher (p = 0.024) in the emergent group (n = 10, 29.4 %) compared to the elective group (n = 2, 6.25 %). Conclusion: Our study demonstrates a clinically significant link between the level of visceral fat and the severity of diverticulitis. Patients with higher V/S fat ratios were more likely to undergo emergency surgery for diverticulitis, have more complications and a longer LOS. Larger studies evaluating the effect of weight loss surgery on the incidence of diverticulitis and the possibility of recommending weight loss surgery in the setting of diverticulosis should be explored.



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Indocyanine Green Enhanced Fluorescence to Assess Bowel Perfusion During Laparoscopic Colorectal Resection

Comparison of Short-Term and Oncologic Outcome of Robotic and Laparoscopic Rectal Resection for Rectal Cancer

Luigi Boni, MD, FACS1, Elisa Cassinotti, MD, PhD1, Giulia David, MD1, Abe Fingerhut, MD, FACS, Hon, ASA, Hon, FRCS, Hon, Ed2, 1 Minimally Invasive Surgery Center, 2Section for Surgical Research, Department of Surgery Medical University of Graz

Wai Lun Law, Dominic C Foo, The University of Hong Kong

Aims: Anastomotic leakage after colorectal surgery is a severe complication. One possible cause of anastomotic leakage is insufficient vascular supply. The aim of this study is to evaluate the feasibility and the usefulness of intraoperative assessment of vascular anastomotic perfusion in colorectal surgery using indocyanine green (ICG) enhanced fluorescence. Methods: Between May 2013 and October 2014 all anastomosis and resection margins in colorectal surgery were investigated using fluorescence angiography (KARL STORZ GmbH & Co. KG, Tuttlingen, Germany) intraoperatively to assess colonic perfusion prior to and after completion of the anastomosis, both in right and left colectomies. Results: 107 patients undergoing colorectal laparoscopic resections were enrolled: 40 right colectomies, 10 splenic flexure segmental resections, 35 left colectomies, and 22 anterior resections. In 90 % of cases the indication for surgery was cancer and high ligation of vessels was performed. Based on the fluorescence intensity, the surgical team judged the distal part of the proximal bowel to be anastomosed insufficiently perfused in 4/107 patients (2 anterior, 1 sigmoid and 1 segmental splenic flexure resections for cancer), and consequently, further proximal ‘‘re-resection’’ up to a ‘‘fluorescent’’ portion was performed. None of these patients had a clinical leak. The overall morbidity rate was 30 %; one patient undergoing right colectomy had an anastomotic leakage, apparently unrelated to ischemia; there were no clinical evident anastomotic leakages in colorectal resections including all low anterior resections. Conclusions: ICG enhanced fluorescent angiography provides useful intraoperative information about the vascular perfusion during colorectal surgery and may lead to change the site of resection and/or anastomosis, possibly affecting the anastomotic leak rate. Larger further randomized prospective trials are needed to validate this new technique.

Introduction: Laparoscopic resection for rectal cancer has been proven to be feasible and oncologically safe. However, it is a complex procedure and there are limitations with the current equipment and instruments. The surgical robotic system can overcome some of these limitations and facilitate the procedure. This study aimed to compare the short-term as well as oncologic outcomes of robotic rectal resection with laparoscopic resection. Methods: Patients who suffered from mid to distal rectal cancer (within 12 cm from the anal verge) and underwent laparoscopic or robotic low anterior resection from January 2008 to June 2015 were included. Data were collected prospectively and comparison was made between the laparoscopic and the robotic groups. Results: During the study period, 171 and 220 consecutive patients underwent laparoscopic and robotic rectal resection for cancer, respectively. The mean age was 65.9 years in both groups (p = 0.98). The median tumor distance was 8 cm and 7 cm from the anal verge for laparoscopic and robotic groups, respectively (p = 0.06). More patients in the robotic group had comorbidity (p = 0.03) and preoperative chemoradiation (0.019). Abdominoperineal resection was performed in 9.9 % and 5 % in the laparoscopic and robotic groups, respectively. The median operating time for robotic resection was significantly longer, 260 min vs. 225 min (p \ 0.001). Conversion rates of laparoscopic and robotic were 3.5 % and 0.8 %, respectively (p = 0.308). The median hospital stay was 6 days. (p = 0.29). There was no difference in the stage of disease, distal margin or positive circumferential margin rates. Complications rates of laparoscopic and robotic surgery were 22.2 % and 19.1 %, respectively (p = 0.528). There was a significantly higher incidence of postoperative urinary retentions in L-TME 10.5 % vs. 4.1 % (p = 0.024). The 5-year cancer specific survivals were similar in the two groups (79.1 % vs. 81.9 %, p = 0.829) (Fig. 1) and there was no difference in the local recurrence rate. Conclusions: In the treatment of mid to low rectal cancer, robotic-assisted approach is associated with a low conversion and a high sphincter preservation rate. It also offered better bladder function after the operation. The oncologic outcomes were similar to laparoscopic resection.

Fig. 1 .


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Preparing for the Worst- Predicting Who Will Fail in a Multimodal Enhanced Recovery Pathway

The Relationship Between Number of Intersections of Staple Lines and Anastomotic Leakage After Double Stapling Technique in Laparoscopic Colorectal Surgery

Deborah S Keller1, Irlna Tantchou, MD2, Sergio Ibarra1, Juan R Flores-Gonzalez, MD1, Matt Schultzel, DO2, Eric M Haas, MD, FACS, FASCRS3, 1Colorectal Surgical Associates, 2Colorectal Surgical Associates; University of Texas Medical Center at Houston, 3 Colorectal Surgical Associates; Houston Methodist Hospital; University of Texas Medical Center at Houston Background: Enhanced Recovery Pathways (ERP) have proven to improve outcomes in colorectal surgery. The specific elements in ERPs continue to develop, with multimodal pain management further enhancing recovery. Despite these advances, some patients continue to have unexpected prolonged lengths of stay. Prolonged length of stay (LOS) is associated with higher costs of care and postoperative morbidity. Our goal was to identify the patient and procedural variables associated with failure of an established ERP. Methods: A prospective departmental database was reviewed to evaluate consecutive patients that underwent minimally invasive colorectal surgery with a multimodal ERP. Patients were stratified into ERP success and ERP failure based on LOS C5 days (mean + 1 SD). Preoperative demographic, perioperative procedural, and postoperative outcome variables were analyzed. Univariate analysis was performed to identify differences in demographic and procedural variables between the ERP success and ERP failure groups. A logistic regression model was used to identify variables predictive of ERP failure. Results: Between 8/1/13 and 7/31/15, 274 patients met inclusion criteria and were analyzed- 229 ERP successes and 45 failures. The mean age, gender, and BMI were similar across cohorts. The failures had significantly higher rates of preoperative anxiety (p = 0.0352), anxiolytic medication (p = 0.0103), chronic pain (p = 0.0040), prior abdominal surgery (p = 0.0313), and chemoradiation (p = 0.0301). The main indication for surgery was colon cancer (26.7 failure, 32.8 % success) and procedure performed a segmental resection (31.1 % failure, 43.2 % success) in both groups. The failures had significantly higher conversion rates (p = 0.0002), blood loss (p = 0.0417), transfusions (p = 0.0032), and longer operative times (p = 0.0099). Rates of stoma creation were similar. Postoperatively, failures had higher complication rates (p = 0.0012), longer time to return of flatus (p = 0.0101) and bowel movements (p = 0.0005), longer lengths of stay (p = 0.0001), and higher reoperation rates (p = 0.0182). Total costs for failures were significantly higher than ERP successes (p = 0.0182). In the regression model, the variables independently associated with ERP failure were anxiety (OR 2.28, 95 % CI 1.04, 4.98, p = 0.0389), chronic pain (OR 10.03, 95 % CI 2.04, 49.29, p = 0.0045), and intraoperative conversion (OR 8.02, 95 % CI 1.92, 33.52, p = 0.0043). Conclusions: There are identifiable preoperative and intraoperative factors associated with longer LOS despite following a standardized ERP. By prospectively preparing for these high-risk patients, postoperative clinical and financial results could be improved.

Seunghun Lee, MD, Seunghyun Lee, MD, Byeonggwon Ahn, MD, Kosin University Gospel Hospital Introduction: Laparoscopic intracorporeal colorectal anastomosis with double stapling technique (with linear and circular stapling devices) is difficult because of unsuitable cutting angle in narrow pelvic cavity. For reasons of tilted and long linear staple line of rectal stump, circular anastomotic plane can make multiple intersections of staple lines. The present study was designed to assess whether multiple intersections after double stapling technique is the risk factor of anastomotic complication in laparoscopic colorectal surgery. Methods and Procedures: 128 consecutive left colon and rectal cancer patients who underwent laparoscopic rectal resection with double stapling technique were enrolled in this study. In all cases, operator tried to reduce intersections by inversion technique (After introducing circular endostapler through the anus and opening integrated trocar of endostapler on the linear staple line, either one or both edge of linear staple line were folded and stuck into the integrated trocar to hide staple line inside the rim of the anvil). They were subdivided into three groups: 58 patients with no intersection of staple lines (Group A), 62 patients with 1 point of intersection (Group B) and 8 patients with 2 points of intersection (Group C). Intraoperative air leakage, incomplete cut ring, postoperative bleeding, anastomotic stenosis and leakage were compared between the three groups. Results: Clinical or radiologic apparent anastomotic leakage was identified in 1 (group C) of 128 patients (0.7 %). Overall anastomotic leakage rate was 0 % (0/58) in group A, 0 % (0/62) in group B and 12.5 % (1/8) in group C (p = 0.001). In univariate analysis, intersections of staple lines were associated with anastomotic complications. There were no statistically significant differences between three groups in multivariate analysis. Conclusion: The number of intersections of staple lines is associated with anastomotic leakage and inversion technique is useful method of avoiding anastomotic leakage. Using an appropriate technique by skilled operator, double stapling technique for laparoscopic anterior resection is safe and feasible.

S099 Long-Term Results of Laparoscopic Intersphincteric Resection with Quadrant Resection of Upper External Sphincter in Cases of the Very Low Rectal Cancer Seung Hyun Baek, MD, NahmGUN Oh, PhD, Pusan National University Hospital Purpose: Laparoscopic interspincteric resection is an increasing optional surgical tool in the treatment of very low rectal cancer below 4 cm from anal verge. This study is designed to evaluate the long-term oncological and functional outcomes of laparoscopic intersphincteric resection for T2 and T3 rectal cancer situated below 4 cm from the anal verge. Methods: From 2000 to 2010, A total of 62 consecutive patients with low rectal cancer underwent curative laparoscopic intersphincteric resection. After preoperative radio-chemotherapy, patients with overt T2 lesion were 24 cases and received traditional laparoscopic intersphincteric resection (Group I: standard laparoscopic intersphincteric resection), and patients with borderline cases or T3 lesion were 38 cases and received extended laparoscopic intersphincteric resection with quadrant resection of upper external sphincter and primary repair of the external sphincter (Group II: extended laparoscopic intersphincteric resection). Results: The grade I, II of continence by Kirwan’s classification was 91.7 %, 86.8 % in Group I and II and the mean Wexner score were 3.2 ± , 3.8 ± in Group I and II. The five-year overall survival rate was 94 percent, and the five-year disease-free survival rate was 86 percent. There were no postoperative mortality. Conclusions: This extended laparoscopic intersphinteric resection with quadrant resection of upper external sphincter is able to obtain good post-operative continence status, OS and DFS. This extended laparoscopic intersphincteric resection can be alternative to laparoscopic abdominoperineal resection for very low rectal cancer without compromising chance of cure and can improve quality of life.



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Laparoscopic Versus Open Surgery for Colorectal Cancer in Elderly Patients: Does History of Abdominal Surgery Influence the Surgical Outcome?

Single Institution Experience with Laparoscopic-Assisted Transgastric ERCP

Seiichiro Yamamoto, MD, PhD1, Takao Hinoi, MD, PhD2, Hiroaki Niitsu, MD1, Minoru Hattori2, Ichio Suzuka, MD3, Yosuke Fukunaga4, Takashi Yamaguchi, MD5, Masazumi Okajima, MD, PhD6, Hideki Ohdan1, Masahiko Watanabe, MD, PhD7, 1Hiratsuka City Hospital, 2Hiroshima University, 3Kagawa Prefectural Center Hospital, 4Cancer Institute Hospital, 5Kyoto Medical Hospital, 6 Hiroshima City Hiroshima Citizens Hospital, 7Kitasato University School of Medicine Introduction: Several reports suggested that the laparoscopic surgery (LS) is not inferior to the open surgery (OS), and that LS can be an acceptable alternative to OS in elderly patients with colon and rectal cancer. However, safety and feasibility of LS in elderly patients with past history of abdominal surgery has not yet been established. To examine the technical and oncological feasibility of LS in elderly patients with past history of abdominal surgery, we conducted a propensity scoring matched case–control study. Patients and Methods: The present study included data that were collected in the multicenter, case-controlled study entitled ‘‘Retrospective study of laparoscopic colorectal surgery for elderly patients’’, which aimed to assess the safety and efficacy of laparoscopic colorectal cancer surgery in patients C80 years old. Forty-one member hospitals of the Japan Society of Laparoscopic Colorectal Surgery participated in the study, and 2065 elderly patients who underwent LS or OS between January 2003 and December 2007 were enrolled. Of these, we included 587 patients who had history of abdominal surgery, and received curative and elective surgery for stage 0 to III CRC. Of all included patients, 408 patients received OS, and 179 received LS. After matching, 153 patients were included in each cohort. Surgical outcomes were compared between LS and OS. Because the current study is retrospective nature, propensity scores were used to match members of the LS and OS groups. The P-value \0.05 was determined statistically significant. Results: LS resulted in significantly longer surgical duration (220 minutes vs 170 minutes, p \ 0.001), but significantly less blood loss (39 vs 100 ml, p \ 0.001), while there were no significant differences in number of surgical procedure harvested lymph node, and resection margin between the two groups. Postoperative recovery including length of stay (12 vs 14 days, p = 0.002), and days to fluid (2 vs 3 days, p \ 0.001) and solid diet (4 vs 5 days, p \ 0.001), were significantly faster in the LAP group. Moreover, overall morbidity (43 vs 66 percent, p = 0.009) and postoperative ileus (7 vs 19 percent, p = 0.023) were significantly less observed in the LAP group while other morbidities were not significant. In the survival analyses, overall survival and disease-free survival were not different between the two groups. Conclusion: In elderly colon and rectal cancer patients with past history of abdominal surgery, LS can be performed safely, and LS group tended to show lower postoperative morbidity than OS group.


Katherine I Habenicht, MD, Michael McCormick, Myron S Powell, MD, Adolfo Z Fernandez, MD, Carl J Westcott, MD, Stephen S McNatt, MD, Wake Forest Baptist Medical Center Background: Laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP) is used to diagnose and treat patients with altered anatomy in which transoral endoscopy for biliary disease is not technically feasible. This procedure is now an accepted pathway for patients status post Roux-en-y gastric bypass who present with diagnosis of choledocholithiasis and associated pathologies (concomitant cholelithiasis, cholecystitis, cholangitis, gallstone pancreatitis). We describe our experience at our institution to add to the body of literature about this rarely performed operation. Methods: An electronic medical record chart search of our tertiary referral hospital was performed dating from September 2012 to September 2015, identifying patients who underwent LAERCP per operative records. These charts were retrospectively reviewed for demographic and clinical data, as well as outcomes. Results: Eleven patients (10 female) were identified. Average age was 57 years (range 41–67). Mean BMI at time of intervention was 35.2 (±7.39). Mean time since bypass was 7.5 years. Mean preoperative total bilirubin was 1.49 mg/dL, white blood cell count was 8.4 9 103, alkaline phosphatase was 263 U/L. Mean length of stay at our institution was 3.2 days. Three patients underwent simultaneous cholecystectomy with intraoperative cholangiogram. Three patients underwent cholecystectomy with abnormal cholangiogram within 48 hours at referring institution prior to our intervention. Remaining patients had cholecystectomy on average 9 years previously. Mean follow-up was 7.4 months. One gastrostomy tube was left in place and used for an additional transgastric ERCP for retained common bile duct stones and removal of biliary stent 6 weeks postoperatively, and was successfully removed. A second patient was converted to open procedure, suffered post-ERCP pancreatitis and acute renal failure, required critical care admission, hemodialysis, and percutaneous drainage of retroperitoneal abscess with subsequent video-assisted retroperitoneal debridement for pancreatic necrosis evacuation. No patients suffered morbidity related to the surgical access of the stomach. We encountered no perioperative mortality. Conclusion: Biliary obstruction after roux-en Y gastric bypass occurs in a small patient population, but requires LAERCP for reliable clearance of the common bile duct. Our case series demonstrates 1/11 (9 %) patients with morbidity beyond that seen with transoral ERCP in patients without altered anatomy. We conclude that the procedure is effective in stone removal and may carry complication rates are slightly higher than typical transoral ERCP.

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S251 Table 1 Crosstabulation of Alvarado score set at C7 as the indication of the operation in pregnancy

Alvarado Score with C-Reactive Protein Accurately Predicts Acute Appendicitis During Pregnancy – Algorithmic Approach Goran Augustin, PhD, Petar Matosevic, MD, Tomislav Secan, MD, University Hospital Center Zagreb and School of Medicine University of Zagreb Introduction: Diagnosis of acute appendicitis (AA) in pregnancy is more difficult due to physiologic changes, a higher rate of nausea/vomiting and non-specific abdominal pain in pregnancy. Study goals were to evaluate the diagnostic accuracy of the Alvarado Score (AS) in pregnancy and C-reactive protein (CRP) as an additional indicator for the diagnosis. The final goal was a construction of a decisionmaking algorithm. Methods and Procedures: Operated patients between 2005 and 2014 were analyzed retrospectively. AS was calculated from the medical records. The cut-off point of 7 was taken as the indication for the operation. The control (not operated) group was collected prospectively from January 2013 to January 2014 in the same department and by same abdominal surgeons. This group consisted of consecutive pregnant patients with RLQ abdominal pain in which the possibility of AA was ruled out by AS score and CRP. Results: There were 16 operated and 16 not operated patients. Patients’ age and weeks of pregnancy were not statistically different. In total, 15 of 16 (93.8 %) operated patients had confirmed AA, remaining patient having appendicolith. Of these 15 confirmed cases only one had AS of only 6, others 7 or higher. All patients in the non-operated group had AS 5 or lower. CRP was statistically significantly higher in the operated group (Table 1). Conclusions: Alvarado score with the addition of CRP is an excellent tool for the prediction of AA during pregnancy. In patients with AS of 5–6 diagnostic modalities are mandatory. Constructed diagnostic algorithm should be tested in prospective multicentric studies to confirm its value.

S103 Intra-Abdominal Insufflation as a Diagnostic Modality for Penetrating Anterior Abdominal Wall Trauma in a Busy Urban Center: A Retrospective Case-Series Vadim Meytes, DO, Michael Amaturo, DO, Elizabeth E Price, Filippo Romanelli, Michael Timoney, MD, NYU Lutheran Medical Center The algorithm for evaluating patients with anterior abdominal stab wounds has been a topic of discussion for many years. It has constantly been evolving in order to be able to manage these patients quickly, accurately, and inexpensively. Over the years, the algorithm has involved less invasive approaches in order to reduce length of hospital stay and cost. Currently, penetrating anterior abdominal wall trauma is managed by CT scans, local wound exploration, FAST exams, or serial abdominal exams followed by either diagnostic laparoscopy or exploratory laparotomy and close observation. Here we aim to propose a new algorithm for the management of these patients utilizing Veress needle abdominal insufflation to evaluate for posterior abdominal sheath violation in order to avoid further invasive nontherapeutic management. Eight patients admitted to our Level 1 trauma center with penetrating anterior abdominal wall injuries were evaluated using either local wound exploration or CT scan followed by diagnostic laparoscopy for any intra-abdominal pathology. These cases were then retrospectively evaluated for the efficacy of Veress needle insufflation as a diagnostic modality. Positive insufflation test was viewed as the inability to reach or maintain a target intra-abdominal pressure of 15 mm Hg or if the surgeon could visibly see or hear CO2 escaping from the stab wound. Eight patients from December 2013 to June 2014 presented after sustaining penetrating anterior abdominal stab wounds. Five patients underwent local wound exploration which revealed violation of the anterior abdominal fascia. The other three patients had CT scans with suspicious findings. All eight patients went to the operating theater for diagnostic laparoscopy. Upon intra-abdominal insufflation using a Veress needle to a target pressure of 15 mm Hg, all patients with posterior abdominal sheath violations (5) had CO2 escape from their wound. All patients without a violation did not have CO2 escape. Our results showed a sensitivity/ specificity of 100 % and positive predictive value/negative predictive value of 100 %. Utilizing our technique of intra-abdominal insufflation combined with monitoring for CO2 escape, we were able to successfully rule out posterior abdominal sheath injuries. We propose this as a novel diagnostic modality in the decision making for the need of a formal exploration of penetrating anterior abdominal wall injuries. With further research, our technique can be used safely, accurately and in a timely manner for the injured trauma patient. Our technique would allow for a decreased number of nontherapeutic diagnostic laparoscopies, less risk of complications, and decreased overall cost.



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Outcome of Laparoscopic Management for Patients Diagnosed with Acute Perforated Diverticulitis

Use of NSQIP Risk Calculator to Determine Treatment of Acute Cholecystitis

Ahmad Mirza, Simon Galloway, The University Hospital of South Manchester, Manchester, UK

Mary C Nally, MD, John Kubasiak, MD, Shauna Sheppard, MD, Hongyu Zhao, Jennifer Poirier, PhD, Daniel J Deziel, MD, Samir K Gupta, MD, Rush University Medical Center

Introduction: Acute diverticulitis is associated with considerable morbidity and mortality. Management of this pathology has evolved in recent decades. Laparoscopic surgery has added new dimension to the management of this disease and has lead to avoidance of potential open surgery and faecal diversion. We aim to review patients admitted to our hospital with acute diverticulitis and the subsequent laparoscopic management. Methods: We conducted review of all patients who were admitted with acute diverticulitis between 2005 to 2014. We identified patients who had confirmed diagnoses of acutely perforated diverticulitis. We collected the general demographic details, surgical management, pre-operative, intra-operative and post-operative course. We also collected long term patient outcome data. Results: 289 patients were identified who had acute diverticular perforation. All patients had radiological imaging and were classed as Hinchey’s type I (n = 96, 33 %), II (n = 78,27 %), III (n = 69, 24 %) and IV (n = 46, 16 %). 64 (22 %) patients proceeded for laparoscopic peritoneal lavage and grouped as Hinchey’s type II (n = 16), III (n = 48). CT guided drainage was performed in type II (n = 36) and type III (n = 26) patients. 18 patients who initially had CT guided drainage underwent laparoscopic lavage (n = 11) and laparotomy (n = 7) at the same admission. The median in-hospital stay for patients undergoing laparoscopic procedure (3 days, range 3 to 11) was significantly better (p = 0.04) than CT drainage (6 days, range 5 to 16) and laparotomy (8 days, range 6 to 23). The 30 day morbidity was 19 % (laparoscopy), 32 % (CT drainage) and 46 % (laparotomy) [p = 0.01]. In the first year following the initial procedure, 8 patients were readmitted who underwent initial laparoscopic lavage as compared to 17 re-admissions for patients undergoing CT guided drainage (p = 0.03). Conclusion: Laparoscopic lavage is a promising intervention in the management of acutely perforated diverticular disease. It decreases the need for radical resection and diverting stoma. It also helps in the early recovery and decreased post-operative morbidity.

Introduction: Traditionally, acute cholecystitis has been managed operatively with cholecystectomy. Percutaneous drainage is used to temporize the acute infection in high risk patients with significant comorbidities, life threatening acute illness, surgically hostile abdomens, or disseminated disease needing palliation. Evidence exists showing benefits of both treatments, but, as demonstrated in a recent Cochrane review, there is limited data to identify parameters for patient selection. We propose that the NSQIP Risk Calculator can be used as a tool to distinguish patients who would benefit from each procedure. Methods: A retrospective chart review was conducted from 2010 to 2015. Patients were identified based on CPT code as having undergone cholecystectomy or cholecystostomy. To isolate critically ill patients, those in the cholecystectomy cohort with ASA less than 3 and those in the cholecystostomy cohort with surgically hostile abdomens or need of palliation were excluded. Statistical analyses including Welch’s t-test and Fisher’s exact test were conducted to compare the amount of predicted risk using the ACS NSQIP Surgical Risk Calculator and the actual outcomes associated with each procedure. Results: When patients receiving a cholecystectomy (n = 215) were compared to those who underwent cholecystostomy (n = 22), there were statistically significant differences in both the NSQIP predicted risk as well as in actual outcomes (p \ 0.05).



Mean calculated risk % (SD) Serious complications*

5.8 (5.4)

20.2 (9.1)

Any complications*

9.3 (8.0)

28.8 (13.7)

Cardiac complications*

0.5 (0.8)

2.9 (2.3)

Cost Effectiveness of Prophylactic Appendectomy: A Markov Model


0.8 (1.5)

16.6 (15.6)

Karina A Newhall, MD1, Ben Albright, MS2, Philip P Goodney, MD, MS3, Thadeus L Trus, MD4, 1Veterans Affairs Outcomes Group, Veterans Affairs Medical Center, White River Junction, Vermont, 2 Yale School of Medicine, 3Dartmouth Hitchcock Medical Center; The Dartmouth Institute for Health Policy and Clinical Practice; VA Outcomes Group, 4Dartmouth Hitchcock Medical Center

Serious complications*

23 (11 %)

12 (55 %)

Any complications*

26 (12 %)

12 (55 %)

Cardiac complications*

1 (\0.05 %)

3 (14 %)


0 (0 %)

2 (9 %)


Introduction: The role of prophylactic (or incidental) removal of a grossly healthy appendix during unrelated pelvic or abdominal surgery to eliminate the future risk and costs of appendicitis remains controversial. No publications to date employ a rigorous cost-effectiveness model that includes the varying risk of appendicitis over a lifetime, the possibility of antibiotic treatment, or the societal cost of the disease. The objective of this study was to determine whether prophylactic appendectomy performed at the time of an unrelated elective laparoscopic surgery could be cost saving for the health care system from a societal perspective. We hypothesized that given the higher incidence of appendicitis in young adults, this approach would be cost-effective in younger patients. Methods: We considered hypothetical patient cohorts of varying ages from 18 to 80, undergoing elective laparoscopic abdominal and pelvic procedures. A Markov decision model using cost per-life year as the main outcome measure was constructed to simulate the trade-off between cost and risk of prophylactic appendectomy and the ongoing risk of developing appendicitis, with downstream costs and risks. Rates, probabilities, and costs of disease, treatment, and outcomes by patient age and gender were extracted from the literature. Sensitivity analyses were conducted using complications and costs of prophylactic appendectomy. Results: With our base case assumptions, including added cost of prophylactic appendectomy of $660, we find that prophylactic removal of the appendix is cost saving in young patients (18–27 for males, and 18–28 for females) undergoing elective surgery. The margin of cost savings increases exponentially with age: a 20 year old female undergoing elective surgery could save $130/life year by undergoing a prophylactic appendectomy, while a 40-year old female would lose $130/life year. When the risk of the prophylactic appendectomy exceeds the risk of laparoscopic appendectomy for appendicitis or the cost exceeds $1080, it becomes more cost-saving to forego the prophylactic procedure. Conclusions: Prophylactic appendectomy can be cost saving for patients younger than age thirty undergoing elective laparoscopic abdominal and pelvic procedures.


Actual outcomes ( %)

* Using significant for FWER = .05

Conclusion: Cholecystostomy is a less invasive treatment option for high risk patients who have the potential for significant morbidity and mortality with surgical intervention for the treatment of acute cholecystitis. As patients who underwent cholecystostomy had statistically higher rates of pre procedure risk and actual complications compared to cholecystostomy patients, we propose that the NSQIP risk calculator can be used to identify patients who would benefit from cholecystostomy tube placement prior to a definitive operation.

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Timing of Cholecystectomy Following Endoscopic Sphincterotomy: A Population-Based Study

Impact of Adherence to Care Pathway Interventions on Recovery Following Bowel Resection Within an Established Enhanced Recovery Program

Brett D Mador, MD1, Avery B Nathens, MD, MPH, PhD1, Wei Xiong, MSc1, O N Panton, MB2, S M Hameed, MD, MPH2, 1 Sunnybrook Health Sciences Centre, 2University of British Columbia Introduction: Choledocholithiasis is commonly treated initially with endoscopic sphincterotomy, followed by cholecystectomy to definitively address the underlying problem of cholelithiasis. While the benefits of early cholecystectomy have been realized in other populations, the preferred timing for this subset of patients is less well established. We performed a large, population-based analysis to determine the frequency, benefits, and practice variance in regards to early cholecystectomy on a provincial level. Methods and Procedures: Patients undergoing endoscopic sphincterotomy followed by cholecystectomy in British Columbia, Canada from January 2001 to December 2011 were identified using fee-code billing data. Multiple databases were linked to obtain information on demographics, admissions, procedures, mortality, and census geographic data. Student’s t-test and chi-square test were used to compare groups (early versus delayed cholecystectomy). Logistic regression analysis was performed for length of stay (LOS) and biliary re-admission data. Outcome data was risk-adjusted for age, gender, comorbidities, socio-economic status (SES), and year of procedure. Variability of early cholecystectomy rates across census areas was determined using funnel plots of adjusted odds ratios. Results: 4287 patients met inclusion criteria. 1905 (44.4 %) underwent early cholecystectomy, defined as surgery within 14 days of sphincterotomy. Mean interval to cholecystectomy was 2 days for the early cholecystectomy group and 61 days for delayed. There was a significant difference in hospital LOS favoring early cholecystectomy for patients with documented gallstone disease (p \ 0.05). Patients initially admitted to a surgical service were more likely to undergo early cholecystectomy (0.60 vs 0.36, p \ 0.001). There was no difference between groups in terms of mortality or SES. There was wide variability in rates of early cholecystectomy among census areas (range 0.20–0.66) and health regions (range 0–0.96) which was not explained by population density or geography. Conclusion: A significant clinical benefit is associated with early cholecystectomy for gallstone disease post-sphincterotomy. Despite this, a large amount of clinical variance exists in regard to timing of cholecystectomy which seems to be primarily institution-dependent.

Nicolo Pecorelli, MD1, Olivia Hershorn1, Gabriele Baldini, MD, MSc2, Julio F Fiore Jr., MSc, PhD1, Barry L Stein, MD2, A S Liberman, MD2, Patrick Charlebois, MD2, Franco Carli, MD, MPhil2, Liane S Feldman, MD2, 1Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, 2McGill University Health Centre Introduction: Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program (ERP). However, the impact of overall adherence to the pathway and the relative contribution of each intervention is unclear. The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes, and to identify key ERP elements predicting successful recovery following bowel resection. Methods: Prospectively collected data entered in an international registry specifically designed for ERPs was reviewed. Patients undergoing elective bowel resection in a single university-affiliated center between 2012 and 2014 were treated within an ERP implemented in 2010 and comprising 23 care elements. Primary outcome was successful recovery defined by absence of complications, discharge by postoperative day 4 and no readmission. Secondary outcomes were 30-day complication rate and severity as measured by the comprehensive complication index (CCI). Regression analyses adjusted for potential confounders were conducted to evaluate the association between adherence to ERP interventions and outcomes, and to identify key ERP interventions predicting successful recovery. Results: 347 patients were included in the study (mean age 63.2 years, males 52 %, laparoscopy 80 %, pelvic surgery 35 %, malignancy 65 %). Median primary LOS was 4 days (IQR 3–7). Median overall patient adherence to the pathway was 78 % (IQR 70–87 %). Adherence to single ERP elements ranged from 25 % for balanced intraoperative IV fluids to 100 % for preoperative education, opioid-sparing multimodal analgesia, antibiotic and thromboembolic prophylaxis. 156 (45 %) patients had a successful recovery. Morbidity occurred in 175 (50 %) patients with median CCI 8.6 (IQR 0–22.6). There was a positive dose-effect relationship between adherence and successful recovery (OR 1.43 for every additional element, 95 %CI 1.27–1.60, p \ 0.001), 30-day postoperative morbidity (OR 0.76, 95 %CI 0.69–0.85, p \ 0.001), and CCI (coefficient -0.18, 95 %CI -0.25 to -0.12, p \ 0.001). A laparoscopic approach (OR 4.51, 95 %CI 2.35–8.65, p \ 0.001), early termination of IV infusion (OR 2.08, 95 %CI 1.21–3.57, p = 0.008) and early mobilization out of bed (OR 2.11, 95 %CI 1.07–4.20, p = 0.031) significantly predicted successful recovery. In addition to laparoscopy, early mobilization and early termination of IV infusions, intraoperative balanced IV fluids was significantly associated with a reduction in complication rate and reduced CCI. Conclusions: Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity. In an established ERP where overall compliance was high, laparoscopic approach, perioperative fluid policy and patient mobilization remain key elements associated with improved outcomes.



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Standard Laparoscopic Versus Robotic Retromuscular Ventral Hernia Repair

Don’t Fix It If it Isn’t Broken: A Survey of Preparedness for Practice Among Graduates of Fellowship Council Accredited Fellowships

Jeremy A Warren, MD, William S Cobb, MD, Joseph A Ewing, MS, Alfredo M Carbonell, DO, Greenville Health System, University of South Carolina School of Medicine, Greenville Laparoscopic ventral hernia repair (LVHR) is widely performed, with comparable recurrence rates to those reported with open repairs, but much lower incidence of surgical site infection (SSI). However, there is potential for delayed complications associated with intraperitoneal placement of prosthetic mesh, particularly if a subsequent abdominal operation (SAO) is required. Incidence of enterotomy or bowel resection during SAO with intraperitoneal mesh is as high as 20 %. Robotic instrumentation allows greater flexibility and dexterity to allow duplication of an open retromuscular hernia repair, which is our standard open technique, using a minimally invasive approach. Robotic retromuscular ventral hernia repair (RRVHR) combines the lower wound morbidity associated with laparoscopy, with complete abdominal wall reconstruction (AWR) and extraperitoneal mesh placement previously only possible with open repair. All LVHR and robotic RRVHR performed in our institution between June 2013 through May of 2015 and contained in the American Hernia Society Quality Collaborative (AHSQC) database were analyzed. Continuous bivariate analyses were done with Students t-test. Continuous non-parametric data were compared with Chisquared test, or Fishers Exact for small sample sizes (n \ 5). P-values \0.05 were considered statistically significant. One-hundred three LVHR and 53 RRVHR were performed. Patients were similar in race, ethnicity, comorbidities, wound classification, and American Society of Anesthesiology score, though the laparoscopic patients were older (60.2 v 52.9 yrs; p = 0.001). Mean hernia width and area were similar (6.9 v 6.5 cm, p = 0.508; 88 cm2 v 82 cm2, p = 0.685). Mesh area was larger with RRVHR (435 cm2 v 339 cm2, p = 0.014). Fascial closure was achieved in 96.2 % of robotic and 50.5 % of laparoscopic cases (p \ 0.001). Mesh was placed in an intraperitoneal position in 90.3 % of laparoscopic repairs, and in a retromuscular or preperitoneal position in 96.2 % of robotic repairs. A myofascial release was performed in 64.2 % of RRVHR. Operative time was longer robotically (245 v 122 min, p \ 0.001). Seroma was more common after RRVHR (47.2 % v 16.5 %, p \ 0.001), but SSI was similar (3.8 % v 1 %, p = 0.592). Median length of stay was significantly shorter after RRVHR (1 v 2 days, p = 0.004). Mean direct hospital cost was similar (LVHR $13,943 v RRVHR $19,532; p = 0.07). Our technique for RRVHR obviates the need for intraperitoneal mesh and affords true abdominal wall reconstruction with myofascial releases to offset tension and allow midline fascial closure. RRVHR is comparable in perioperative morbidity and cost to standard laparoscopic repair, but with significantly shorter length of stay despite a longer operative time and greater tissue dissection.


Yusuke Watanabe, MD1, Amin Madani, MD1, Katherine M McKendy, MD1, Ghada Enani, MBBS1, Elif Bilgic, BSc1, Iman Ghaderi, MD2, Gerald M Fried, MD1, Liane S Feldman, MD1, Melina C Vassiliou, MD, MEd1, 1Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation, McGill University Health Centre, 2 Department of Surgery, Section of Minimally Invasive & Robotic Surgery, University of Arizona Objective: The majority of general surgery residents are extending their training through fellowships. No studies have examined whether Fellowship Council-accredited fellowships (FCAF) adequately prepare surgeons for independent practice and help them achieve their career goals. The objectives of this mixed-methods study were to identify the factors that are important to trainees as they seek fellowships and enter the work force, and then to determine their perceived preparedness for clinical practice, while identifying gaps in fellowship training. Methods: We conducted 14 semi-structured interviews of graduated fellows and 2 focus groups of previous fellows and program directors. An online survey was then developed, based on an iterative qualitative analysis of interviews and focus groups, using Grounded Theory. The survey was then circulated by email to fellows who graduated from FCAF from 2011 to 2014. Results: Five central themes emerged from the qualitative data and were used as a framework for the survey: professional development, job marketability, autonomy, networking, and practice management. There was an overall response rate of 41 % (n = 201/498; 2013–2014 graduates: 50 %, 2012–2013 graduates: 37 %, and 2011–2012 graduates: 33 %). Of 201 respondents, 97 % were highly satisfied with their operative and non-operative experiences; 83 % acquired jobs aligned with their skills and expectations, while 13 % sought additional training after fellowship. Respondents who intended to learn a given procedure felt competent after fellowship to perform 51(85 %) of the 60 procedures listed. They would have liked more experience in advanced therapeutic endoscopy [23/56 (41 %)], complex and revisional bariatric surgery [laparoscopic BPD-DS: 8/15 (53 %), laparoscopic revisional procedures: 29/94 (31 %)], and uncommon laparoscopic procedures such as common bile duct exploration [34/90 (38 %)], esophagectomy [14/32 (44 %)], and adrenalectomy [39/106 (37 %)]. Thirty-one percent expressed the desire for more autonomy in the management of complications. Educational gaps existed mostly in areas of coding and billing (43 %), hiring administrative staff (42 %), and managing insurance issues (34 %). Conclusions: FCAF seem to adequately prepare surgeons for independent practice. Graduates acquire jobs that are aligned with their career goals and expectations, and they are highly satisfied with their individualized training experiences. Fellowships address most of the gaps identified in residency training. Future efforts should focus on the remaining identified gaps to improve the programs further.

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The Use of Patient Factors to Improve Operative Duration Prediction During Laparoscopic Cholecystectomy

Barrett’s Esophagus After Roux-en-Y Gastric Bypass: Does Regression Occur?

Cornelius A Thiels, DO, MBA, Denny Yu, PhD, Amro Abdelrahman, MBBS, Elizabeth Habermann, PhD, Susan Hallbeck, PhD, Juliane Bingener, MD, Mayo Clinic

Maria Veronica Gorodner, MD, Gaston Clemente, MD, Alejandro Grigaites, MD, Programa Unidades Bariatricas, Argentina

Introduction: Reliable prediction of operative duration is essential for maximizing resource utilization, reducing cost, and improving patient and surgical team satisfaction. Traditional scheduling systems utilize historical operative durations by procedure type to forecast future procedures. We hypothesized that the inclusion of patient-specific factors would improve the accuracy in predicting operative duration. Methods: We reviewed all cases for a common operation, elective laparoscopic cholecystectomy (LC) performed between January 2007 to June 2013 at a single institution. Non-elective procedures and those with concurrent procedures were excluded. Univariate analysis evaluated the effect of the following patient factors on operative duration: age, gender, BMI, ASA, liver function test (LFT), WBC, amylase, smoking, and comorbidities. Multivariable linear regression models were constructed using the significant factors (p \ 0.05). The patient factors model was compared to the institutional prediction model, which uses historical surgeon specific operative duration. External validation was performed using the National Surgical Quality Improvement Program (NSQIP) database. Results: 1801 LC patients met the inclusion criteria. Univariate analysis of female sex was associated with reduced operative duration (-7.52 minutes, p \ 0.001 vs male sex) while increasing BMI (+5.06 minutes BMI 25–29.9, +6.89 minutes BMI 30–34.9, +10.38 minutes BMI 35–39.9, +17.02 minutes BMI 40+, all p \ 0.05 vs normal BMI), increasing ASA (+7.39 minutes ASA III, +38.26 minutes ASA IV, all p \ 0.01 vs ASA I), and elevated LFTs (+4.85 minutes, p = 0.018 vs unknown LFTs) were predictive of increased operative duration. A model was then constructed using these predictive factors. Of the patients with available institutional predicted operative duration (n = 633), the traditional institutional model was poorly predictive of actual operative duration (R2 = 0.001) compared to the patient factors model (R2 = 0.079). The addition of surgeon as a variable in the patient factors model further improved predictive ability of the model (R2 = 0.175, Fig. 1). The model remained predictive on external validation using n = 20,034 LC patients from the NSQIP database (R2 = 0.103). Conclusion: The current operative scheduling standard is unreliable and may contribute to costly over- and under-estimation of operative duration. The use of routinely-available pre-operative patient factors can improve the prediction of operative duration during LC.

Introduction: Barrett’s esophagus (BE) is recognized as a premalignant lesion for esophageal adenocarcinoma. BE appears as a consequence of gastroesophageal reflux disease (GERD), which is clearly increased among obese population. There is no question that laparoscopic Roux-en-Y gastric bypass (LRYGB) is the best treatment option for obesity combined with GERD. However, data on evolution of BE after LRYGB are scarce. Methods and Procedures: Candidates for bariatric surgery were studied with esophagogastroduodenoscopy (EGD) and gastric biopsy preoperatively. If BE was suspected, esophageal biopsy was performed as well. If BE was confirmed, LRYGB was indicated. Patients with BE underwent surveillance EGD with multiple systematic biopsies yearly. Patients undergoing RYGB who had BE with at least 1-year follow up were included in this study. Demographics, pre and postoperative data, and follow up tests were reported. Results: Between 10/07 and 9/15, 1948 patients underwent laparoscopic bariatric surgery at our institution. There were 1522 (78 %) LRYGB, 369 (19 %) laparoscopic sleeve gastrectomies (LSG), and 57 (3 %) revisions. Sixteen patients had BE preoperatively, and they all underwent RYGB; 9 of them (56 %) were eligible for this study. There were 4 women and 5 men, mean age 47 ± 11 years, initial BMI 43 ± 7 kg/m2. Mean follow up was 31 ± 35 months; % excess weight loss (EWL) was 56 ± 35. There were 7 short segment BE (SSBE) and 2 long segment (LSBE). On pre and postop EGD, BE length was 2.2 ± 1.9 and 1.9 ± 1.3 cm respectively (p = NS). Postop EGD was compatible con BE in all cases, although esophageal biopsy showed remission in 3 (33 %) cases, (2 SSBE and 1 LSBE). One patient was indefinite for dysplasia and remained the same after the operation. Conclusion: Our preliminary data showed that LRYGB is a suitable treatment option for obese patients with BE, demonstrated by 33 % regression rate of this premalignant disease. Although BE persisted in the remaining patients, no progression to dysplasia was observed. A larger number of patients and longer follow up are needed for more definitive conclusions.

S113 Laparoscopic Ileal Interposition with a BMI-Adjusted Sleeve Gastrectomy for Control of Type-2 Diabetes Surendra Ugale, MD, Kirloskar Hospital & Asian Bariatrics

Fig. 1 Relationship between actual and predicted operative duration for three models

Background: Compliance with medical management of ‘‘Diabesity’’ is poor, leading to the gradual deterioration of pancreatic B cell function, increased requirement of medications and eventual complications. An evolving procedure, Laparoscopic ileal interposition (II) with a BMI-adjusted sleeve gastrectomy (SG), offers good control of type-2 diabetes and other metabolic derangements and also helps in weight reduction without causing significant malabsorption. There are two versions of this procedure, jejunal (nondiverted) and duodenal (diverted) ileal interposition. It is effective in controlling T2DM not only in obese but also in non obese. Methods: The II & SG was performed at two hospitals, as a multicenter study, in 490 patients from February 2008 to December 2013. Patients had mean age of 43.5 years, mean duration of diabetes was 9.5 years and mean preoperative body mass index (BMI) of 29.5 kg/m2. 2/3rds of the patients had BMI less than 35. All patients had poorly controlled type 2 diabetes mellitus (mean HbA1c- 9.8 %), despite use of oral hypoglycemic agents (OHA) and/or insulin. 64 % patients had hypertension, 60 % had dyslipidemia and 45 % had significant microalbuminuria. The primary outcome was remission of diabetes (HbA1c less than 6.0 % without OHAs/insulin) and secondary outcomes were changes in components of metabolic syndrome. Results: With a mean follow up of 24 months (range between 10 and 72 months), postoperative glycemic parameters, (fasting blood sugar (FBS), post lunch blood sugar (PLBS) and HbA1c) improved in all patients at all intervals. Hospital stay was between four and six days; operative duration ranged between 240 and 360 minutes. 72 % had complete remission of diabetes (HbA1c less than 6 without any medication); 81.5 % had partial remission. Mean weight loss was 23.5 % (18 to 28 %). Resolution of hypertension was seen in 92.5 % (blood pressure less than 130/80 mmHg), dyslipidemia in 89.5 % and microalbuminuria in 80 %. At two years mean fall in HbA1c (26.5 %) was more than the reduction in BMI (21 %; range between 15 and 25 %). The main post operative problems were food intolerance, seen in 12 %; diarrhea and abdominal pain seen in 4 %. Total complication rate was 7.75 % (38 out of 490 patients) and mortality rate from procedure was 0.2 %. Conclusions: This multicenter study suggests that laparoscopic ileal interposition with sleeve gastrectomy is a promising procedure for control of type 2 diabetes, hypertension, obesity and associated metabolic abnormalities, especially with a low recurrence rate and minimal nutritional concerns.



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Is Patient Satisfaction Associated with 30-Day Postoperative Outcomes in a Population Primarily Undergoing Laparoscopic Procedures?

A New Perspective on the Value of Minimally Invasive Colorectal Surgery-Payer, Provider, and Patient Benefits

Kristel Lobo Prabhu, MD, Ahmad Elnahas, MD, MSc, FRCSC, Michelle Cleghorn, Allan Okrainec, MDCM, MHPE, FACS, FRCSC, Fayez Quereshy, MD, MBA, FRCSC, Timothy Jackson, MD, MPH, FRCSC, FACS, University Health Network Introduction: With the movement towards greater transparency in the reporting of healthcare outcomes, patient satisfaction is becoming a priority. Ensuring patient satisfaction with their health care encounter plays a key role in delivering quality care. The purpose of this study was to determine the relationship between patient satisfaction and 30-day postoperative outcomes in patients undergoing general surgical procedures. Methods and Procedures: Satisfaction surveys were distributed to patients following discharge from the general surgery service at an academic hospital between June 2012 and March 2015. The survey required patients to rate their level of satisfaction with services related to their surgery using a 5-point Likert scale. 30-day postoperative outcomes, specifically length of stay (LOS), readmission, and surgical complications, were obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Satisfaction ratings were used to divide patients into satisfied (score of 4 or 5) and unsatisfied groups (score of 1 to 3). Chi-squared analysis was used to compare these cohorts with respect to the proportion of patients experiencing adverse clinical outcomes. Results: 757 patient satisfaction surveys were completed, representing a 67.5 % response rate. The mean age of patients surveyed was 52.2 years (SD 15.9); 60 % of patients were female. The majority of patients underwent a laparoscopic procedure (85.8 %) and were admitted following surgery as inpatients (72 %). 91.5 % of patients were considered satisfied with their care. 30-day readmission (3.3 % vs. 12.5 % in the satisfied and unsatisfied group, respectively; p \ 0.01), 30-day minor complications (6.5 % vs. 17.2 %; p \ 0.01), and 30-day overall complications (9.8 % vs. 18.8 %; p = 0.03) were associated with lower patient satisfaction. Prolonged hospital stay (LOS greater than the sample median) (22.5 % vs. 31.2 %; p = 0.24), and 30-day major complications (3.3 % vs. 1.6 %; p = 0.44) were not found to be significantly associated with patient satisfaction. Conclusions: Our study found a significant association between patient satisfaction and 30-day readmission and the occurrence of postoperative complications. Given this association, further study is warranted to evaluate patient satisfaction as a health care quality indicator.

Deborah S Keller, MS, MD1, Kate Fitch, RN, MEd2, Andrew Bochner, BA2, Eric M Haas, MD, FACS, FASCRS3, 1Colorectal Surgical Associates, 2Milliman, 3Colorectal Surgical Associates; Houston Methodist Hospital; University of Texas Medical Center at Houston Background: While the clinical benefits of minimally invasive surgery (MIS) have been proven over open surgery, the overall financial benefits are yet to be fully explored. Our goal was to evaluate the financial benefits of MIS from the payer’s perspective to demonstrate the value of minimally invasive colorectal surgery. The reduction in cost, complications, and readmissions with MIS could result in an overall benefit to the healthcare system. Methods: A claim-based analysis using commercial Truven MarketScanÒ data identified all 2013 elective, non-metastatic, inpatient colectomy cases. Member eligibility was required in all months of 2012 and C1 month of 2013. Cases were stratified into open or MIS approaches based on ICD-9 procedure codes: Open; 45.71–45.76. 45.79, 45.82, 45.83 MIS; 17.31–17.36, 17.31, 45.81. Care episodes (colectomy inpatient stay and 30 days post discharge) were compared for average allowed costs (amount paid to providers by the payer plus member cost sharing) and readmission rates after adjusting for demographics, comorbidities, geographic region, and malignant diagnosis. Results: 4,615 elective, non metastatic inpatient colectomies were identified - 2,054 (44.5 %) open and 2,561 (55.5 %) MIS. Total allowed episode costs for MIS colectomy were significantly lower than open colectomy ($37,540 vs. $45,284, p \ 0.001). During the inpatient colectomy stay, open cases had greater ICU utilization (3.9 % open vs. 2.0 % MIS, p \ 0.001) and a significantly longer LOS than MIS (6.39 vs. 4.44 days, p \ 0.001). The MIS cohort had significantly lower average allowed costs for the inpatient colectomy stay ($33,183 MIS vs. $39,585 open, p \ 0.001). Post discharge, open cases had significantly higher readmission rates per 100 cases (11.54 vs. 8.28; p = 0.0013), higher average readmission costs ($3,055 vs. $2,514; p = 0.1858), and greater 30-day healthcare costs than MIS ($5,699, vs. $4,377; p = 0.0033). The overall cost savings between MIS and open surgery were $7,744 per patient (Table 1). Conclusions: In a commercially insured population undergoing elective colectomy for non-metastatic cases, the risk adjusted allowed costs for MIS colectomy episodes were significantly lower than open. The overall cost difference between MIS and open surgery was almost $8,000 per patient. These results highlight an opportunity for health plans and employers to realize benefits by shifting from open to MIS for colectomy. With the increasing number of health systems participating in bundled payment arrangements and accountable care shared savings programs, the potential from cost shifting to MIS will become even more important.

Table 1 Outcomes for open and MIS colectomy


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The SmartOR: A Distributed Sensor Network to Improve Operating Room (OR) Efficiency

Mortality After Esophagectomy is Heavily Impacted by Center Volume

Albert Y Huang, MD, Guillaume Joerger, MS, Remi Salmon, PhD, Brian Dunkin, MD, Vadim Sherman, MD, Barbara Bass, MD, Marc Garbey, PhD, Houston Methodist

Hans F Fuchs, MD1, Cristina R Harnsberger, MD1, Ryan C Broderick, MD1, David C Chang, PhD2, Bryan J Sandler, MD1, Garth R Jacobsen, MD1, Michael Bouvet3, Santiago Horgan, MD1, 1Center for the Future of Surgery, Division of Minimally Invasive Surgery, University of California, San Diego, 2Department of Surgery, Codman Center, Massachusetts General Hospital, Harvard Medical School, Boston MA, 3Department of Surgery, Division of Surgical Oncology, University of California, San Diego

Introduction: OR time is estimated to cost $100 per minute. Despite the significant expense of this valuable resource, best practice achieves only 70 % efficiency. Compounding this problem is a lack of real-time actionable date. Most current OR utilization programs require labor intensive data entry by a member of the OR team and are subject to scrutiny. Automated systems require installation and maintenance of expensive tracking hardware throughout the institution. This study developed an inexpensive, automated OR utilization system, and analyzed data from multiple operating rooms Methods and Procedures: OR activity was deconstructed into four room states. A sensor network was then iteratively developed to automatically and reliably capture these states resulting in simplifying the system down to four sensors, a local wireless network, and a data capture computer (SmartOR). Two systems were then installed into two clinical operating rooms, recordings captured 24/7, and data compared to that recorded in the current OR management systems. The SmartOR recorded the following events: any room activity, patient entry/exit time, anesthesia time, laparoscopy time, room turnover time, and time surgeon identified the patient preoperatively. Results: From November 2014 to May 2015 data was collected from 388 cases. Comparison to that in the current management system showed excellent correlation. The mean turnover time was 36 minutes. However, only 66 % of cases met the institutional goal of B30 minutes. Data analysis also identified outlier cases (times [ 2 SD from mean) in the domains of time from patient entry into the OR to intubation (10 % of cases) and time from extubation to patient exiting the OR (13 % of cases). In addition, time from surgeon identification of patient to scheduled procedure start time was 8 min 4 s (Institution bylaws require 30 minutes ahead of scheduled start time), yet OR teams required 17 min 56 s on average to bring a patient into the room after surgeon identification. These indisputable findings correlate with the OR manager report of 74 % late first-case starts due to ‘‘unavailability’’ of the surgeon. Conclusions: The Smart OR automatically and reliably captures data on OR room state and, in real-time, identifies outlier cases that may be examined closer to improve efficiency. Because no manual entry is required the data is indisputable and allows OR teams to maintain a patient-centric focus.

Introduction: The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume and to analyze if low-risk subgroups exist. Methods and Procedures: We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998–2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients \18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (\6), intermediate (6–19), and high (C20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine if hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology. Results: A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %, all p \ 0.05), and multivariate analysis revealed that high hospital volume and the laparoscopic approach had a protective effect (OR 0.54 and 0.71, respectively). Independent predictors of mortality were age C65 years, African American race, diagnosis of squamous cell carcinoma (SCC), comorbid disease (cardiovascular, pulmonary, renal, and hepatic), and hospital volume of B20 esophageal resections for malignancy per year. On subgroup analyses for low and intermediate volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high volume hospitals (p \ 0.05). There was no difference in mortality between low and medium volume hospitals and between subgroups (Fig. 1). Conclusions: No lower risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is heavily impacted by center volume and the usage of minimally invasive techniques.

Fig. 1 Multivariate analysis of mortality in subgroups (Reference: High volume, highlighted with red line)



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Intraoperative Mucosal Perforation During Laparoscopic Achalasia Surgery: Impact of Preoperative Pneumatic Balloon Dilation

A Comparative Study of Outcomes Between Single-Site Robotic And Multi-port Laparoscopic Cholecystectomy: An Experience from a Tertiary Care Center

Yoshihito Souma, MD1, Kiyokazu Nakajima, MD, FACS2, Eiji Taniguchi Eiji Taniguchi, MD3, Tsuyoshi Takahashi, MD2, Yukinori Kurokawa, MD, FACS2, Makoto Yamasaki, MD2, Yasuhiro Miyazaki, MD2, Tomoki Makino, MD2, Takeyoshi Yumiba, MD1, Shuichi Ohashi, MD1, Shuji Takiguchi, MD2, Masaki Mori, MD, FACS2, Yuichiro Doki, MD2, 11. Department of Surgery, Osaka Central Hospital, Osaka, Japan, 22. Department of Gastroenterological Surgery, Osaka University Graduate School of Medicine, Osaka, Japan, 33. Department of Surgery, Otemae Hospital, Osaka, Japan

Banujan Balachandran, MS1, Taha Mustafa, MD1, Theadore A Hufford, MD1, Kunal Kochar, MD1, Leela M Prasad, MD1, Suela Sulo, PhD3, Joubin Khorsand, MD2, 1Division of Colon and Rectal Surgery, Advocate Lutheran General Hospital, 2General Surgery, Advocate Lutheran General Hospital, 3Russell Institute for Research & Innovation, Advocate Lutheran General Hospital

Introduction: Pneumatic balloon dilation (PBD) has been preferred as the primary treatment for esophageal achalasia since it is relatively easy to perform, generally requires no hospital stay, and is cost-efficient in short-term. However, laparoscopic cardiomyotomy is eventually required in refractory cases as a definitive treatment after failed PBD. The forceful tear of lower esophageal sphincter (LES) during PBD potentially causes post-procedural reactive fibrosis around LES, and controversy has still remained regarding whether preoperative PBD can be a potential hazard of perioperative complication, such as intraoperative mucosal perforation, and adverse effect on postoperative esophageal function. The aim of this study was to evaluate whether preoperative PBD represents a risk factor of surgical complications and affects the symptomatic and/or functional outcomes of laparoscopic Heller myotomy with Dor fundoplication (LHD). Methods: A retrospective chart review was conducted on the prospectively complied surgical database including 103 consecutive patients with esophageal achalasia who underwent LHD from November 1994 to September 2014. The following data were compared between the patients with preoperative PBD (PBD group; n = 26) and without PBD (non-PBD group; n = 77): 1) patient’s demographics; age, gender, body mass index, duration of symptoms and severity of disease. 2) operative findings; operating time, blood loss, intraoperative complications. 3) postoperative outcome; complications, symptom relief, and necessity of postoperative treatments. 4) pre- and post-operative manometric data and profile of 24-hour esophageal pH monitoring. Results: 1) No significant differences were observed between PBD and non-PBD groups in the patients’ demographics. 2) Operative findings were similar between the two groups, but the incidence of intraoperative mucosal perforation was significantly higher in PBD group (n = 8; 30.7 %) compared to non-PBD group (n = 6; 7.9 %) (p = 0.005). 3) Postoperative complication was not encountered in both groups. The differences were not significant in postoperative clinical symptoms and necessity of postoperative treatments. Endoscopically proven gastro-esophageal reflux disease were developed in 3 patients in PBD group, and in 5 patients in non-PBD group (p = 0.40). 4) LES pressure was effectively reduced in both groups, and no differences were observed in manometric data and profile of 24-hour pH monitoring between the two groups. Multivariate logistic regression analysis showed that the history of preoperative PBD was significantly associated with intraoperative mucosal perforation (odds ratio: 4.96 [95 % CI: 1.39 to 17.61, p = 0.013]). Conclusions: Although postoperative outcomes are not affected, a special caution should be required in patients with preoperative PBD when performing LHD.


Introduction: To determine the safety and efficacy of single-site robotic cholecystectomy compared to multi-port laparoscopic cholecystectomy within a highvolume tertiary health care center. Methods and Procedures: A retrospective analysis of prospectively maintained data was conducted on patients undergoing single-site robotic cholecystectomy or multi-port laparoscopic cholecystectomy between October 2011 and July 2014. All surgeries included in the study were performed by a single surgeon. Pre-operative (i.e. age, gender), peri-operative (i.e. operative time, intra-operative complications, conversions), and post-operative (i.e. length of stay, immediate post-operative complications, delayed post-operative complications) data were collected from hospital and office medical records. Statistical analysis was performed using SPSS software, version 23.0 with Student’s t test used to compare continuous data and Chi Square or Fisher’s Exact test for assessing categorical data. A p-value of 0.05 was considered statistically significant. Results: Within the established time frame, 415 (61 %) single-site robotic cholecystectomies and 263 (39 %) multi-port laparoscopic cholecystectomies were performed. Laparoscopic patients had a greater mean BMI (30.5 vs. 29.0 kg/m2; p = 0.008) and were more likely to have undergone prior abdominal surgery (83.3 vs. 41.4 %; p \ 0.001) than those in the robotic group. More patients with preexisting co-morbidities (76.1 % vs. 67.2 %; p = 0.014), including coronary artery disease (p = 0.027) and COPD (p = 0.049) were also found within the laparoscopic group. The average console time and docking time was 57 minutes and 6.8 minutes respectively, for all robotic procedures. No statistically significant differences were seen in the total operative time or the rate of conversions to open procedures between the two groups. The mean length of hospital stay post-procedure was shorter for patients within the single-site robotic group (1.9 vs. 2.4 days; p = 0.012). However, in the short-term, patients who underwent single-site robotic procedures were diagnosed more frequently with wound infections (3.9 % vs. 1.1 %, p = 0.037) and had more reported complaints of abdominal pain (8.4 % vs. 4.2 %; p = 0.032). Furthermore, in the long-term, patients also developed incisional hernias much more frequently within the single-site robotic group than in the multi-port laparoscopic group (6.5 % vs. 1.9 %; p = 0.006). No statistically significant differences were seen in the mean length of follow-up within the two groups of patients. Conclusion: Single-site robotic cholecystectomy is a safe option for otherwise younger, more active patients without severe co-morbidities. Incisional hernias and wound infections are potential complications more likely to occur for patients undergoing single-site robotic cholecystectomy, as opposed to multi-port laparoscopic cholecystecomy and patients should be informed of these risks prior to their procedures.

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The Impact of Standardization on Short and Longterm Outcomes in Bariatric Surgery

Surgeon Case Volume and Readmissions After Roux-en-Y Gastric Bypass: More is Less

Lisa N Aird, MD, MHSc1, Ruth Breau1, Dennis Hong, MD, MSc2, Scott Gmora2, Mehran Anvari3, 1Centre for Minimal Access Surgery, 2 St. Joseph’s Healthcare, 3Ontario Bariatric Network

Adam Celio, MD, Matthew Burruss, MD, Kevin Kasten, MD, Walter Pofahl, MD, Walter Pories, MD, William Chapman, MD, Konstantinos Spaniolas, MD, Department of Surgery, Brody School of Medicine at East Carolina University

Introduction: The purpose of this study is to determine if there has been an improvement in morbidity, mortality, and clinical outcomes since 2010, when the Ontario Bariatric Network (OBN) led a province-wide initiative to establish standardized care for bariatric patients. This has led to the creation of 9 bariatric centers, a centralized referral system, and a registry to gather patient data. Standardization of procedures has progressed yearly, including guidelines for pre-operative assessment, patient selection and peri and post-operative care. Methods and Procedures: Analysis of the OBN registry data was performed by fiscal year between April 2010-March 2015. Three-month post-operative complication rates and 30-day post-operative mortality were calculated. The mean percentage of weight loss at 1, 2 and 3-years post-operative, and regression of obesity-related diseases were calculated. The Chi-Square Test and the McNemar test were used to compare unpaired and paired nominal data, respectively. Results: A total of 8043 patients were entered into the bariatric registry between April 2010-March 2015. Thirty-day mortality was rare (\0.075 %) and showed no significant difference between years (Table 1). Three-month post-operative complication rates significantly decreased with time (Table 1). The mean percentage of weight loss at 1, 2, and 3 years postoperative showed stability at 33.2 % (9.0 SD), 34.1 % (10.1 SD), and 32.7 % (10.1 SD), respectively. Finally, significant regression in obesity-related comorbidities was demonstrated at 1-year postoperative, and showed continued improvement at 2-years postoperative. Conclusion: Evidence indicates the implementation of a standardized preoperative assessment, patient selection, operative approach and peri and post-operative care has resulted in improvements in complication rates and supported prolonged weight loss and regression of obesity-related diseases in patients undergoing bariatric surgery in Ontario.

Table 1 Mortality and 3-month complication rate by year of surgery and degree of standardization 2010/11 2011/12 2012/13 2013/14 2014/15 (N = 268) (N = 1192) (N = 2405) (N = 2405) (N = 1739) Standardization






Mortality (%)










20.2 3-month Complication Rate (%)

Introduction: Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is a commonly performed bariatric procedure. Readmissions are being used as an indicator of quality care and there is a nationwide emphasis to reduce their incidence. Prior studies have explored surgeon case volume and patient outcomes in various surgical fields. In LRYGB surgery, surgeon volume studies have focused on technical outcomes, mainly using state registries to assess complication rates with limited data on readmissions. Our aim was to use nationwide data to explore the relationship between surgeon case volume and hospital readmissions following LRYGB. Methods and Procedures: The Bariatric Outcomes Longitudinal Database (Surgical Review Corporation; Raleigh, NC) for 2011 was used for the purposes of this study. Analysis was restricted to patients who underwent non-revisional LRYGB. Surgeons performing more than 50 LRYGB during the study period were defined as high volume surgeons (HVS). A multivariable logistic regression model was used to examine the effect of surgeon volume on 30 day readmission while controlling for patient demographics and comorbidities. Data is presented as percentage or mean (standard deviation). Results: We identified 32,521 patients that underwent LRYGB with an overall 30 day readmission rate of 5.5 %, mean age 45.7 (12.0), and mean BMI 47.2 (8.0). There were no major differences in BMI [47.3 (8.1) vs 47.1 (7.9) p = 0.282] or age [45.5 (12.0) vs 45.8 (12.0) p = 0.030] between low volume surgeon (LVS) and HVS patients. HVS patients were more likely to have an American Society of Anesthesiology score [2 (74.7 % vs 80.8 %, p \ 0.001). LVS patients were more likely to be readmitted compared to those with a HVS (OR = 0.85, 95 % CI 0.77–0.94), with a readmission rate of 6.1 % vs 5.2 % (p = 0.001). Additionally, LVS patients had higher rates of 30 day mortality (0.2 % vs 0.1 %, OR = 0.50, 95 % CI 0.27–0.91), complication (10.5 % vs 8.6 %, OR = 0.81, 95 % CI 0.75–0.87), reoperation (3.7 % vs 3.0 %, OR = 0.82, 95 % CI 0.72–0.93), and anastomotic leak (0.6 % vs 0.4 %, OR = 0.64, 95 % CI 0.46–0.87). Conclusion: Readmission after LRYGB is significantly associated with surgeon operative volume; surgeons that perform less than 50 LRYGB per year are more likely to have 30 day readmissions and complications. Our findings support other more generalized studies that suggest surgeon case volume is inversely associated with increased risk of adverse outcomes and complications, and suggest that performance of LRYGB by high volume surgeons may decrease hospital readmission and healthcare utilization.

* Chi-square test (p \ 0.05)



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Surgical Outcomes at Bariatric Centers of Excellence: Are They All Excellent?

GERD and Acid Reduction Medication Use Following Gastric Bypass and Sleeve Gastrectomy

Andrew M Ibrahim, MD, Amir A Ghaferi, MD, MS, Jyothi Thumma, MPH, Justin B Dimick, MD, MPH, University of Michigan, Center for Healthcare Outcomes & Policy

Alex C Barr, MS, Dr. Jon Gould, Dr. James R Wallace, Dr. Matthew I Goldblatt, Matthew Bosler, Matthew Frelich, Medical College of Wisconsin

Introduction: As bariatric surgery continues to grow among the most common operations in the United States, increased attention is being given to the associated perioperative risk. One strategy to improve quality for this population is to restrict bariatric procedures to Centers of Excellence (COEs.) Little is known, however, about how much variation exists across these COEs. Methods: We performed a retrospective review of surgical outcomes at COEs across 9 states performing 1 of 3 common bariatric procedures between 2009–2011. Data was obtained from the Healthcare Cost and Utilization Project – State Inpatient Database and Medicare Provider Analysis and Review file which included unique hospital identification numbers allowing comparisons across 254 Centers of Excellence. For each hospital, we calculated the risk and reliability adjusted serious complications rates within 30 days of the index operation. A multilevel regression model was utilized to assess the variation in outcomes across COEs within each state. Results: Wide variation exists across COEs for bariatric surgery. For example, the risk and reliability adjusted complication rates at COEs in the State Inpatient Database varied 28 fold (N = 148; range 0.3 % to 8.6 %) with top and bottom quintiles differing by 3.4 fold (top quintile 0.8 %; bottom quintile 2.7 %; p \ 0.005.) We repeated the analysis among Medicare beneficiaries and found similar COE variation; hospital level postoperative complications varied 13 fold (N = 254; range 1.4 % to 13.7 %) with top and bottom quintiles differing by 2 fold (top quintile 2.4 %; bottom quintile 4.7 %; p \ 0.005.) Each individual state also demonstrated significant variation in post-operative complications rates ranging from 2.6 fold (MA; top quintile 1.0 to bottom quintile 2.6 %; p \ 0.005.) to 4.6 fold (FL; top quintile 0.8 % to bottom quintile 3.7 %; p \ 0.005.) Conclusions: Even within Centers of Excellence for bariatric surgery, wide variation exists in serious post-operative complications. Restricting patients to COEs may not achieve desired quality improvement intended by professional organizations. Additionally, like non-COEs, COEs would benefit from substantial quality improvement interventions to reduce variation.

Background: Gastroesophageal reflux disease is a common comorbid medical condition of obesity. Two of the most commonly performed bariatric surgical procedures are laparoscopic sleeve gastrectomy and laparoscopic Roux-en Y gastric bypass. The sleeve gastrectomy has been associated with de novo and worsening GERD following surgery in several studies. For this reason, many morbidly obese patients with GERD are counseled to undergo gastric bypass rather than sleeve gastrectomy. Given this practice pattern, we sought to determine acid reduction medication (ARM) utilization in bariatric surgical patients to undergo either a sleeve gastrectomy or gastric bypass prior to surgery and at 1 year postop in a single bariatric surgical program. Methods: This study was a retrospective review of adult patients who underwent either Roux en-Y gastric bypass or sleeve gastrectomy for morbid obesity at a single institution between January 2011 and July 2015. All procedures were performed by one of three experienced bariatric surgeons. Data was prospectively entered in a clinical database and retrospectively reviewed. Results: A total of 125 patients met the inclusion criteria. Eighty gastric bypass and 45 sleeve gastrectomy procedures were included. Patient demographics (age, sex, and race), pre-operative BMI and weight did not differ between groups. ARM utilization was more prevalent in gastric bypass patients prior to surgery, although this did not reach statistical significance. At 12 months postop, sleeve patients had a significantly higher rate of overall ARM use, new ARM use, and persistent ARM use than gastric bypass patients (Table 1). Conclusion: Laparoscopic sleeve gastrectomy is associated with a significantly increased likelihood that acid reduction medications will be necessary for GERD symptom control 12 months following surgery when compared to gastric bypass. This is despite the fact that most patients with GERD are advised to undergo a gastric bypass. Further study on the mechanisms of persistent and de novo GERD in these sleeve gastrectomy patients is needed to minimize this surgical side effect of sleeve gastrectomy.

Table 1 . P-value Laparoscopic Laparoscopic Roux-en-Y sleeve gastrectomy (%) gastric bypass (%) Pre-op ARM use




12 month ARM use




Pre-op ARM, DC @ 12 month



New ARM @ 12 month


Pre-op ARM, no change 12 month 82


6.7 31

0.005 0.003 0.005

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Individualizing Counseling for The Bariatric Patient: A Predictive Model for Long Term Mortality Following Bariatric Surgery

Does Sleeve Gastrectomy Affect the Geometry and Tone of The Gastroesophageal Junction?

Andrew T Bates, Jie Yang, Maria Altieri, Mark Talamini, Aurora Pryor, Dana Telem, Stony Brook Medical Center Introduction: Based on data previously published by our institution, this study aims to develop a long-term mortality probability calculator for bariatric patients. Methods: Using SPARCS NY longitudinal administrative database, 7,862 adult patients who underwent bariatric surgery from 1999–2005 were analyzed. A multiple Cox proportional hazard model was used to build a prediction model for post procedure long-term mortality. The baseline survival function was estimated by exponentiating the negative empirical cumulative hazard function. Internal validation of the model was based on bootstrapping and C-index was calculated to evaluate discrimination accuracy of the model and shrinkage estimates were used for further calibration. External validation was based on SPARCS data from 2006–2010. Results: The mean bariatric mortality rate was 2.5 % with 8–14 years of follow-up. The long-term mortality risk stratification model included the following identified risk factors associated with an earlier time-to-death: age, male gender, Medicare/ Medicaid insurance, congestive heart failure, rheumatoid arthritis, pulmonary circulation disorders and diabetes. The final model was predictive (c-index = 0.74 for internal validation, c-index = 0.70–0.73 for external validation years 2006–2010) for long term mortality. The hazard ratio prediction model was described below. The shrinkage used in calibration step was 0.879. The attached table details the c-index of the model and external validation results (Table 1; Fig. 1). Conclusion: The model effectively predicts long-term mortality following bariatric surgery through both internal and external validation. A computerized application allowing easy input of patient specific information and output of individual longterm mortality risk as compared to the general and obese population is under development.

Table 1 .

Silvana Perretta, MD, Antonio D’Urso, MD, Marius Nedelcu, MD, Michel Vix, MD, Bernard Dallemagne, MD, Didier Mutter, MD, Department of Digestive and Endocrine surgery, University of Strasbourg Introduction: The role of sleeve gastrectomy (SG) in causing postoperative gastroesophageal reflux remains controversial. Whereas previous data has clearly demonstrated that intragastric pressure increases significantly after SG, the effect of the procedure on the geometry and compliance of the gastroesophageal junction GEJ) has been studied to a lesser extent. In this study we sought to assess the opening and distensibility of the GEJ before and after the SG procedure, as part of an ongoing European multicenter collaborative project FFSI (Functional Foregut Surgery Imaging) which seeks to derive a better understanding the physiology of the SG procedure. Methods and Procedures: 15(8F) patients were studied with mean age of 35 ± 10,04 years, and BMI of 42,23 ± 4,82. No patient complained of GERD symptoms prior to SG, no patient was on proton pump inhibitor medication, and all patients had negative EGD and UGI series. No patient had a hiatal hernia greater than 1 cm. After establishment of pneumperitoneum, an EndoFLIP EF325N catheter (Crospon, Galway, Ireland) was placed so as to straddle the GEJ, and measurements of diameter and distensibility were taken at balloon inflation diameters of 30 ml and 40 mL. The measurement was repeated upon completion of the sleeve. A paired t test comparing opening diameter and distensibility pre and postprocedure was conducted to assess the effect of the SG procedure on the GEJ. Results: At 30 mL inflation (n = 15), mean (SD) GEJ opening diameter was 8.4(1.0) mm preprocedure versus 10.2(2.0) mm postprocedure, a mean increase of 1.7 mm (P = 0.005). At 40 mL inflation (n = 14), mean GEJ opening diameter was 10.7(1.8) mm before versus 11.7(2.4) mm postprocedure, a mean increase of 1.0 mm (P = 0.11). At 30 mL inflation (n = 14), mean GEJ distensibility was 2.3(0.8) mm2/ mmHg before versus 2.9(1.6) mm2/mmHg postprocedure, a mean increase of 0.6 mm2/mmHg (P = 0.2). At 40 mL inflation (n = 12), mean GEJ distensibility was 2.7(1.2) mm2/mmHg before versus 3.2(1.5) mm2/mmHg postprocedure, a mean increase of 0.4 mm2/mmHg (P = 0.34). Conclusions: This preliminary data from the FFSI study strongly suggests that GEJ diameter is widened by the SG procedure, which would logically suggest that the risk of gastroesophageal reflux is increased. Whereas the data suggest that the GEJ is more distensible after SG, a higher powered study with a larger sample size will be required to determine if the effect is statistically significant.

S126 Preoperative Endoscopy in Bariatric Patients may Change Surgical Strategy Francisco Schlottmann, Romina Reino, Marina Spano, Martin Galvarini, Jose Alvarez Gallesio, Rudolf Buxhoeveden, Hospital Aleman of Buenos Aires

Fig. 1 Multiple CX proportional Hazard Model

Introduction: While esophagogastroduodenoscopy (EGD) is mandatory prior to any gastric surgery, many centers considered it unnecessary before bariatric surgery. However, because sleeve gastrectomy (SG) could negatively impact on gastroesophageal reflux disease (GERD), endoscopic findings could change the strategy to a Roux-en-Y gastric bypass (RYGB), which is considered the gold standard for treatment the obese patient with GERD. The aim of this study was to evaluate the utility of the EGD before bariatric surgery. Methods and Procedures: A retrospective study based on a prospectively loaded database was performed. A consecutive series of bariatric surgery candidates with preoperative EGD were included. The sample was divided into two groups according to the presence or absence of GERD like symptoms before surgery. G1: patients without symptoms and G2: patients with symptoms. Abnormal EGD findings were defined as presence of hiatal hernia, esophagitis and / or Barrett’s esophagus. Results: Between 2008 and 2015, a total of 193 patients were included; 123 (63.7 %) patients were female. Mean age was 46 (18–71) years. Mean preoperative BMI was 44.5 kg/m2 (31–96). Distribution among groups was as follows: G1, 136 patients (70 %), and G2, 57 patients (30 %). Abnormal findings consistent with GERD were found in 40 patients (29.4 %) in G1 and in 30 patients (52.6 %) in G2. Gastric bypass was performed in 90 % of patients with abnormal EGD in G1 and in 80 % of patients in G2 patients with abnormal EGD. Conclusions: EGD should be requested as a routine preoperative study in patients undergoing bariatric surgery because its findings could change the surgical strategy



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Truth in Bariatric Surgery Advertising Among Academic and Non-academic Centers

Early Discharge in the Bariatric Population Does Not Increase Post Discharge Resource Utilization

J. Aaron Barnes1, Sarah E Billmeier, MD, MPH2, Gina L Adrales, MD, MPH2, 1Geisel School of Medicine, 2Dartmouth Hitchcock Medical Center

Joshua Rickey, MD, Dimitrios Stefanidis, MD, FACS, FASMBS, Keith Gersin, MD, FACS, FASMBS, Timothy Kuwada, MD, FACS, FASMBS, Carolinas Medical Center

Introduction: Numerous advertisements for obesity treatments target a potentially vulnerable population. The purpose of this study is to evaluate the content of directto-patient consumer advertising by bariatric surgery programs. Methods: Internet sites containing patient information regarding bariatric surgery were collected through a comprehensive internet search using terms associated with weight loss and weight loss surgery. Inclusion criteria included sources published by hospitals or practices offering bariatric surgery. Open forums, blogs, video interviews or news-related sites were excluded. Sources were assessed for accuracy of information and completeness of content provided along four areas: resolution of diabetes or hypertension, weight loss, and risk of complications for laparoscopic adjustable gastric banding (LAGB), gastric bypass (RYGB), and longitudinal sleeve gastrectomy (LSG) for both academic and non-academic bariatric surgery programs. Comparison of reporting by academic (AC) or non-academic centers (NAC) was performed by Fisher’s exact test. Results: A total of 65 sites including 21 academic centers were identified. 62 sites (29 % academic) advertised for LAGB with 27.4 % claiming diabetes resolution or cure (including 16.7 % of AC’s and 31.8 % of NAC’s) and 22.5 % of LAGB sites claiming resolution of hypertension (16.7 % of AC’s and 25.0 % of NAC’s). 62.9 % of LAGB sites reported excess weight loss with ranges of 40–80 % among AC’s and 21–90 % among NAC’s. Of 52 RYGB sites, 44.2 % reported diabetes resolution (44.4 % AC, 44.1 % NAC), 40.4 % listed hypertension resolution (27.8 % AC, 47.1 % NAC) and 75 % reported weight-loss (72.2 % AC, 27.0 % NAC) ranging from 33–85 % among AC’s and 50–100 % excess weight loss among NAC’s. Of 53 LSG sites, 24.5 % reported diabetes resolution (18.6 % AC, 27.0 % NAC), 26.4 % reported hypertension resolution (8.6 % AC, 29.7 % NAC), and 50.9 % reported weight loss (37.5 % AC, 56.8 % NAC) ranging 33–85 % among AC’s and 30–85 % among NAC’s. No risks were reported by 30.6 % LAGB, 26.9 % RYGB, and 45.3 % LSG sites. Fewer sites quantified risk (22.3 % LAGB, 17.3 % RYGB, 5.7 % LSG). There were no significant differences in reporting rates by academic versus non-academic programs. Conclusions: There was consistency in effectiveness reporting among academic and nonacademic bariatric programs. Balanced patient information was not uniformly presented with a number of sites failing to report any risks. In an era when patients increasingly rely on the internet for health information, bariatric surgery programs should re-evaluate the content of their digital patient information.

Introduction: There is a growing interest in enhanced recovery after surgery (ERAS). Reducing postoperative length of stay (LOS) is a major tenant of ERAS. However, reducing LOS may increase post discharge resource utilization. The high volume and standardized protocols in bariatric surgery, make it particularly well suited for ERAS. We recently revised our ERAS protocol for bariatric surgery with a goal LOS of one day. Prior to this, the target LOS was two days. Prior to this, the goal LOS was two days. The goal of this study was to compare hospital readmissions, emergency room visits and patient office calls before and after implementation of ERAS. Methods and Procedures: We performed a retrospective chart review of a single surgeon series of laparoscopic sleeve gastrectomy (LSG) and laparoscopic gastric bypass (LGB). The ‘‘ERAS’’ group had a target LOS of one day, while the ‘‘standard discharge’’ (SD) group’s target LOS was two days. An equal number of SD patients were included to match the number of ERAS patients. The primary outcomes were hospital re-admissions, ED visits, and patients calls to the office within 30 days of surgery (as noted in the electronic medical record). When comparing the primary outcomes between the ERAS and SD groups, patients who had LOS beyond the target were excluded. The groups were analyzed using a paired student T test, with statistical significance defined as a p \ .05. Results: ERAS was initiated in January of 2015 with 107 patients identified in this group. An additional 107 patients who immediately preceded ERAS represented the standard discharge (SD) group. These two groups had similar demographics. Compared to the ERAS group, the SD patients had a significantly higher percentage of patients who met their target LOS (Table 1a). The SD group (overall and LGB) had a significantly higher rate of hospital re-admissions (Table 2b, d), this was the only significant difference in primary outcomes between the two groups. Conclusions: Our study demonstrates that reducing the target discharge to postoperative day one is feasible and does not significantly increase the rate of hospital readmissions, ED visits or patient calls to our office. Further research is necessary to refine bariatric surgery ERAS protocols and to determine if this patient population can safely be discharged sooner than postoperative day 1.

Table 1 .

Table 2 .


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S129 Safety and Efficacy of a New Endoscopic Duodenal-Jejunal Bypass Liner (DJBL) in Morbidly Obese Subjects Implanted for up to Three Years Nicolas Quezada1, Erick Castillo1, Rodrigo Munoz1, Fernando Pimentel1, Dannae Turiel1, Alex Escalona2, Palmenia Pizarro1, 1 Pontificia Universidad Catolica de Chile, 2Universidad de Los Andes Introduction: The duodenal-jejunal bypass liner (DJBL, EndoBarrier) is an endoscopic device that mimics the duodenal-jejunal exclusion of the Roux-en-Y gastric bypass. Previous reports have shown significant weight loss in morbidly obese patients and improvement in type 2 diabetes (T2DM) for up to one-year. Aim: The aim of this study was to evaluate safety and efficacy in obese subjects implanted with a new (second generation (2G/Long-term)) DJBL for 1, 2 and 3 years. Methods: Morbidly obese subjects were enrolled in a single arm, open label, prospective trial and implanted with the new DJBL (2G). Patients were annually offered to continue on trial and signed a new consent. Primary endpoint was safety with the use of the DJBL (2G). Secondary endpoints included weight change from baseline to 1, 2 and 3 years. Results: The DJBL was implanted endoscopically in 80 of 81 subjects (age: 35 ± 9 y; 69 % female; weight: 109 ± 17 kg; BMI: 42.2 ± 5.4 kg/m2), seventeen patients (21 %) with type 2 diabetes. One subject could not be implanted due to unfavorable anatomy. Implantation and x-ray time were 30 ± 18 min and 8 ± 5 min, respectively. Two patients presented a short esophageal perforation during explantation attempt at 52 and 104 weeks. These complications were successfully managed with endoscopic closure in one patient and medical treatment in the other one. Explant was performed 4 and 12 weeks later, respectively with no issues. Sixty eight patients (85 %) presented any adverse event during the follow-up and 45 (56 %) were admitted due to adverse events during the follow-up. There were 8(10 %) early explants due to severe adverse events; liver abscess (3), upper GI bleeding (3), cholangitis (1), acute pancreatitis (1) mostly occurring during the second year. In the completer population at 52 week (71 patients), 104 (40 patients) and 156 weeks (10 patients), mean weight was; 90 ± 15, 91 ± 16 and 93 ± 13 kg, respectively (p \ 0.0001), equivalent to 44 ± 16, 40 ± 22 and 39 ± 20 % EWL (p \ 0.001). Conclusion: This study shows a significant and sustained weight loss after 3 years of treatment with this new DJBL. Serious adverse events, mostly after the first year prevents the use of this new DJBL for more than one year.

S130 EndostimÒ Les Stimulation Therapy Improves Gerd in Patients with Laparoscopic Sleeve Gastrectomy (LSG) Alejandro Nieponice, PhD1, Yves Borbely2, Leonardo Rodriguez3, Henning G Schulz4, Camilo Ortiz5, Michael Talbot6, David Martin7, Nicole Bouvy8, 1Fundacion Favaloro, 2Inselspital Bern University Hospital, 3Centro Clinico de Obesidad, Diabetes y Reflujo, 4 Evangelisches Krankenhaus Castrop-Rauxel, 5Hospital El Tunal, 6St. George Hospital, 7Concord Hospital, 8Maastricht University Medical Center LSG is the most commonly performed bariatric procedure in the US/Canada and the Asia-Pacific region. However, LSG can result in new GERD and may worsen preexisting GERD.i LSG patients with GERD not well controlled with PPI do not have good treatment options except for more invasive, anatomy-altering gastric bypass surgery. LES electrical stimulation therapy has shown to improve outcomes in GERD patients.ii–iii Aim: To evaluate the safety and efficacy of LES stimulation in LSG patients with GERD not controlled with maximum dose PPI therapy. Method: Patients with LSG associated GERD with bothersome symptoms on maximum PPI dose underwent LES stimulator implant procedure and were enrolled

S263 in an international patient registry prospectively tracking outcomes in GERD patients treated with LES electrical stimulation. Electrical stimulation was delivered at 5 mA, 220 uSec pulse in 12, 30 minute sessions daily. GERD outcomes pre and post-stimulation were evaluated. Results: 12 patients, 66 % (8/12) women at 8 centers have been treated. Median age was 46 (IQR 34–55) years. All (12/12) were on at least daily double-dose PPIs. At their last follow-up (median = 12 months), 75 % (6/8) were off-PPIs and one each was using PPIs on \50 % of days and standard dose once a day. The latter was on daily PPI for GI prophylaxis for chronic steroid therapy for kidney transplants and not GERD symptoms. Median esophageal pH at baseline was 16.4 % (IQR 8.5–22.4), which improved to 1.3 % (IQR 0.4–2.2) % at last follow-up at least 6 month post-implant (n = 6; p = 0.01). All patients improved esophageal acid exposure, 83 % (5/6) patients had normalized acid exposure and 1/6 patient had [40 % improvement in distal esophageal acid exposure. Median GERD-HRQL scores at baseline was 25 (IQR 18–31) which improved to 4 (IQR 3–10) at last follow-up (n = 6; p = 0.015). No SAEs related to the device or procedure were reported. No dysphagia or other GI side effects were reported. Conclusion: Preliminary results on patients with LSG and GERD with bothersome symptoms despite maximal medical therapy, treated with LES electrical stimulation, revealed that LES stimulation is safe and results in a significant improvement in GERD symptoms and esophageal acid exposure. Most patients were off their PPI therapy with remaining taking PPI at a reduced dose. Data from a larger patient experience for this indication is being collected using the international registry trial. i JAMA Surgery 2014; 149: 328–34. ii Surg Endosc. 2013; 27(4):1083–1092. iii Aliment Pharmacol Ther. 2015; 42(5):614–25.

S131 The Effects of Bariatric Surgeries on Non-alcoholic Fatty Liver Disease Tamader Aldoheyan, Mazen Hassanain, MBBS, FRCSC, FACS, PhD, Atheer Al-Sabhan, Shaden Alamro, Amnah Al-Mulhim, MD, King Saud University Background: Non-alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease and is known to be associated with obesity. Bariatric surgery has been shown to be the most effective method for weight reduction, however no conclusive data exists on the potential beneficial effects of weight reduction surgery on NAFLD. Objective: Characterize liver histology, metabolic status and liver function changes of patients undergoing bariatric surgery, prior to and after weight reduction procedures. Methods: This is a preliminary report of an IRB-approved prospective cohort study, recruiting patients undergoing bariatric surgery. All patients signed informed consents. Biopsies were obtained at baseline (intraoperatively) and 3 months postoperatively. Clinical characteristics, biochemical profile and histopathological data (steatosis, NAFLD activity score (NAS), hepatocyte ballooning, lobular inflammation and degree of fibrosis) were obtained at each time point. Results: Fifteen patients were included, 6 were male and the median age was 34 ± 8 years old. At baseline, one patient had dyslipidemia, one had diabetes and 2 patients had hypertension, which did not change at follow-up. The average body mass index went from 44.8 ± 7.8 kg/m2 to 34.6 ± 6.3 kg/m2 at follow-up (p \ 0.001). On histopathology, 6 out of 9 patients with pre-op steatosis (median score 2 (1–3)) had reduced steatosis scores post-op (p = 0.022), fibrosis (median score 1 (1–2)) was also reduced in 7 patients (p = 0.003) and NAS score was decreased from 4 (3–5) to 2 (1–3) (p = 0.004). The changes in lobular inflammation and hepatocyte ballooning were not statistically significant on follow-up. Conclusion: Preliminary results of this study describe histopathological changes following weight reduction surgery and suggest that hepatic steatosis, fibrosis and NAFLD activity score are reduced 3 months after surgery. (Registration number: NCT01619215). Disclosure: The clinical trial is financially supported by NPST (National Plan for Science and Technology).


2016 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA, 16-19 March 2016 : Oral Presentations.

2016 Scientific Session of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Boston, Massachusetts, USA, 16-19 March 2016 : Oral Presentations. - PDF Download Free
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