A comparative study on comprehensive, objective outcomes of laparoscopic Heller myotomy with per-oral endoscopic myotomy (POEM) for achalasia.

OBJECTIVE: To compare symptomatic and objective outcomes between HM and POEM. BACKGROUND: The surgical gold standard for achalasia is laparoscopic Heller myotomy (HM) and partial fundoplication. Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their safety and efficacy. METHODS: Data on consecutive HMs and POEMs for achalasia from 2007 to 2012 were collected. PRIMARY OUTCOMES: swallowing function-1 and 6 months after surgery. SECONDARY OUTCOMES: operative time, complications, postoperative gastro-esophageal reflux disease (GERD). RESULTS: There were 101 patients: 64 HMs (42% Toupet and 58% Dor fundoplications) and 37 POEMs. Presenting symptoms were comparable. Median operative time (149 vs 120 min, P < 0.001) and mean hospitalization (2.2 vs 1.1 days, P < 0.0001) were significantly higher for HMs. Postoperative morbidity was comparable. One-month Eckardt scores were significantly better for POEMs (1.8 vs 0.8, P < 0.0001). At 6 months, both groups had sustained similar improvements in their Eckardt scores (1.7 vs 1.2, P = 0.1).Both groups had significant improvements in postmyotomy lower esophageal sphincter profiles. Postmyotomy resting pressures were higher for POEMs than for HMs (16 vs 7.1 mm Hg, P = 0.006). Postmyotomy relaxation pressures and distal esophageal contraction amplitudes were not significantly different between groups. Routine postoperative 24-hour pH testing was obtained in 48% Hellers and 76% POEMs. Postoperatively, 39% of POEMs and 32% of HM had abnormal acid exposure (P = 0.7). CONCLUSIONS: POEM is an endoscopic therapy for achalasia with a shorter hospitalization than HM. Patient symptoms and esophageal physiology are improved equally with both procedures. Postoperative esophageal acid exposure is the same for both. The POEM is comparable with laparoscopic HM for safe and effective treatment of achalasia.

Overall survival by pattern of recurrence following curative intent surgery for colorectal liver metastasis.

BACKGROUND: Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), patterns of recurrence and subsequent survival outcomes are not widely reported. METHODS: An institutional database (January 2002-December 2012) was reviewed to evaluate patterns of recurrence following CIS for CRLM. RESULTS: 163 patients with CRLM underwent successful CIS. Median follow-up and disease-free interval were 33 and 16 months, respectively. 5-year overall survival (OS) was 55%. After initial CIS, 102 (63%) patients recurred: liver-44% (5-year OS 55%), lung-15% (5-year OS 45%), and other/multifocal-41% (5-year OS 24%). OS for isolated liver and lung recurrences were not significantly different. Liver only recurrence was associated with 1-5 mm liver resection margins (P = 0.048). Lung only recurrence was associated with extrahepatic metastasis (at the time of initial CRLM) (P = 0.025). Other/multifocal recurrence was associated with bilobar CRLM (P = 0.026), and extrahepatic metastasis (P = 0.028). CONCLUSIONS: Patterns of recurrence following CIS for CRLM have important implications for OS. 5-year OS was similar between isolated lung and liver recurrences. During CIS, decreased liver resection margin may be associated with increased risk of liver only recurrence. Patients with aggressive primary or metastatic liver disease are at higher risk for pulmonary or other/multifocal recurrence.

Technique of per-oral endoscopic myotomy (POEM) of the esophagus (with video).

BACKGROUND: Per-Oral Endoscopic Myotomy (POEM) is becoming an acceptable alternative to laparoscopic cardiomyotomy for esophageal motility disorders. The aim of this video is to provide key technical steps to completing this procedure. METHOD: Each patient underwent diagnostic investigations including high resolution manometry (HRM), esophageogastroduodenoscopy (EGD), and timed-barium swallow for primary esophageal motility disorders preoperatively. Patients undergoing POEM procedures are preoperatively prepared by taking Nystatin swish-and-swallow for 3 days, 24 h of clear liquid diet, and 12 h of NPO. Preoperative antibiotics are given. Under general anesthesia and with the patient in the supine position, endoscopy with CO2 insufflation is prepared. Special endoscopic instruments and electrocautery settings are required to perform the POEM procedure, as illustrated in the slides. POEM is performed in six key/critical steps: (1) diagnostic endoscopy; (2) taking measurements; (3) esophageal mucosotomy creation; (4) submucosal tunneling; (5) selective circular myotomy of the anterior lower esophageal sphincter; and (6) closure of the mucosotomy. According to our protocol, all patients get an esophogram the next morning after surgery prior to discharge. The patient receives objective testing (HRM with 24 PH Impedance test, EGD, and timed-barium swallow) 6 months postoperatively. CONCLUSION: In six key steps, POEM can be accomplished as described in the video.

Gastro-bronchial fistula closed by endoscopic fistula plug (with video).

BACKGROUND: Fistulae between the tracheobronchial tree and the gastric conduit post-esophagectomy are a rare but sometimes fatal complication. Clinical presentation can range from asymptomatic to acute pulmonary decompensation. Traditional management options, such as esophageal exclusion alone or combined with transthoracic fistula division, and closure (with tissue interposition), are highly invasive, technically difficult, and associated with variable success rates. This video presents closure of highly complex, chronic esophagobronchial fistula (EBF) using simultaneous bronchoscopic and upper endoscopic techniques. METHODS: Diagnostic bronchoscopy and upper endoscopy are performed to assess the size and location of fistulae. Fistulae with sufficient luminal size to accommodate a biologic plug were selected for treatment. Steps of EBF plug insertion. (1) Wire across fistula with ends exposed through the mouth. (2) Delivery sheath passed across wire from bronchial side to esophageal side (3) Plug loaded on the esophageal side of the sheath. (4) Plug pulled into position across the fistula from esophageal to bronchial side. (5) Delivery sheath released from bronchial side. RESULTS: Two of four fistulae were suitable for plug therapy. A temporary covered-stent was placed to help maintain the plugs in place. Endoscopy at 1 month showed healing of the plugged fistula following stent removal. Respiratory symptoms were improved with no further episodes of pneumonia. Over course of 2 years, the patient has required three additional endoscopic procedures to control new fistulae from this broad area of exposed lung paranchyma, but the initial fistula plug repair is durable. CONCLUSION: Post-esophagectomy fistula is a morbid complication and the surgical treatments available are highly morbid and have variable success rates. Due to the development of new endoscopic technologies, the endotherapy has assumed new prominence for treatment of enteric fistula. This complex case illustrates feasibility of endoscopic fistula treatment using dual scope, biologic plug application which effectively controlled this patient's EBF symptoms.

Endoscopic therapies for leaks and fistulas after bariatric surgery.

Bariatric surgery is the most effective treatment for the medical comorbidities associated with morbid obesity. Though uncommon, staple line or anastomotic leaks after bariatric surgery are highly morbid events and challenging to treat. In selected patients without severe sepsis or distant pollution, endoscopic transluminal peritoneal drainage may provide source control. For leaks within 3 days of surgery, endoscopic stenting does not appear to speed closure but does permit oral nutrition. In uncomplicated situations, the risk of migration and resulting complications of enteric stents appear to overshadow the benefits. Initial treatment failures and leaks presenting more than 48 hours after surgery respond to enteric diversion by endoscopic stenting. Occlusion of the leak by injection of fibrin glue also shows promise; however, these case series are limited to a small number of patients. Endoclips may work best to occlude leaks and close fistulas if the epithelium is debrided. As suturing technology improves, direct internal closure of fistulas may prove feasible. Therapeutic endoscopy offers several technologies that can assist in the closure of early leaks and that are essential to the treatment of late leaks and fistulas after bariatric surgery.

Subxyphoid thyroidectomy: a feasibility study.

OBJECTIVE: The cultural desire to avoid cervical incisions and increasing concern for cosmetic outcomes has motivated surgeons to develop alternative approaches to thyroid surgery. The Direct Drive Endoscopic System (DDES) platform combines a flexible endoscope with a pair of separately controlled articulating instruments through a single, flexible, access system. We hypothesized that the DDES platform would permit single-incision minimally invasive thyroid lobectomy without robotic assistance. METHODS: This is a single-cadaver feasibility study. A single, 2.2-cm subxyphoid incision was used for access. The platform's 55-cm flexible sheath was secured to the operating table rails and introduced into the subcutaneous space. A flexible pediatric endoscope was simultaneously introduced with 2 interchangeable 4-mm instruments. Blunt dissection and electrocautery were used to create the tunnel in the otherwise free central plane. The thyroid was dissected using a superior to inferior technique while maintaining the critical steps of traditional thyroid surgery. A Veress needle introduced through the lateral neck provided additional retraction. RESULTS: The total operating time was 2.5 hours. The subcutaneous tunnel was safe and accommodated the DDES well. Visualization was adequate. Graspers, scissors, and hook cautery were used to complete the lobectomy. The ergonomics, articulation, and strength of the instrumentation were sufficient. CONCLUSIONS: Subxyphoid thyroidectomy is technically possible and avoids the difficulties inherent to a transaxillary approach while still avoiding cosmetically unappealing cervical scars. Continued technological refinement will only expand the therapeutic possibilities of flexible endoscopy while minimizing the physical insult to patients and maximizing aesthetics for patients.

Morbidity of total pancreatectomy with islet cell auto-transplantation compared to total pancreatectomy alone.

BACKGROUND: In pancreatitis, total pancreatectomy (TP) is an effective treatment for refractory pain. Islet cell auto-transplantation (IAT) may mitigate resulting endocrinopathy. Short-term morbidity data for TP + IAT and comparisons with TP are limited. METHODS: This study, using 2005-2011 National Surgical Quality Improvement Program data, examined patients with pancreatitis or benign neoplasms. Morbidity after TP alone was compared with that after TP + IAT. RESULTS: In 126 patients (40%) undergoing TP and 191 (60%) patients undergoing TP + IAT, the most common diagnosis was chronic pancreatitis. Benign neoplasms were present in 46 (14%) patients, six of whom underwent TP + IAT. Patients in the TP + IAT group were younger and had fewer comorbidities than those in the TP group. Despite this, major morbidity was more frequent after TP + IAT than after TP [n = 79 (41%) versus n = 36 (29%); P = 0.020]. Transfusions were more common after TP + IAT [n = 39 (20%) versus n = 9 (7%); P = 0.001], as was longer hospitalization (13 days versus 9 days; P < 0.0001). There was no difference in mortality. CONCLUSIONS: This study is the only comparative, multicentre study of TP and TP + IAT. The TP + IAT group experienced higher rates of major morbidity and transfusion, and longer hospitalizations. Better data on the longterm benefits of TP + IAT are needed. In the interim, this study should inform physicians and patients regarding the perioperative risks of TP + IAT.

Defining "the elderly" undergoing major gastrointestinal resections: receiver operating characteristic analysis of a large ACS-NSQIP cohort.

OBJECTIVE: "The elderly" is an often used but poorly defined descriptor of surgical patients. Investigators have used varying subjectively determined age cutoffs to report outcomes in the elderly. We set out to use objective outcomes data to determine the "at-risk" elderly population. PATIENTS: 129,331 patients identified from the ACS-NSQIP database (2005-2010) undergoing major gastrointestinal resections. OUTCOME: Mortality. STATISTICAL METHODS: Locally weighted regression was used to fit the trend line of mortality over age. Receiver operating characteristic analysis was used to identify the "predictive age" for mortality. RESULTS: Mortality steadily increases with age. On receiver operating characteristic analysis, there is a nonlinear transition zone (50-75 years of age) flanked by 2 linear zones on either end. The younger linear zone showed a low mortality increase (0.5% per decade). Larger mortality increase with age (5.3% per decade) was observed at the older age end. Similar patterns were observed for large-volume surgical subtypes, with clustering of a "critical age" beyond which mortality increases dramatically at 75 ± 2 years. Receiver operating characteristic analysis identified the "optimum age" for mortality being 68.5 years (area under the curve = 0.72, sensitivity = 66.6%, and specificity = 65.5%). CONCLUSIONS: Mortality risk for major gastrointestinal surgical resections starts increasing at 50 years of age, and at 75 years of age, it starts increasing very rapidly. The optimum age of 68.5 years predicts mortality with the best combination of sensitivity and specificity. These ages should be used to standardize outcome data and focus perioperative resources to improve outcomes.

Night-shift work and risk of breast cancer: a systematic review and meta-analysis.

A 2007 report by the International Agency for Research on Cancer classified night-shift work as possibly carcinogenic to humans, emphasizing, in particular, its association with breast cancer. Since this report and the publication of the last systematic review on this topic, several new studies have examined this association. Hence, to provide a comprehensive update on this topic, we performed a systematic review and meta-analysis. We searched Medline, Embase, CINAHL, Web of Science (Conference Proceedings), and ProQuest dissertations for studies published before March 1, 2012, along with a manual search of articles that cited or referenced the included studies. Included were observational case-control or cohort studies examining the association between night-shift work and breast carcinogenesis in women, which all ascertained and quantified night-shift work exposure. The search yielded 15 eligible studies for inclusion in the systematic review and meta-analysis. Using random-effects models, the pooled relative risk (RR) and 95 % confidence intervals (CIs) of breast cancer for individuals with ever night-shift work exposure was 1.21 (95 % CI, 1.00-1.47, p = 0.056, I (2) = 76 %), for short-term night-shift workers (<8 years) was 1.13 (95 % CI, 0.97-1.32, p = 0.11, I (2) = 79 %), and for long-term night-shift workers (≥8 years) was 1.04 (95 % CI, 0.92-1.18, p = 0.51, I (2) = 55 %), with substantial between-study heterogeneity observed in all analyses. Subgroup analyses suggested that flight attendants with international or overnight work exposure and nurses working night-shifts long-term were at increased risk of breast cancer, however, these findings were limited by unmeasured confounding. Overall, given substantial heterogeneity observed between studies in this meta-analysis, we conclude there is weak evidence to support previous reports that night-shift work is associated with increased breast cancer risk.

Peroral endoscopic esophageal myotomy: defining the learning curve.

BACKGROUND: Peroral endoscopic myotomy (POEM) is an endoscopic alternative to laparoscopic esophageal myotomy. It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management. OBJECTIVE: Determine the learning curve for POEM. DESIGN: Prospective cohort study. SETTING: Tertiary-care teaching hospital. PATIENTS: The study involved the first 40 consecutive patients undergoing the POEM procedure under a prospective institutional review board protocol (research.gov #NCT01399476, 1056). INTERVENTION: Peroral endoscopic myotomy for esophageal motility disorders. MAIN OUTCOME MEASUREMENTS: Length of procedure (LOP) and technical errors (inadvertent mucosotomy). RESULTS: A total of 40 patients underwent POEM. The mean LOP was 126 ± 41 minutes. The mean myotomy length was 9 cm (range, 6-20 cm). The LOP per centimeter myotomy and variability decreased as our experience progressed. The means (± standard deviation) of the LOP per centimeter myotomy were as follows: first cohort, 16 ± 4 minutes; second, 17 ± 5 minutes; third, 13 ± 3 minutes; fourth, 15 ± 2 minutes; and fifth, 13 ± 4 minutes. The incidence of inadvertent mucosotomy also decreased with increasing experience, to 8, 6, 4, 0, and 1, respectively. These minor complications were repaired intraoperatively with clips. There were 7 patients with capnoperitonium and another with bilateral capnothoraces that were associated with hemodynamic instability but resolved by Veress needle decompression. Two patients required endoscopy in the early postoperative period: self-limited hematemesis in one and radiologic evidence of leakage at the mucosotomy site in another. LIMITATIONS: Nonrandomized study. CONCLUSION: Mastery of operative technique in POEM is evidenced by a decrease in LOP, variability of minutes per centimeter of myotomy, and incidence of inadvertent mucosotomies and plateaus in about 20 cases for experienced endoscopists. The learning curve can be shortened with very close supervision and/or proctoring.

Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia.

BACKGROUND: Per-oral endoscopic myotomy (POEM) requires advanced flexible endoscopic skills, especially in the management of complications. METHODS: We present a full-thickness esophagotomy while performing POEM and repair using an endoscopic suturing device. STANDARD OPERATIVE TECHNIQUE: An anterior esophageal 2 cm mucosectomy is created 7-10 cm proximal to the gastroesophageal junction after a submucosal wheal is raised. A submucosal tunnel is created and extended to 2 cm on the gastric cardia. A selective circular myotomy is performed. The mucosectomy is closed using endoscopic clips. CASE PRESENTATION: An inadvertent full-thickness esophagotomy was created while performing the mucosotomy on an inadequate submucosal wheal. We were able to resume the POEM technique at the initial esophagotomy site. There was a discussion to convert to laparoscopy. However, as we succeeded in creating the tunnel, we continued with the POEM technique. After the selective myotomy was completed, we used an endoluminal suturing device (Overstitch, Apollo Endosurgery, Austin TX) to close the full-thickness esophagotomy in two layers (muscular, mucosal). A covered stent was not an option because the esophagus was dilated, which precluded adequate apposition. The patient had an uneventful postoperative course. At 9-month follow-up, had excellent palliation of dysphagia without reflux. CONCLUSIONS: This case demonstrates the importance of identifying extramucosal intrathoracic anatomy, thus emphasizing the need for an experienced surgeon to perform these procedures, or at a minimum to be highly involved. Raising an adequate wheal is crucial before mucosectomy. Inadequacy of the wheal may reflect local esophageal fibrosis. If this fails at multiple locations in the esophagus, it may be prudent to convert to laparoscopy. This case also demonstrates the need for advanced flexible endoscopic therapeutic tools and a multidisciplinary approach to manage potential complications.

Simultaneous colorectal and hepatic procedures for colorectal cancer result in increased morbidity but equivalent mortality compared with colorectal or hepatic procedures alone: outcomes from the National Surgical Quality Improvement Program.

BACKGROUND: Simultaneous colorectal and hepatic surgery for colorectal cancer (CRC) is increasing as surgery becomes safer and less invasive. There is controversy regarding the morbidity associated with simultaneous, compared with separate or staged, resections. METHODS: Data for 2005-2008 from the National Surgical Quality Improvement Program (NSQIP) were used to compare morbidity after 19,925 colorectal procedures for CRC (CR group), 2295 hepatic resections for metastatic CRC (HEP group), and 314 simultaneous colorectal and hepatic resections (SIM group). RESULTS: An increasing number of simultaneous resections were performed per year. Fewer major colorectal and liver resections were performed in the SIM than in the CR and HEP groups. Patients in the SIM group had a longer operative time and postoperative length of stay compared with those in either the CR or HEP groups. Simultaneous procedures resulted in higher rates of postoperative morbidity and major morbidity than CR procedures, but not HEP procedures. This difference was driven by higher rates of wound and organ space infections, and a greater incidence of septic shock. Mortality rates did not differ among the groups. CONCLUSIONS: Hospitals in the NSQIP are performing more simultaneous colonic and hepatic resections for CRC. These procedures are associated with increases in operative time, length of stay and rate of perioperative complications. Simultaneous procedures do not, however, increase perioperative mortality.

Predictors of marginal ulcers after laparoscopic Roux-en-Y gastric bypass.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a highly effective therapy for morbid obesity. As the most common postoperative complication, marginal ulcers (MU) present a significant disease burden. The etiology of marginal ulcers after gastric bypass has not been clearly defined. The purpose of this study was to identify independent risk factors for MU. METHODS: We performed a retrospective study of a single surgeon's experience performing LRYGB between July 2001 and January 2006 in a United States private practice and university hospital. We investigated patient factors and comorbidities associated with the development of marginal ulcers. The five most common comorbidities were hypertension, type 2 diabetes mellitus, gastroesophageal reflux disease, hyperlipidemia, and obstructive sleep apnea. We analyzed these factors using multivariate logistic regression adjusting for demographics, BMI, and all comorbidities. RESULTS: In our 763 patients, 89% were female, 84.7% were African-American, and the mean BMI was 50.2 kg/m(2) before surgery. Marginal ulcers occurred in 23 patients (3.01%) over a mean of 64 months. On χ(2) analysis, hypertension, gastroesophageal reflux disease, hyperlipidemia, and sleep apnea were significantly correlated with MU. On multivariate analysis, the odds of marginal ulcer formation were 7.84 among hypertensive patients with a 95% confidence interval of 1.75-35.06 (P = 0.007). Hypertension was the only significant predictor of marginal ulcer disease. CONCLUSION: In our study, marginal ulcers occurred more frequently in patients with preoperative hypertension. At higher risk, these patients could be good candidates for extended acid suppression prophylaxis after LRYGB.

Does fellow participation in laparoscopic Roux-en-Y gastric bypass affect perioperative outcomes?

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) requires specialized training commonly acquired during a fellowship. We hypothesized that fellows affect patient outcomes and this effect varies during training. METHODS: We included all LRYGB from the 2005 to 2009 American College of Surgeons-National Surgical Quality Improvement Program database. Cases without trainees (attending) were compared to those with trainees of ≥6 years (fellow). Outcomes were pulmonary, infectious, and wound complications and deep venous thrombosis (DVT). Multivariable regression controlled for age, BMI, and comorbidities. RESULTS: Of the 18,333 LRYGB performed, 4,349 (24%) were fellow cases. Fellow patients had a higher BMI (46.1 vs. 45.7, p < 0.001) and fewer comorbidities. Mortality was 0.2 and 0.1% and overall morbidity was 4.8 and 6.0% for attending and fellow groups, respectively. On adjusted analysis, mortality was similar, but fellow cases had 30% more morbidity (p = 0.001). Specifically, fellows increased the odds of superficial surgical site infections (SSSIs) [odds ratio (OR) = 1.4, p = 0.01], urinary infections (UTIs) (OR = 1.7, p = 0.002), and sepsis (OR = 1.5, p = 0.05). During the first 6 months, fellows increased the odds of DVT (OR = 4.7, p = 0.01), SSIs (OR = 1.5, p = 0.001), UTIs (OR = 1.8, p = 0.004), and sepsis (OR = 1.9, p = 0.008). By the second half of training, fellow cases demonstrated outcomes equivalent to attending cases. CONCLUSIONS: Involving fellows in LRYGB may increase DVT, SSIs, UTIs, and sepsis, especially early in training. By completion of their training, cases involving fellows exhibited outcomes similar to cases without trainees. This supports both the need for fellowship training in bariatric surgery and the success of training to optimize patient outcomes.

Advances in the Pharmacologic Treatment of Hepatocellular Carcinoma.

Medical therapy for hepatocellular carcinoma (HCC) is an area of active investigation because fewer than 25% of patients are candidates for curative resection or transplantation. Single agent doxorubicin, the former standard of care, generated a 10% tumor response but resulted in substantial toxicity. The resulting recommendation of the NCCN has been to administer cytotoxic chemotherapy only under clinical protocol. More recently, newer drugs with more specific targets have forced re-consideration of palliative chemotherapy in clinical practice. Bevacizumab is a promising therapy but data is limited to Phase 2 trials without impressive results. Sorafenib is the prototype multi-kinase inhibitor, which has demonstrated some but limited survival benefit in advanced HCC. This has subsequently become the standard of care. Epidermal growth factor receptor, the target of rapamycin (mTOR) pathway, transforming growth factor-ß, and cyclin-dependent kinases have been recent targets of ongoing study for potential therapeutics. Overall, current therapeutics have been so promising that adjuvant therapy after curative treatment in under investigation to reduce recurrence.

End of the road for a dysfunctional end organ: laparoscopic gastrectomy for refractory gastroparesis.

INTRODUCTION: Gastroparesis is a functional disorder resulting in debilitating nausea, esophageal reflux, and abdominal pain and is frequently refractory to medical treatment. Therapies such as pyloroplasty and neurostimulators can improve symptoms. When medical and surgical treatments fail, palliative gastrectomy is an option. We examined outcomes after gastrectomy for postoperative, diabetic, and idiopathic gastroparesis. METHODS: A prospective database was queried for gastrectomies performed for gastroparesis from 1999 to 2013. Primary outcomes were improvements in pre- versus postoperative symptoms at last follow-up, measured on a five-point scale. Secondary outcome was operative morbidity. RESULTS: Thirty-five patients underwent laparoscopic total or near-total gastrectomies for postoperative (43 %), diabetic (34 %), or idiopathic (23 %) gastroparesis. Antiemetics and prokinetics afforded minimal relief for one third of patients. There were no mortalities. Six patients suffered a leak, all treated with surgical reintervention. With a median follow-up of 6 months, nausea improved or resolved in 69 %. Chronic abdominal pain improved or resolved in 70 %. Belching and bloating resolved for 79 and 89 %, respectively (p < 0.01). CONCLUSIONS: Regardless of etiology, medically refractory gastroparesis can be a devastating disease. Near-total gastrectomy can ameliorate or relieve nausea, belching, and bloating. Chronic abdominal pain commonly resolved or improved with resection. Despite attendant morbidity, gastrectomy can effectively palliate symptoms of gastroparesis.

Measuring surgical quality: a national clinical registry versus administrative claims data.

BACKGROUND: This study compared postoperative complications of patients who underwent pancreaticoduodenectomy (PD) recorded in the National Surgical Quality Improvement Program (NSQIP) to patients who underwent PD recorded in the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). METHODS: Data included 8,822 PD cases recorded in NSQIP and 9,827 PD cases recorded in NIS performed between 2005 and 2010. Eighteen postoperative adverse outcomes were identified in NSQIP and then matched to corresponding International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes in NIS. Using logistic regression, the relationship between database and postoperative complications was determined while accounting for patient factors. RESULTS: Patients undergoing PD in the NIS were more likely to have several adverse outcomes, including urinary tract infection (odds ratio (OR) = 1.42, p < 0.001), pneumonia (OR = 1.51, p < 0.001), renal insufficiency (OR = 2.39, p < 0.001), renal failure (OR = 1.67, p = 0.005), graft/prosthetic failure (OR = 9.35, p < 0.001), and longer length of stay (1.1 days, p < 0.001). They were less likely to have cardiac arrest (OR = 0.45, p = 0.002), postoperative sepsis (OR = 0.38, p < 0.001), deep vein thrombosis (OR = 0.18, p < 0.001), and cerebrovascular accident (OR = 0.04, p = 0.003). CONCLUSIONS: There is considerable discordance between NSQIP and NIS in the assessment of postoperative complications following PD, which underscores the value of recognizing the capabilities and limitations of each data source.

Multivisceral and extended resections during pancreatoduodenectomy increase morbidity and mortality.

BACKGROUND: Improvements in outcomes after pancreatoduodenectomy (PD) have permitted more complex resections. Complete extirpation at PD may require multivisceral resection (MVR-PD); however, descriptions of morbidity of MVR-PD are limited to small, single-institution series. METHODS: The National Surgical Quality Improvement Project database (2005-2011) was used to compare 30-day postoperative morbidity of PD with MVR-PD. Concurrent resection of colon, small bowel, stomach, kidney, or adrenal gland defined MVR-PD. RESULTS: Of 9,927 PDs, MVR-PD was performed in 273 patients (3%). MVR included colon (58%), small bowel (30%), and gastric (12%) resections. Preoperative comorbidities were similar between groups. Pancreatic, duodenal, or periampullary cancer was present in 75% of patients. Mortality (8.8% vs 2.9%) and major morbidity (56.8% vs 30.8%) were much greater for MVR-PD versus PD alone (P < .001). MVR-PD patients also experienced greater rates of wound, pulmonary, cardiac, thromboembolic, renal, and septic complications. On multivariable regression, MVR was an independent predictor of death (odds ratio [OR], 3.4; P < .001), overall morbidity (OR, 3.01; P < .001), major morbidity (OR, 3.21; P < .001), and minor morbidity (OR, 1.65; P = .03). Among patients undergoing PD+MVR, colectomy was an independent predictor of increased overall morbidity (OR, 1.96; P = .03) and major morbidity (OR, 1.90; P = .02). CONCLUSION: Margin-negative resection may require MVRs at the time of PD. MVR at is associated with 3-fold mortality and substantial morbidity after adjusting for comorbidities. Colectomy independently predicted major morbidity. At PD, the morbidity of MVR should be approached with caution when attempting margin-negative resection.

Perioperative outcomes of pancreaticoduodenectomy compared to total pancreatectomy for neoplasia.

PURPOSE: Total pancreatectomy (TP) eliminates the risk and morbidity of pancreatic leak after pancreaticoduodenectomy (PD). However, TP is a more extensive procedure with guaranteed endocrine and exocrine insufficiency. Previous studies conflict on the net benefit of TP. METHODOLOGY: A comparison of patients undergoing non-emergent, curative-intent TP or PD for pancreatic neoplasia using the National Surgical Quality Improvement Project data from 2005-2011 was done. Main outcome measures were mortality and major and minor morbidities. RESULTS: Of the 6,314 (97%) who underwent PD and the 198 (3%) who underwent TP, malignancy was present in 84% of patients. The two groups were comparable at baseline. Mortality was higher after TP (6.1%) than DP (3.1%), p = 0.02. Adjusting for differences on multivariable analysis, TP carried increased mortality (OR 2.64, 95% CI 1.3-5.2, p = 0.005). TP was also associated with increased rates of major morbidity (38 vs. 30%, p = 0.02) and blood transfusion (16 vs. 10%, p = 0.01). Infectious and septic complications occurred equally in both groups. CONCLUSION: The morbidity of a pancreatic fistula can be eliminated by TP. However, based on our findings, TP is associated with increased major morbidity and mortality. TP cannot be routinely recommended for to reduce perioperative morbidity when pancreaticoduodenectomy is an appropriate surgical option.

Determinants of repeat curative intent surgery in colorectal liver metastasis.

INTRODUCTION: Following curative intent surgery (CIS) for colorectal liver metastasis (CRLM), repeat CIS for recurrence improves survival. The factors associated with repeat CIS are not widely reported. METHODS: An institutional database (January 2002-December 2012) was reviewed to evaluate factors influencing repeat CIS. RESULTS: One hundred sixty-three patients with colorectal liver metastasis (CRLM) underwent successful CIS. Median follow-up and disease-free interval (DFI) was 33 and 16 months, respectively. After initial CIS, 102 patients (63%) recurred. Fifty-three patients (52%) underwent a repeat CIS. After repeat CIS, 33 patients (62%) developed a second recurrence, and in 13 patients (39%), a third CIS was possible. DFI decreased following initial CIS (first CIS vs. second CIS vs. third CIS [20 vs. 15 vs. 8.5 months], p < 0.001). Overall 5-year survival in all patients was 55%; patients who recurred had a 5-year survival of 67% if they underwent repeat CIS vs. 7.8% if they were managed palliatively. Second CIS was less likely with a postoperative complication, other/multifocal recurrence, or DFI <12 months. CONCLUSION: Despite high recurrence and decreasing DFI, repeat CIS provides a survival benefit. Postoperative complications, DFI, number, and pattern of recurrence influence the decision to pursue repeat CIS.